1. Pancreatic Cancer Michael G T Raraty Consultant Pancreatic Surgeon

2. Pancreatic Cancer Stats http://www.cancerresearchuk.org/cancer- info/cancerstats

3. Incidence 2009-2011 http://www.cancerresearchuk.org/cancer- info/cancerstats

4. Trends over time 1975-2011 http://www.cancerresearchuk.org/cancer- info/cancerstats

5. Risk Factors Baseline ~ 10/100,000 population/year RiskProportion of cancers Smokingx 230 Genetic factorsx 5-1010 Chronic Pancreatitisx 10-201 Hereditary Pancreatitisx 35-70<1 Age >70x 5- Type II DMx 1.5-2- Obesityx 1.7- High fat dietx 1.7- Previous gastric surgeryx 1.8- Sclerosing Cholangitisx 14- Helicobacter Pylorix 1.8-

6. Hereditary cancer syndromes Peutz-Jeghers FAMM Familial breast/ovarian cancer FPC Hereditary Pancreatitis Von Hippel-Lindau Cystic Fibrosis FAP HNPCC

7. ‘Classic’ symptoms Obstructive Jaundice –50% –Truly ‘painless’ in about 10%, most will have some pain, but not biliary colic Pain –70% –Back / epigastrium –Relieved by sitting forward Nausea / Vomiting Weight Loss Anorexia

8. Other symptoms New onset type 2 diabetes mellitus –underweight or normal weight patient, not associated with weight gain Resistant dyspepsia/persistent epigastric pain IBS like symptoms in those >45 years –very rare as a new onset symptom at this age Altered bowel habit –Increased bowel movement frequency and offensive smelling stools –Suggestive of exocrine insufficiency Venous Thromboembolism –may be a manifestation of an underlying abdominal malignancy

10. Blood tests Full blood count –anaemia rare except for ampullary tumours Liver function tests –Obstructive jaundice –Elevated gamma GT / Alk Phos may precede bilirubin Serum glucose –Diabetes or impaired glucose tolerance CA19-9 –Sensitivity of ~80% and a specificity of 83% –Normal levels do not exclude diagnosis –Better for treatment monitoring

11. Investigations U/S –Often first line for jaundice –May demonstrate pancreatic mass Contrast-enhanced CT –Gold standard –Essential for staging

12. Referrals to Pancreatic MDT

13. Referral sources 2013 Arrowe Park 198Swansea2 Aintree 105Christie, Manchester1 Whiston 95Blackpool1 Southport 76Abergele1 Warrington 75Devon & Exeter1 Chester 71Wyre Valley1 Wrexham 37Londonderry1 Bangor 21Nottingham1 GP 20Newcastle1 Glan Clwyd 17Bradford1 Nobles 17Leeds1 Liverpool Womens’ 5Turkey1 LHCH 3External referrals774 Clatterbridge 3 Spire Liverpool 1Internal referrals from RLBUHT246 Macclesfield 1 1020

14. Presumed Pancreas Cancers 542 Cancer or pre- malignant 475 Inoperable at Staging 367 Surgery 108 Resection 93 Bypass 15 Benign 67 Surgery 44 Resection 40 Bypass 4 No operation 23 2013 (resection rate 20%)

15. Length of pathway 2013 Referral to MDTMean 6.5, Median 4 MDT to DTTMean 10.6, Median 7 DTT to surgeryMean 26.2, Median 22 Referral to SurgeryMean 43.3, Median 39 NB: DTT to surgery time includes pre-operative anaesthetic assessment clinic +/- staging laparoscopy

16. Chemotherapy >80% now receive adjuvant chemotherapy after surgery (Gemcitabine +/- others) Minority of unresectable patients fit for palliative chemotherapy (Folfirinox) –50% if locally advanced –36% if metastatic Role of neo-adjuvant chemotherapy currently being explored –ESPAC-5

17. Long-term survival rates - post resection 1 year survival 61% >75% 5 year survival 6% >25% X 2 LR =12.70 P<0.001

18. Summary Pancreatic Cancer is the 9 th commonest cancer in the UK It is the 5 th commonest cause of cancer death Notoriously late presentation, early metastases and poor survival rates Vague symptoms If diagnosed early enough for surgical resection, then chances of surviving beyond five years increase ten-fold

19. Resources http://www.pancreaticcancer.org.uk/ https://pancreaticcanceraction.org/ http://www.cancerresearchuk.org/about- cancer/type/pancreatic-cancer/http://www.cancerresearchuk.org/about- cancer/type/pancreatic-cancer/ http://elearning.rcgp.org.uk/course/info.php?id=103