Pancreatic cancer - a cancer we still don't understand

- Medicine still does not fully understand the biology of pancreatic cancer. Why does it kill so quickly, even before the disease has spread? Why does it recur so often? Progress in systemic treatment of this cancer is unbearably slow, so therapies that additionally extend median survival by even a few months are successful, says Dr Leszek Kraj, from the Department of Oncology at the Medical University of Warsaw.

Approximately 4,000 Poles die each year from pancreatic cancer. What is the reason for this high number of deaths? Can you see any trends in the patient population in recent years?

Compared with other cancers, the prognosis is inauspicious. Unfortunately, in the case of pancreatic cancer, the number of deaths is almost equal to the number of cases. Five-year survival is only 8-9% of patients. It is detected most often in the form of already disseminated or locally advanced disease. Only 10% to 20% patients qualify for surgery, and even so, the risk of recurrence after surgery is high. As a result of the pandemic and difficult access to healthcare, advanced cases are far more numerous than before.

Instead, worldwide trends say that in 2030, this cancer will become the third or even second cause of cancer deaths, although today it is in 5th-7th place. And this is because we are getting better at treating other cancers and, although more people are getting the disease, fewer and fewer are dying. According to statistics, in the US, as many people died from pancreatic cancer in 2018 as from breast cancer, although six times as many people suffer from the latter.

Usually conversations about cancer are not easy. Is it possible to talk about pancreatic cancer treatment with optimism?

Unfortunately, we still do not understand the biology of this cancer. Why it kills so quickly, even before it has spread, annihilating its host. For example, in the case of very aggressive melanoma, if we cut it out early with adequate margins, in 90% we are assured that this is the end of treatment. Meanwhile, in the case of pancreatic cancer, we cut out the tumour within the boundaries of healthy organs, and it usually recurs anyway.

Nor do we know exactly why it kills so quickly. The pancreas is, after all, a non-critical organ, without which it is nowadays possible to live. There are patients who have their pancreas removed for various reasons. They are given digestive enzymes and supplemented with insulin. Then why is cancer developing in such an organ so dangerous? After all, we see patients with so-called neuroendocrine tumours of the pancreas. Even if significant pancreatic involvement or distant metastases are then observed in these patients, we are able to treat them for years. In the case of classic adenocarcinoma of the pancreas, and this is the most common type of pancreatic cancer, this is virtually impossible. The significant cachexia, or so-called tumour cachexia, that often accompanies this cancer is also a big mystery to us. Why do patients with a tumour size of 3-4 cm often lose several kilograms of body weight?

Can we speak of prevention in the case of pancreatic cancer?

We know the risk factors for this cancer. These include cigarette smoking, alcohol abuse, chronic pancreatitis, physical inactivity or obesity. But we are unable to offer any secondary prevention to patients in risk groups. We do not currently have the tools for early detection of this cancer through screening, as is the case with colorectal or breast cancer. Fortunately, it is a relatively rare cancer, yet we have several million people in our country who smoke, are obese or drink excessively. Approximately 4,000 to 5,000 people a year suffer from pancreatic cancer, while a total of 170,000 suffer from other cancers.

A patient hears a diagnosis of pancreatic cancer, and what next? What options does he have today?

The first option considered, as with other cancers, is surgical treatment. Physically getting rid of this cancer, if technically feasible, offers the chance of a complete cure. But only 10% to 20% patients qualify for such treatments. If the cancer is advanced, systemic treatment - chemotherapy - is used. In the first line of treatment, there are three basic regimens available today, which are selected according to the patient's condition. Recently, data have also emerged on so-called maintenance treatment for patients with BRCA1 and BRCA2 genetic mutations. These are drugs from the so-called PARP inhibitor group (olaparib).

In advanced pancreatic cancer, we can still speak of an unmet medical need. How does the drug Onivyde respond to this need?

We are running out of therapeutic options for second-line treatment. Liposomal irinotecan, a chemotherapeutic agent (irinotecan in this case) packaged in liposomes, penetrates better into the tumour tissues. The liposomes accumulate within the tumour and slowly release the drug, making it last longer. The combination of this drug with 5-Fluorouracil has been shown to extend median survival by approximately two months in patients treated with second-line therapy. This does not seem like much. However, in the case of pancreatic cancer, unlike, for example, breast or prostate cancer, extending median survival by 2 months in the absence of other therapeutic options is a significant advance. In Poland, this therapy is currently not yet reimbursed.

Source: medexpress.co.uk


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