What is the pancreas?
The pancreas is an oblong flattened gland located deep in the abdomen. It is an integral part of the digestive system. It is about 6 inches long and is shaped like a flat pear. The widest part of the pancreas is the head, the middle section is the body, and the thinnest part is the tail.

Illustration: pancreas and nearby organs.

WHAT DOES THE PANCREAS DO?
The pancreas produces insulin and other hormones. These hormones help the body use or store the energy that comes from food. The pancreas also makes pancreatic juices which contain enzymes that help digest food. The pancreas releases the juices into a system of ducts leading to the common bile duct. The common bile duct empties into the duodenum, the first section of the small intestine.

Illustration: the pancreas, common bile duct, and small intestine.

WHAT IS CANCER?
Cancer is the illness or condition that is caused when cells multiply uncontrollably forming a growth or tumor and destroying healthy tissue.

WHAT IS THE DIFFERENCE BETWEEN A BENIGN OR MALIGNANT TUMOR?
Benign tumors are not cancer and are usually not life threatening. In most cases, benign tumors can be removed and do not come back. Cells from benign tumors do not spread to tissues around them or to other parts of the body.

Malignant tumors are cancer. The term malignant is used to describe a tumor that invades the tissue around it and may spread to other parts of the body.  Malignant tumors are more serious and may be life threatening.

HOW DOES CANCER SPREAD?
Cancer cells can break away from a malignant tumor and enter the bloodstream or lymphatic system. That is how cancer cells metastasize, or spread from the original cancer (primary tumor) to form new tumors in other organs.

WHERE DOES PANCREATIC CANCER BEGIN?
Most pancreatic cancers begin in the ducts that carry pancreatic juices. Cancer of the pancreas may be called pancreatic cancer or carcinoma of the pancreas.

WHAT IS ISLET CELL CANCER?
A rare type of pancreatic cancer that begins in the cells that make insulin and other hormones.

WHAT IS METASTATIC PANCREATIC CANCER?
When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if cancer of the pancreas spreads to the liver, the cancer cells in the liver are pancreatic cancer cells. The disease is metastatic pancreatic cancer, not liver cancer. It is treated as pancreatic cancer, not liver cancer.

IS PANCREATIC CANCER CONTAGIOUS?
No.  Cancer does not spread from person to person.

WHAT CAUSES PANCREATIC CANCER?
No one knows the exact causes of pancreatic cancer though research has shown that people with certain risk factors are more likely to develop pancreatic cancer. Risk factors include:

• Cigarette smoking - Cigarette smoke contains a large number of carcinogens (cancer causing chemicals.) Therefore, it is not surprising that cigarette smoking is one of the biggest risk factors for developing pancreatic cancer. According to some reports smokers have a 2-3 fold increased risk of developing pancreatic cancer.
• Age - The risk of developing pancreatic cancer increases with age. Over 80% of the cases develop between the ages of 60 and 80.
• Race - Studies in the United States have shown that pancreatic cancer is more common in the African-American population than it is in the white population. Some of this increased risk may be due to socioeconomic factors and to cigarette smoking.
• Gender - Cancer of the pancreas is more common in men than in women. This may be, in part, because men are more likely to smoke than women.
• Religious Background - Pancreatic cancer is proportionally more common in Jews than the rest of the population. This may be because of a particular inherited mutation in the breast cancer gene (BRCA2) which runs in some Jewish families.
• Chronic pancreatitis - Long-term inflammation of the pancreas (pancreatitis) has been linked to cancer of the pancreas.
• Diabetes - There have been a number of reports which suggest that diabetics have an increased risk of developing pancreatic cancer.
• Peptic ulcer surgery - Patients who have had a portion of their stomach removed (partial gastrectomy) appear to have an increased risk for developing pancreatic cancer.
• Diet - Diets high in meats, cholesterol fried foods and nitrosamines may increase the risk, while diets high in fruits and vegetables may reduce the risk of pancreatic cancer.

IF I THINK I MAY BE AT RISK, WHAT SHOULD I DO?
People who think they may be at risk for pancreatic cancer should discuss this concern with their doctor. The doctor may suggest ways to reduce the risk and can plan an appropriate schedule for checkups.

