Pancreatic Cancer: Difference between revisions

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'''Original Editors '''- Jaimin Shah&nbsp;[[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]
'''Original Editors '''- Jaimin Shah [[Pathophysiology of Complex Patient Problems|from Bellarmine University's Pathophysiology of Complex Patient Problems project.]]  
 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  &nbsp; 
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[[Image:Blah.jpg|frame|Anatomical Position of Pancreas]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
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== Definition/Description  ==
== Definition/Description  ==
[[Image:Blah.jpg|Anatomical Position of Pancreas|alt=|right|frameless]]Pancreatic Cancer is a malignant disease of the pancreas. “Pancreatic adenocarcinoma is a highly lethal disease, which is usually diagnosed in an advanced state.”<ref name="Li et al">Li C, Heidt DG, Dalerba P, Burant CF, Zhang L, Adsay V, Wicha M, Clarke MF, Simeone DM. [https://aacrjournals.org/cancerres/article/67/3/1030/533872/Identification-of-Pancreatic-Cancer-Stem-Cells Identification of pancreatic stem cells]. Cancer research. 2007 Feb 1;67(3): 1030-1037</ref> The malignant tumor can be located near the head, body, or the tail of the pancreas. The pancreas is an organ that helps secrete insulin and glucagon which helps control blood glucose levels in the body. Pancreatic cancer is the fourth common cancer among men and the fifth leading cause of cancer in women. There are two types of pancreatic cancers which are exocrine cancer and endocrine cancer. “Pancreatic ductal adenocarcinoma (PDAC) compromises 90% of pancreatic cancers.”<ref name="Shore et al">Shore S, Vimalachadran D, Raraty MGT, Ghaneh P. Cancer in the elderly: pancreatic cancer. Surgical Onocology 2004;13:201-210</ref> Exocrine pancreatic cancers are the most common of pancreatic cancers. Exocrine pancreatic cancer is involved in the ducts of the pancreas that secrete juices. [[Image:Blah3.jpg|alt=|right|frameless]]Key Points


Pancreatic cancer is a malignant disease of the pancreas. “Pancreatic adenocarcinoma is a highly lethal disease, which is usually diagnosed in an advanced state.”<ref name="Li et al">Li C, Heidt DG, Dalerba P, Burant CF, Zhang L, Adsay V, Wicha M, Clarke MF, Simeone DM. Identification of pancreatic stem cells. Cancer Res 2007;67: 1030-1037</ref>&nbsp; The malignant tumor can be located near the head, body, or the tail of the pancreas. The pancreas is an organ that helps secrete insulin and glucagon which helps control blood glucose levels in the body. Pancreatic cancer is the fourth common cancer among men and the fifth leading cause of cancer in women. There are two types of pancreatic cancers which are exocrine cancer and endocrine cancer. “Pancreatic ductal adenocarcinoma (PDAC) compromises 90&nbsp;% of pancreatic cancers.”<ref name="Shore et al">Shore S, Vimalachadran D, Raraty MGT, Ghaneh P. Cancer in the elderly: pancreatic cancer. Surgical Onocology 2004;13:201-210</ref> Exocrine pancreatic cancers are the most common of pancreatic cancers. Exocrine pancreatic cancer is involved in the ducts of the pancreas that secrete juices. [[Image:Blah3.jpg|frame|center]]
* The pancreas is a gland that secretes digestive enzymes and insulin.  
 
* The symptoms of pancreatic cancer are often vague and common to many other disorders.
&nbsp;&nbsp;
* Pancreatic cancer is often only diagnosed in its later stages, which makes it difficult to treat.<ref name=":0">Better Health Pancreratic Cancer Available:https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pancreatic-cancer#diagnosis-of-pancreatic-cancer (accessed 3.9.2021)</ref>
 
== Prevalence  ==
 
“It is estimated 43,140 men and women will be diagnose with and 36,800 men and women will die of cancer&nbsp;of the pancreas in 2010”<ref>U.S National Institutes of Health-National Cancer Institute. SEER Stat Fact Sheets: pancreas. http://seer.cancer.gov/statfacts/html/pancreas.html(accessed 16 March 2011)</ref><br>“Pancreatic cancer is the fourth most common cause of cancer death for men and women in US”<ref name="Farma et al">Farma JM, Santillan AA, Melis M, Walters J, Belinc D, Chen D, Eikman EA, Malafa M. PET/CT fusion scan enhances CT staging in patients with pancreatic neoplasms. Annals of Surgical Oncology 2008;15(9):2465-2471</ref>&nbsp;; about 32,000 people die each year. Pancreatic cancer has the lowest 5-year survival rate (3 to 5&nbsp;%). Pancreatic cancer is more common in black men and women than whites. “In the United States, the age-adjusted incidence of pancreatic cancer is higher in blacks (14.9 cases per 100,000) than in whites (11.1 cases per 100,000) and it is higher in men (12.8 cases per 100,000) than in women (10.0 cases per 100,000).”<ref name="Maitra et al">Maitra A, Hruban RH. Pancreatic Cancer. Annu Rev Pathol 2008;3:157-188</ref> The peak incidence of pancreatic cancer occurs in the 7th and 8th decade. <br>Pancreatic cancer is rare in people under the age of 45, the risk increases after age of 50. The risk factors associated with pancreatic cancer include family history, genetic syndromes, tobacco use, exposure to chemicals, obesity, diets in high fats and meat, diabetes mellitus, hx of chronic pancreatitis, and hx of partial gastrectomy. “Individuals with a strong family history of pancreatic cancer have a significantly increased risk of developing the disease themselves.”<ref name="Maitra et al" /> “The lifetime risk for developing pancreatic cancer for men and women is 1.27%. 1 in 80 men and women will develop cancer in their lifetime.”<ref name="Chari et al">Chari ST. Detecting early pancreatic cancer-problems and prospects. Semin Oncol 2007;34(4):284-294</ref>
 
