Pancreatic cancer is the fourth most common cause of cancer-related mortality in the Unites States[1] . Approximately 85% of pancreatic cancers are ductal adenocarcinomas, which are discussed here. Less common pancreatic tumors include endocrine tumors, carcinoid tumors, and lymphoma.

The characteristic presentation includes an insidious onset of weight loss, fatigue, anorexia, and gnawing abdominal or back pain. The most common symptom is epigastric pain with radiation to the back, which often improves upon bending forward. In addition, painless jaundice, dark urine, acholic stools, pruritis, migratory thrombophlebitis, or Courvoisier sign (a palpable, nontender gallbladder) may be present.[2]

Unfortunately, by the time symptoms appear, the cancer has often become quite advanced. At the time of diagnosis, more than 80% of patients have advanced tumors marked by either local extension into adjacent organs (such as the liver) or distant metastases, resulting in a poor long-term survival rate. Most patients die within a year of diagnosis.

Risk Factors

Age: The condition is rare before age 45, but increases thereafter with age.[3]

Gender: Males have a slightly higher risk than females with a ratio of 1.3-1.[4]

Race: Blacks have a slightly higher incidence of pancreatic cancer than whites.[4]

Smoking: Cigarette smoking is one of the major risk factors for developing pancreatic cancer and accounts for approximately 25% of all cases.[5]

Obesity: Excess weight increases the risk of pancreatic cancer.[6]

Physical inactivity: The lack of physical activity is a risk factor.[7]

Diabetes and insulin resistance: Both diabetes and insulin resistance are associated with an increased risk of pancreatic cancer.[8] ,[9] There is also some evidence that diabetes can be a consequence of pancreatic cancer, rather than the cause.[10]

Chronic Pancreatitis: The presence of chronic inflammation of the pancreas increases the risk of pancreatic cancer. One study showed that individuals with chronic pancreatitis had a standardized incidence ratio (the ratio of observed to expected cases) of 26.3.[11]

Family history: About 5%-10% of patients with pancreatic cancer have a first-degree relative with the disease.[12] Most of these cases have no clearly defined gene mutation. However, there are also several clearly defined genetic syndromes, including Peutz-Jeghers syndrome, hereditary breast/ovarian cancer syndrome and familial adenomatous polyposis, that carry a predisposition for pancreatic and other types of cancer.[13] Hereditary pancreatitis (autosomal dominant) is a rare form of chronic pancreatitis which carries an increased risk of pancreatic cancer.[14]

ABO blood type: Having a non-O blood type carries an increased[15] risk for pancreatic cancer.

Periodontal disease: Several studies show that periodontal disease is associated with an increased risk of pancreatic cancer.[16] ,[17]

Alcohol: Heavy alcohol use is also associated with increased pancreatic cancer risk.[18]

Dietary factors: (see Nutritional Considerations).

Diagnosis

Patients with unexplained weight loss, painless jaundice or subacute epigastric pain without other obvious cause should undergoing further evaluation with laboratory testing for liver function. Tests for lipase and amylase should also be done if pain is the presenting symptom. In addition, an abdominal CT scan should be performed. Abdominal ultrasound is sometimes used, but is less sensitive.

For patients with a suspicious pancreatic mass who are reasonable surgical candidates, surgical resection is most often recommended. Patients who are not surgical candidates or have a high suspicion of metastatic disease require a biopsy for a definitive diagnosis. This can be done percutaneously or endoscopically. Endoscopic options include cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS).

Once a diagnosis is made, the tumor is staged using the tumor-node-metastasis (TNM) system to determine if it is resectable. This is usually done with CT, MRI, PET scanning or staging laparoscopy, depending on the clinical situation.

Treatment

Despite advances in treatment, the prognosis for pancreatic cancer remains poor, and surgical resection is the only curative treatment. Only about 15%-20% of pancreatic cancers are found to be potentially resectable at the time of diagnosis. Common surgical procedures include pancreaticoduodenectomy (the Whipple procedure), which involves removal of the duodenum, head of the pancreas, and gallbladder, and t otal or distal pancreatectomy. Treatment with chemotherapy and/or radiation following surgery may improve survival rates.

If the tumor is unresectable, palliation may be attempted via radiation, chemotherapy, or surgical intervention to relieve bile duct and GI tract obstructions. Adequate pain control is also an important part of palliative care.

