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Pancreatic Cancer

Pancreatic cancer is the #4 killing cancer in USA.  About 33,000 cases occur a year and about 32,000 deaths a year from pancreatic cancer.  It is deadly because it isn’t diagnosed until too late.  Only 15% of those diagnosed with pancreatic cancer are considered for surgery, but even then their 5 year survival rate is only 25% (if no spread to lymph nodes) and 10% for those with spread to lymph nodes. 

Risk factors: Usually occurs after the age of 45.  Greater in men and in African Americans.  Smoking, diabetes mellitus, chronic pancreatitis, and genetics.  10% persons with pancreatic cancer have family history of it.

Clinical: Weight Loss, Abdominal Pain (from navel region radiating straight to the back), and jaundice.  The belly pain is often worse with eating and is a dull ache.  Fatty stools (floaters and light colored stools) and diarrhea due to pancreatic insufficiency, anorexia, and early satiety (feeling filled up after on a few bites).  Bloating and belching can be early symptoms.   Virchow’s node is a left supraclavicular lymph node.  Symptoms probably start 3 years before diagnosis is made.

Diagnosis:  abdominal ultrasound is 80% sensitive in picking up pancreatic cancer.  CT, MRI are 90% sensity.  ERCP (endoscopy all the way into the duodenum) is 90% sensitive.  A fine needle aspirate is 90% sensitive (guided by ultrasound or CT).  Though not proven doing the needle aspirate can spread the tumor by “leaking” cancer cells out, it isn’t usually done in a patient who is going to have surgical resection.

            For staging the spread of the cancer, Helical CT and IV contrast (for CT angiography) can see if the cancer has spread into the major arteries and veins.  Hopefully it hasn’t. But it isn’t sensitive enough to pick up metastasis to the liver if the cancers there are small.  MRCP is better at detecting spread of cancer into the liver.

            Endoscopic ultrasound is 90% sensitive in detecting pancreatic cancer and can be useful in staging.

            CA 19-9 is a blood test to check on the pancreatic tumor marker.  It is about 80% sensitive so isn’t good as a screen for early pancreatic cancer.  The bigger the tumor, the higher the CA 19-9.  So high level such as more than 1000 usually indicates surgery isn’t going to be helpful.

Treatment: Surgery with adjuvant chemotheraphy might be helping people survive longer – in those who were candidates for surgery.  For those with inoperatable cancer, palliative treatment (meaning minimize the pain and problems) is suggested.

Prevention:  for those at higher risk for pancreatic cancer, it has not been shown yet if checking tumor marker CA 19-9 is useful and having CT scan or ultrasound will work.  Also your insurance, if you have it, probably won’t cover it.

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Ovarian Cancer

Ovarian Cancer occurs in about 22,000 American women a year.  More than 16,000 of them will die from the cancer, which outnumbers both cervical and uterine cancers combined.  If ovarian cancer is diagnosed in the later stages (which is usually the case), the 5 year survival is on 20-30%.  On the other hand if diagnosed at Stage I, it is 90-95% 5-year survival. 

Risk Factors: majority of women with ovarian cancer don’t have any risk factors.  But risk factors include: older age, never pregnant, infertility, family history (10-15% of cases of ovarian cancer), and Ashkenazi Jewish.  BRCA 1 or 2 gene is a genetic cause of ovarian cancer (associated with breast cancer; 20-40% lifetime risk of ovarian cancer. In women with BRCA gene, prophylactic removal of ovaries and Fallopian tubes reduces the risk of ovarian cancer down to 5% (cancer can develop in the peritoneal lining despite no ovaries, or there was already an occult – meaning hidden – cancer.)

Screening: because tests are expensive and the prevalence is too low, is not cost effective to screen.  Blood test for CA-125 is not recommended because it is used only to follow the course of already diagnosed ovarian cancer.  Transvaginal ultrasound is not cost-effective.  Doing screening also can be very misleading because a positive test is only correct 10-23% of the time.  So 90% of women would have an incorrect positive test, leading to unnecessary emotional distress and surgery.  Also doing CA-125 testing with transvaginal ultrasound detects 5% of cases in stage I ovarian cancer according to the PLCO study.

Clinical: 95% women do have symptoms a few month before diagnosis but they are pretty vague – such as abdominal distention, bloating, pelvic pain, constipation, nausea, anorexia, losing appetite soon after eating, and increasing abdominal girth.  Statistically it appears the most important symptoms to distinguish ovarian cancer vs. IBS (irritable bowel syndrome) are: pelvic pain, bloating, increasing abdominal girth, urinary urge and frequency,

Diagnosis: CA-125 blood test, transvaginal ultrasound, pelvic examination.  Ascites (fluid in the abdominal cavity) can be drained and tested for ovarian cancer.  Staging of the cancer is done during surgery – usually laparoscopy  Also a complete hysterectomy is done for women who don’t want to bear kids in the future.  This means removing the uterus, Fallopian tubes, and ovaries.  For those who want to become pregnant in the future, if the cancer hasn’t spread or involved the other ovary, surgery is more sparing – though there is a risk of the spared ovary developing cancer.

Treatment: as mentioned above surgery is needed to remove the cancer.  Chemotherapy is usually recommended, though of some controversy.

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