&nbsp;&nbsp;&nbsp;[[Image:Smoke-that-cigarette.jpg|frame|left|cigarette-- risk factor]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:800px-High Fat Foods - NCI Visuals Online.jpg|frame|right|A display of high fat foods such as cheeses, chocolates, lunch meat, french fries, pastries, doughnuts, etc-National Cancer Institute-Unknown Author]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 
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<br>
== Epidemiology ==


<br>  
* Pancreatic cancer accounts for 22% of all deaths due to gastrointestinal malignancy, and 5% of all cancer deaths. In general, it is a malignancy of the [[Older People Introduction|elderly]] with over 80% of cases occurring after the age of 60.<ref name=":1">Radiopedia pancreatic Cancer Available: https://radiopaedia.org/articles/pancreatic-ductal-adenocarcinoma-2 (accessed 3.9.2021)</ref>
* Pancreatic cancer is the fourth most common cause of cancer death for men and women in US.<ref name="Farma et al">Farma JM, Santillan AA, Melis M, Walters J, Belinc D, Chen D, Eikman EA, Malafa M. PET/CT fusion scan enhances CT staging in patients with pancreatic neoplasms. Annals of Surgical Oncology 2008;15(9):2465-2471</ref>
* Pancreatic cancer is more common in black men and women than whites. <br>Pancreatic cancer is rare in people under the age of 45, the risk increases after age of 50.


<br>
== Etiology ==
[[Image:Smoke-that-cigarette.jpg|frame|cigarette-- risk factor|alt=]]Risk factors include:


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>  
* cigarette smoking: the strongest environmental risk factor
 
* a diet rich in animal fats and protein
<br>  
* obesity
 
* family history: three or more first-order relatives with pancreatic cancer results in ~20x risk
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
* hereditary syndromes<ref name=":1" />
* Possible risk factors include heavy alcohol consumption, coffee consumption, physical inactivity, high red meat consumption, and two or more soft drinks per day.
* Ten percent have a genetic cause such as genetic mutations or association with syndromes eg multiple endocrine neoplasia type 1<ref name=":2">Puckett Y, Garfield K. [https://www.ncbi.nlm.nih.gov/books/NBK518996/ Pancreatic Cancer]. InStatPearls [Internet] 2021 Aug 11. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK518996/ (accessed 3.9.2021)</ref>.


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
 
Most clinical presentations of pancreatic cancers are vague and delay the potential diagnosis. “Pancreatic cancer is relatively asymptomatic during its early course. The vague presentation includes back and epigastric pain.”<ref name="Shore et al" /> Symptoms associated with pancreatic cancer include:[[Image:Abdominal pain.jpg|alt=|right|frameless]]
Most clinical presentations of pancreatic cancers are vague and delay the potential diagnosis. “Pancreatic cancer is relatively asymptomatic during its early course. The vague presentation includes back and epigastric pain.”<ref name="Shore et al" />&nbsp; Symptoms associated with pancreatic cancer include:<br>
*Pain is the presenting symptom in between 31% and 71% of pancreatic cancer patients
 
*Jaundice
Pain  
*Digestive Problems
 
*Blood Clots
Jaundice  
*Weight Loss
 
*Abdominal or Back Pain
Digestive Problems  
*Gallbladder Enlargement
 
*Dark Urine
Blood Clots<br>
*Nausea and Vomiting <ref name="Shore et al" />
 
Advanced Cancer symptoms:
Weight Loss  
*Weakness or very feeling tired
 
*Loss of appetite or fullness <br>  
Abdominal or Back Pain  
 
Gallbladder Enlargement  
 
Dark Urine<br>
 
Nausea and Vomiting <br>
 
&nbsp;
 
Abdominal pain is more common among patients with pancreatic cancer. The pain is insidious in onset originating in the epigastric region moving towards the sides and back<ref name="Shore et al" />.&nbsp; “Pain is the presenting symptom in between 31% and 71% of pancreatic cancer patients”<ref name="Shore et al" />
 
&nbsp; [[Image:Abdominal pain.jpg|frame|center]]
 
[[Image:Jaundice.jpg|frame|center]]Jaundice occurs from compression of the biliary duct. “About 70% of PDACs occur in the head of the pancreas.”<ref name="Shore et al" /> Therefore, patients are more likely to have this as symptomatic manifestation.&nbsp;
 
<br>
 
Advanced Cancer symptoms:<br>Weakness or very feeling tired <br>Loss of appetite or fullness <br>  


== Associated Co-morbidities  ==
== Associated Co-morbidities  ==


Diabetes<ref name="Extermann">Extermann M. Interaction between comorbidity and cancer. Cancer Control 2007;14(1):13-22</ref>  
[[Diabetes]]<ref name="Extermann">Extermann M. Interaction between comorbidity and cancer. Cancer Control 2007;14(1):13-22</ref>  
 
