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PANCREATIC CANCER

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When clinicians use the term pancreatic cancer, they refer to adenocarcinoma of the pancreas, one of the most challenging malignancies facing oncologists today. This disease is characterized by significant morbidity and poor prognosis.

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At the University of Texas MD Anderson Cancer Center (MDACC), we manage patients with pancreatic cancer with a multidisciplinary team and view palliation as the primary goal. However, for patients with potentially resectable disease, we take an aggressive approach whenever appropriate. In the setting of advanced disease, cure is not possible, but as our understanding of carcinogenesis, invasion, and metastasis expands, more effective therapeutic strategies are expected to emerge. This chapter reviews our current knowledge about pancreatic cancer, including its epidemiology, risk factors, molecular biology, diagnosis and staging, and clinical strategies for therapy.

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HARD FACTS ABOUT PANCREATIC CANCER

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Pancreatic cancer, the most common pancreatic neoplasm, is an aggressive and often rapidly fatal malignancy. In the United States, it represents 2% of all cancer cases but accounts for 5% of all cancer deaths (1). Currently, it is the fourth leading cause of cancer death, ranking behind lung, colorectal, and breast cancer. While evidence suggests marginal improvements in 5-year survival rates over the last 25 years (2% in 1974-1976, 3% in 1983-1985, and 4% in 1992-1997), life expectancy remains short and is generally measured in months (2). By 2030, deaths due to pancreas cancer are projected to increase dramatically and will become the second leading cause of cancer-related death (3). Significant improvements in survival have been hampered by a number of factors, including inefficient screening strategies, technically challenging and often debilitating surgery, and minimally effective chemotherapy and radiotherapy.

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Pancreatic cancer is a dynamic disease, and sudden changes in clinical status occur frequently. Patients may rapidly develop worsening pain, biliary obstruction, or stent occlusion with cholangitis, thromboembolism, peritoneal carcinomatosis, or intractable ascites. Any of these problems may preclude the timely delivery of cytotoxic therapy and limit survival. Therefore, most efforts should focus on symptom control, but for patients with adequate performance status (PS), treatment is encouraged.

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EPIDEMIOLOGY

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There are approximately 45,000 new cases of pancreatic cancer each year in the United States and 330,000 cases worldwide. Incidence rates are highest in industrialized societies and Western countries. Of note, the risk of pancreatic cancer among African Americans, in whom pancreatic cancer mortality rates are higher than most other ethnic groups in the United States, is considerably higher than the rates for African blacks (4). These observations implicate environmental factors conspiring with genetic background as causes of the increased risk.

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The risk of developing pancreatic cancer is low in the first three to four decades of life but increases sharply after the age of 50. Average age at the time of diagnosis is 72 years. Pancreatic cancer is uncommon in patients ...

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