Saving people like Jim from a hidden cancer

MEDICAL MATTERS: Disease of the pancreas is difficult to diagnose

I DIDN’T see much of Jim. A stoic individual in his 60s, he was the sort whose philosophy would be “not to bother the doctor” if at all possible. So when he came in to say he was looking for something for indigestion, I was immediately alert. It turned out he had been feeling unwell for about three months; despite trying a range of home and over-the-counter remedies, he couldn’t shift the daily feeling of mild nausea and indigestion. No, he had no abdominal pain, his weight was steady – he had no red flag symptoms to suggest he might have a serious illness.

My sixth sense was activated, and on that basis alone I suggested we run a few tests. I didn’t hear from him again for weeks, until a letter arrived from the consultant to whom I had referred Jim. The news wasn’t good: tests had found cancer of the pancreas, which was fairly well advanced.

Family doctors don’t see many cases of pancreatic cancer, which accounts for about 2 per cent of all invasive malignancies in Ireland. In most cases, unfortunately, the disease is well advanced before it causes symptoms and so the prognosis is not good. Just 6 per cent of patients are alive five years after diagnosis.

According to Dr Deirdre Murray of the National Cancer Control Programme (NCCP), since the incidence and mortality of pancreatic cancer will increase with age, the disease burden will rise in the future with population ageing and increasing life expectancy.

“Pancreatic cancer is predominantly a disease of older people. The median age of presentation in Ireland with pancreatic cancer is 72 years of age. Some 75 per cent of patients are over the age of 65 at the time of presentation,” she says.

These figures underline the importance of the recent opening of the National Pancreatic Surgical Centre at St Vincent’s Hospital in Dublin. With just 20 per cent of pancreatic tumours operable, outcomes for these patients should improve by centralising surgery in one location.

A multidisciplinary team led by consultant surgeon Justin Geoghegan will operate on all patients for whom surgery is appropriate, with chemotherapy and follow-up taking place at the patient’s local hospital.

Dr Susan O’Reilly, director of the NCCP, says she is especially delighted to have expert diagnostic services “all in the same room”, in order to make the crucial decision on whom to operate.

The new centre provides expertise in potentially curative but complex surgery called a Whipple procedure. It can succeed in removing the entire cancer and re-plumbing the small intestine.

Other patients will benefit by placing a small tube (stent) in the bile duct via a flexible telescope to resist compression from the surrounding tumour and to prevent unpleasant symptoms later in the illness.

Why is cancer of the pancreas so difficult to diagnose and treat? The main reason is its location behind the stomach at the back of the abdominal wall. The pancreas is shaped like a fish; extending horizontally, it has a wide head tapering to a narrow tail. The exocrine part of the gland produces a cocktail of enzymes that helps us digest fat, proteins and carbohydrates in food. These enzymes are released into a tube called the pancreatic duct, which carries the pancreatic juices into the small intestine. Exocrine glands and ducts are the source of the commonest type of pancreatic cancer.

But it’s not all bad news where cancer of the pancreas is concerned. In a paper just published in the journal Nature, doctors from John Hopkins University in Maryland have discovered pancreatic cancer develops and spreads much more slowly than previously thought. After the first cancer cell has appeared it takes an average of nearly seven years for that cell to turn into the billions that make up a cancerous tumour the size of a plum. At this point, at least one of the cells within the tumour has the potential to spread to other organs. The researchers say their findings contradict the idea that pancreatic cancers spread early in the disease.

It means that if we could develop an effective method of screening for cancer of the pancreas, we may be able to prevent the disease developing insidiously in people like Jim.