== Medications  ==
 
'''Pain Relief-Opioids'''
 
codeine<br>hydrocodone (Vicodin®, Vicoprofen®)<br>hydromorphone (Dilaudid®)<br>levorphanol (Levo-Dromoran®)<br>morphine (Kadian®, MSIR®, MS Contin®, Oramorph-SR®)<br>oxycodone (Roxicodone®, OxyIR®, OxyContin®, Percodan®)<br>fentanyl (Duragesic®, Actiq®)<br>methadone (Dolophine®)<br>tramadol (Ultram®)<br>MSIR=morphine sulfate immediate release<br>MS Contin=morphine sulfate sustained release<br>Oramorph-SR=morphine sulfate sustained release<br>Roxicodone=oxycodone immediate release<br>OxyIR=oxycodone immediate release<br>OxyContin=oxycodone sustained release<br>Percodan=oxycodone and immediate releas <br>
 
'''Pain Relief- Non-Opioids'''
 
NSAIDs
 
Antidepressants
 
Anticonvulsants
 
== <ref>John Hopkins Medicine-Pancreatic Cancer-Pain Management http://pathology.jhu.edu/pc/TreatmentPain.php?area=tr(accessed 5 April 2010)</ref>&nbsp;<br>Diagnostic Tests/Lab Values&nbsp;  ==
 
'''Spiral CT '''displays continuous images of the body. Dual contrast enhanced spiral CT provides a continuous enhanced spiral CT that may provide diagnostic rates up to 97% for pancreatic cancer<ref name="Shore et al" />. CT scans can also help determine if a tumor is resectable. The sensitivity for determining resectability with a CT scan is in the range of 68% to 96%<ref name="Shore et al" />. The sensitivity drops to 58% when examining tumors less than 2 cm<ref name="Shore et al" />. “Spiral CT with intravenous contrast of the abdomen is the most common test in the assessment of pancreatic adenocarcinoma.” <ref name="Goodman et al">Goodman CC,Fuller KS. Pathology Implications for the physical therapist. In: Goodman CC, Peterson C. The hepatic, pancreatic, and biliary systems. 3rd ed. St. Louis Saunders Elsevier, 2009.p916-918</ref> [[Image:Ct scan.png|frame|left]]
 
'''Carbon antigen 19-9''' is detected in serum and pancreatic juice. “Carbon antigen 19-9 has a reported sensitivity of 70-90%, a specificity of 90%, PPV of 69%, NPV of 90%.”<ref name="Shore et al" /> Carbon antigen 19-9 is produced normal in the body by the pancreas. An elevation of this serum can be indicated for other pancreatic disorders. CA 19-9 is not a useful screening tool for pancreatic cancer in asymptomatic population<ref name="Shore et al" />.
 
'''TNM staging system '''classifies pancreatic adenocarcinoma into tumor size, local invasion, regional lymph node metastases, and distant nonnodal metastatic disease.
 
'''MRI''' is equal in comparison to CT scan for being sensitive in detecting pancreatic cancers. “With improved MRI with T1 and T2 imaging and with fast scanning techniques, tumor detection rate is reported up to 90%."<ref name="Shore et al" />
 
'''Transabdominal Ultrasound '''is used for investigating abdominal pain. “The sensitivity of transabdominal US in diagnosing pancreatic cancer has a wide range between 44% and 94%. Transabdominal US is poor in detecting small lesions of less than 1cm, with a sensitivity of 50%.”<ref name="Shore et al" />
 
'''Endoscopic Ultrasound '''is useful in detecting early pancreatic cancer as small as 2-3cm<ref name="Shore et al" />. “A more recent report of series of 89 patients where EUS was compared with surgical and histopathological TNM staging found the overall accuracy to be 69% and 54% for tumor and nodal status.”<ref name="Shore et al" />
 
'''Endoscopic retrograde cholangiopancreatography (ERCP''') is used for imaging of the pancreatic duct&nbsp;
 
and biliary system. “The sensitivity and specificity of ERCP is 70-82% and 88-94% in symptomatic patients or those with suspected pancreatic cancer.”<ref name="Shore et al" />&nbsp;


&nbsp;&nbsp; [[Image:Endoscopic.jpg|frame|center]]  
== Treatment ==
[[Image:Kwhipple.jpg|alt=|right|frameless]]Most tumours are not resectable at diagnosis.


== Etiology/Causes ==
* Surgery for stage I and II does offer the chance of cure, though with high morbidity (20-30%) and mortality (5%).


&nbsp;The specific cause of pancreatic cancer is unknown. Some of the genes investigated in potential related causes include K''-ras ''mutation, ''p''16, ''p''53, DPC4, ''h''MLH1, and ''h''MLH2.<ref name="Goodman et al" />&nbsp;
Even when resection is possible, the majority of patients succumb to recurrence, with only a doubling of survival in operated patients 1, from 5% to 10% at 5 years. At 12 months following the diagnosis, almost a quarter of the patients will have died<ref name=":1" />.


"The K-''ras ''mutation has been found in over 90% of tested pancreatic adenocarcinomas."<ref name="Goodman et al" />&nbsp;The genes ''p''16, ''p''53, and DPCA4 inactive tumor suppressor genes.  
If the cancer has spread and it is not possible to cure it with surgery, the doctor may still recommend treatment that focuses on improving quality of life by relieving the symptoms (this is called [[Palliative Care Competence Framework for Physiotherapists|palliative]] treatment)<ref name=":0" />.  


hMLH1 and hMLH2 are defective DNA repair genes.<ref name="Goodman et al" />[[Image:Etiology.jpg|frame|center|http://emedicine.medscape.com/article/280605-overview]]&nbsp;
== Diagnosis ==
[[Image:Ct scan.png|alt=|right|frameless]]
* [[Blood Tests|Blood tests]] – to check how well the liver and kidney are working and measure for a protein known as CA19.9.
* Computed Tomography  Scan( [[CT Scans|CT Scan]])
* Magnetic resonance imaging ([[MRI Scans|MRI]])
* [[Ultrasound Scans|Ultrasound]]
* Endoscopy (also called endoscopic retrograde cholangiopancreatography, ERCP)
* Laparoscopy – the internal organs are examined with an instrument inserted into the abdomen through a small cut.
* Tissue biopsy – a small sample of the pancreas is removed with a needle and examined in a laboratory.
* Positron emission tomography (PET) scan – an injection with a glucose solution containing a very small amount of radioactive material is given. The scanner can ‘see’ the radioactive substance. Cancerous cells show up as ‘hot spots’ – areas where the glucose is being taken up.


