Download Pancreatic Cancer - The Family Doctor Association

Pancreatic Cancer
Michael G T Raraty
Consultant Pancreatic Surgeon
Pancreatic Cancer Stats
http://www.cancerresearchuk.org/cancerinfo/cancerstats
Incidence 2009-2011
http://www.cancerresearchuk.org/cancerinfo/cancerstats
Trends over time 1975-2011
http://www.cancerresearchuk.org/cancerinfo/cancerstats
Risk Factors
Baseline ~ 10/100,000 population/year
Risk
Proportion of cancers
x2
30
Genetic factors
x 5-10
10
Chronic Pancreatitis
x 10-20
1
Hereditary Pancreatitis
x 35-70
<1
x5
-
x 1.5-2
-
Obesity
x 1.7
-
High fat diet
x 1.7
-
Previous gastric surgery
x 1.8
-
Sclerosing Cholangitis
x 14
-
Helicobacter Pylori
x 1.8
-
Smoking
Age >70
Type II DM
Hereditary cancer syndromes
•
•
•
•
•
•
•
•
•
Peutz-Jeghers
FAMM
Familial breast/ovarian cancer
FPC
Hereditary Pancreatitis
Von Hippel-Lindau
Cystic Fibrosis
FAP
HNPCC
‘Classic’ symptoms
• Obstructive Jaundice
– 50%
– Truly ‘painless’ in about 10%, most will have some
pain, but not biliary colic
• Pain
– 70%
– Back / epigastrium
– Relieved by sitting forward
• Nausea / Vomiting
• Weight Loss
• Anorexia
Other symptoms
• New onset type 2 diabetes mellitus
– underweight or normal weight patient, not associated
with weight gain
• Resistant dyspepsia/persistent epigastric pain
• IBS like symptoms in those >45 years
– very rare as a new onset symptom at this age
• Altered bowel habit
– Increased bowel movement frequency and offensive
smelling stools
– Suggestive of exocrine insufficiency
• Venous Thromboembolism
– may be a manifestation of an underlying abdominal
malignancy
Blood tests
• Full blood count
– anaemia rare except for ampullary tumours
• Liver function tests
– Obstructive jaundice
– Elevated gamma GT / Alk Phos may precede bilirubin
• Serum glucose
– Diabetes or impaired glucose tolerance
• CA19-9
– Sensitivity of ~80% and a specificity of 83%
– Normal levels do not exclude diagnosis
– Better for treatment monitoring
Investigations
• U/S
– Often first line for jaundice
– May demonstrate pancreatic mass
• Contrast-enhanced CT
– Gold standard
– Essential for staging
Referrals to Pancreatic MDT
1200
1020
1000
782 824 803
800
600
400
200
0
194
254
320
372
440
874
Referral sources 2013
Arrowe Park
Aintree
Whiston
Southport
Warrington
Chester
Wrexham
Bangor
GP
Glan Clwyd
Nobles
Liverpool Womens’
LHCH
Clatterbridge
Spire Liverpool
Macclesfield
198
105
95
76
75
71
37
21
20
17
17
5
3
3
1
1
Swansea
Christie, Manchester
Blackpool
Abergele
Devon & Exeter
Wyre Valley
Londonderry
Nottingham
Newcastle
Bradford
Leeds
Turkey
External referrals
2
1
1
1
1
1
1
1
1
1
1
1
774
Internal referrals from RLBUHT
246
1020
2013
Presumed
Pancreas Cancers
542
Cancer or premalignant
475
Inoperable
at Staging
367
Benign
67
Surgery
108
Resection
93
(resection rate 20%)
Bypass
15
Surgery
44
Resection
40
No
operation
23
Bypass
4
Length of pathway
2013
Referral to MDT
Mean 6.5, Median 4
MDT to DTT
Mean 10.6, Median 7
DTT to surgery
Mean 26.2, Median 22
Referral to Surgery
Mean 43.3, Median 39
NB:
DTT to surgery time includes pre- operative
anaesthetic assessment clinic +/- staging laparoscopy
Chemotherapy
• >80% now receive adjuvant chemotherapy
after surgery (Gemcitabine +/- others)
• Minority of unresectable patients fit for
palliative chemotherapy (Folfirinox)
– 50% if locally advanced
– 36% if metastatic
• Role of neo-adjuvant chemotherapy currently
being explored
– ESPAC-5
Long-term survival rates
- post resection
1 year survival
61% >
75%
5 year survival
X2LR =12.70
P<0.001
6%
>
25%
Summary
• Pancreatic Cancer is the 9th commonest
cancer in the UK
• It is the 5th commonest cause of cancer
death
• Notoriously late presentation, early
metastases and poor survival rates
• Vague symptoms
• If diagnosed early enough for surgical
resection, then chances of surviving
beyond five years increase ten-fold
Resources
• http://www.pancreaticcancer.org.uk/
• https://pancreaticcanceraction.org/
• http://www.cancerresearchuk.org/aboutcancer/type/pancreatic-cancer/
• http://elearning.rcgp.org.uk/course/info.php?id=103