Pancreatic cancer natural history, complications and prognosis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Reddy Kothagadi M.B.B.S[2] Sudarshana Datta, MD [3]
Overview
The symptoms of pancreatic cancer usually develop in the sixth decade of life, and start with symptoms such as jaundice, light-colored stools, dark urine, pain in the upper or middle abdomen and back, unexplained weight loss, anorexia and fatigue.Symptoms typically develop about 20-30 years after exposure to risk factors such as smoking and alcohol. Genetic factors such as alterations in tumor suppressor genes, oncogenes and different signaling pathways are responsible. If left untreated, patients with pancreatic cancer may progress to develop exocrine pancreatic insufficiency arising from pancreatic duct obstruction leading to malabsorption, malnutrition and cachexia. Dudodenal obstruction and biliary obstruction may cause symptoms of bowel obstruction and jaundice. Common complications of pancreatic cancer may arise as a result of the disease or therapy (surgical or medical). Depending on the extent of the tumor at the time of diagnosis, the prognosis is generally regarded as poor, with complete remission extremely rare.
Natural History, Complications and Prognosis
Natural History
- The symptoms of pancreatic cancer usually develop in the sixth decade of life, and start with symptoms such as jaundice, light-colored stools, dark urine, pain in the upper or middle abdomen and back, unexplained weight loss, anorexia and fatigue.
- The symptoms of pancreatic cancer typically develop about 20-30 years after exposure to risk factors such as smoking and alcohol. Genetic factors such as alterations in tumor suppressor genes, oncogenes and different signaling pathways may also be responsible.
- If left untreated, patients with pancreatic cancer may progress to develop exocrine pancreatic insufficiency arising from pancreatic duct obstruction leading to malabsorption, malnutrition and cachexia. Dudodenal obstruction and biliary obstruction may cause symptoms of bowel obstruction and jaundice.
Complications
- Common complications of pancreatic cancer may arise as a result of the disease or therapy:
Malabsorption:
- Exocrine pancreatic insufficiency due to pancreatic duct obstruction by the tumor may lead to malabsorption. Malabsorption in patients presents with anorexia, weight loss, and diarrhea.
Pain
- Patients with advanced pancreatic cancer may develop intractable pain requiring narcotic analgesics and surgical intervention such as neurolysis of celiac ganglia.
Jaundice
- Obstructive jaundice can present with features of cholangitis:
- Fever and chills
- Nausea, vomiting
- Clay-colored stools
- Dark urine
- Yellowish discoloration of skin
- Pruritus
- Right upper quadrant pain
- Anorexia
- Patients may require Endoscopic decompression with stent placement in patients due to biliary obstruction.
Duodenal obstruction
- Patients may develop duodenal obstruction as a result of complications of surgery.
- Duodenal obstruction may be treated with endoscopic stenting or gastrojejunostomy.
Prognosis
- The primary factors that influence prognosis are:
- Whether the tumor is localized and can be completely resected
- Whether the tumor has spread to lymph nodes or elsewhere
- Staging and TNM (tumour, lymph node, metastasis) classification related to incidence, treatment, and prognosis: [1]
| Staging and TNM Classification related to Incidence, Treatment, and Prognosis | ||||
|---|---|---|---|---|
| Stage | TNM Classification | Clinical Classification | Incidence at diagnosis (%) | 5-year survival rate (%) |
| 0 | Tis, N0, M0 | Resectable | 7.5 | 15.2 |
| IA | T1, N0, M0 | — | — | — |
| IB | T2, N0, M0 | — | — | — |
| IIA | T3, N0, M0 | — | — | — |
| IIB | T1-3, N1, M0 | Locally advanced | 29.3 | 6.3 |
| III | T4, any N, M0 | — | — | — |
| IV | Any T, any N, M1 | Metastatic | 47.2 | 1.6 |
5-Year Survival
- For patients with localized disease and small cancers (<2 cm) with no lymph node metastases and no extension beyond the capsule of the pancreas, complete surgical resection is associated with a 5-year survival rate of 18% to 24%.
- Between 2007 and 2010, the 5-year relative survival of patients with pancreatic cancer was 7.2%.[2]
- When stratified by age, the 5-year relative survival of patients with pancreatic cancer was 10% and 4.6% for patients <65 and ≥ 65 years of age respectively.[2]
- The survival of patients with pancreatic cancer varies with the stage of the disease. Shown below is a table depicting the 5-year relative survival by the stage of pancreatic cancer:[2][3]
| Stage | 5-year relative survival (%), (2004-2010) |
| All stages | 6.7% |
| Localized | 25.8% |
| Regional | 9.9% |
| Distant | 2.3% |
| Unstaged | 4.4% |
Shown below is an image depicting the 5-year conditional relative survival (probability of surviving in the next 5-years given the cohort has already survived 0, 1, 3 years) between 1988 and 2010 of pancreatic cancer by stage at diagnosis according to SEER. These graphs are adapted from SEER: The Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.[2]
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References
- ↑ Bond-Smith G, Banga N, Hammond TM, Imber CJ (2012). "Pancreatic adenocarcinoma". BMJ. 344: e2476. doi:10.1136/bmj.e2476. PMID 22592847.
- ↑ 2.0 2.1 2.2 2.3 Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2011, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2011/, based on November 2013 SEER data submission, posted to the SEER web site, April 2014.
- ↑ Ghaneh P, Costello E, Neoptolemos JP (2007). "Biology and management of pancreatic cancer". Gut. 56 (8): 1134–52. doi:10.1136/gut.2006.103333. PMID 17625148.