== ==
These tests also help the doctor find out if the cancer has spread. The cancer may have spread into blood vessels or lymph nodes near the pancreas, or into organs further away, like the liver or the lungs. This is called ‘secondary cancer’ or metastasis. The tests help doctors decide the best treatment.<ref name=":2" />


== Systemic Involvement  ==
== Systemic Involvement  ==


Pancreatic cancers are often diagnosed in advanced stages where the cancer has metastasized to other areas. Pancreatic cancers can metastasize to regional lymph nodes, liver, lungs, duodenum, stomach, colon, and anywhere in the abdominal cavity. Pancreatic cancer can spread to the skin as painful nodules. Usual sites for metastases in pancreatic cancer occur in the liver and peritoneal cavity<ref name="Borad et el">Borad MJ, Saadati H, Lakshmipathy A, Campbell E, Hopper P, Jameson G, Von Hoff DD, Wasif Saif M. Skeletal metastases in pancreatic cancer: a retrospective study and review of the literature. Yale Journal of Biology and Medicine 2009;82:1-6</ref>.  
Pancreatic cancers are often diagnosed in advanced stages where the cancer has metastasized to other areas. Pancreatic cancers can metastasize to regional lymph nodes, liver, lungs, duodenum, stomach, colon, and anywhere in the abdominal cavity. Pancreatic cancer can spread to the skin as painful nodules. Usual sites for metastases in pancreatic cancer occur in the liver and peritoneal cavity<ref name="Borad et el">Borad MJ, Saadati H, Lakshmipathy A, Campbell E, Hopper P, Jameson G, Von Hoff DD, Wasif Saif M. Skeletal metastases in pancreatic cancer: a retrospective study and review of the literature. Yale Journal of Biology and Medicine 2009;82:1-6</ref>.  
== Physical Therapy Management  ==


== Medical Management (current best evidence)  ==
Physical therapy management involves helping the patient live a functional life while dealing with pain, fatigue, and weakness. The patient feels he/she is not able to do much because of the disease and its implications.   
 
Treatment of pancreatic cancer is based on the stage of the tumor<ref name="Goodman et al" />. <br>Resectable Disease- 15-20%<br>Locally advanced- 40-45%<br>Metastatic- 40-45%
 
'''Surgery''' is the primary option if the pancreatic cancer is resectable. “Surgical resection provides the only curative therapy, only appropriate for a minority of clients.”<ref name="Goodman et al" /> “Around 9-15% of patients are suitable for potentially curative resection.”<ref name="Shore et al" />
 
'''Kausch-Whipples (Pancreaticoduodenectomy)''' - This procedure involves the removal of the head of the pancreas, a portion of the small intestine, gallbladder, bile duct, and stomach. [[Image:Kwhipple.jpg|frame]]
 
<br>
 
'''Pylorus preserving pancreaticoduodenectomy (PPPD)'''- This procedure is similar to the Kausch-Whipples except it spares the pylorus. “The preservation of the pyloric sphincter should decrease morbidity and prevent biliary reflux and retention of the duodenal pacemaker should reduce delayed gastric emptying.”<ref name="Shore et al" />
 
'''Left pancreatectomy'''- This procedure involves the removal of the tail of [[Image:Left pancreas removed.jpg|frame|http://www.bcm.edu/pancreascenter/index.cfm?pmid=10420]]the pancreas.
 
<br>
 
<u>'''Unresectable Disease'''</u>
 
'''Biliary and duodenal obstruction'''- "Approximately 70-80% of these patients will present with obstructive jaundice and will require decompressionof the biliary tree."<ref name="Shore et al" />&nbsp;Two techniques that are used are endoscopic stenting and operative bypass<ref name="Shore et al" />.
 
'''Neurolytic celiac plexus block (NCPB)'''- Nerve fibers are block to control pain symptoms. "A recent large randomised controlled trial showed that neurolytic celiac plexus block improved pain relief in unresectable pancreatic cancer patients when compared with systemic analgesic therapy alone."<ref name="Shore et al" />
 
'''Chemotherapy'''- Involves the use of chemicals in destruction of cancerous cells. "Chemotherapy has been shown to be beneficial in pallative therapy trials."<ref name="Shore et al" />&nbsp;5-Fluorouracil and Gemcitabine are commonly used agents in treatment of advanced pancreatic cancer<ref name="Shore et al" />.&nbsp;
 
'''Gene therapy'''
 
'''Immunotherapy'''
 
