Stopping the Silent Killer - Pancreatic Cancer

Dr. Ligresti is chief of gastroenterology at Hackensack University Medical Center, which was recognized recently by U.S. News & World Report as the best hospital in New Jersey for GI treatment. His practice uses advanced interventional endoscopic techniques to diagnose and treat digestive cancers. He is a fellow of the American Society of Gastrointestinal Endoscopy and has served the Bergen county, NJ community for many years.

Newswise — The American Cancer Society’s Cancer Facts & Figures 2023, released last week reports that the five-year survival rate for pancreatic cancer is now 12%, an increase of one percentage point from last year. This is the first time since 2017 that the survival rate has gone up two years in a row, a promising upward trend that points to continued progress in the fight against this tough disease.

Still, the Facts & Figures report also reveals that an estimated 64,050 Americans will be diagnosed with pancreatic cancer in 2023, more people than ever before. Approximately 50,550 Americans are expected to die from this disease -dubbed the silent killer - this year.

You may have heard more talk of pancreatic cancer recently because of famous people who died from it in recent years: Supreme Court Justice Ruth Bader Ginsburg, civil rights legend and Georgia Congressman John Lewis, and Alex Trebek, the host of the TV game show, “Jeopardy!”  But just as significant, perhaps someone in your own family, a colleague, friend, or neighbor has been diagnosed with or died from this disease?

The more people know about the risk factors for pancreatic cancer and its symptoms, the earlier they can be screened, improving their chance for survival if they are diagnosed with this disease or a precursor condition. 

The pancreas is a small organ in the abdomen that produces insulin and other important enzymes to promote digestion of food and regulation of blood sugar. Pancreatic cancer is seldom detected at its early stages when it's most curable. It’s often called “the silent killer,” since most patients don't experience symptoms until the cancer has spread to surrounding organs.

As a gastroenterologist who takes care of patients with pancreatic cancer, I’m doing all I can this month and year-round to help people better understand the risk factors for  pancreatic cancer and to get screened if they need to. Screening is most important for people who have diabetes or who are recently diagnosed with diabetes, and for those who have a family history of pancreatic cancer, a known genetic cancer-causing mutation or who have had chronic pancreatitis, an ongoing inflammation of the pancreas.   

This type of cancer accounts for about three percent of all cancers but it is the 4th leading cause of cancer death for men and women in the United States, making it one of the most lethal forms of malignant diseases. It is slightly more common in men than in women.1,2 

There is an association with pancreatic cancer and race: African Americans are more likely to develop pancreatic cancer than whites.3 The reasons are uncertain but may be related to smoking, diabetes and obesity. 

While anyone can get pancreatic cancer, there are certain risk factors that may contribute to its development. Most pancreatic cancer is diagnosed after age 65. Smoking, diabetes, chronic pancreatitis or inflammation of the pancreas, family history of pancreatic cancer, and inherited (genetic) factors can also play a role such as a mutation in the BRCA gene, which is important in suppressing cancer.  Being overweight may be a factor as well.  Evidence increasingly suggests that during the year or two after the onset of diabetes, a pancreatic cancer diagnosis is more likely.  Moreover one in four people diagnosed with pancreas cancer were first diagnosed with diabetes. On-going research is being done to explore the risks of this time period.

Overall, the prevalence of pancreatic cancer has been significantly rising since 2000, especially in women younger than 55.  It is predicted to become the second-leading cause of cancer death in the world by 2030, overtaking colon cancer. Because of the increase in cases and the potential lethal outcomes of the diagnosis, we absolutely need to raise awareness about who is at-risk for it and encourage screening for it.4

Some good news is that a study published this year in the Journal of Clinical Oncology5 showed that screening programs for people at high risk of developing pancreatic cancers can help detect precancerous conditions and cancers early, when they are most treatable, usually with surgery. The study reported that the five-year survival of patients with a highly aggressive form of pancreatic cancer who participated in screening is 73.3%, and median overall survival is 9.8 years, compared with 1.5 years for patients diagnosed with this condition who had not had the proactive screening, which usually means an annual MRI test or an annual endoscopic ultrasound test.

