Pancreatic cancer: the greatest oncological challenge

Pancreatic cancer: the greatest oncological challenge Cancer of the pancreas is probably the greatest oncological challenge in developed countries today.Firstly, it is common.Over 6000 Britons die of the disease each year.In the United States the incidence of pancreatic cancer has trebled over the past 50 years, and it is now the fourth leading cause of death from cancer.'Secondly, we know less about what causes it than we do about what causes most other common cancers.Thirdly, it is virtually incurable except for the occasional small tumour confined to the pancreatic head.(I exclude cystadenocarcinoma, islet cell cancer, and the rare solid and papillary neoplasm, which together comprise less than 5% of pancreatic tumours.)Fourthly, cure requires a major and hazardous operation, and even palliation is difficult.Pancreatic cancer is common in the old, men, blacks, and cigarette smokers.'There are also weak links with urbanisation, occupational carcinogens, coffee, and alcohol.Gall stone disease, chronic pancreatitis, and diabetes probably confer an increased risk, and, like other diseases seen mainly in developed countries, pancreatic cancer may have a dietary basis, although the agent is unknown.The development of good experimental tumour models may clarify some of these mysteries.As with most cancers the size and stage of the tumour at presentation profoundly influence outcome.Generally 80-90% of patients have metastases at diagnosis, and the five year survival rate is a fraction of 1%.2But for tumours less than 2 cm in diameter a Japanese study reports a five year survival rate (after resection) of 37%.3 Thus the hunt is on for small tumours.Unfortunately the first symptoms are non-specific-malaise, anorexia, weight loss, change in bowel habit,, and epigastric discomfort.4Heralded by pruritus, obstructive jaundice is often a late development; once present it progresses relentlessly and adds to the risks of an operation.Severe pain radiating to the back usually means that it will not be possible to resect the tumour.The recent onset of diabetes is reported in up to a third of patients and may offer a clue to early diagnosis.4Likewise, a sudden increase in insulin requirement should raise the suspicion of cancer in a diabetic.Lastly, migratory thrombophlebitis may be the presenting feature.Pancreatic imaging has improved enormously over the past 20 years with the introduction of ultrasonography, computed tomography, endoscopic retrograde cholangiopancreatography, and selective angiography; magnetic resonance imaging and positron emission tomography may prove to be further refinements.Biopsy specimens can be