== Physical Therapy Management (current best evidence)  ==
 
Physical therapy management involves helping the patient live a functional life&nbsp;while dealing with pain, fatigue, and weakness. The patient feels he/she is not able to do much because of the disease and its implications. "Disability in patients with advanced cancer often results from bed rest, deconditioning, and neurologic and musculosketal complications of cancer or cancer treatment. Terminally ill patients have a high prevelance of weakness, pain, fatigue, and dyspnea in addition to other symptoms."<ref name="Santiago-Palma et al">Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer Supplement 2001;92(4):1049-1052</ref>&nbsp;Improvement in functional ability is necessary for a patient with a diagnosis of cancer to enjoy a quality of life. "Clinical experience suggests that the application of the fundamental principles of rehabilitation medicine is likely to improve care."<ref name="Santiago-Palma et al" />&nbsp;Physical training&nbsp;had&nbsp;a significant&nbsp;and beneficial effects&nbsp;on reducing fatigue<ref name="van Weert et al">van Weert EV, May AM, Korstjens I, Post WJ, van der Schans CP, van den Borne B, Mesters I, Ros WJG, Hoekstra-Weebers JEHM. Cancer-related fatigue and rehabilitation: a randomized controlled multicenter trial comparing physical training combined with congnitive-behavioral therapy with physical training only and with no intervention. Physical Therapy 2010;90(10):1413-1425</ref>.
 
The physical therapy management will consist of controlling symptoms of pain, reducing fatigue, and strengtening weak muscles. Along with these 3 focal points, impairments should be addressed to improve functional abilities. "When patients are terminally ill, both symptom control and maintenance of function become central aspects of their treatment."<ref name="Santiago-Palma et al" />&nbsp;Patients who have advanced cancer will have symptoms of pain, fatigue, generalized weakness, dyspnea, delirium, nausea,&nbsp;vomiting, depression, and anxiety<ref name="Santiago-Palma et al" />. The physical therapist will need to address these symptoms in order for the patient to become independent and reduce the burden of caregivers.&nbsp;"Two-hundred thirty nine of 301&nbsp;patients&nbsp;had difficulties with activities of daily living. A mean 27% improvement in the Barthel mobility index was recorded following rehabilitation."<ref name="Santiago-Palma et al" />
 
Pain is one of the most&nbsp;common symptom&nbsp;of&nbsp;cancer and its advancing state.&nbsp;Severe pain in patients with cancer leads to impaired function. "Knowledge of the biology and natural history of the specific cancer types, including familiarity with common cancer pain syndromes and opioid pharmacology, are important in assessing and managing these patients."<ref name="Santiago-Palma et al" />
 
Physical therapy modalities can also be used for treatment of pain but with caution. "The use of physical modalities such as massage, heat, and cold can be implemented at bedside and aid in the pain management of patients."<ref name="Santiago-Palma et al" />&nbsp;Heat can be utilized when performing ROM exercises in order to reduce the symptoms of pain. "Heat should not be applied to skin areas that are insensitive, have been exposed to radiation, or are atrophic or acutely inflamed."<ref name="Santiago-Palma et al" />&nbsp;Cold therapy should not also be applied to these areas<ref name="Santiago-Palma et al" />.
 
Providing the patient with education on about the cancer and its implications can also be beneficial in physical therapy management. Energy conservation and work simplification can also assist patients in reducing and controlling symptoms<ref name="Santiago-Palma et al" />. Patient education can also include the use of assistive devices if necessary.&nbsp;"Immune function may be improved by moderate exercise."<ref name="Santiago-Palma et al" /> Exercise should be implemented at low intensity levels<ref name="Santiago-Palma et al" />.&nbsp;&nbsp;
 
== Alternative/Holistic Management (current best evidence)  ==
 
Herbal medicine
 
Folk medicine
 
Homeopathy
 
Faith healing
 
New age healing
 
Chiropractic
 
Acupuncture
 
Naturopathy
 
Massage
 
Music therapy
 
Relaxation Techniques
 
<ref>Hirschberg Home Page Pancreatic Cancer-Alternative Treatment http://www.pancreatic.org/site/c.htJYJ8MPIwE/b.891969/k.F228/Alternative_treatment_options_for_pancreatic_cancer.htm (accessed 5 April 2011)</ref>&nbsp;
 
<ref name="Molassiotis et al">Molassiotis A, Fernadez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I, Gudmundsdottir G, Hummerston S, Ahmad AMA, Platin N, Kearney N, Patiraki E. Use of complementary and alternative medicine in cancer patients: a european survey. Annals of Oncology 2005;16:655-663</ref>
 
== Differential Diagnosis<ref name="Dragovich">Dragovich T, Erickson RA,Larson CR. Pancreatic Cancer.emedicine on medscape.http://emedicine.medscape.com/article/280605-overview. Updated March 11, 2011. Accessed April 26, 2011.</ref>  ==
 
Abdominal Aortic Aneurysm<br>Ampullary Carcinoma<br>Bile Duct Strictures<br>Bile Duct Tumors<br>Cholangitis<br>Pancreatitis, Acute<br>Cholecystitis<br>Pancreatitis, Chronic<br>Choledochal Cysts<br>Choledocholithiasis<br>Cholelithiasis<br>Duodenal ulcers<br>Gastric ulcers<br>Neoplasms of endocrine pancreas<br>Intestinal Ischemia<br>Gastric Lymphoma<br>Pancreatic Lymphoma<br>Heptacellular Carcinoma<br>
 
