Diagnosis and Management of Pancreatic Cancer



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Am Fam Physician. 2014 Apr 15;89(8):626-632.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on pancreatic cancer, written by the authors of this article

  Related Curbside Consultation: The Hospice Referral

Author disclosure: No relevant financial affiliations.

Pancreatic cancer remains the fourth leading cause of cancer-related deaths in the United States. Risk factors include family history, smoking, chronic pancreatitis, obesity, diabetes mellitus, heavy alcohol use, and possible dietary factors. Because more than two-thirds of adenocarcinomas occur in the head of the pancreas, abdominal pain, jaundice, pruritus, dark urine, and acholic stools may be presenting symptoms. In symptomatic patients, the serum tumor marker cancer antigen 19-9 can be used to confirm the diagnosis and to predict prognosis and recurrence after resection. Pancreas protocol computed tomography is considered standard for the diagnosis and staging of pancreatic cancer. Although surgical resection is the only potentially curative treatment for pancreatic ductal adenocarcinomas, less than 20% of surgical candidates survive five years. The decision on resectability requires multidisciplinary consultation. Pancreatic resections should be performed at institutions that complete at least 15 of the surgeries annually. Postoperatively, use of gemcitabine or fluorouracil/leucovorin as adjuvant chemotherapy improves overall survival by several months. However, more than 80% of patients present with disease that is not surgically resectable. For patients with locally advanced or metastatic disease, chemoradiotherapy with gemcitabine or irinotecan provides clinical benefit and modest survival improvement. Palliation should address pain control, biliary and gastric outlet obstruction, malnutrition, thromboembolic disease, and depression.

The American Cancer Society estimated 43,920 cases of pancreatic cancer, with approximately 37,390 deaths, in the United States in 2012. It remains the fourth leading cause of cancer-related deaths.1 The age-adjusted annual incidence rates of pancreatic cancer in men and women have been slowly increasing, but it remains an uncommon cancer. Although there is an equal prevalence in both sexes, there is a slightly higher occurrence in black persons compared with white persons.2 More than 90% of these cancers are pancreatic ductal adenocarcinomas, which are the focus of this review.3

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Pancreas protocol computed tomography is considered the standard for diagnosis and staging of pancreatic cancer.

C

14, 15

The decision on resectability requires multidisciplinary consultation, and distinction should be made between tumors that are resectable, borderline resectable, or unresectable.

C

20

Pancreatic resections should be performed at institutions that complete at least 15 of these surgeries annually.

B

2226

Adjuvant chemotherapy with gemcitabine (Gemzar) or fluorouracil/leucovorin improves overall survival in patients with resected pancreatic ductal adenocarcinomas (two to three months).

B

2830

Irinotecan (Camptosar), a new chemotherapeutic agent, is an option for patients with metastatic pancreatic adenocarcinoma to improve progression-free and overall survival.

B

31

For patients with locally advanced or metastatic pancreatic cancer, chemoradiotherapy with gemcitabine provides clinical benefit and modest survival improvement (two to three months).

B

3033

Placement of endoscopic biliary or enteral stents for biliary and gastric outlet obstruction provides palliative relief for persons with unresectable pancreatic cancer.

B

3740

For prevention of recurrent thromboembolic disease in persons with pancreatic cancer, low-molecular-weight heparin is preferred over warfarin (Coumadin).

B

42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Pancreas protocol computed tomography is considered the standard for diagnosis and staging of pancreatic cancer.

C

14, 15

The decision on resectability requires multidisciplinary consultation, and distinction should be made between tumors that are resectable, borderline resectable, or unresectable.

C

20

Pancreatic resections should be performed at institutions that complete at least 15 of these surgeries annually.

B

2226

Adjuvant chemotherapy with gemcitabine (Gemzar) or fluorouracil/leucovorin improves overall survival in patients with resected pancreatic ductal adenocarcinomas (two to three months).

B

2830

Irinotecan (Camptosar), a new chemotherapeutic agent, is an option for patients with metastatic pancreatic adenocarcinoma to improve progression-free and overall survival.

B

31

For patients with locally advanced or metastatic pancreatic cancer, chemoradiotherapy with ge

The Authors

MARIA SYL D. DE LA CRUZ, MD, is an instructor in the Department of Family and Community Medicine at Thomas Jefferson University in Philadelphia, Pa. At the time this article was written, she was a clinical lecturer and women's health fellow in the Department of Family Medicine at the University of Michigan School of Medicine in Ann Arbor.

ALISA P. YOUNG, MD, is a clinical lecturer in the Department of Family Medicine at the University of Michigan School of Medicine.

MACK T. RUFFIN, IV, MD, MPH, is the Dr. Max and Buena Lichter Research Professor and the associate chair for research programs in the Department of Family Medicine at the University of Michigan School of Medicine, and is a member of the University of Michigan Comprehensive Cancer Center in Ann Arbor.

Address correspondence to Mack T. Ruffin, IV, MD, MPH, University of Michigan School of Medicine, 1018 Fuller St., Ann Arbor, MI 48104-1213 (e-mail: mruffin@umich.edu). Reprints are not available from the authors.

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