This study helps to justify to the health care system the value, in both clinical and human terms, of regular pancreatic imaging surveillance for patients who meet recommended pancreatic surveillance criteria. 

To further support regular screening, in 2020 the International Cancer of the Pancreas Screening (CAPS) Consortium recommended pancreatic surveillance for high-risk individuals to detect early pancreatic cancer and its high-grade precursors.6  The CAPS Consortium suggested that  such screening be performed by multidisciplinary teams in research centers with appropriate expertise.5  

At Hackensack University Medical Center, where I see and treat patients, we offer an innovative surveillance program that screens individuals who are at high-risk for developing familial or hereditary pancreatic cancer. This new initiative is the first of its kind in New Jersey, and patients who are eligible receive both an imaging test and a recently approved biomarker blood test that measures the immune system’s response to the cancer.  You can find out more information about the program HERE or by calling my office at 551-996-3091.

It’s important to emphasize that usually the signs of pancreatic cancer don’t appear until the disease is in more advanced stages. Symptoms may include abdominal pain that radiates to the back, loss of appetite or unintentional weight loss, jaundice (yellowing) of the skin or eyes, light colored stools, dark colored urine, very itchy skin, diabetes that is difficult to control, fatigue and blood clots.  Unfortunately, once symptoms appear, the disease is often in it’s later stages, where cure becomes improbable.

A variety of imaging tests are used to diagnose pancreatic cancer. An ultrasound, CT scan, MRI, or PET scan can help physicians see a clearer picture of the pancreas. An endoscopic ultrasound, or EUS, uses a tiny camera that is placed down the esophagus and into the stomach to get a close-up view of the pancreas. During the EUS, a biopsy of tissue can be collected for further testing. Sometimes pancreatic cancer can shed specific proteins called tumor markers in  blood. Doctors may request blood tests to identify elevation of these markers.

If a diagnosis is confirmed, the next step is to determine the extent or stage of the cancer. The stages are numbered one through four and may need to be determined by additional testing.

Surgery is used to physically remove the cancer and the immediate surrounding area. Many factors are considered when I recommend treatment for pancreatic cancer,  including the overall health of the patients and their personal preferences and circumstances. One type of therapy or a combination may be considered: Chemotherapy kills cancerous cells that may be throughout the body. Radiation, similarly, kills the cancer cells, but with high-energy beams directed at the tumor.

But before we can get to a customized treatment plan for diagnosed patients , we have to identify patients who are at risk for pancreatic cancer and get them screened regularly.  This November, during Pancreatic Cancer Awareness Month, if you or someone you know may be at risk for this potentially deadly form of cancer, make an appointment as soon as you can with your primary care doctor to discuss the risks and to get referred for a discussion about screening with experts in the field.  Pancreatic cancer need not be a silent or deadly cancer if we make plans to screen for it regularly, catch it early and get patients the life-extending and life-saving treatments they deserve. 

Sources

1 American Cancer Society, Key Statistics for Pancreatic Cancer, 2022

2National Cancer Institute, Surveillance, Epidemiology, and End Results Program, 2022

3Johns Hopkins Medicine, 2022

4JAMA Network Open, “Estimated Projection of US Cancer Incidence and Death to 2040,” 2021, 4(4). 4708.

5 “The Multicenter Cancer of Pancreas Screening Study: Impact on Stage and Survival,”

ascopubs.org › doi › abs › jco.22.00298

Five-year survival to date of the patients with a screen-detected PDAC is 73.3%, and median overall survival is 9.8 years, compared with 1.5 years for patients diagnosed with PDAC outside surveillance (hazard ratio [95% CI]; 0.13 [0.03 to 0.50], P = . 003).Jun 15, 2022

6”Management of patients with increased risk for familial pancreatic cancer: updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium,” GUT, June 1, 2020.