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Pancreatic Cancer Care at BMC
In a highly supportive and collaborative environment, pancreatic cancer physicians who are nationally recognized leaders in the care of patients with all stages of pancreatic cancer provide the most advanced, coordinated, and comprehensive medical care available—treatment that is effective and innovative in curing and controlling cancer and managing its impact on quality of life.
At BMC, diagnosis and treatment of patients with pancreatic cancer combines the resources of a multidisciplinary clinical center dedicated to personal, patient-focused care with the state-of-the-art expertise and technological advances of a major teaching hospital. As the primary teaching affiliate of the Boston University Chobanian & Avedisian School of Medicine, BMC is at the forefront of clinical practice, surgical expertise, and research in oncology.
Boston Medical Center's Hepatobiliary and Pancreatic Tumor Program was established in 2008 to effectively treat the growing number of patients being diagnosed with cancers of the liver, bile ducts, gallbladder, and pancreas.
What Is Pancreatic Cancer?
Pancreatic cancer is caused by the abnormal growth of cells in the pancreas.
The pancreas is located deep inside the abdomen behind the stomach in an area called the retroperitoneum and is surrounded by the liver, spleen, small intestine, and other organs.
There are two types of glands in the pancreas: exocrine glands and endocrine glands. Exocrine glands produce pancreatic enzymes that help to digest proteins and starches. These enzymes are secreted into the pancreatic duct and empty into the first part of the small intestine, called the duodenum, when eating.
Endocrine glands (found in clusters called islets) produce insulin and other regulatory hormones. These hormones circulate through the body via the bloodstream and keep various systems in check. For example, insulin helps regulate blood sugar levels.
Pancreatic tumors can be benign (noncancerous) or malignant (cancerous). Benign tumors are generally not life threatening and can often be removed. Malignant tumors, on the other hand, can be life threatening, as they sometimes invade surrounding tissues and organs and can spread to distant sites in the body.
Pancreatic cancers are divided by location. Proximal pancreatic cancers are cancers that develop in the uncinate process and head of the pancreas. Distal pancreatic cancers are cancers that develop in the body and tail of the pancreas.
Pancreatic cancers can develop in both exocrine and endocrine cells. Exocrine tumors are more common than endocrine tumors (also referred to as islet cell tumors or neuroendocrine tumors).
Symptoms of Pancreatic Cancer
Many early-stage pancreatic cancers do not cause symptoms, with symptoms only developing with progression. Common symptoms include:
- Yellow skin and eyes, dark urine, and pale stools (jaundice)
- Pain in the upper abdomen
- Chronic pain the middle part of the back
- Nausea and vomiting
- Stools that float in the toilet
- Loss of appetite or feeling full
- Unintentional weight loss
- Weakness and fatigue
Many of these symptoms can be caused by health problems other than pancreatic cancer. Individuals experiencing any of these symptoms should see their physician.
Causes of Pancreatic Cancer
Although the exact causes of pancreatic cancer remain unknown, certain risk factors connected to the disease have been identified:
- Tobacco use: Smoking tobacco is a key risk factor for developing pancreatic cancer. Smokers are at twice the risk of developing the disease as nonsmokers (American Cancer Society 2015a).
- Age and sex: The risk of developing pancreatic cancer increases with age, and the disease is more prominent in men versus women.
- Race: Pancreatic cancer occurs more frequently in African Americans than Caucasians, although the reasons for this are not completely understood.
- Family history and genetic mutations: One in 10 cases of pancreatic cancer are considered familial and are thought to be the result of genetic mutations (American Cancer Society 2015a). Genetic testing can detect these mutations in some cases.
- Obesity: The risk of developing pancreatic cancer is approximately 20% higher in people who are overweight or obese (American Cancer Society 2015b).
- Diabetes: Type 2 diabetes is associated with pancreatic cancer, and while the association is not clear, it may increase a person's risk of developing the disease.
- Pancreatitis and cirrhosis: The risk of developing pancreatic cancer is higher in people who have chronic pancreatitis (inflammation of the pancreas) and cirrhosis (scarring of the liver due to inflammation).
