Focus on diagnosis and treatment of pancreatic cancer

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Pancreatic cancer: diagnosis

If the doctor suspects that someone has pancreatic cancer, he will first ask the patient’s medical history, family medical history, and check for signs of the disease. The following tests can be used to diagnose pancreatic cancer.

General test

1. Physical examination

The doctor will check your skin and eyes to see if it is yellow, which is a sign of jaundice.

Abnormal fluid accumulation in the abdomen, called ascites, may be another sign of cancer.

2. Blood test

Doctors can take blood samples to check for abnormal levels of bilirubin and other substances.

CA19-9 is a tumor marker. CA19-9 is often higher in patients with pancreatic cancer, but CA 19-9 should not be used as an indicator for the diagnosis of pancreatic cancer, because the high level of CA 19-9 may also be a sign of other diseases. Examples include pancreatitis, liver cirrhosis and obstruction of the common bile duct.

3. Image inspection

The imaging examination helps the doctor find out where the cancer is and whether it has spread from the pancreas to other parts of the body.

Computer tomography (CT or CAT) scan.

Positron emission tomography (PET) scan or PET-CT scan.

Ultrasound

Endoscopic Ultrasound (EUS)

Endoscopic retrograde cholangiopancreatography (ERCP)

Percutaneous transhepatic cholangiography (PTC)

Biopsy and tissue examination

Fine needle aspiration (FNA), using fine needles inserted into the pancreas to aspirate cells.

4. Molecular detection of tumor

Your doctor may recommend laboratory tests on tumor or blood samples to find various biomarkers. Biomarkers are proteins and genes specific to specific cancers, and the results of these tests may help guide treatment decisions.

Pancreatic cancer: staging

The more common method of staging pancreatic cancer is to divide it into 4 categories: according to whether it can be surgically removed and where it is distributed

Resectable pancreatic cancer

This pancreatic cancer can be surgically removed. The tumor may only be located in the pancreas or extend outside of it, but it has not grown to an important artery or vein in this area. There is no evidence that the tumor has spread beyond the pancreas. About 10% to 15% of patients are at this stage when they are diagnosed.

Border resectable pancreatic cancer

Tumors that may be difficult or impossible to surgically remove at first diagnosis, but after chemotherapy and / or radiation therapy, the tumor can be reduced first, then the tumor can be surgically removed later, marginal cancer cells are negative, marginal negative means no visible Cancer cells are left behind.

Locally advanced pancreatic cancer

This type of lesion is still located in the area around the pancreas, but because it has grown into a nearby artery or vein or nearby organ, it cannot be surgically removed. However, there is no indication that it has moved to any distance in the body. About 35% to 40% of patients are at this stage at the time of diagnosis.

Metastatic pancreatic cancer

The tumor has spread beyond the pancreas, such as the liver or the distant part of the abdomen. About 45% to 55% of patients are at this stage when they are diagnosed.

TNM staging

Doctors often use the TNM system to stage pancreatic cancer patients who can be operated on. Many patients with pancreatic cancer cannot undergo surgery. Therefore, the TNM system is not applicable to all pancreatic cancers like other cancers.

Stage 0: refers to carcinoma in situ, the cancer has not yet grown out of the pipeline (Tis, N0, M0).

Stage IA: The pancreatic tumor is 2 cm or smaller and has not spread to lymph nodes or other parts of the body (T1, N0, M0).

Stage IB: The pancreatic tumor is larger than 2 cm and has not spread to lymph nodes or other parts of the body (T2, N0, M0).

Stage IIA: The tumor is beyond the pancreas, but the tumor has not spread to nearby arteries or veins, and has not spread to any lymph nodes or other parts of the body (T3, N0, M0).

Stage IIB: A tumor of any size that has not spread to nearby arteries or veins, but has spread to lymph nodes and has not spread to other parts of the body (T1, T2 or T3; N1; M0)

Stage III: The tumor has spread to nearby arteries, veins, and / or lymph nodes, but has not spread to other parts of the body (T4, N1, M0).

Stage IV: Any tumor that has spread to other parts of the body (any T, any N, M1).

