In a new report, published in the American Association for Cancer Research’s journal, Cancer Research, The Pancreatic Cancer Action Network in Manhattan Beach, Calif., projects that lung cancer will remain the number one cause of cancer-related death, and that pancreatic and liver cancers will surpass breast, prostate, and colorectal cancers to become the second and third leading causes of cancer death, respectively.
Healthline sat down with two cancer experts to discuss the report's findings.
Pointing out that the rate of pancreatic cancer incidence and death has been increasing for about 15 years, Otis W. Brawley, M.D., chief medical officer of the American Cancer Society (ACS), told Healthline he is skeptical about the report's projections.
“The assumptions that colorectal, prostate, and breast cancer mortality will continue going downward in the way they have gone down in the last 20 years are off. We have had a drop in breast cancer death rates over the last 20 years of 35 percent. I hope these assumptions are correct, but knowing the patterns of cancer in the U.S., I cannot say it is definitely going to happen.”
Obesity and Smoking Are Problematic in U.S.
Citing obesity for the increase in pancreatic cancer, Brawley said, “In the 1970s, the American population started having tremendous obesity problems. Twenty to 30 years of obesity increases one’s risk of getting pancreatic cancer dramatically. You don’t see these rises (in pancreatic cancer) in European or Asian countries, which don’t have the obesity epidemic. It makes us think obesity is more of a factor than smoking, but smoking is clearly a risk factor, as is excessive alcohol.”
Weight gain later in life, such as from menopause, increases the risk for 11 other cancers, in addition to pancreas, said Brawley, pointing out that 15 percent of American adults were obese in 1970 versus over 35 percent today. Fifty percent of black female adults are obese; 43 to 45 percent of Hispanics are obese; and 45 percent of Mexican-American Hispanics are obese. Men are five to 10 percentage points lower than women.
Environmental Factors, History of Pancreatitis
Celina Ang, M.D., assistant professor at the Icahn School of Medicine at Mount Sinai in New York, told Healthline that the rise in pancreatic cancer is also due to the fact that people are living longer and over time they have cumulative exposure to environmental factors, such as toxins.
Ang continued, “A history of pancreatitis, which is an inflammation of the pancreas, due to number of factors, including alcohol, gall stones, medications, and certain medical procedures, and family history, are also factors.”
In addition to being high risk factors, Ang said that obesity and smoking can also complicate treatment and make it more difficult for pancreatic patients to tolerate treatment.
Pancreatic Cancer Is Not Detected Early
Pointing out that success in treating cancers of the prostate, colon, breast, and lung is based on finding these cancers early, when they are still confined, Brawley said, “The very biologic nature of the pancreas is that it does not have the outer surface layer of tissue to confine the tumor. It is in a position in the middle of the abdomen; when spread starts in the pancreas, you have a local tumor. All of a sudden, little pieces break off and go all over the abdomen. The spread in breast and lung is local and then it gets farther away from the primary tumor. Pancreatic cancer goes from stage one to stage four very quickly and very early.”
Jeanne Digangi knows the angst of being diagnosed with pancreatic cancer. After having one of her kidneys removed, which was cancerous, she underwent MRIs. After one such test, her doctor told her he had found a spot on her pancreas.
“That was almost two years ago. I was recommended to a surgeon. The surgeon said they can remove it,” Digangi said.
But after being scheduled for surgery, when Digangi came out of the operating room and into the recovery room, she was told the surgeons couldn't operate.
“I had a feeling. I asked why. They said there were a couple of spots; we felt it would be better if we didn't operate,” said Digangi. For 15 months Digangi underwent chemotherapy treatments, which she received from a port that was inserted in her breast.
Acknowledging that she was a smoker for many years and that she is overweight, Digangi said many of her relatives, including her parents, have died from cancer.
“Every six months they would give me an MRI and check to see if this tumor is growing. This past March they did laparoscopic surgery to see if the nodules were still there. They said the tumor looked better than when they first saw it. They did a biopsy on those nodules and those were not cancer. At that point they gave me three options: You can have surgery, stop chemo and we will watch you, or you can continue on your chemo. I chose to continue. I didn't want the surgery. I didn't want to stop the chemo, because it is holding everything at bay. Now I am taking chemo pills,” said Digangi.
One thing that is immediately noticeable upon speaking with Digangi is that she has a love of life and a love for the people who treat her at Mount Sinai in New York. She is also the epitome of a “trooper” and she is very optimistic.
Radiation and Chemotherapy
When queried about advancements in treatments and screenings, Brawley said that using chemo and radiation after surgery has helped to improve the cure rate and survival rate, "but the nature of the tumor, and the fact it has already started feeding off metastasis, makes a screening test very difficult.”
Ang pointed out that a few inherited cancer syndromes are associated with pancreas cancer, such as people who harbor BRC mutations. “Those (mutations) are typically found in individuals of Ashkenazi Jewish descent, with a history of ovarian, prostate, and male breast cancer, but that only includes a small percentage of the population. Unfortunately, somebody has to be diagnosed first, to present to us, and then based on their family history, that might lead us to screen family members and identify other people at risk for whom screening measures could be implemented,” Ang said.
Noting that the majority of pancreas cancers present in the head of the pancreas, Ang said, “There are a lot of important anatomical structures running through that area. By the time the tumor grows to sufficient size, it may cause jaundice and that’s what alerts us. If a tumor arises in the tail of the pancreas, those tumors may not present until much later, because we aren’t necessarily alerted by the development of jaundice. The biology of pancreas cancer is it tends to disseminate early. It’s an aggressive cancer, and biologically it has a strong propensity to metastasize.”
About 40 percent of patients diagnosed with pancreas cancer have potentially operable cancer and surgery can be helpful, according to Ang.
“There’s always the concern, especially as the tumor stage becomes more advanced, that there could be microscopic cells that have already metastasized to distant sites, and those are not going to be addressed by surgery," said Ang.
She continued, "That’s where giving chemotherapy after surgery, and possibly radiation, comes in. The role of radiation is controversial, but we have good data showing that giving chemo after surgery has an adjuvant or preventative measure, and it can help to delay the time to cancer progressing and can improve survival. But it’s not a guarantee that the cancer will never return. “
The Diabetes Connection?
Commenting on studies that show a connection between diabetes and pancreatic cancer, Ang said many patients who develop pancreas cancer had a history of diabetes that became more difficult to control during the months, or even up to a year or two preceding their diagnosis.
“It’s only in retrospect we recognize this was a harbinger that pancreatic cancer was going to develop. In terms of which comes first, the chicken or the egg, it goes back to healthy lifestyle measures, such as exercise, watching one’s refined sugar intake, and avoiding alcohol and smoking.”
Ang recommended that people watch their weight, avoid toxins such as cigarette smoke, and eat a well-balanced diet high in fruits, vegetables, and fish. If they have diabetes, they should try to control the disease.
Acknowledging that pancreas cancer is a very aggressive disease, Ang said, “Within the population who have pancreas, even those with metastatic pancreas, there is a lot of heterogeneity. Research is being done to try to characterize the underpinnings of that heterogeneity. Why are certain patients, despite having metastatic disease, living longer and less symptomatic versus other patients who are much sicker?
Ang concluded, “Generally speaking, the symptoms can be quite vague, such as abdominal discomfort, weight loss, anorexia, and jaundice. Unfortunately, a lot of times development of these symptoms indicate pancreas cancer is fairly advanced; but again, improvements in surgical technique and in how we give chemo have been able to improve outcomes of patients. It’s still a work in progress.”