Nutritional Considerations

The risk for pancreatic cancer appears to be significantly related to insulin resistance. Obesity, diabetes, lack of exercise, and diets known to impact insulin resistance and risk for malignancy in general are known to moderate risk. Evidence indicates that the major dietary determinants of increased pancreatic cancer risk include meat and other sources of animal fat, while fruits, vegetables, and whole grains, appear to reduce risk. 19,20

Avoiding animal products. In the NIH-AARP Diet and Health study, the risk for pancreatic cancer was 20% greater in those eating the most meat, compared with those eating the least. Red meat, high-temperature cooked meat, and heme iron from red meat were all associated with roughly 20% greater risk, comparing the highest vs. lowest consumers. Risk increased to over 30% greater in frequent consumers of "well done” or “very well done” meat, compared with those who generally avoid meat cooked in this fashion.[19] Part of this risk has been attributed to the proinflammatory effects of advanced glycation end products found in meat.[20] Conversely, intake of beans, lentils, other plant foods is associated with significantly reduced risk for pancreatic cancer. [3]

Reducing fat intake. Higher compared with lower intakes of animal fat were associated with a 43% greater risk for pancreatic cancer in the NIH-AARP Diet and Health study.[21] Similarly, in a group of 27,111 male smokers aged 50-69 years who were followed for a 12-year period, those who ate the most saturated fat had a significantly higher risk for pancreatic cancer, compared with nonsmokers who ate the least saturated fat.[22] On the other hand, evidence indicates that individuals consuming the highest amount of polyunsaturated fat have a 13% lower risk for pancreatic cancer, compared with those eating the least.[23]

Increasing consumption of fruits, vegetables, and whole grains. Higher compared with lower fruit and vegetable intakes are associated with a roughly 25% lower risk for pancreatic cancer,[24] and cruciferous vegetables may be especially protective.[25] Consuming the highest dietary amounts of selenium, vitamin C, vitamin E, β-carotene and β-cryptoxanthin was associated with a 30%-53% lower risk for pancreatic cancer.[26] Intake of the highest amount of whole grains was associated with a roughly 25% lower risk for pancreatic cancer, compared to the lowest intakes.[27]

Weight control. Individuals at a body mass index (BMI) of 25 and below are at low risk for pancreatic cancer, but the risk increases by 10% as BMI increases from 25-30, and the risk is greatest at a BMI over 35.[28] Exercise is weakly yet statistically significantly associated with a lower risk for pancreatic cancer.[29]

Limiting or avoiding alcohol. As noted above, heavy alcohol use is associated with pancreatic cancer risk. Avoiding or limiting alcohol use has many potential benefits, in addition to potentially reducing pancreatic cancer risk.[30]

Diet and Prognosis for Pancreatic Cancer

Few studies have examined the effect of dietary changes on survival after diagnosis. One study found a 4-fold increase in median survival (13 months versus 3 months) in patients with pancreatic cancer who followed a macrobiotic diet (composed mainly of whole grains, land and sea vegetables, beans, legumes, and small amounts of fruit) compared with those eating omnivorous diets.[31] Other studies have revealed a longer survival in patients taking an omega-3 fatty acid-containing supplement when compared with those on conventional nutrition therapy.[32] Further studies are needed to establish relationships between diet and pancreatic cancer survival.

Orders

See Basic Diet Orders Chapter

Smoking cessation.

Exercise prescription.

What to Tell the Family

Pancreatic cancer typically has a poor prognosis. While dietary factors appear to play a role in risk and possibly in survival, further studies are necessary to clarify these relationships.

