Urgent Calls for Effective Earlier Disease

Muhammad Wasif Saif
Yale Cancer Center, Yale University School of Medicine. New Haven, CT, USA
Introduction
Pancreatic carcinoma is unfortunately usually a fatal
disease. Pancreatic cancer in its early stages is a
protean disease that can be difficult to distinguish from
other common disorders that may cause similar
symptoms. Early diagnosis is therefore often a problem.
Many patients have sought care for symptoms for
weeks to months before a definitive diagnosis of
pancreatic cancer is made. The collective median
survival time of all patients is 4-6 months. Most
patients eventually succumb to local invasion and
metastatic disease. Patients who are deemed resectable
with potential curative resection (only about 20% of
patients), median survival time ranges from 12-19
months, and the 5-year survival rate remains 15-20%.
Increase in Annual Number of Pancreatic Head
Resections Does not Affect Mortality of Pancreatic
Cancer in the United Kingdom
Ypsilantis et al. [1] submitted a letter in response to our
recent publications [2, 3] and evaluated the trends in
the annual numbers of pancreatic head resections
performed in the United Kingdom during the last seven
years, in order to identify any potential effect on the
overall disease mortality. Retrospective analysis of the
United Kingdom National Hospital Admission
Episodes Database, provided by the NHS Information
Centre, was performed. The incidence of pancreatic
cancer has remained unchanged between 1999 and
2007, with an increase in the number of hospital
admissions of all patients with pancreatic cancer (mean
annual increase of 8.6%). The number of pancreatic
head resections was increased by 71%, which however
has not altered appreciably the overall disease mortality.
The authors acknowledge the limitations of a
retrospective review and caution careful interpretation
of the results.
Incidence and Mortality
The incidence of pancreatic cancer has risen slowly
over the years. In 2008, an estimated 37,680 new cases
of pancreatic cancer (18,770 in men and 18,910 in
women) were estimated to be diagnosed in the United
States; 34,290 persons (17,500 men and 16,790 women)
died of the disease in 2008 [4]. The overall incidence
of pancreatic cancer is approximately 8-10 cases per
100,000 persons per year [5, 6]. Although the overall
incidence of pancreatic cancer has been relatively
stable for decades, the incidence of pancreatic cancer in
males has been slowly dropping over the past 2
decades, while the incidence in females has increased
slightly. These trends probably represent the effect of
changing smoking rates for men and women. On the
other hand, pancreatic cancer ranks 13th in incidence
but 8th as a cause of cancer death worldwide [4, 5].The
highest incidence rate is approximately 13 cases per
100,000 persons per year in African American males in
the United States. Native Hawaiian males and men of
Korean, Czech, Latvian, and New Zealand Maori
ancestry also have high incidence rates, that is, 11
cases per 100,000 persons per year. Most other
countries have incidence rates of 8-12 cases per
100,000 persons per year. In some areas of the world,
pancreatic cancer is quite infrequent; for example, the
incidence in India is less than 2 cases per 100,000
persons per year [7].
Pancreatic cancer is the fourth leading cause of death
among both men and women, comprising 6% of all
cancer-related deaths. The incidence of pancreatic
Received June 17th, 2009
Keywords Adenocarcinoma; Carcinoma, Pancreatic Ductal;
Cholangiopancreatography, Endoscopic Retrograde; Endosono-
graphy; General Surgery; Pancreatic Neoplasms; Salvage Therapy;
Treatment Failure; Whipple Disease
Correspondence Muhammad Wasif Saif
Yale Cancer Center, Yale University School of Medicine, 333
Cedar Street, FMP 116, New Haven, CT, USA
Phone: +1-203.737.1569; Fax: +1-203.785.3788
E-mail: wasif.saif@yale.edu
Document URL http://www.joplink.net/prev/200907/28.html