== Case Reports/ Case Studies ==


[http://scholarworks.boisestate.edu/cgi/viewcontent.cgi?article=1124&context=td A Case Study on the Use of Athletic Performance Strategies in an Elite Athlete’s Management of Pancreatic Cancer]<ref name="Harris">Harris BE. A case study on the use of athletic performance strategies in an elite athlete's management of pancreatic cancer. Boise State University Theses and Dissertations 2010.</ref><br>
"Disability in patients with advanced cancer often results from bed rest, deconditioning, and neurologic and musculosketal complications of cancer or cancer treatment. Terminally ill patients have a high prevelance of weakness, pain, fatigue, and dyspnea in addition to other symptoms."<ref name="Santiago-Palma et al">Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer Supplement 2001;92(4):1049-1052</ref>Improvement in functional ability is necessary for a patient with a diagnosis of cancer to enjoy a quality of life. "Clinical experience suggests that the application of the fundamental principles of rehabilitation medicine is likely to improve care."<ref name="Santiago-Palma et al" /> Physical training had a significant and beneficial effects on reducing fatigue<ref name="van Weert et al">van Weert EV, May AM, Korstjens I, Post WJ, van der Schans CP, van den Borne B, Mesters I, Ros WJG, Hoekstra-Weebers JEHM. Cancer-related fatigue and rehabilitation: a randomized controlled multicenter trial comparing physical training combined with congnitive-behavioral therapy with physical training only and with no intervention. Physical Therapy 2010;90(10):1413-1425</ref>.


<br>[http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6T44-4Y3V1J2-5-3&_cdi=4964&_user=6406088&_pii=S1047279709003664&_origin=gateway&_coverDate=02%2F28%2F2010&_sk=999799997&view=c&wchp=dGLbVtz-zSkzV&md5=aff1ba5bf16ded37d1cd60e39ecae679&ie=/sdarticle.pdf Past Medical History and Pancreatic Cancer Risk: Results From a Multicenter Case-Control Study]<ref name="Maisonneuve et el">Maisonneuve P, Lowenfels AB, Bueno-De-Mesquita HB, Ghadirian P, Baghurst PA, Zatonski WA, Miller AB, Duell EJ, Boffetta P, Boyle P. Past medical history and pancreatic cancer risk: results from a multicenter case-control study. Ann Epidemiol 2010;20:92-98</ref>  
The physical therapy management will consist of controlling symptoms of pain, reducing fatigue, and strengtening weak muscles. Along with these 3 focal points, impairments should be addressed to improve functional abilities. "When patients are terminally ill, both symptom control and maintenance of function become central aspects of their treatment."<ref name="Santiago-Palma et al" /> Patients who have advanced cancer will have symptoms of pain, fatigue, generalized weakness, dyspnea, delirium, nausea, vomiting, [[depression]], and anxiety<ref name="Santiago-Palma et al" />. The physical therapist will need to address these symptoms in order for the patient to become independent and reduce the burden of caregivers. "Two-hundred thirty nine of 301 patients had difficulties with activities of daily living. A mean 27% improvement in the Barthel mobility index was recorded following rehabilitation."<ref name="Santiago-Palma et al" />  


<br>  
Pain is one of the most common symptom of cancer and its advancing state. Severe pain in patients with cancer leads to impaired function. "Knowledge of the biology and natural history of the specific cancer types, including familiarity with common cancer pain syndromes and opioid pharmacology, are important in assessing and managing these patients."<ref name="Santiago-Palma et al" />  


[http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6W85-4V7DBRT-T-1&_cdi=6645&_user=6406088&_pii=S1470204508703371&_origin=gateway&_coverDate=01%2F31%2F2009&_sk=999899998&view=c&wchp=dGLzVzz-zSkzk&md5=355ddd84bff074fca26df5929304805c&ie=/sdarticle.pdf New-onset diabetes: a potential clue to the early diagnosis of pancreatic cancer]<ref name="Pannala et al">Pannala R, Basu A, Petersen GM, Chari ST. New-onset diabetes: a potential clue to the early diagnosis of pancreatic cancer. Lancet Oncol 2009;10:88-95</ref>  
Physical therapy modalities can also be used for treatment of pain but with caution. "The use of physical modalities such as massage, heat, and cold can be implemented at bedside and aid in the pain management of patients."<ref name="Santiago-Palma et al" /> Heat can be utilized when performing ROM exercises in order to reduce the symptoms of pain. "Heat should not be applied to skin areas that are insensitive, have been exposed to radiation, or are atrophic or acutely inflamed."<ref name="Santiago-Palma et al" /> Cold therapy should not also be applied to these areas<ref name="Santiago-Palma et al" />.


<br>  
Providing the patient with education on about the cancer and its implications can also be beneficial in physical therapy management. Energy conservation and work simplification can also assist patients in reducing and controlling symptoms<ref name="Santiago-Palma et al" />. Patient education can also include the use of [[Assistive Devices|assistive devices]] if necessary. "Immune function may be improved by moderate exercise."<ref name="Santiago-Palma et al" /> Exercise should be implemented at low intensity levels<ref name="Santiago-Palma et al" />.<br>


[http://www.medscape.com/viewarticle/472537 Cough as the Presenting Symptom of Pancreatic Adenocarcinoma]<ref name="Richwine et al">Richwine RT, Ahmed N, Mortensen M. Cough a the prestenting symptom of pancreatic adenocarcinoma. J Am Board Fam Med 2004;17(1)</ref>
== Differential Diagnosis ==
Typically, at the time of diagnosis of pancreatic cancer, 52% have distant metastasis, and 23% have local spread.


