Pancreatic Cancer UK

The European Pancreatic Club met in July 2005 in Graz, Austria under the presidency of Thomas Griesbacher. The meeting is devoted to all aspects of pancreatic disease, there was considerable discussion of research and clinical studies relating to pancreatic cancer.

The changes in the mechanisms of normal cells which lead them to become malignant are gradually becoming clearer. A number of different research teams are working on various aspects and we hope that by gradually working out the different steps in the pathway of malignant change that in the future it will be possible to devise ways of preventing malignant change, or even possibly reversing it. For the most part however these studies are confined to the laboratory, and our understanding at the moment is too fragmentary to offer hope of therapeutic advances in the near future.

One particularly promising area seems to be the regulation of blood vessel formation in and around tumours. As tumours grow in size they need to develop a blood supply and ways of blocking this process (called angiogenesis) may be effective in limiting tumour growth. It seems also that the same mechanisms that lead to blood vessels growing into tumours are involved in the ability of malignant cells to grow into blood vessels and then spread to other parts of the body. These treatments may therefore have a double advantage of helping to prevent metastasis.

Epidemiology of pancreatic cancer

There are two well known factors that are associated with pancreatic cancer. Smoking is the most important environmental risk factor. However once a person has developed pancreatic cancer the outcome was not related to whether they continue to smoke or not. It seems clear therefore that smoking is a cause of pancreatic cancer but does not affect the process once it has started.

Diabetes is a long term condition that has been known for many years to be associated with pancreatic cancer. Some patients with cancer develop diabetes, and this might be one way to identify early cases. In one study of 109 patients with pancreatic cancer, 17 had diabetes diagnosed in the year before the diagnosis of cancer. This supports the view that a person over the age of 50 who has no family history of diabetes, and is not obese, who develops diabetes for no obvious reason, should be investigated to rule out pancreatic cancer.

Diagnosis

Other studies on the diagnosis of pancreatic cancer have been disappointing. PET CT is a new imaging technique which can combine images of the anatomical structures, together with information about function. Although this technique is designed to be specific for picking up malignant lesions, its application to pancreatic tumours has been disappointing. However work continues to refine the technique and the place of PET CT will become clearer in the next few years.

Treatment

An increasing number of surgical series include a substantial number of patients who have tumour extending out of the pancreas to involve adjacent structures such as the portal vein. In pancreatic surgical centres with a high throughput, where the skills exist to operate safely, removal of a section of the portal vein can make sure that the tumour is completely removed, avoiding leaving microscopic remnants at the resection margin. However the risk of complications after that type of surgery is greater; this has to be set against the potential for improving the radical nature of the operation.

Expert reports on Adjuvant therapy

A symposium discussed the role of additional chemotherapy or radiotherapy after surgical removal of pancreatic cancer. Improvements in the chemotherapy of inoperable cancer have shown that gemcitabine is the drug most likely to prolong survival. After surgical removal of pancreatic cancer the risk of recurrence is extremely high and it is logical to offer some postoperative treatment. The ESPAC-1 study showed that treatment with 5FU could improve survival rates after surgery, and currently the ESPAC-3 study is testing whether gemcitabine can give better results than 5FU after surgery. A trial from Germany reported that gemcitabine after surgery was a significant improvement on surgery alone, with almost twice as many patients surviving 5 years after the operation.

The place of radiotherapy after surgery remains unclear. Some large studies have shown no effect of radiotherapy and one (ESPAC) even suggested that radiotherapy might be harmful. The EORTC is conducting a randomised trial comparing postoperative gemcitabine alone, and postoperative gemcitabine with radiotherapy. This is an important study, which will take some time to produce results. In the meantime the ESPAC study group is starting a trial to look at the place of radiotherapy in the specific case of surgical treatment with microscopic remnants of tumour after operation.

There is considerable effort at present in the field of gene therapy. The meeting received an update on this topic but all these studies remain experimental, and there is no therapy available for wider use in the near future.

European Cancer Network

The most exciting development at the EPC was the launching of the European Cancer Network, a research collaboration involving workers from a number of different countries, with a main focus on early diagnosis. This network is heavily focussed on the use of genetic studies to identify changes which take place in pancreatic cancer cells, and which might be used to develop more sensitive tests for early diagnosis.

This network will develop projects over the next few years. An important strand of this study will be the identification of individuals at high risk, to focus the effort of diagnosis where a positive result is most likely. This successful collaboration is a really significant development for the pancreatic cancer field which has (and still does) suffered from relative under funding of cancer research.