Pancreatic cancer natural history, complications and prognosis

Patients with pancreatic cancer present with symptoms such as jaundice, light-colored stools, dark urine, and epigastric pain in the sixth decade of life. If left untreated, patients with pancreatic cancer may progress to develop exocrine pancreatic insufficiency arising from pancreatic duct obstruction leading to malabsorption, malnutrition and cachexia. Common complications of pancreatic cancer include intractable pain and obstructive jaundice that develop as a result of surgical intervention. Depending on the extent of the tumor at the time of diagnosis, the prognosis is generally regarded as poor, with complete remission being extremely rare.

The natural history of pancreatic cancer is as follows:^[1][2][3]

• The symptoms of pancreatic cancer usually develop in the sixth decade of life, and start with symptoms such as jaundice, light-colored stools, dark urine, pain in the upper or middle abdomen and back, unexplained weight loss, anorexia and fatigue.
• The symptoms of pancreatic cancer typically develop about 20-30 years after exposure to risk factors such as smoking and alcohol. Genetic factors such as alterations in tumor suppressor genes, oncogenes and different signaling pathways may also be responsible.
• If left untreated, patients with pancreatic cancer may progress to develop exocrine pancreatic insufficiency arising from pancreatic duct obstruction leading to malabsorption, malnutrition and cachexia. Dudodenal obstruction and biliary obstruction may cause symptoms of bowel obstruction and jaundice. Metastasis may occur to different sites.

Common complications of pancreatic cancer may arise as a result of the disease or therapy:^{[4][5][6][7][8][9][10]}

• Malabsorption
  • Exocrine pancreatic insufficiency due to pancreatic duct obstruction by the tumor may lead to malabsorption. Malabsorption in patients presents with anorexia, weight loss, and diarrhea.
• Intractable pain
  • Patients with advanced pancreatic cancer may develop intractable pain requiring narcotic analgesics and surgical intervention such as neurolysis of celiac ganglia.^[4][11]
• Jaundice
  • Obstructive jaundice can present with features of cholangitis:
    • Fever and chills
    • Nausea, vomiting
    • Clay-colored stools
    • Dark urine
    • Yellowish discoloration of skin
    • Pruritus
    • Right upper quadrant pain
    • Anorexia
• Patients may require Endoscopic decompression with stent placement in patients due to biliary obstruction.
• Duodenal obstruction
  • Patients may develop duodenal obstruction as a result of complications of surgery.
  • Duodenal obstruction may be treated with endoscopic stenting or gastrojejunostomy.

• The primary factors that influence prognosis are:
  • Whether the tumor is localized and can be completely resected
  • Whether the tumor has spread to lymph nodes or elsewhere

Staging and TNM (tumour, lymph node, metastasis) classification related to incidence, treatment, and prognosis:^[12]

• The percentage of people who live for a minimum of five years after diagnosis is called the 5- year survival rate.
• Survival rates for exocrine pancreatic cancer:
  • Lifespan is found to be longer in patients treated with surgery, as opposed to other patients.
  • The 5-year survival rate for people at various stages of pancreatic cancer are as follows based on the most recent statistics of the American Cancer Society are as follows:^[13][14]

• • • Stage IA: 14%
    • Stage IB: 12%
    • Stage IIA 7%
    • Stage IIB 5%
    • Stage III 3%
    • Stage IV 1%
  • Survival rates for neuroendocrine pancreatic tumors (treated with surgery) are as follows:
    • Stage I pancreatic NETs 61%
    • Stage II pancreatic NETs 52%
    • Stage III pancreatic NETs 41%
    • Stage IV pancreatic NETs 16%
  • Five year survival rate of tumors not removed by surgery is 16%

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