WHAT ARE THE SYMPTOMS?
In the early stages, pancreatic cancer is extremely difficult to detect because often there are no symptoms. But, as the cancer grows, symptoms may include:

• Pain in the upper abdomen or upper back
• Yellow skin and eyes, and dark urine from jaundice
• Weakness
• Loss of appetite
• Nausea and vomiting
• Weight loss

These symptoms are not sure signs of pancreatic cancer. An infection or other problem could also cause these symptoms. Only a doctor can diagnose the cause of a person's symptoms. Anyone with these symptoms should see a doctor so that the doctor can treat any problem as early as possible.

HOW IS PANCREATIC CANCER DIAGNOSED?
Pancreatic cancer can be difficult to detect and diagnose. A variety of techniques can be used to establish a diagnosis. These techniques include lab tests, CT scan, endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP).

Although all of these techniques may reveal a suspicious mass in the pancreas, by far the best diagnostic method remains histopathology.

Lab tests - The doctor may take blood, urine, and stool samples to check for bilirubin and other substances. Bilirubin is a substance that passes from the liver to the gallbladder to the intestine. If the common bile duct is blocked by a tumor, the bilirubin cannot pass through normally. Blockage may cause the level of bilirubin in the blood, stool, or urine to become very high. High bilirubin levels can result from cancer or from noncancerous conditions.

CT scan  (computed tomography) - An x-ray machine linked to a computer takes a series of detailed pictures. The x-ray machine is shaped like a donut with a large hole. The patient lies on a bed that passes through the hole. As the bed moves slowly through the hole, the machine takes many x-rays. The computer puts the x-rays together to create pictures of the pancreas and other organs and blood vessels in the abdomen.

Ultrasonography - The ultrasound device uses sound waves to produce a pattern of echoes as they bounce off internal organs. The echoes create a picture of the pancreas and other organs inside the abdomen. The echoes from tumors are different from echoes made by healthy tissues. The ultrasound procedure may use an external or internal device, or both types:

Transabdominal ultrasound - To make images of the pancreas, the doctor places the ultrasound device on the abdomen and slowly moves it around.

EUS (Endoscopic ultrasound) - The doctor passes a thin, lighted tube (endoscope) through the patient's mouth and stomach, down into the first part of the small intestine. At the tip of the endoscope is an ultrasound device. The doctor slowly withdraws the endoscope from the intestine toward the stomach to make images of the pancreas and surrounding organs and tissues.

ERCP (endoscopic retrograde cholangiopancreatography) - The doctor passes an endoscope through the patient's mouth and stomach, down into the first part of the small intestine. The doctor slips a smaller tube (catheter) through the endoscope into the bile ducts and pancreatic ducts. After injecting dye through the catheter into the ducts, the doctor takes x-ray pictures. The x-rays can show whether the ducts are narrowed or blocked by a tumor or other condition.

PTC (percutaneous transhepatic cholangiography) - A dye is injected through a thin needle inserted through the skin into the liver. Unless there is a blockage, the dye should move freely through the bile ducts. The dye makes the bile ducts show up on x-ray pictures. From the pictures, the doctor can tell whether there is a blockage from a tumor or other condition.

Biopsy - In some cases, the doctor may remove tissue. A pathologist then uses a microscope to look for cancer cells in the tissue. The doctor may obtain tissue in several ways. One way is by inserting a needle into the pancreas to remove cells. This is called fine-needle aspiration. The doctor uses x-ray or ultrasound to guide the needle. Sometimes the doctor obtains a sample of tissue during EUS or ERCP. Another way is to open the abdomen during an operation.

BIOPSY QUESTIONS

• What kind of biopsy will I have?
• How long will it take? Will I be awake? Will it hurt?
• Are there any risks?
• How soon will I know the results?
• If I do have cancer, who will talk to me about treatment? When?

WHAT IS STAGING?
When pancreatic cancer is diagnosed, the doctor needs to know the stage, or extent, of the disease to plan the best treatment. Staging is a careful attempt to find out the size of the tumor in the pancreas, whether the cancer has spread, and if so, to what parts of the body. The results of various diagnostic tests will indicate how far the cancer has progressed and determine the stage. Subsequent decisions about treatment will be based upon the stage assigned.