Relapse: Relapsed cancer is cancer that has recovered after treatment. If the cancer does return, there will be another round of testing to understand the extent of the recurrence. These tests and scans are usually similar to what was done during the original diagnosis.

Pancreatic cancer: treatment options

The most common treatment options for pancreatic cancer are listed below. The current treatment options for pancreatic cancer are surgery, radiation therapy, chemotherapy, and targeted therapy. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and patient preference and overall health.

The earlier the pancreatic cancer is detected, the higher the successful cure rate. However, active treatment can help control the disease of patients with advanced pancreatic cancer to help them live longer.

Pancreatic cancer surgery

Surgeons remove all or part of the pancreas according to the location and size of the pancreatic tumor, and the area of ​​healthy tissue surrounding the tumor is often removed. The purpose of the operation is to have a “clean edge”, which means to go to the edge of the operation, except for healthy tissue, there are no cancer cells.

Unfortunately, only about 20% of patients with pancreatic cancer can undergo surgery because most pancreatic cancer has already metastasized at the time of diagnosis. If surgery is not a first choice, you and your doctor will talk about other treatment options.

Pancreatic cancer surgery can be used in combination with radiation therapy and / or chemotherapy. Radiation therapy and chemotherapy are usually given after surgery and are called adjuvant therapy. Chemotherapy and radiotherapy given before surgery to shrink the tumor are called neoadjuvant therapy. If these treatments are given before surgery, the tumor usually needs to be restaged before surgery.

Surgeons can perform different types of surgery depending on the purpose of the surgery:

Laparoscopy

The surgeon may choose to start with a laparoscope to see if the cancer has spread to other parts of the abdomen. If it has already metastasized, surgical removal of the primary tumor is generally not recommended.

Surgical removal of pancreatic tumor

The method of surgery depends on where the tumor is located in the pancreas, and nearby lymph nodes are removed as part of the surgery.

If the cancer is only in the head of the pancreas, the surgeon may perform a Whipple operation, which is an extensive operation in which the surgeon removes the head and small intestine, part of the bile duct and stomach of the pancreas, and then reconnects the digestive tract and bile duct system .

If the cancer is in the tail of the pancreas, the common operation is distal pancreatectomy. In this operation, the surgeon removes the tail of the pancreas, the pancreas body, and the spleen.

If the cancer spreads to the pancreas, or is located in many areas of the pancreas, a total pancreatectomy may be required. Pancreatectomy is the removal of the entire pancreas, part of the small intestine, part of the stomach, common bile duct, gallbladder and spleen.

After the operation, the patient needs to stay in the hospital for several days and may need to rest at home for about a month. Side effects of surgery include fatigue and pain in the first few days after surgery. Other side effects caused by the
removal of the pancreas include indigestion and diabetes.

Radiation therapy in pancreatic cancer

Radiation therapy uses high-energy x-rays or other particles to destroy cancer cells. The most common type of radiation therapy is called external radiation therapy, which is radiation given from a machine outside the body.

External radiation therapy is the most commonly used type of radiation therapy for pancreatic cancer. Radiation treatment plans (plans) are usually given by a specific number of treatments over a period of time.

There are different methods of radiation therapy:

Traditional radiation therapy is also called conventional or standard radiation therapy. It is given a lower dose of radiation therapy every day for 5 to 6 weeks.

Stereotactic radiotherapy (SBRT) or Cyber ​​knife

Stereotactic radiotherapy (SBRT) or Cyber ​​knife can be given a higher dose of treatment every day for a short duration, usually about 5 days. This is a newer type of radiation therapy that can provide more localized lesion treatment and requires fewer treatments. Only in specialized radiotherapy centers with experience and expertise can this technique be used to treat pancreatic cancer.

Chemotherapy in pancreatic cancer

Chemotherapy is usually given at the same time as radiation therapy because it can enhance the effect of radiation therapy, which is called radiation sensitization. The combined use of chemotherapy and radiotherapy may shrink the tumor and help the doctor remove the tumor again through surgery. However, when used concurrently with radiation therapy, the dose of chemotherapy is usually lower than that of chemotherapy alone.

Radiation therapy may help reduce the possibility of pancreatic cancer recurrence or re-growth, but there are still many uncertainties about whether it can prolong the patient.

