Understanding Pancreatic Cancer: Symptoms and Treatments

The deaths of talk show host Jerry Springer, Supreme Court Justice Ruth Bader Ginsburg, U.S. Congressman John Lewis, and Jeopardy host Alex Trebek from pancreatic cancer have brought attention to this challenging-to-treat disease. Even though pancreatic cancer is rare — about 64,000 cases are diagnosed each year in the U.S. — it is the third-leading cause of cancer death after lung and colorectal cancers, according to the National Cancer Institute. Because pancreatic cancer is often detected in late stages, the five-year survival rate for patients is about 12%.

While the statistics are discouraging, there’s reason to be hopeful, says Dr. Allyson Ocean, a medical oncologist and attending physician in gastrointestinal oncology at NewYork-Presbyterian/Weill Cornell Medical Center.

“We are at a critical point where we are going to see breakthroughs happen in this disease,” says Dr. Ocean. “I also think it’s going to start with early detection, because the earlier we find this, the better off people are going to be and we’re going to get better outcomes.”

Dr. Ocean, who is also an associate professor of clinical medicine at Weill Cornell Medicine, spoke with Health Matters about the disease’s risk factors, symptoms, and treatment, including advances on the horizon.

Where is the pancreas and what does it do?

The pancreas is a long, sausage-like organ that is very close to the spine behind the abdomen. It has two primary functions: It produces digestive enzymes so we can digest our foods and process the nutrients within them. The second major role is to regulate sugar metabolism through the production of insulin.

 What are the main risk factors for pancreatic cancer?

They include the development of type 2 diabetes later in life, obesity, smoking, alcohol use, a history of pancreatitis, and hereditary factors. Pancreatic cancer is much more common in African Americans — in fact, the incidence rate for African Americans is the highest of any racial or ethnic group, according to the National Cancer Institute. And there are also some very rare familial syndromes (passed on genetically) that can lead to pancreatic cancer.

With respect to diabetes, it could be that individuals develop diabetes and then the cancer forms or that the cancer is forming because of other risk factors and the cancer leads to the late-onset diabetes. Many patients who are diagnosed with pancreatic cancer had developed diabetes within the preceding couple of years. In fact, one out of every 125 people with new-onset diabetes develops pancreatic cancer within three years of their diagnosis.

What are the common symptoms?

Back pain, particularly back pain that wakes someone up at night, is a classic symptom. Other common symptoms are weight loss, abdominal pain, and jaundice (the yellowing of the eyes and skin), which results when the tumor blocks the bile ducts.

The problem is that these symptoms can be attributed to other, more common diagnoses. People think it’s gas, constipation, or irritable bowel syndrome, which causes pain and other digestive symptoms. As a result, the cancer is most often diagnosed late, meaning that it has already metastasized, or spread, to other parts of the body when it’s found. Also, the symptoms don’t happen until the cancer that’s growing in the pancreas is fairly large.

Less common symptoms include the development of blood clots out of the blue and the development or worsening of depression.

How is pancreatic cancer detected?

Currently there is no screening test. However, we are on our way to having one, probably in the next few years. There is an ongoing clinical trial investigating a blood test called CancerSEEK, which is funded by the Lustgarten Foundation and Stand Up To Cancer, that identifies mutations and cancer proteins in the blood associated with pancreatic cancer and other cancers. Before a screening test can be approved for wide use, you have to evaluate it in thousands of patients, and that is happening.

Right now the disease is usually detected when someone finally comes to their physician with symptoms and gets further workup. That will most likely include blood tests that show if their pancreatic enzymes and liver function tests are elevated. Ultimately, they get imaging tests, which pick up the mass in the pancreas and/or sites where the cancer has spread. Once the cancer is found, a biopsy is needed.

How can people increase the chances of an earlier diagnosis if they have pancreatic cancer?

If you’re experiencing something worrying and you go to the doctor and they tell you it’s nothing or something else, but the symptoms persist, go back or see a new doctor and be an advocate for yourself. People know their bodies best. It’s also extremely important to tell your doctor if pancreatic cancer runs in your family.

What are the treatments for pancreatic cancer?

Surgery to remove the tumor in conjunction with other treatments like chemotherapy and radiation are the only known cure for pancreatic cancer. I and others who treat this disease believe that this is a systemic disease, meaning that the cells have already entered the bloodstream as it has been growing. So if you just cut it out and don’t treat the bloodstream, which is what chemotherapy does, then there’s a significant risk of it returning.