WHAT KINDS OF QUESTIONS SHOULD I ASK MY DOCTOR(S)?
The shock and stress that people may feel after a diagnosis of cancer can make it hard for them to think of everything they want to ask the doctor. Often it helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some patients also want to have a family member or friend with them when they talk to the doctor-to take part in the discussion, to take notes, or just to listen.  Always remember that the doctor is there to answer your questions dont be afraid to voice your opinion or question any action or procedure.

If you are meeting with a surgeon or oncologist for the first time, you may want to ask:

• Have you ever treated a PC patient before?
• If this is a surgeon, how many surgeries have you performed on PC patients?
• What has the general outcome of those patients been?
• Where were you trained? (medical school, residency)
• Which surgeons did you study under?

At any point in the relationship with your physician, you have the right to ask:

• What is the diagnosis?
• What treatments are recommended?
• Are there other treatment options available that you do not provide? (i.e. protocol treatments, herbal therapy, touch therapy, other alternative therapies)
• What are the benefits of each treatment?
• What are the side effects of each treatment?
• What are the medications being prescribed?
• What are they for?
• What are their side effects?
• Are there any clinical drug trials I can participate in?
• How should I expect to feel during the treatment(s)?
• What are the risks of the treatment(s)?
• Will my diet need to be changed or modified?
• Will I need to take enzymes, vitamins, etc?
• Do not forget to ask about the things that are most important to you:
• How will this affect my ability to work?
• Can this treatment be done as an outpatient so that I can spend more time at home with family?
• Will I have any physical limitations?
• How will my current lifestyle be changed?
• Finally - and most importantly - ask these questions of YOURSELF:
• Does my doctor appear interested in answering my questions?
• Or, does my doctor look annoyed when I ask questions, like I'm doubting their expertise or I am holding them up?
• Do I feel that my doctor cares about my medical outcome?

If you are uncomfortable with the results of some of these questions, you may want to re-evaluate your choice of physician or get a second opinion.

SHOULD I PARTICIPATE IN A CLINICAL TRIAL?
Cancer of the pancreas is very hard to control with current treatments. For that reason, many doctors encourage patients with this disease to consider taking part in a clinical trial. Clinical trials are an important option for people with all stages of pancreatic cancer.  For more information on Clinical Trials click here (link to HopeLink/Clinical trials section of website)

WHAT IS PALLIATIVE THERAPY?
Palliative therapy aims to improve quality of life by controlling pain and other problems caused by pancreatic cancer.

WHAT IS AN ONCOLOGIST?
An oncologist is a doctor who specializes in treating cancer. Specialists who treat pancreatic cancer include surgeons, medical oncologists, and radiation oncologists.

SHOULD I GET A SECOND OPINION?
Yes.  While some insurance companies require a second opinion; others may cover a second opinion if the patient requests it. Gathering medical records and arranging to see another doctor may take a little time. But in most cases, a brief delay to get another opinion will not make therapy less helpful.

There are a number of ways to find a doctor for a second opinion:

The Cancer Information Service (1-800-4-CANCER) can tell callers about treatment facilities, including cancer centers and other programs supported by the National Cancer Institute, and can send printed information about finding a doctor.

A local medical society, a nearby hospital, or a medical school can usually provide the name of specialists.

The Official ABMS Directory of Board Certified Medical Specialists lists doctors' names along with their specialty and their educational background. This resource is available in most public libraries.

The American Board of Medical Specialties (ABMS) also offers information by telephone and on the Internet. The public may use these services to check whether a doctor is board certified. The telephone number is 1-866-ASK-ABMS (1-866-275-2267). The Internet address is http://www.abms.org/newsearch.asp.

WHAT ARE THE AVAILABLE TREATMENT OPTIONS?
People with pancreatic cancer may have several treatment options. Depending on the type and stage, pancreatic cancer may be treated with surgery, radiation therapy, or chemotherapy. Some patients have a combination of therapies.  For more information, select one of the links below:

Link to treatment options.

WHEN IS SURGERY POSSIBLE?
Generally if the cancer is localized, surgical treatment, via resection or removal of the tumor, can be pursued. This means that the cancer has not spread to any blood vessels, distant lymph nodes or other organs, such as the liver or lung. These characteristics are determined through various diagnostic techniques.

WHAT TYPES OF SURGICAL PROCEDURES ARE PERFORMED TO TREAT PANCREATIC CANCER?
This depends where the tumor is located within the pancreas. The five parts of the pancreas are reviewed below. For a detailed explanation and illustrations of a particular surgical procedure, click on the name of the procedure.