Risk factors currently under study include diet (particularly a diet high in animal fat) and alcohol consumption (American Cancer Society 2015a; National Cancer Institute 2010)
Stages of Pancreatic Cancer
Staging is used to determine the extent of the cancer. The most common system used to stage pancreatic cancer is the American Joint Committee on Cancer’s TNM system. The TNM system takes into account the size of the primary tumor (T), whether cancer is present in nearby lymph nodes (N), and whether the cancer has metastasized (spread) to other organs or tissues in the body (M). View TNM staging for pancreatic cancer here.
The three categories are combined to determine the overall stage of the cancer. This is called stage grouping.
- Stage I: The cancer is only present in the pancreas.
- Stage II: The cancer has invaded nearby tissues but has not invaded nearby blood vessels. The cancer may have spread to the lymph nodes.
- Stage III: The cancer has invaded nearby blood vessels.
- Stage IV: The cancer has spread to other organs in the body.
(National Cancer Institute 2010)
The grade of the cancer—how the cells appear under a microscope—also plays an important role in determining the extent of the cancer. Cancers are graded on a scale of G1 (the cells appear relatively normal) to G3 (or G4) (the cells appear very abnormal).
For treatment purposes, physicians may group pancreatic cancers into the following four categories:
- Resectable: The entire cancer can be surgically removed.
- Borderline resectable: Surgeons may be able to remove the entire cancer, even though it may have spread to nearby blood vessels. Sometimes a trial of chemotherapy is performed to try to shrink the tumor prior to surgery.
- Locally advanced (unresectable): The cancer is still local, but it cannot be entirely removed.
- Metastatic: The cancer has spread to distant sites in the body.
(American Cancer Society 2015a)
Patients are encouraged to discuss cancer staging and treatment options with their physicians.
Gastroenterology and Hepatobiliary Tumor Board at BMC
The results of the diagnostic tests are discussed at the Gastroenterology/Hepatobiliary Tumor Board. During this weekly meeting, the entire multidisciplinary team comes together to discuss new cases and develop individualized treatment plans for each patient.
Treatments & Services
Pancreatic Cancer Surgeries
Surgery is currently the most effective treatment for pancreatic cancer. The two types of surgery used to treat pancreatic cancer are potentially curative surgery and palliative surgery. Potentially curative surgery is performed if it appears the cancer can be removed entirely. If the cancer has spread too far to be completely removed, patients may be treated with palliative surgery. Rather than try to cure the cancer, the goals of palliative surgery are to relieve symptoms and prevent problems caused by the cancer, such as the cancer blocking the bile ducts or the intestine.
Chemotherapy is a medication or combination of medications used to treat cancer. Chemotherapy can be given orally (as a pill) or injected intravenously (IV).
Targeted therapy is a type of cancer treatment that uses drugs or other substances to precisely identify and attack cancer cells. Usually, targeted therapy does less damage to normal cells than other cancer treatments.
Radiation uses special equipment to deliver high-energy particles, such as x-rays, gamma rays, electron beams or protons, to kill or damage cancer cells. Radiation (also called radiotherapy, irradiation, or x-ray therapy) can be delivered internally through seed implantation or externally using linear accelerators (called external beam radiotherapy, or EBRT).
CyberKnife delivers highly targeted beams of radiation directly into tumors, in a pain-free, non-surgical way. Guided by specialized imaging software, we can track and continually adjust treatment at any point in the body, and without the need for the head frames and other equipment that are needed for some other forms of radiosurgery.
Palliative Care for Pancreatic Cancer
Patients receive palliative care to control pain and other symptoms caused by the cancer and to relieve the side effects of treatment. There are several methods of pain control, including pain medicines, nerve blocks (a procedure in which alcohol is used to block pain), and complementary therapies (such as massage or acupuncture). Palliative surgery, such as stent placement or bypass surgery, may also be used to relieve bile duct blockage and the symptoms it may cause.