However, because pancreatic tumors are found so late, only about 15% to 20% of people diagnosed with the disease are eligible for surgery. The majority of cases are not operable because the tumor is so large or it’s in a place that is encroaching upon the major blood vessels that course through the pancreas. Cancer that has already spread through the body is also not operable, and systemic therapy is used, which has been shown to extend survival. The rate of recurrence can be as high as 80% even if you have surgery.

Is there a role for new approaches to treating cancer, such as immunotherapy and precision medicine?

Yes. We know that there is a hereditary component to pancreatic cancer, so the guidelines for treatment now include genetic testing — both of a patient’s blood and the tumor itself, which is what precision medicine is. We test the tumor genes because we want to see why the tumor is growing, if we can figure out the pathways leading to its growth, and whether there are drugs that target that pathway to inhibit it so that we can affect the growth of the cancer cells.

Research is also underway on vaccines and immunotherapy, which harnesses the patient’s own immune system to fight cancer. Immunotherapy is only useful for the 1% of pancreatic cancers that are considered to be immune-related. But there are a lot of clinical trials now combining chemotherapy and immunotherapy. The goal of these treatments is to wake up components of the immune system with immunotherapy drugs so that they go after and kill the cancer. Another active area of research is medicines that interfere with cancer metabolism, the way the cancer cell gets its energy supply to sustain its growth.

How can patients diagnosed with pancreatic cancer maintain a positive outlook?

I tell my patients not to compare themselves to everybody with this disease because every cancer is different and acts differently. Yes, the statistics are bad, but not everybody falls into those bad categories. There are a lot of people who beat this disease and we don’t hear their stories.

That was the crux of why one of my patients and I developed an organization called Let’s Win! Pancreatic Cancer. Several years ago, I was treating Anne Glauber, an executive in the public relations field who was told that she had stage 4 pancreatic cancer and that there was nothing that could help her. She said, “We have to give patients a message of hope because there is hope here.” So we created an information platform for pancreatic cancer that connects patients to doctors and researchers in real time. (Anne passed away in 2017, more than three years after her diagnosis.)

Importantly, Let’s Win! Pancreatic Cancer has partnered with the Elvin Howard, Sr. Pancreatic Cancer Advocacy Foundation, based in Louisiana, to try to bridge racial disparities and get the word out to African Americans that they need to be aware of the disease, that they’re at higher risk, and that they should consider participating in clinical trials. In an effort to reach even more patients, the Let’s Win! Pancreatic Cancer platform is fully bilingual in Spanish.

How optimistic are you about the future for pancreatic cancer patients?

I’m hopeful, but the only way we’re going to change the outlook for those with this disease and get to better options is to perform clinical trials. Only about 4% of pancreatic cancer patients enter clinical trials, which is very low. It’s even lower in minority communities.

We encourage anyone who’s diagnosed with pancreatic cancer to ask about clinical trials before they start treatment. A clinical trial takes the standard of care for treatment and then adds an experimental treatment to it. We don’t know if that experimental agent will be beneficial to the patient, and it may even be detrimental. That’s the part of the trial that is scary for patients. However, I feel that with this disease, we really can’t be scared of the treatments. We need to get to a place where we have better treatment options, and that comes through clinical trials.

Allyson Ocean, M.D., is a medical oncologist and attending physician in gastrointestinal oncology at NewYork-Presbyterian/Weill Cornell Medical Center; an associate professor of clinical medicine at Weill Cornell Medicine; and a medical oncologist at The Jay Monahan Center for Gastrointestinal Health. She has published numerous peer-reviewed articles and abstracts and is an active member of several professional societies, including the American Society of Clinical Oncology, American Association for Cancer Research, and the Pancreatic Cancer Research Team. Dr. Ocean is a co-founder of Michael’s Mission, a nonprofit to support patients with colorectal cancer, and a co-founder and Chair of the Scientific Advisory Board of Let’s Win! Pancreatic Cancer. Dr. Ocean is leading numerous clinical trials investigating radiolabeled antibodies, antibody-drug conjugates, oncolytic viruses, cancer metabolism-based therapies, and targeted therapies in pancreatic cancer.