Definition

Pancreatic cancer originates from the cells of the pancreas, an essential digestive organ responsible for producing enzymes for digestion and regulating blood glucose levels. The pancreas comprises the head, neck, body, and tail. Enzymes produced by the pancreas travel through passages, combining with the bile duct, and reaching the duodenum, a part of the small intestine. Pancreatic cancer is known for its severity and is considered one of the deadliest forms of cancer.

Causes

Pancreatic cancer arises from various factors that cause mutations in pancreatic cells, leading to changes in their genetic composition. Genes, responsible for instructing normal cell functions, are altered in cancerous cells, directing them to replicate rapidly and persist, contrary to the natural cell life cycle. Accumulated mutated cells form tumors that, if untreated, can spread to other organs directly or through blood and lymph circulation.

Pancreatic carcinoma manifests in two main types of cells:

• Adenocarcinoma: Originating from the cells in the pancreatic passages responsible for expelling enzymes into the small intestine, adenocarcinoma constitutes approximately 93% of pancreatic cancer cases.
• Neuroendocrine Pancreas Tumor: Arising from pancreas cells that produce insulin, a hormone regulating blood glucose levels.

Risk factor

• Smoking

Smoking is the most prevalent risk factor for pancreatic cancer, contributing to around 30% of cases. Smokers face a twofold increased risk of pancreatic cancer compared to non-smokers. Individuals who have smoked for over 40 years are at a fivefold higher risk of developing pancreatic carcinoma.

• Obesity

Obesity is a risk factor observed from childhood to adulthood and into advanced age. Red meat consumption is associated with an increased risk of pancreatic cancer, while poultry and dairy consumption shows no such correlation. Diets rich in vegetables and fruits, especially those containing folate, are linked to a reduced risk.

• Diabetes Mellitus

Diabetes mellitus, a condition related to insulin production in the pancreas, is another risk factor. Individuals with diabetes for five or more years have twice the risk of developing pancreatic cancer.

• Chronic pancreatitis

Chronic pancreatitis, characterized by prolonged inflammation of the pancreas, increases the risk of pancreatic cancer. The longer the inflammation persists, the higher the risk.

• Genetic factor

Genetic factors contribute to 5-10% of pancreatic cancer cases. Some genetic factors may lead to chronic pancreatitis, eventually progressing to cancer, while others directly predispose individuals to cancer.

Symptoms

Pancreatic cancer symptoms often become apparent only in advanced stages. These symptoms include:

• Abdominal Pain: Pain in the abdomen that may radiate to the back.
• Loss of Appetite: A decrease in appetite, leading to reduced food intake.
• Weight Loss: Unintended and significant weight loss.
• Jaundice: Yellowing of the skin and eyes (jaundice).
• Stool Changes: Pale-colored stools.
• Urine Changes: Dark or tea-colored urine.
• Skin Itchiness: Itching of the skin.
• New-Onset Diabetes or Uncontrolled Diabetes: The diagnosis of diabetes or worsening control of existing diabetes.
• Clotting Disorders: Bruising easily or the presence of unexplained bruises on the skin.
• Fatigue: Easy fatigue and weakness.

Diagnosis

Diagnosing pancreatic cancer involves a comprehensive process that includes various examinations and tests to gather crucial information. Initially, the patient's medical history is thoroughly reviewed, with a focus on factors like smoking, alcohol consumption, and family history of similar symptoms. Physical examinations follow, which may involve palpation to detect abdominal masses indicative of pancreatic cell involvement, potential spread to the liver, or lymph node enlargement due to tumor pressure on blood vessels.

Laboratory tests play a crucial role in the diagnostic process, with blood tests assessing bilirubin levels, pancreatic enzymes, liver enzymes, and tumor markers. While these tests may not provide a definitive diagnosis, they aid in the differential diagnosis. 

Various imaging tests, such as CT scans, ultrasonography (USG), endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP), and MRI, are employed to visualize the pancreas and surrounding areas, providing valuable insights.

Biopsy procedures, considered the gold standard for diagnosis, involve examining pancreatic tissue. This can be accomplished during endoscopy, where tissue samples are obtained using a needle. In cases where facilities for endoscopy are not available, biopsy guidance through CT scans may be utilized. 

Management

The treatment approach for pancreatic cancer is determined by the disease's severity and the overall health of the patient. In the early stages, surgical intervention, such as the Whipple procedure, may be considered. This procedure involves excising the tumor from the head of the pancreas and a portion of the duodenum. If the cancer is located in the body or tail of the pancreas, the excision involves the removal of lymph nodes. Additionally, when larger blood vessels are involved, surgery may be required to reconstruct or graft tissue to form new blood vessels.

For advanced stages of pancreatic cancer where surgery is not viable, treatment options typically involve chemotherapy and/or radiotherapy. The management of pancreatic cancer often includes palliative treatment, focusing on alleviating symptoms and enhancing the patient's quality of life when a cure is not possible. Palliative interventions may target pain relief, address obstructions in the gallbladder to reduce jaundice and manage obstructions in the small intestine.

Dietary considerations are crucial, given the pancreas's role in producing enzymes for digestion. Damage to the pancreas can disrupt the digestion of proteins and fats, leading to malabsorption. Therefore, dietary adjustments, such as avoiding high-fat and high-protein foods, can help reduce the risk of malabsorption. Supplementation with enzymes may also be recommended to aid in the digestion and absorption of nutrients. 

Complications

Complications of pancreatic carcinoma will follow as the disease progresses. These complications can include weight loss due to tumor cells taking energy for other parts of the body, as well as decreased appetite due to nausea and malabsorption, due to a decrease in the number of body enzymes. In addition, tumors in pancreatic cancer can press on the bile ducts, causing blockages which then result in jaundice. This tumor can also press on the nerves in the stomach, causing pain. Not only that, tumors can also press on the intestines so that food digestion becomes ineffective.

Prevention

Preventing pancreatic cancer involves adopting lifestyle changes and minimizing risk factors. Quitting smoking is a crucial step, and it takes approximately 5-10 years after quitting for the risk of cancer to decrease significantly in former smokers. Maintaining an ideal body weight is another important factor in reducing the risk of pancreatic cancer.  Weight management can be achieved through a combination of regular exercise and a balanced diet. Gradual and sustainable weight loss, targeting 0.5 to 1 kg per week, is recommended. This can be accomplished by incorporating regular physical activity and consuming a diet rich in vegetables, fruits, and whole grains in appropriate portions. Such a diet not only supports weight management but also provides essential nutrients that contribute to overall health and may help in preventing cancer.

When to see a doctor?

It's crucial to promptly consult with a doctor if you experience unintended weight loss, jaundice, or abdominal pain, particularly if there's a family history of pancreatic cancer. Early diagnosis and treatment are essential in halting the progression of pancreatic cancer and enhancing overall quality of life.