Side effects of radiation therapy may include fatigue, mild skin reactions, nausea, stomach upset and diarrhea. After treatment, most of the side effects will disappear.

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells by preventing their ability to grow and divide.

Patients can receive 1 drug or a combination of different drugs at the same time. The following are the drugs approved by the US Food and Drug Administration (FDA) for pancreatic cancer:

Capecitabine (Xeloda)

Erlotinib (Tarceva)

Fluorouracil (5-FU)

Gemcitabine (Gemzar)

Irinotecan (Camptosar)

Folic acid (Wellcovorin)

Paclitaxel (Abraxane)

Nanoliposome irinotecan (Onivyde)

Oxaliplatin (Eloxatin)

When two or more drugs are used together, there are usually more side effects. Drug combination therapy is usually best for patients with good physical conditions and can take care of themselves.

Which drug combination to use depends on the cancer center, especially the oncologist’s experience with the drug, as well as the different side effects and the overall health of the patient. The chemotherapy for pancreatic cancer is divided into the following types according to time:

First-line chemotherapy

This usually refers to the first treatment for patients with locally advanced or metastatic pancreatic cancer.

Second-line chemotherapy

When first-line treatment does not work or drug resistance cannot control cancer growth, the cancer is called refractory cancer. First-line treatment sometimes does not work at all and is called drug resistance. In this case, if the patient’s overall health is good, the patient may benefit from treatment with other drugs. The current major pancreatic cancer research is mainly focused on the development of other second-line treatment drugs, as well as third-line treatment drugs and other treatment drugs, some of which have shown considerable hope.

Non-standard treatment

Non-standard treatment means that the drug used is not an indication for FDA approved treatment, which means that the FDA has not approved the drug for pancreatic cancer treatment, which is different from the drug’s instructions for use. For example, if your doctor wants to use drugs approved only for breast cancer to treat pancreatic cancer. At present, doctors recommend it only when there is substantial evidence that the drug may be effective for another disease. This evidence may include previously published studies, promising results from ongoing studies, or tumor genetic testing results suggesting that the drug may work.

Chemotherapy side effects

The side effects of chemotherapy depend on which drugs patients receive, and not all patients have the same side effects. Side effects may include loss of appetite, nausea, vomiting, diarrhea, gastrointestinal problems, aphthous ulcers, and hair loss. People who receive chemotherapy are also more likely to have white blood cells, red blood cells, and thrombocytopenia due to chemotherapy, and are prone to infection, blood stasis, and bleeding.

Certain drugs used for pancreatic cancer are also associated with specific side effects. For example, capecitabine can cause redness and discomfort in the palms and soles of the feet. This condition is called hand-foot syndrome. Oxaliplatin can cause numbness and tingling in the fingers and toes, and is called peripheral neuropathy. Peripheral neuropathy is also a side effect of paclitaxel. These side effects usually disappear between treatments and after treatment ends, but some symptoms may last longer and worsen as the treatment continues.

Understand the basic knowledge of chemotherapy and prepare for treatment. Drugs used to treat cancer are constantly being evaluated. Talking to your doctor is usually the best way to understand the medicine prescribed for you, its purpose and its potential side effects or interaction with other medicines. Learn more about your prescription drugs by using a searchable drug database.

Targeted drug therapy

Targeted therapy is a treatment for cancer-specific genes, proteins or tissue environments that contribute to cancer growth and survival. This treatment can prevent the growth and spread of cancer cells, while reducing damage to healthy cells.

Recent studies have shown that not all tumors have the same target. To find the most effective treatment, your doctor may perform a tumor genetic test to determine the genes, proteins, and other factors in the tumor. This helps doctors better find the most effective treatment for each patient.

Erlotinib is approved by the FDA for use in combination with gemcitabine in the treatment of patients with advanced pancreatic cancer. Erlotinib can block the role of epidermal growth factor receptor (EGFR), an abnormal protein that helps the growth and spread of cancer. Side effects of erlotinib include acne rashes.

Metastatic pancreatic cancer treatment

If the cancer spreads from its primary site to another part of the body, doctors call it metastatic cancer. If this happens, it is a good idea to talk to a doctor with experience in treatment. Different doctors can have different opinions on the best standard treatment plan. In addition, participation in clinical trials may be an option.