Cancer in the Head, Neck or Uncinate Process of the Pancreas: The Whipple Procedure

Cancer in the Body or Tail of the Pancreas: Distal Pancreatectomy and Splenectomy

QUESTIONS TO ASK THE DOCTOR BEFORE SURGERY?

• What kind of operation will I have?
• How will I feel after the operation?
• How will you treat my pain?
• What other treatment will I need?
• How long will I be in the hospital?
• Will I need a feeding tube after surgery? Will I need a special diet?
• What are the long-term effects?
• When can I get back to my normal activities?
• How often will I need checkups?

WHAT IS RADIATION THERAPY?

Radiation therapy (also referred to as radiotherapy) uses high-energy rays to kill cancer cells.  Radiation therapy may be administered alone, or in combination with surgery, chemotherapy, or both.

QUESTIONS TO ASK THE DOCTOR BEFORE RADIATION THERAPY

• Why do I need this treatment?
• When will the treatments begin? When will they end?
• How will I feel during therapy? Are there side effects?
• What can I do to take care of myself during therapy? Are there certain foods that I should eat or avoid?
• How will we know if the radiation is working?
• Will I be able to continue my normal activities during treatment?

WHAT IS CHEMOTHERAPY?
Chemotherapy is the use of drugs to kill cancer cells. Doctors also give chemotherapy to help reduce pain and other problems caused by pancreatic cancer. It may be given alone, with radiation, or in combination with surgery and radiation.

Chemotherapy is systemic therapy and is most often delivered intravenuously. Once in the bloodstream, the drugs travel throughout the body.

Usually chemotherapy is an outpatient treatment. However, depending on which drugs are given and the patient's general health, the patient may need to stay in the hospital.

QUESTIONS TO ASK BEFORE CHEMOTHERAPY.

• Why do I need this treatment?
• What will it do?
• What drugs will I be taking? How will they be given? Will I need to stay in the hospital?
• Will the treatment cause side effects? What can I do about them?
• How long will I be on this treatment?

WHAT ARE THE POSSIBLE SIDE EFFECTS?
Because cancer treatment may damage healthy cells and tissues, unwanted side effects are common. These side effects depend on many factors, including the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. The health care team will explain possible side effects and how they will help the patient manage them.

Surgery
The side effects of surgery depend on the extent of the operation, the person's general health, and other factors. Most patients have pain for the first few days after surgery. Pain can be controlled with medicine, and patients should discuss pain relief with the doctor or nurse.

Removal of part or all of the pancreas may make it hard for a patient to digest foods. The health care team can suggest a diet plan and medicines to help relieve diarrhea, pain, cramping, or feelings of fullness. During the recovery from surgery, the doctor will carefully monitor the patient's diet and weight. At first, a patient may have only liquids and may receive extra nourishment intravenously or by feeding tube into the intestine. Solid foods are added to the diet gradually.

Patients may not have enough pancreatic enzymes or hormones after surgery. Those who do not have enough insulin may develop diabetes. The doctor can give the patient insulin, other hormones, and enzymes.

Radiation Therapy
Radiation therapy may cause patients to become very tired as treatment continues. Rest is important, but doctors usually advise patients to try to stay as active as possible. In addition, when patients receive radiation therapy, the skin in the treated area may sometimes become red, dry, and tender.

Radiation therapy to the abdomen may cause nausea, vomiting, diarrhea, or other problems with digestion. The health care team can offer medicine or suggest diet changes to control these problems. For most patients, the side effects of radiation therapy go away when treatment is over.

Chemotherapy
The side effects of chemotherapy depend on the drugs and the doses the patient receives as well as how the drugs are administered. As with other types of treatment, side effects vary from patient to patient.

Patients who undergo chemotherapy may also be more likely to get infections, bruise or bleed easily, and may have less energy. Since systemic therapy affects rapidly dividing cells, patients may lose their hair and may have other side effects such as poor appetite, nausea and vomiting, diarrhea, or mouth sores. Usually, these side effects go away gradually during the recovery periods between treatments or after treatment is over. The health care team can suggest ways to relieve side effects.

