Barry retired 2 months ago, having recently turned 63. He prepared well for retirement, and has started working with a number of organisations he wishes to support in a voluntary capacity. Barry readily says that being able to spend more time with his grandchildren is what he has been most looking forward to in retirement. He had not felt unwell, though retrospectively realises that he had lost some weight. So, when he rapidly developed painless jaundice, it was a huge shock to discover that he has pancreatic cancer. His life, hopes and plans have been turned upside down.
The statistics around pancreatic cancer make disturbing reading: 10 000 new cases of pancreatic cancer are diagnosed each year in the UK. It has the worst 1y survival rate of any cancer. It is the 5th most common cause of cancer death, despite being the 11th most common cancer. Only 10% of cases will be resectable at the time of presentation.
Painless jaundice, the classic presentation of pancreatic cancer, is usually a relatively late symptom.
Our difficulty is that pancreatic cancer is easily missed because its symptoms can be vague and varied. Initial presenting features are often non-specific and are common to many other conditions which present in a similar age group, for example back pain or abdominal pain. To diagnose it early, we need a high degree of suspicion. Key points from the ‘top tips’ for GPs produced by Macmillan Cancer Support and Pancreatic Cancer UK include:
Consider pancreatic cancer:
- In patients with new-onset diabetes, especially if aged over 60 or if previously stable diabetes suddenly becomes unstable.
- If conditions such as GORD, gallstones, IBS, hepatitis or pancreatitis are not improving with treatment.
- In new-onset mechanical back pain associated with gastrointestinal symptoms.
- In repeated consultations for GI symptoms that are not resolving.
CT is the gold standard investigation for suspected pancreatic cancer.
NICE 2018 guidance highlights the ongoing need some will have for nutritional support, including pancreatic enzyme supplements. It also recognises the importance of psychological support where there are ongoing gastrointestinal symptoms, fatigue and pain. It notes that coeliac plexus block may be considered where pain management is complex.
In a recent webinar, we discussed pancreatic cancer: ‘the one that got away’. Professor Andrew Hart (a consultant Gastroenterologist at the Norfolk and Norwich University Hospital, and Pancreatic Cancer UK consultant) joined Dr David Plume (GP and Red Whale GP Update Cancer Course Director) for this webinar, which was produced in association with MacMillan Cancer Support.
Professor Hart describes it as the most aggressive cancer there is, with the worst prognosis of any cancer. He notes that the pancreas has lots of reserve. This, along with its retroperitoneal location, contribute to late presentation. The discussion covers risk factors (smoking, conditions causing insulin resistance, genetic factors, etc.) and how to approach those with more ‘nebulous symptoms’. It also covers treatment and longer-term issues for these patients: many may struggle with significant pain and psychological issues. And then there are issues around absorption.
This Pearl is produced in association with Macmillan Cancer Support and Pancreatic Cancer UK. As well as diagnosis and management, it looks at risk factors, genetics, screening for familial pancreatic cancer and tumour markers.
Click below to see our summary of: 2018 NICE guidance on the diagnosis and management of pancreatic cancer, as well as the 2015 NICE suspected cancer referral guidelines, along with articles from the Lancet and BMJ on pancreatic cancer, and 'top tips' for GPs from Macmillan Cancer Support and Pancreatic Cancer UK..
And click here to view the webinar (1h duration) on pancreatic cancer.