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cancer

Where are the $s for pancreatic cancer research?
Where are the $s for pancreatic cancer research? Unfortunately, in comparison to more commonly seen malignancies in the United States such as colorectal, breast and even lung cancer, very little is spent on research.

This situation needs to be changed if we are to turn a deadly cancer into one that is curable and preventable.


Thirty-seven thousand individuals are diagnosed each year with pancreatic cancer; and unfortunately, nearly as many will die from the disease. Despite being a relatively uncommon cancer, its mortality rate far exceeds that of other malignancies. As a result, it is the fourth leading cause of cancer deaths in the United States.

Risk factors for pancreatic cancer include advanced age, especially those between the ages of sixty and seventy years; tobacco abuse; excessive alcohol intake, and a diet that is high in fat content. Despite these known risk factors, with the exception of age, it is still difficult to identify any particular risk in most individuals that develop pancreatic cancer. There are rare hereditary conditions that can lead to some individuals being at a higher risk for developing the disease. Former President Jimmy Carter’s family is an example of this situation. His father, brother and sister all died from pancreatic cancer.

Approximately eighty-percent of individuals diagnosed with pancreatic cancer are not candidates for surgery to treat their cancer. Before discussing pancreatic cancer any further, however, it is important to understand the basic function and purpose of the pancreas. The pancreas serves two functions; one is called the exocrine function and the other is called the endocrine function. The exocrine function allows the pancreas to secrete digestive juices or enzymes that help us digest our food and obtain nutrition. The endocrine function of the pancreas produces hormone-like substances that regulate the blood sugar and other vital body chemicals. Patients who have surgery to remove the pancreas, whether to treat cancer or for other reasons, are likely to be dependent on enzymes taken in a pill form as well as other hormonal substances such as insulin which is taken by injection to substitute for the function of the pancreas.

Unfortunately, approximately eighty-percent of individuals diagnosed with pancreatic cancer are not candidates for surgery to treat their cancer. These patients are considered terminal and management of the disease becomes the focus. Over the years, options for management have included palliative chemotherapy with or without radiation or hospice for comfort measures alone. The goal of palliative therapy is not to cure the cancer, but to reduce pain and suffering. Regardless of which decision is made, until recently, there was very little evidence that the outcome would change. A few high level studies have now demonstrated that about ten-to twenty- percent of patients receiving chemotherapy respond to the treatment. In addition, even more have an improvement in their quality of life and seem to have less pain while taking the treatment. This information has led many to decide to take chemotherapy treatment even though the long-term outcome has not been altered.

By the time the weight loss, abdominal pain, with or without the jaundiced appearance occurs, the disease is already at an advanced, incurable stage. No Early Warnings
One of the main complications associated with pancreatic cancer is upper abdominal pain, which seems to radiate deeply toward the mid-back area. This pain occurs because the cancer irritates a large group of nerves known as the celiac plexus, which lie just below the pancreas. Some physicians who are pain specialists will destroy or ablate these nerves by using either alcohol or some other form of intervention to improve pain control.


With the limited success of chemotherapy in treating a majority of patients with pancreatic cancer, there has been a great interest in pursuing the latest form of cancer treatment known as biologic.
Why is pancreatic cancer so deadly? The reasons vary and some are be yet to be discovered. One of the main reasons is the lack of early warning signs. By the time the weight loss, abdominal pain, with or without the jaundiced appearance occurs, the disease is already at an advanced, incurable stage. There are no physical barriers to the pancreas that would prevent rapid spread of the disease. The pancreas is not contained in a capsule; it sits in close proximity to other vital structures in the mid to upper abdomen. Additionally, once the cancer is discovered it seems to be extremely resistant to the chemotherapy medications that are necessary to control an advanced malignancy. There are disagreements as to whether aggressive treatment is futile because even after patients have undergone surgery to remove all identifiable cancer, most eventually succumb to the illness. It is, therefore, debatable as to what treatment should be followed after surgery to prevent a recurrence. This type of treatment is known as adjuvant therapy. In the United States, it is still more popular among cancer specialists to treat patients with a combination of chemotherapy and radiation after the cancer has been surgically removed. The radiation is often administered daily from an external radiation device known as a linear accelerator and during the five to six weeks of radiation, chemotherapy is administered at a variety of times each week. In Europe, there has been less acceptance of the radiation part of the treatment and patients have primarily received chemotherapy alone.

