Pancreatic Cancer

The single largest improvement comes with understanding and treating malnutrition. The pancreas has two main functions (1) it makes hormones which control sugar levels in the blood. Diabetes is a disease well known and understood (2) it makes around three pints of liquid a day which contains enzymes. These enzymes mix with food in the intestines and break down fat, sugars (carbohydrates) and proteins into tiny molecules which can be absorbed from the intestine. Without enzymes food can be chewed, swallowed and will pass through the intestine largely undigested meaning that the goodness from food is not extracted. This leads to cramp and bloating as water is pulled into the intestines after a meal and often diarrhoea (this may be associated with fat seen in the stool and stool may float and be difficult to flush). Over just a few weeks a person will experience weight loss and in the longer term deficiency of vitamins and other micronutrients. This problem is given the name pancreatic exocrine insufficiency (PEI). It is our opinion that this term does not signify the true danger of this problem. This is pancreas failure. Like other organ failure (think of kidney, liver or heart failure for example) if left untreated the consequences are very serious.

As described above a reduction in quality of life occurs due to unpleasant symptoms after eating, weight loss and nutrient deficiency. However, strong evidence now shows that, if left untreated, this reduces survival. This is not surprising – a typical adult needs 1700 to 2000 calories per day and protein to produce energy and replace old and damaged cells. When this cannot occur malnutrition occurs rapidly. Untreated, these people are on a diet, 24 hours a day, without realising it. Unlike a diet, they cannot simply eat more to stop this problem progressing.

Pancreatic enzyme replacement therapy (PERT) are capsules with pancreas enzymes in them. They are taken with food and break food down in the intestine and can correct PEI. They improve symptoms, quality of life, help prevent weight loss and help patients stay strong. This helps patients to receive their cancer treatments. In studies of patients with pancreatic cancer PERT improves survival. De la Inglesia and colleagues collated data from eleven studies and showed that PERT improved survival by 4 months among people who had unresectable cancer. To put this in context, this benefit is similar, if not more than what is realised with most forms of palliative chemotherapy.

In studies led by Keith Roberts, patients undergoing surgery had a six month increase in survival and in a further national study every patient, regardless of treatment and cancer stage had benefit in terms of PERT. In that study, the benefit of PERT to survival was equivalent to surgery or chemotherapy. 

Who should receive PERT? NICE guidelines are clear that all patients with pancreatic cancer should receive PERT, however a national audit (RICOCHET) showed wide variation in PERT prescribing and that most patients were not prescribed PERT.

It is advisable to take a proton pump inhibitor with PERT. These medicines (example, lansoprazole, omeprazole) reduce acid production by the stomach. In normal health, the pancreas also produces bicarbonate which neutralises stomach acid. However, with cancer, like enzymes, bicarbonate cannot reach the bowel. In this scenario, the content of the intestines are acidic rather than neutral. Pancreas enzymes, including PERT, work best at a neutral pH and very little function when pH <5.5.

Many patients with pancreatic cancer develop jaundice due to the bile duct being blocked where it enters the pancreas. If you are suitable for surgery, the best treatment is a direct to surgery pathway. However, most centres in the UK place a stent in the bile duct to relieve the jaundice before surgery. The disadvantages are the time needed to organise the camera test to place the stent (called ERCP) and there are risks which include infection and pancreatitis. If mild these problems don’t cause a major issue, but if major they can result in hospital admission, admission to intensive care and can delay or prevent surgery or rarely lead to death. It is therefore quicker and safer to operate quickly without the stent. This provides early treatment and reduces risk. This is recommended by NICE but is not practiced widely. We have a successful program and have operated on hundreds of patients with jaundice and have a great experience of this pathway.

If you do need a stent (if surgery is not possible, if you need chemotherapy before surgery or if you have complications of jaundice) then the type of stent is very important. Plastic stents are often used but are narrow and can block easily and are associated with increased infections, when compared to expanding metal stents.

Chemotherapy is a key part of treatment for patients that undergo surgery. Receiving and completing all cycles of chemotherapy is key. However, national studies from the UK, Canada, Netherlands, USA and Japan show that only half to three quarters of patients receive chemotherapy. When individual hospitals are analysed, there is wide variation. By addressing nutrition with PERT and by working with your oncologist, we can help you start and complete your therapy.

There is no standard system for follow up after surgery. However, regular scans can reassure patients, and if cancer does come back, it can be picked up early when there is a better chance for treatment and more options available.

There are two things which have made a huge difference in the care of these patients (1) chemotherapy given before surgery [neoadjuvant therapy] and (2) surgeons with experience of working with the blood vessels around the pancreas. Because we are surgeons working in one of, if not the, highest volume pancreatic surgery units in the UK we have a huge experience (~ 2000 pancreatoduodenectomies). Furthermore, through liver transplantation we have skills and experience not shared by most pancreas surgeons. 

These factors mean that we have one the largest, if not the largest, practice to treat borderline and locally advanced cancer with surgery in the UK. We will work with your oncologist to get the best chance to get to surgery and to have surgery.