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JOP. J Pancreas (Online) 2009 Jul 6; 10(4):464-465.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 10, No. 4 - July 2009. [ISSN 1590-8577]
465
cancer has risen slowly over the years. The death rate
has risen from 5 per 100,000 population in 1930 to
more than 10 per 100,000 in 2003 [4, 5].
Late Diagnosis and Late Stage at Diagnosis
Pancreatic cancer is notoriously difficult to diagnose in
its early stages. At the time of diagnosis, 52% of all
patients have distant disease and 26% have regional
spread. No screening tools are validated at present.
Multidisciplinary Management of Pancreatic
Cancer
The management of pancreatic carcinoma is a
multidisciplinary process. In the best setting, the
management of pancreatic cancer would entail
consultations with a gastroenterologist, medical
oncologist, surgical oncologist, radiologist, radiation
oncologist, pathologist, nutritionist and a social worker.
A gastroenterologist would perform EUS and/or ERCP
(with or without stent placement) for definitive
diagnosis. A medical oncologist operates to select and
administer chemotherapy (neoadjuvant, adjuvant, or
palliative). In addition, he would also manage
supportive care, especially pain and nausea. The
surgeon may perform diagnostic laparoscopy or even
laparoscopic ultrasonography prior to an attempt at
curative resection. If curative resection is not feasible
due to local invasion or distant metastasis, surgeon may
operate for palliation of biliary and/or duodenal
obstruction. An interventional radiologist may be
required to manage percutaneous transhepatic
cholangiography if indicated. Consultation with a
radiation oncologist is usually considered at the
discretion of a medical oncologist when combined
chemoradiotherapy may be beneficial either in the
neoadjuvant, adjuvant or palliative setting. A
pathologist helps in confirming the diagnosis and
identifies high risk factors. In addition, a genetic
counselor should be part of a time to recognize any
genetic or familial predisposition to develop pancreatic
cancer.
Deterrence/Prevention
• Stop smoking;
• prevent a diet high in energy intake and low in fresh
fruits and vegetables;
• avoid excessive alcohol consumption (chronic
pancreatitis -> pancreatic cancer).
Conclusions
The disease is notoriously difficult to diagnose in its
early stages. At the time of diagnosis, more than 50%
of patients have distant disease and 26% have regional
invasion. We concur that it is possible that the
percentage of patients amenable to surgery is still too
small to affect the overall disease mortality, which
would support urgent calls for effective earlier disease
detection. In the meantime, more effective multi-modal
therapeutic strategies are needed to improve survival in
this challenging disease.
Conflict of interest The author has no potential
conflicts of interest
References
1. Ypsilantis E, Courtney ED, Warren H. Increase in Annual
Number of Pancreatic Head Resections Does not Affect Mortality of
Pancreatic Cancer in the United Kingdom. JOP. J Pancreas (Online)
2009 Jul 6; 10(4):462-3.
2. Lee MX, Saif MW. Screening for early pancreatic ductal
adenocarcinoma: an urgent call! JOP. J Pancreas (Online) 2009;
10(2):104-8. [PMID 19287101]
3. Li J, Saif MW. Advancements in the management of pancreatic
cancer. JOP. J Pancreas (Online) 2009; 10(2):109-17. [PMID
19287102]
4. American Cancer Society. Cancer Facts and Figures, 2008.
Atlanta, GA, USA: American Cancer Society, 2008.
5. Anderson KE, Mack T, Silverman D. Cancer of the pancreas. In:
Schottenfeld D, Fraumeni JF Jr, eds. Cancer Epidemiology and
Prevention. 3rd Ed. New York: Oxford University Press; 2006.
6. Flanders TY, Foulkes WD. Pancreatic adenocarcinoma:
epidemiology and genetics. J Med Genet Nov 1996; 33:889-98.
[PMID 8950667]
7. American Cancer Society. Cancer Facts and Figures for African
Americans 2007-2008. Atlanta, GA, USA: American Cancer Society,
2007.

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