The first question that any reasonable person with this diagnosis will ask is “Can I be cured from this cancer?“
And the simple answer is “yes” but “it depends ….“
Let’s first understand what we mean by cure, complete remission, response and survival in the management of cancer of the pancreas:
- Cure: is the complete resolution/eradication of the disease with no further chance of it coming back. In the field of cancer medicine it is almost impossible to confirm that one is cured of their disease despite all the best efforts to do so. The concept of cure is more of a time issue in that the longer the patient remains without any evidence of disease the higher the likelihood that the disease has been completely eradicated.
- Complete remission: is defined as complete disapperance of all previously noted abnormalities (considered to be cancer) using standard clinical methods such as laboratory tests, x-rays and scans. It is the first step towards a chance of “cure”.
- Response: is defined as a decrease in size of tumor or improvement in a test result that directly or indirectly measures tumor activity. Although response assessment is important in determining treatment effectiveness sometimes the overall assessment of a patient rather than the individual shrinkage of tumor is more important. This is especially important for pancreatic cancer.
- Survival: is simply being alive with or without active disease.
So, what do we mean by “it depends”?
Based on our current knowledge and experience, the best chance to remain disease free (in complete remission) and may be being cured is complete removal of the tumor by surgery. Therefore, “staging” of disease to demonstrate the extend of disease is very important first step in management of this cancer.
What is staging and what is involved?
In order to define the extend of disease (Is it still limited to the pancreas or has it spread to surrounding tissues or organs, such as lymph nodes, liver or other organs?) the usual first step is to do a CT scan of the abdomen and chest. This will allow the assessment of the pancreas, liver, lymph nodes, stomach, lung, duodenum and the blood vessels. If there is no clear evidence of extensive disease the surgeon may order further imaging studies to better define the anatomy of the area to optimize the chances for successful removal of tumor. These studies may include an angiography (radiological test to see the blood vessels in the bed of the pancreas) and/or laparoscopy (looking into the abdomen with a scope through a small inscision in the abdominal wall). These additional studies are not required and are only useful in selected cases. However, high quality helical (spiral) CT scans are very important.
The staging of pancreas cancer has been standardized (TNM stating) like other cancers and it is based on three elements: first, the size and invasiveness of the primary tumor (T), second, the involvement of local lymph nodes (N) and third the involvement of other distant organs also called distant metastasis (M). Based on the degree of each of these elements combined a stage is defined (Stage 0 to 4). Although staging is routinely done on every pancreatic cancer case, as you will read later on, the surgical decision is not necessarily based on the TNM staging.