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Gastrointestinal cancer-14-Pancreas


Welcome to the 14th part of educational series on GastroIntestinal Cancers. We learned in part 13 about treatment of anal cancer where chemotherapy combined with radiotherapy is standard treatment, and allows avoidance of permanent colostomy. Today we will discuss pancreas cancer.

Question: Dear Dr. Chiragbhai, is pancreas cancer very difficult to treat?

Answer: This is a cancer which mostly presents in very advanced stages, because of nonspecific symptoms like nausea, dyspepsia, depression, weight loss, jaundice. Also, apart from surgery, other modalities have limited activity.

Que: How is it treated then?

Ans: Once again, surgery is the primary treatment, but is often not possible because of advanced stage. Therefore, a very good evaluation is important to decide resectability, using at least a good CT scan, and a multidisciplinary evaluation. EUS and laparoscopy, where available, add to the decision making in some cases.

Que: What type of surgery is performed?

Ans: Whipple procedure or pancreaticoduodenectomy. This is a major surgery with significant risk of death or severe morbidity. Studies have indicated that centers performing more than 5 such surgeries per year, preferably over 20 per year, have the best results. This is similar to what we have discussed in earlier parts of this series with relation to other major surgeries. Mortality difference between centers could be as high as 20% vs 4%. Therefore, this issue should be considered strongly in choosing center.

Que: What other important issues should be evaluated?

Ans: Some of the patients are “borderline resectable”. Such patients should be considered for preoperative chemotherapy plus radiotherapy, as some of these patients can be converted to clearly resectable disease, providing long term survival.

One important point should be emphasized at this point: biopsy is frequently not easy or comes back as normal or inconclusive, when done as CT guided or EUS guided. If patient has potentially resectable disease and clinically and radiologically pancreas cancer is more likely, surgery should be done, without trying for repeated biopsies.

However, biopsy confirmation is a must for non surgical therapies e.g. chemotherapy.

Also, biliary drainage is required in most cases. However it is not urgent if patient does not have jaundice or signs of infection(cholangitis). It can be in form of a stent, generally placed by ERCP, or surgical.

Que: What about role of other modalities?

Ans: Unfortunately, role of other modalities at present is limited. Postoperative chemotherapy and possibly chemoradiotherapy adds somewhat to the results, and should be given to increase survival in this otherwise dreadful disease. However, many patients are not in a position to receive radiotherapy after this major surgery, which often takes long time for patient to recover. Chemotherapy alone is probably sufficient, based on some recent studies i.e. ESPAC-1 (for use of 5-FU) and CONKO-001 (for use of gemcitabine).

Addition of newer medicines and targeted therapies have shown no or very limited impact so far.

Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA),
Diplomate American Board of Oncology and Hematology.
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. 079 26754001