== Resources <br> ==
Differential diagnosis before imaging and biopsy includes the following: acute pancreatitis, chronic [[Pancreatitis|pancreatitis,]] cholangitis, [[cholecystitis]], choledochal cyst, [[Peptic Ulcers|peptic ulcer disease,]] cholangiocarcinoma, and [[Gastric Cancer|gastric cancer]].<ref name=":2" />


National Cancer Institute [http://www.cancer.gov/cancertopics/types/pancreatic www.cancer.gov/cancertopics/types/pancreatic]
American Cancer Society&nbsp;[http://www.cancer.org/cancer/pancreaticcancer/index www.cancer.org/cancer/pancreaticcancer/index]
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
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== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:Bellarmine_Student_Project]] [[Category:Oncology]]
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[[Category:Medical]]  
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Latest revision as of 12:33, 4 December 2023

Original Editors - Jaimin Shah from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Jaimin Shah, Admin, Elaine Lonnemann, Lucinda hampton, WikiSysop, Kirenga Bamurange Liliane, Wendy Walker, Evan Thomas, Kim Jackson and Chelsea Mclene

Definition/Description[edit | edit source]

Pancreatic Cancer is a malignant disease of the pancreas. “Pancreatic adenocarcinoma is a highly lethal disease, which is usually diagnosed in an advanced state.”[1] The malignant tumor can be located near the head, body, or the tail of the pancreas. The pancreas is an organ that helps secrete insulin and glucagon which helps control blood glucose levels in the body. Pancreatic cancer is the fourth common cancer among men and the fifth leading cause of cancer in women. There are two types of pancreatic cancers which are exocrine cancer and endocrine cancer. “Pancreatic ductal adenocarcinoma (PDAC) compromises 90% of pancreatic cancers.”[2] Exocrine pancreatic cancers are the most common of pancreatic cancers. Exocrine pancreatic cancer is involved in the ducts of the pancreas that secrete juices.

Key Points

  • The pancreas is a gland that secretes digestive enzymes and insulin.
  • The symptoms of pancreatic cancer are often vague and common to many other disorders.
  • Pancreatic cancer is often only diagnosed in its later stages, which makes it difficult to treat.[3]

Epidemiology[edit | edit source]

  • Pancreatic cancer accounts for 22% of all deaths due to gastrointestinal malignancy, and 5% of all cancer deaths. In general, it is a malignancy of the elderly with over 80% of cases occurring after the age of 60.[4]
  • Pancreatic cancer is the fourth most common cause of cancer death for men and women in US.[5]
  • Pancreatic cancer is more common in black men and women than whites.
    Pancreatic cancer is rare in people under the age of 45, the risk increases after age of 50.

Etiology[edit | edit source]

cigarette-- risk factor

Risk factors include:

  • cigarette smoking: the strongest environmental risk factor
  • a diet rich in animal fats and protein
  • obesity
  • family history: three or more first-order relatives with pancreatic cancer results in ~20x risk
  • hereditary syndromes[4]
  • Possible risk factors include heavy alcohol consumption, coffee consumption, physical inactivity, high red meat consumption, and two or more soft drinks per day.
  • Ten percent have a genetic cause such as genetic mutations or association with syndromes eg multiple endocrine neoplasia type 1[6].

Characteristics/Clinical Presentation[edit | edit source]

Most clinical presentations of pancreatic cancers are vague and delay the potential diagnosis. “Pancreatic cancer is relatively asymptomatic during its early course. The vague presentation includes back and epigastric pain.”[2] Symptoms associated with pancreatic cancer include:

  • Pain is the presenting symptom in between 31% and 71% of pancreatic cancer patients
  • Jaundice
  • Digestive Problems
  • Blood Clots
  • Weight Loss
  • Abdominal or Back Pain
  • Gallbladder Enlargement
  • Dark Urine
  • Nausea and Vomiting [2]

Advanced Cancer symptoms:

  • Weakness or very feeling tired
  • Loss of appetite or fullness

Associated Co-morbidities[edit | edit source]

Diabetes[7]

Treatment[edit | edit source]

Most tumours are not resectable at diagnosis.

  • Surgery for stage I and II does offer the chance of cure, though with high morbidity (20-30%) and mortality (5%).

Even when resection is possible, the majority of patients succumb to recurrence, with only a doubling of survival in operated patients 1, from 5% to 10% at 5 years. At 12 months following the diagnosis, almost a quarter of the patients will have died[4].

If the cancer has spread and it is not possible to cure it with surgery, the doctor may still recommend treatment that focuses on improving quality of life by relieving the symptoms (this is called palliative treatment)[3].

Diagnosis[edit | edit source]

  • Blood tests – to check how well the liver and kidney are working and measure for a protein known as CA19.9.
  • Computed Tomography Scan( CT Scan)
  • Magnetic resonance imaging (MRI)
  • Ultrasound
  • Endoscopy (also called endoscopic retrograde cholangiopancreatography, ERCP)
  • Laparoscopy – the internal organs are examined with an instrument inserted into the abdomen through a small cut.
  • Tissue biopsy – a small sample of the pancreas is removed with a needle and examined in a laboratory.
  • Positron emission tomography (PET) scan – an injection with a glucose solution containing a very small amount of radioactive material is given. The scanner can ‘see’ the radioactive substance. Cancerous cells show up as ‘hot spots’ – areas where the glucose is being taken up.

These tests also help the doctor find out if the cancer has spread. The cancer may have spread into blood vessels or lymph nodes near the pancreas, or into organs further away, like the liver or the lungs. This is called ‘secondary cancer’ or metastasis. The tests help doctors decide the best treatment.[6]

Systemic Involvement[edit | edit source]

Pancreatic cancers are often diagnosed in advanced stages where the cancer has metastasized to other areas. Pancreatic cancers can metastasize to regional lymph nodes, liver, lungs, duodenum, stomach, colon, and anywhere in the abdominal cavity. Pancreatic cancer can spread to the skin as painful nodules. Usual sites for metastases in pancreatic cancer occur in the liver and peritoneal cavity[8].