PAIN MANAGEMENT
How is pain controlled?
The management of pain for patients with pancreatic cancer is one of the most important aspects of their care. Pain is a common symptom that can be successfully controlled. The best management of pain is aggressive therapy with constant assessment. The patient with pancreatic cancer who is experiencing pain can maintain his/her quality of life. Pain can be relieved or reduced in several ways:

Medication
The use of opioids (or narcotics, the strongest pain relievers available) is the main way to treat pain from pancreatic cancer. Other types of medicines used to relieve pain that are not opioids are: acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs). At times, medicines called adjuvant analgesics are also used. These are medicines used for purposes other than the treatment of pain but help in relieving pain in some situations.

Types of Opioids Recommended for Pain of Pancreatic Cancer*

• codeine
• hydrocodone (Vicodin, Vicoprofen)
• hydromorphone (Dilaudid)
• levorphanol (Levo-Dromoran)
• morphine (Kadian, MSIR, MS Contin, Oramorph-SR)
• oxycodone (Roxicodone, OxyIR, OxyContin, Percodan)
• fentanyl (Duragesic, Actiq)
• methadone (Dolophine)
• tramadol (Ultram)
• MSIR=morphine sulfate immediate release
• MS Contin=morphine sulfate sustained release
• Oramorph-SR=morphine sulfate sustained release
• Roxicodone=oxycodone immediate release
• OxyIR=oxycodone immediate release
• OxyContin=oxycodone sustained release
• Percodan=oxycodone and immediate release
  *Opioids are available only by prescription

Non-Opioids Recommended for Pain of Pancreatic Cancer

acetaminophen
    Tylenol (classified as a non-opioid)

Radiation
High-energy rays can help relieve pain by shrinking the tumor.

Nerve block
The doctor may inject alcohol into the area around certain nerves in the abdomen to block the feeling of pain.

Surgery
The surgeon may cut certain nerves to block pain.

The doctor may suggest other ways to relieve or reduce pain. For example, massage, acupuncture, or acupressure may be used along with other approaches to help relieve pain. Also, the patient may learn relaxation techniques such as listening to slow music or breathing slowly and comfortably.

QUESTIONS TO ASK YOUR DOCTOR ABOUT PAIN CONTROL

• What can be done to relieve my pain?
• What can we do if the medicine does not work?
• What other options do I have for pain control?
• Will the pain medicines have side effects?
• What can be done to manage the side effects?
• Will the treatment limit my activities (i.e., working, driving, etc.)?

NUTRITION
(Insert article on nutrition from newsletter.)

ARE THERE SUPPORT GROUPS FOR PEOPLE WITH PANCREATIC CANCER?
Living with a serious disease such as pancreatic cancer is not easy. Some people find they need help coping with the emotional and practical aspects of their disease. Support groups can help. In these groups, patients or their family members get together to share what they have learned about coping with their disease and the effects of treatment.

People living with pancreatic cancer may worry about the future. They may worry about caring for themselves or their families, keeping their jobs, or continuing daily activities. Concerns about treatments and managing side effects, hospital stays, and medical bills are also common. Doctors, nurses, and other members of the health care team can answer questions about treatment, diet, working, or other matters. Meeting with a social worker, counselor, or member of the clergy can be helpful to those who want to talk about their feelings or discuss their concerns. Often, a social worker can suggest resources for financial aid, transportation, home care, emotional support, or other services. For more information or assistance please call (INSERT OUR CONTACT INFO/NUMBER)

WHAT ARE CLINICAL TRIALS?
Doctors in clinics and hospitals are searching for a cure.  In their efforts, they often conduct clinical trials. These are research studies in which people take part voluntarily. In these trials, researchers are studying ways to treat pancreatic cancer. Research already has led to advances in treatment methods, and researchers continue to search for more effective approaches to treat this disease.

Patients who join clinical trials have the first chance to benefit from new treatments that have shown promise in earlier research. They also make an important contribution to medical science by helping doctors learn more about the disease.

Although clinical trials may pose some risks, researchers take very careful steps to protect their patients.

In trials with people who have pancreatic cancer, doctors are studying new drugs, new combinations of chemotherapy, and combinations of chemotherapy and radiation before and after surgery. For more information on clinical trials please visit (SELECTED LINK)

WHAT ABOUT ALTERNATIVE TREATMENTS?
Biological therapy is also under investigation. Scientists are studying several cancer vaccines to help the immune system fight cancer. Other studies use monoclonal antibodies to slow or stop the growth of cancer.