Diagnostics and Tests
Pancreatic cancer can be difficult to diagnose early, as symptoms frequently do not develop until the later stages of the disease. Patients who are experiencing any of the symptoms of pancreatic cancer should see their physician, who will perform a series of diagnostic exams and tests. The results of these exams and tests will also help the patient and his or her physician decide the best treatment options.
Pancreatic Cancer Imaging Tests and Procedures
Several types of imaging tests and procedures are used to diagnose pancreatic cancer. The patient’s physician may request one or more of the following:
Computed Tomography (CT) Scan
CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut.
Magnetic Resonance Imaging (MRI)
This test uses a magnetic field, radiofrequency pulses, and a computer to produce detailed images of body structures in multiple places. You may be asked to drink a contrast solution for better imaging, and you will most likely lie on a moving table as pictures are taken.
Diagnostic ultrasound, also called sonography or diagnostic medical sonography, is an imaging method that uses high-frequency sound waves to produce images of structures within the body. The images can provide valuable information for diagnosing and treating a variety of diseases and conditions. Most ultrasound examinations are done using a sonar device outside the body, though some ultrasound examinations involve placing a device inside the body.
Positron Emission Tomography (PET) scan
A PET scan is used to detect cellular reactions to sugar. Abnormal cells tend to react and "light up" on the scan, thus helping physicians diagnose a variety of conditions. For the PET scan, a harmless chemical, called a radiotracer, is injected into your blood stream.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
During an ERCP, the gastroenterologist uses an endoscope, a long, thin, flexible tube with a light and camera at the end, through the esophagus, the stomach, and the first part of the small intestine, called the duodenum.
You will receive an intravenous sedative and pain medication. Once comfortable, the physician will then examine the area using an endoscope—a lighted tube with a small camera at the end. The physician will be able to view any abnormalities and take a tissue samples (biopsies) if necessary.
A common tool for disease screening, blood tests provide information about many substances in the body, such as blood cells, hormones, minerals, and proteins.
Any suspicious mass of tissue or tumor is subject to a biopsy, or removal of cells from the mass. This is the only technique that can confirm the presence of cancer cells.
Gastrointestinal malignancies, health disparities
Gastrointestinal malignancies, neuroendocrine tumors (NETs)
Medical Oncology Nurse Practitioners
Stomach cancer; Pancreatic cancer; pancreatitis; Hereditary cancer syndromes, Cancer prevention, Surgical risk reduction
Endocrine surgery, surgical oncology
Surgical oncology; Liver, pancreas, and biliary cancers; Stomach cancer; Sarcoma; Melanoma
Interventional neuroradiology, vascular and interventional radiology
Liver disease, viral hepatitis, liver lesions
Endoscopic diagnosis, gastrointestinal disorders
Gastroenterology Nurse Practitioner
BMC offers a number of clinical trials specifically for pancreatic cancer patients. Promising new techniques in the diagnosis, treatment, and care of patients with cancer are tested in these studies. The number and types of clinical trials available are constantly changing.
"I recently had my second surgery with Dr. McAneny. I feel very fortunate & privileged he is my surgeon. His compassion is undeniable, surgical skills beyond exceptional, and no limit to his patience and understanding. I had many questions, he answered them all, and I never felt rushed at appointments. He is a great surgeon and a wonderful person. He is second to none!"
"Dr. Tseng is so knowledgeable, personable and caring. She puts you at ease, give you hope and confidence in your outcome and makes you feel like you are her priority (which you are). I will forever be thankful for having found her."
American Cancer Society. 2015a. Pancreatic Cancer Overview. PDF.
-----2015b. "What are the risk factors for pancreatic cancer?" Last modified January 9, 2015.
American Joint Committee on Cancer. 2009. Pancreas Cancer Staging. 7th ed. PDF. https://cancerstaging.org/references-tools/quickreferences/Documents/PancreasSmall.pdf
National Cancer Institute. 2010. What You Need To Know About™ Cancer of the Pancreas. Bethesda: National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. https://www.mycareplusonline.com/sites/default/files/cmgfiles/WYNTK_Pancreas_Cancer.pdf
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