Physical Therapy Management[edit | edit source]

Physical therapy management involves helping the patient live a functional life while dealing with pain, fatigue, and weakness. The patient feels he/she is not able to do much because of the disease and its implications.

"Disability in patients with advanced cancer often results from bed rest, deconditioning, and neurologic and musculosketal complications of cancer or cancer treatment. Terminally ill patients have a high prevelance of weakness, pain, fatigue, and dyspnea in addition to other symptoms."[9]Improvement in functional ability is necessary for a patient with a diagnosis of cancer to enjoy a quality of life. "Clinical experience suggests that the application of the fundamental principles of rehabilitation medicine is likely to improve care."[9] Physical training had a significant and beneficial effects on reducing fatigue[10].

The physical therapy management will consist of controlling symptoms of pain, reducing fatigue, and strengtening weak muscles. Along with these 3 focal points, impairments should be addressed to improve functional abilities. "When patients are terminally ill, both symptom control and maintenance of function become central aspects of their treatment."[9] Patients who have advanced cancer will have symptoms of pain, fatigue, generalized weakness, dyspnea, delirium, nausea, vomiting, depression, and anxiety[9]. The physical therapist will need to address these symptoms in order for the patient to become independent and reduce the burden of caregivers. "Two-hundred thirty nine of 301 patients had difficulties with activities of daily living. A mean 27% improvement in the Barthel mobility index was recorded following rehabilitation."[9]

Pain is one of the most common symptom of cancer and its advancing state. Severe pain in patients with cancer leads to impaired function. "Knowledge of the biology and natural history of the specific cancer types, including familiarity with common cancer pain syndromes and opioid pharmacology, are important in assessing and managing these patients."[9]

Physical therapy modalities can also be used for treatment of pain but with caution. "The use of physical modalities such as massage, heat, and cold can be implemented at bedside and aid in the pain management of patients."[9] Heat can be utilized when performing ROM exercises in order to reduce the symptoms of pain. "Heat should not be applied to skin areas that are insensitive, have been exposed to radiation, or are atrophic or acutely inflamed."[9] Cold therapy should not also be applied to these areas[9].

Providing the patient with education on about the cancer and its implications can also be beneficial in physical therapy management. Energy conservation and work simplification can also assist patients in reducing and controlling symptoms[9]. Patient education can also include the use of assistive devices if necessary. "Immune function may be improved by moderate exercise."[9] Exercise should be implemented at low intensity levels[9].

Differential Diagnosis[edit | edit source]

Typically, at the time of diagnosis of pancreatic cancer, 52% have distant metastasis, and 23% have local spread.

Differential diagnosis before imaging and biopsy includes the following: acute pancreatitis, chronic pancreatitis, cholangitis, cholecystitis, choledochal cyst, peptic ulcer disease, cholangiocarcinoma, and gastric cancer.[6]

References[edit | edit source]

  1. ↑ Li C, Heidt DG, Dalerba P, Burant CF, Zhang L, Adsay V, Wicha M, Clarke MF, Simeone DM. Identification of pancreatic stem cells. Cancer research. 2007 Feb 1;67(3): 1030-1037
  2. ↑ 2.0 2.1 2.2 Shore S, Vimalachadran D, Raraty MGT, Ghaneh P. Cancer in the elderly: pancreatic cancer. Surgical Onocology 2004;13:201-210
  3. ↑ 3.0 3.1 Better Health Pancreratic Cancer Available:https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pancreatic-cancer#diagnosis-of-pancreatic-cancer (accessed 3.9.2021)
  4. ↑ 4.0 4.1 4.2 Radiopedia pancreatic Cancer Available: https://radiopaedia.org/articles/pancreatic-ductal-adenocarcinoma-2 (accessed 3.9.2021)
  5. ↑ Farma JM, Santillan AA, Melis M, Walters J, Belinc D, Chen D, Eikman EA, Malafa M. PET/CT fusion scan enhances CT staging in patients with pancreatic neoplasms. Annals of Surgical Oncology 2008;15(9):2465-2471
  6. ↑ 6.0 6.1 6.2 Puckett Y, Garfield K. Pancreatic Cancer. InStatPearls [Internet] 2021 Aug 11. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK518996/ (accessed 3.9.2021)
  7. ↑ Extermann M. Interaction between comorbidity and cancer. Cancer Control 2007;14(1):13-22
  8. ↑ Borad MJ, Saadati H, Lakshmipathy A, Campbell E, Hopper P, Jameson G, Von Hoff DD, Wasif Saif M. Skeletal metastases in pancreatic cancer: a retrospective study and review of the literature. Yale Journal of Biology and Medicine 2009;82:1-6
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 Santiago-Palma J, Payne R. Palliative care and rehabilitation. Cancer Supplement 2001;92(4):1049-1052
  10. ↑ van Weert EV, May AM, Korstjens I, Post WJ, van der Schans CP, van den Borne B, Mesters I, Ros WJG, Hoekstra-Weebers JEHM. Cancer-related fatigue and rehabilitation: a randomized controlled multicenter trial comparing physical training combined with congnitive-behavioral therapy with physical training only and with no intervention. Physical Therapy 2010;90(10):1413-1425
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