Pancreatic Cancer Awareness Month

Pancreatic cancer remains a difficult malignancy to treat. Pancreatic Ductal Adenocarcinoma (PDAC) is notoriously challenging, as a large proportion are inoperable at presentation and many early-stage cancers recur even after surgical resection. Pancreatic Neuroendocrine tumour (PNET) is less common and offers a more favourable prognosis.

Institutions are devoting considerable resources to overcome this challenge, and there are reasons to be cautiously optimistic as we’ve made significant progress in recent years. It’s worth reflecting on some of these during this Pancreatic Cancer Awareness Month.

Recent advances

Innovative surgical approaches

Surgery remains the only path to cure, and advances in operative techniques have given us more options to achieve resections with curative intent. These include dissection techniques to reduce the risk of local recurrence through a more complete clearance of the surrounding soft tissue. Portal vein involvement, common in more advanced disease, are now managed with well-described techniques for resection and reconstruction. Arterial involvement, long considered a no-go zone, can be managed with new approaches, however, this is remains experimental and should only be offered to very selected patients in specialised, high-volume centres.

Neoadjuvant chemotherapy

Neoadjuvant therapy, given prior to surgery, serves several purposes. It offers downstaging of borderline resectable and initially unresectable PDAC (up to 60% can be converted to resectable with modern regimes). It also offers a ‘test of biology’ so that patients with rapidly progressing tumours i.e., poor biology are spared high-risk surgery for little to no benefit. Finally, even patients with early-stage resectable disease are sometimes offered upfront chemotherapy to treat presumed micrometastases, however, trials are underway to understand the additional benefit of this approach.

The road ahead

Early detection

There are currently no viable screening strategies for PDAC. Its low incidence in the general population combined with the low specificity of CA-19.9 makes the likelihood of false positives unacceptably high. Our current strategy of surveilling people at known increased risk – family history, chronic pancreatitis, pancreatic cystic lesions – captures a substantial, but relatively small proportion of people with PDAC. Recently, people over 50 years of age with new onset diabetes have emerged as a promising group of interest for early detection strategies. There are multiple centres working on the details of how early detection might be pursued in this group (what test, how often, etc.), and develop trial protocols gather evidence of the benefits and risks.  

Novel systemic therapies

We now know that PDAC is in fact a heterogenous group of cancers that vary in prognosis and treatment response. There has been a surge in research into how we may differentiate them based on molecular subtypes and genomic expressions to develop therapies that overcome PDAC’s resistance to standard chemotherapy. New classes of therapy are being rigorously studied: (i) Immunotherapy, which recruits the body’s own defence system to fight cancer cells; (ii) Targeted therapy, which targets specific proteins present on cancer cells; (iii) Therapies that target the tumour microenvironment as a means to influence tumour behaviour and response to treatment. 

All this new development means that it is essential for patients to be assessed and treated in specialised, experienced centres within a multi-disciplinary team setting.

Dr Lim offers surgical treatment of pancreatic cancers in Canberra and makes every effort to see patients with new cancer diagnoses within a week. He performs high-risk complex cases in Sydney.

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