For many years in the United States and Europe, the main chemotherapy medication to treat pancreatic cancer was 5-fluorouracil, also known as 5-FU. The effectiveness of this medication in both the advanced and early stages of the disease has been modest at best. A little over a decade ago, a medication known as gemcitabine or Gemzar®, became the most utilized cancer drug based on studies which determined that this medication was not only well tolerated but actually improved the outcome of pancreatic cancer patients in comparison to the best supportive care which involved no chemotherapy treatment.

More Research Needed
Improvements in the outcome of pancreatic cancer will come out of the fact that this is a disease that touches everyone. Most Americans know someone who has had pancreatic cancer, whether that person is a friend, family member, or well known celebrity. Much needs to be done to change the present outcome of this disease and improve upon earlier diagnosis. Unfortunately, in comparison to more commonly seen malignancies in the United States such as colorectal, breast and even lung cancer, very little is spent on research. In fact, less than twelve thousand dollars per year per person is spent on research despite the high death rate from this cancer. This situation needs to be changed if we are to turn a deadly cancer into one that is curable and preventable.
Newer Treatments
With the limited success of chemotherapy in treating a majority of patients with pancreatic cancer, there has been a great interest in pursuing the latest form of cancer treatment known as biologic, or more targeted therapy. Biologic therapy involves the use of chemicals that alter the growth pattern of cancer cells and in some cases actually improves the response to older chemotherapy medications when given together. Other gastrointestinal tumors such as colorectal cancer have demonstrated that the combination of these new biologic therapies such as cetuximab and bevacizumab have benefited patients when combined with traditional chemotherapy. Unfortunately, only one trial has demonstrated that biologic therapy has improved upon the survival length of pancreatic patients. This trial combined gemcitabine with a medication known as erlotinib. Although this trial was considered a success, it only demonstrated a modest two-week survival advantage when this medication was given with gemcitabine as opposed to giving gemcitabine alone. Nevertheless, these results were considered a statistical success and became a new standard for treating many advanced pancreatic cancer patients. Oncologists have noted occasional good outcomes among individuals treated with gemcitabine, and we are eager to learn why this is the case. I have had some patients do exceptionally well on gemcitabine while others never seem to derive any clinical benefit. One case involved a very ill, seventy-year-old gentleman diagnosed with pancreatic cancer that had spread to his liver. As a result, he had developed a large amount of fluid in his abdomen know as ascites. I started to recommend hospice care alone, but at the family’s request, I agreed to try gemcitabine. The patient had an excellent response and lived for two more years. He even went back to working in the family’s hardware store during his therapy. More recent research into the treatment of pancreatic cancer has led to the discovery of a particular marker in some pancreatic cancer cells known as human equilibrative nucleoside transporter type 1 or hENT-1. It appears that this protein on the cancer cells allows it to transport or bring in the gemcitabine, as this drug is a nucleoside-like drug. The findings are preliminary but are interesting and thought provoking and may lead to better treatment outcomes for more pancreatic cancer patients.

As with any cancer, early detection is the best way to beat the diagnosis. While most individuals that develop pancreatic cancer have no relatives with this diagnosis, many who do are helping to identify ways to screen for this very deadly cancer. Recent studies with these individuals have demonstrated that there may be a benign precursor to pancreatic cancer similar to that of colon polyps developing into colon cancers. These lesions are known as intraductal papillary mucinous adenomas and may be detected early by genetic testing followed by ultrasound imaging techniques. By removing these benign tumors, one may be able to prevent later development of deadly pancreatic cancer tumors.

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"Where are the $s for pancreatic cancer research?"
   authored by:
ONCOLOGY
Dr. Fleming earned his MD degree from the University of Louisville, Kentucky, and completed his fellowship at the University of Kentucky which included an externship at the National Cancer Institute.He became a tenured professor in hematology/oncolog...



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