The treatment plan for metastatic pancreatic cancer may include a combination of the above treatments, and the treatment plan depends largely on the patient’s overall health and preferences.

First-line treatment includes:

The combination of chemotherapy with fluorouracil, leucovorin, irinotecan and oxaliplatin is called FOLFIRINOX.

Gemcitabine plus paclitaxel is used as first-line treatment or second-line treatment for patients who have received FOLFIRINOX.

Second-line treatment includes the following options. These are commonly used in patients who have disease progression or have severe side effects during first-line treatment.

For patients who have already received gemcitabine and paclitaxel, a combination of fluorouracil and irinotecan or oxaliplatin is a possible choice. For patients whose physical conditio
ns cannot accept multiple drugs, capecitabine is the option with fewer side effects.

For patients who have already received FOLFIRINOX, a regimen containing gemcitabine, such as gemcitabine alone or in combination with paclitaxel, is a suitable option.

Pancreatic cancer: research

Doctors are working hard to learn more about the treatment of pancreatic cancer, how to prevent pancreatic cancer, how to effectively treat it, and how to provide the best care for patients.

Genetics and molecular research

In cancer, damaged or abnormal genes can cause uncontrolled cell growth. Many new research advances are based on identifying damaged genes and proteins, repairing them or changing them to treat pancreatic cancer.

Various molecular techniques (such as DNA sequencing and mutation analysis) can now be used to analyze pancreatic tumor samples to look for genetic changes. These analyses can now even be performed on blood samples because the new technology allows the collection and analysis of tumor DNA present in the blood. Doctors can find targeted new drugs to treat pancreatic cancer based on genetic testing information.

Immunotherapy in pancreatic cancer

Immunotherapy aims to enhance the body’s natural defense capabilities against cancer. It uses materials made by the body or laboratory to improve or restore the function of the immune system and target the treatment of pancreatic cancer.

An example of immunotherapy is a cancer vaccine, which can be made from a variety of sources, including pancreatic cancer cells, bacterial or human specific tumor cells. Many clinical trials have been completed or are in progress, attempting to use vaccines to treat various types of cancer, including pancreatic cancer. According to the patient’s condition, vaccine therapy can be given after chemotherapy, during chemotherapy or during alternative chemotherapy.

Another type of immunotherapy is a drug called an immune checkpoint inhibitor, which includes PD-1 and CTLA-4 antibodies. Immune checkpoint inhibitors have been approved for other types of cancer, such as melanoma and lung cancer, but are currently not suitable for pancreatic cancer. In general, these drugs are not very effective for pancreatic cancer. However, they may be suitable for a few pancreatic cancer patients with certain genetic mutations. The ongoing pancreatic cancer research is testing the combined effect of immune checkpoint inhibitors and chemotherapy or other new immunotherapy.

In addition, researchers are studying methods to collect and genetically modify T cells, which is called adoptive immunotherapy.

Targeted therapy

Erlotinib is currently approved for targeted therapy of pancreatic cancer and is used in combination with gemcitabine. Scientists are studying other drugs that may block the growth and spread of 6 7 6 7 tumors, as a single drug and as part of a combination therapy for pancreatic cancer. However, other targeted therapies, including bevacizumab (Avastin) and cetuximab (Erbitux), have not been shown to prolong the lives of pancreatic cancer patients. A gene called Ras is often mutated in pancreatic cancer. Researchers are very interested in Ras, but drug development for this specific gene is very difficult.

Gene therapy in pancreatic cancer

Gene therapy is the delivery of specific genes to cancer cells, usually carried by specially designed viruses. The normal genes that are delivered to the center of the cancer cells are inserted into the working genes of the cancer cells as the cancer cells divide, replacing the abnormalities that contribute to cancer growth. Genes that cause cancer cells to die.

Chemotherapy

Newer and stronger types of standard chemotherapy are still being studied. One example is nanoliposome irinotecan, which has now been approved as a second-line treatment for advanced pancreatic cancer.

Cancer stem cells

Pancreatic cancer stem cells are cells that may be particularly resistant to cancer. Current research is focused on finding drugs that may specifically target cancer stem cells.

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