References

  1. Siegel RL, Miller KD, Jemal A: Cancer statistics, 2016. CA Cancer J Clin 66:7, 2016 Jan-Feb  [PMID:26742998]
  2. Porta M et al: Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage. Clin Transl Oncol 7:189, 2005  [PMID:15960930]
  3. Zhang J et al: Patterns and trends of pancreatic cancer mortality rates in Arkansas, 1969-2002: a comparison with the US population. Eur J Cancer Prev 17:18, 2008  [PMID:18090906]
  4. Ries LA, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1973-1996. National Cancer Institute, Bethesda, MD 2000.
  5. Lowenfels AB, Maisonneuve P: Epidemiology and risk factors for pancreatic cancer. Best Pract Res Clin Gastroenterol 20:197, 2006  [PMID:16549324]
  6. Li D et al: Body mass index and risk, age of onset, and survival in patients with pancreatic cancer. JAMA 301:2553, 2009  [PMID:19549972]
  7. Stolzenberg-Solomon RZ et al: Adiposity, physical activity, and pancreatic cancer in the National Institutes of Health-AARP Diet and Health Cohort. Am J Epidemiol 167:586, 2008  [PMID:18270373]
  8. Huxley R et al: Type-II diabetes and pancreatic cancer: a meta-analysis of 36 studies. Br J Cancer 92:2076, 2005  [PMID:15886696]
  9. Wolpin BM et al: Hyperglycemia, insulin resistance, impaired pancreatic β-cell function, and risk of pancreatic cancer. J Natl Cancer Inst 105:1027, 2013  [PMID:23847240]
  10. Chari ST et al: Pancreatic cancer-associated diabetes mellitus: prevalence and temporal association with diagnosis of cancer. Gastroenterology 134:95, 2008  [PMID:18061176]
  11. Lowenfels AB et al: Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group. N Engl J Med 328:1433, 1993  [PMID:8479461]
  12. Olson SH, Kurtz RC: Epidemiology of pancreatic cancer and the role of family history. J Surg Oncol 107:1, 2013  [PMID:22589078]
  13. Brentnall TA: Management strategies for patients with hereditary pancreatic cancer. Curr Treat Options Oncol 6:437, 2005  [PMID:16107246]
  14. Klein AP: Genetic susceptibility to pancreatic cancer. Mol Carcinog 51:14, 2012  [PMID:22162228]
  15. Wolpin BM et al: ABO blood group and the risk of pancreatic cancer. J Natl Cancer Inst 101:424, 2009  [PMID:19276450]
  16. Michaud DS et al: A prospective study of periodontal disease and pancreatic cancer in US male health professionals. J Natl Cancer Inst 99:171, 2007  [PMID:17228001]
  17. Chang JS et al: Investigating the Association Between Periodontal Disease and Risk of Pancreatic Cancer. Pancreas 45:134, 2016  [PMID:26474422]
  18. Lucenteforte E et al: Alcohol consumption and pancreatic cancer: a pooled analysis in the International Pancreatic Cancer Case-Control Consortium (PanC4). Ann Oncol 23:374, 2012  [PMID:21536662]
  19. Taunk P, Hecht E, Stolzenberg-Solomon R: Are meat and heme iron intake associated with pancreatic cancer? Results from the NIH-AARP diet and health cohort. Int J Cancer 138:2172, 2016  [PMID:26666579]
  20. Jiao L et al: Dietary consumption of advanced glycation end products and pancreatic cancer in the prospective NIH-AARP Diet and Health Study. Am J Clin Nutr 101:126, 2015  [PMID:25527756]
  21. Larsson SC et al: Meat, fish, poultry and egg consumption in relation to risk of pancreatic cancer: a prospective study. Int J Cancer 118:2866, 2006  [PMID:16385571]
  22. Stolzenberg-Solomon RZ et al: Prospective study of diet and pancreatic cancer in male smokers. Am J Epidemiol 155:783, 2002  [PMID:11978580]
  23. Yao X, Tian Z: Saturated, Monounsaturated and Polyunsaturated Fatty Acids Intake and Risk of Pancreatic Cancer: Evidence from Observational Studies. PLoS ONE 10:, 2015  [PMID:26110621]
  24. Wu QJ et al: Consumption of fruit and vegetables reduces risk of pancreatic cancer: evidence from epidemiological studies. Eur J Cancer Prev 25:196, 2016  [PMID:26075658]
  25. Li LY et al: Cruciferous vegetable consumption and the risk of pancreatic cancer: a meta-analysis. World J Surg Oncol 13:, 2015  [PMID:25889229]
  26. Burney PG, Comstock GW, Morris JS: Serologic precursors of cancer: serum micronutrients and the subsequent risk of pancreatic cancer. Am J Clin Nutr 49:895, 1989  [PMID:2718925]
  27. Lei Q et al: Whole Grain Intake Reduces Pancreatic Cancer Risk: A Meta-Analysis of Observational Studies. Medicine (Baltimore) 95:, 2016  [PMID:26945361]
  28. Aune D et al: Body mass index, abdominal fatness and pancreatic cancer risk: a systematic review and non-linear dose-response meta-analysis of prospective studies. Ann Oncol 23:843, 2012  [PMID:21890910]
  29. Behrens G et al: Physical activity and risk of pancreatic cancer: a systematic review and meta-analysis. Eur J Epidemiol 30:279, 2015  [PMID:25773752]
  30. Gupta S et al: Risk of pancreatic cancer by alcohol dose, duration, and pattern of consumption, including binge drinking: a population-based study. Cancer Causes Control 21:1047, 2010  [PMID:20349126]
  31. Carter JP et al: Hypothesis: dietary management may improve survival from nutritionally linked cancers based on analysis of representative cases. J Am Coll Nutr 12:209, 1993  [PMID:8409076]
  32. Ma YJ et al: The consumption of omega-3 polyunsaturated fatty acids improves clinical outcomes and prognosis in pancreatic cancer patients: a systematic evaluation. Nutr Cancer 67:112, 2015  [PMID:25425246]

Last updated: January 12, 2018

Citation

* When formatting your citation, note that all book, journal, and database titles should be italicized* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Pancreatic Cancer ID - 1342011 Y1 - 2018/01/12/ PB - Nutrition Guide for Clinicians UR - https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342011/all/Pancreatic_Cancer ER -