62
Pancreatic Cancer
Gaurav Aggarwal and Suresh T. Chari
Questions and Answers
Q1.An 80-year-old gentleman presents to you for a follow
up visit. He has a history of hypertension and coronary
artery disease. His brother was recently diagnosed with
pancreatic cancer at age 75. He would like to “be
checked to make sure he does not have it”. He is currently asymptomatic. Which of the following is the
most appropriate response to the patient’s request?
A.Order a pancreas protocol CT scan to look for pancreatic cancer.
B.Check a CA19-9 level. If it is elevated, then obtain
a pancreas protocol CT scan.
C.Check a fasting blood glucose. If it is >126, then
obtain a pancreas protocol CT scan.
D.Counsel the patient and explain that screening for
pancreatic cancer is not routinely recommended.
E.Refer the patient for an endoscopic ultrasound.
Answer: D.
Screening for pancreatic cancer remains a challenge
because of the absence of a high risk population and a
feasible screening test. Current guidelines do not recommend routine screening for pancreatic cancer.
Q2.A 70-year-old African-American male returns to see
you his annual physical examination. He is an athletic
gentleman without any chronic diseases. He exercises
regularly and eats a diet rich in fruits and vegetables.
He has smoked 1 pack of cigarettes a day since age 20.
He takes over the counter Ibuprofen 2–3 times a week
for headaches. He was adopted, so family history is not
available. He recently read an article about pancreatic
cancer being more common in African-American men
and wonders what you think he should do to prevent it.
You recommend:
A. “Stop the Ibuprofen.”
B. “Stop smoking.”
C. “It is very difficult to make any recommendations
without knowing your family history.”
D.“You can not do anything to reduce your risk of
pancreatic cancer.”
E.“Let us check a blood test for CA19-9 to see if you
have pancreatic cancer.”
Answer: B.
Numerous studies have demonstrated an increased risk
(relative risk 1.5–3) of pancreatic cancer in smokers,
likely related to aromatic amines. This risk increases
with greater intensity (³30 cigarettes/day), duration
(³50 years) and cumulative smoking dose (³40 packyears). The risk diminishes to baseline after 15 years of
smoking cessation. Diets rich in fat and meat are also
linked to the development of pancreatic cancer, while
fruits and vegetables have a protective effect against the
cancer. Studies of the association between pancreatic
cancer and alcohol, caffeine, NSAIDs have yielded
conflicting data and remain inconclusive.
Q3.An 87-year-old nursing home resident with a history of
vascular dementia is brought to the emergency room for
shortness of breath. He has multiple comorbidities
including hypertension, diabetes, coronary artery disease, and peripheral arterial disease. At baseline, he is
bed bound and nonverbal. A CT of the chest is performed
to rule out a pulmonary embolus. CT shows evidence of
a new pneumonia but no embolus. Incidental note is
made for a 3 cm hypo-attenuating lesion in the pancreatic head without evidence of vascular involvement. You
discuss the scan with the radiologist who suspects that
this is most likely pancreatic cancer, which is resectable.
The patient’s daughters, who are very involved in his
care, ask you “What will we do about this?”
A.Obtain a pancreas protocol CT scan to determine if
the mass is resectable.
B.Obtain an endoscopic ultrasound for FNA of the
mass.
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_62, © Springer Science+Business Media, LLC 2012
581
582
G. Aggarwal and S.T. Chari
C.No further testing, proceed with surgery since the
mass appears to be resectable.
D.Discuss palliative measure including hospice referral.
E.Recommend all his daughters be screened for pancreatic cancer.
Answer: D.
In this particular case regardless of the resectability of the
cancer, the patient is not a candidate for surgery or even
chemoradiation, given his severe physical and mental
debility. Therefore, further testing would not change management and should be avoided. A hospice referral for palliative management would be appropriate in this patient. If
this patient had been a surgical candidate, then a pancreatic protocol CT scan would be the next step in determining the resectability of the cancer. Routine screening for
pancreatic cancer is not recommended.