Pancreatic Cancer Diagnosis and Management
Epidemiology and Risk Factors
- Cigarette smoking is the strongest modifiable risk factor for pancreatic cancer, according to the European Society for Medical Oncology 1
- Adult-onset diabetes without predisposing features or family history should raise suspicion for pancreatic cancer, as stated by the American Gastroenterological Association 1, 2
- Chronic pancreatitis and unexplained acute pancreatitis in patients over 50 years increase the risk of pancreatic cancer, as reported by the National Comprehensive Cancer Network 1, 2
- Hereditary pancreatitis and familial pancreatic cancer syndromes confer elevated risk of pancreatic cancer, according to the International Cancer Genome Consortium 1
- Familial adenomatous polyposis increases the risk of periampullary cancers, as stated by the American College of Gastroenterology 1
Pathophysiology
- Ductal adenocarcinoma accounts for 95% of pancreatic epithelial tumors, as reported by the National Cancer Institute 2
- Most patients present at locally advanced stages with vascular invasion and lymph node metastases, according to the American Joint Committee on Cancer 1
- Only 10-20% of patients have resectable disease at diagnosis, as stated by the Society of Surgical Oncology 2
Clinical Presentation
- Obstructive jaundice is the most common presenting symptom for head lesions, according to the European Society for Medical Oncology 3
- Unexplained weight loss, upper abdominal or back pain, and steatorrhea are common symptoms of pancreatic cancer, as reported by the American Gastroenterological Association 3
- New-onset diabetes in patients over 50 without family history, obesity, or steroid use should raise suspicion for pancreatic cancer, as stated by the American Diabetes Association 3, 2
Diagnostic Workup
- Abdominal ultrasound is the first-line imaging modality for suspected pancreatic cancer, according to the American College of Radiology 1, 2, 5
- Blood counts and liver enzymes should be included in the initial workup, as reported by the National Comprehensive Cancer Network 2
- CA 19-9 level should be measured in the absence of jaundice, according to the American Society of Clinical Oncology 6
- Chest x-ray should be performed to evaluate for intrathoracic metastases, as stated by the American Thoracic Society 7
Staging and Resectability Assessment
- No radiographic interface between primary tumor and mesenteric vasculature on high-definition imaging is a criterion for resectable disease, according to the Society of Surgical Oncology 6
- No evidence of extra-pancreatic disease is required for resectable disease, as reported by the National Comprehensive Cancer Network 2
- Pancreatic protocol CT or MRI with MRCP accurately delineates tumor size, infiltration, and metastatic disease, according to the American College of Radiology 1, 2, 5
Treatment Approach
- Primary surgical resection followed by 6 months of adjuvant chemotherapy is the standard approach for resectable pancreatic cancer, according to the National Comprehensive Cancer Network 6, 2
- FOLFIRINOX is recommended for patients with locally advanced unresectable disease and ECOG PS 0-1, as stated by the American Society of Clinical Oncology 7
- Gemcitabine plus nab-paclitaxel is an alternative regimen for metastatic pancreatic cancer, according to the European Society for Medical Oncology 5
Palliative Care and Symptom Management
- Endoscopic stent placement is preferable to trans-hepatic stenting for relief of obstructive jaundice, according to the American Society for Gastrointestinal Endoscopy 4
- Self-expanding metal stents are preferred for patients with life expectancy >3 months, as reported by the European Society for Medical Oncology 8, 5
- Patients with severe pain must receive opioids, with morphine generally being the drug of choice, according to the World Health Organization 8, 5
Multidisciplinary Care Requirements
- Multidisciplinary collaboration to formulate treatment and care plans should be the standard of care for patients with pancreatic cancer, according to the National Comprehensive Cancer Network 7, 6
- Goals of care discussion, including advance directives, should be performed with the patient and caregivers, as stated by the American Society of Clinical Oncology 7, 6