Pancreatic cancer cases on the rise

There needs to be a less “nihilistic” attitude towards pancreatic cancer, as despite its increasing prevalence and high mortality rate, better detection and treatment strategies are emerging, bringing hope for improved outcomes, the Irish Society of Gastroenterology Summer Meeting 2023 heard.

Dr Grainne O’Kane, Consultant Oncologist, St James’s Hospital, Dublin, gave a tour de force presentation on the genomic landscape of pancreatic cancer, and challenges and opportunities for early detection, during the dedicated session on early neoplasia of the upper gastrointestinal (GI) tract.

She noted that there are over 400 cases of pancreatic cancer diagnosed in Ireland (about 500 cases including Northern Ireland) annually, with the majority diagnosed late with locally advanced or metastatic disease. It is an aggressive cancer with non-specific symptoms and there remains a lack of screening strategies and new treatment therapies. Only 10-to-15 per cent of cases are resectable at the time of diagnosis, with a further 20-to-25 per cent borderline resectable, and 60-to-70 per cent locally advanced unresectable. Chemotherapy remains a mainstay of treatment in this cancer.

There is clearly a need for increased awareness and prevention strategies for pancreatic cancer given its rising prevalence in Europe, Dr O’Kane told the meeting.

“What we want, obviously, is to see people diagnosed earlier, as you can actually cure it in the earlier stages“

“In oncology, we are seeing an alarming increase in the number of young-onset cancers, particularly in GI cancers. Pancreatic cancer will become the second leading cause of cancer-related mortality [soon], based on National Cancer Registry Ireland information, and this really calls for an awareness and prevention strategy,” she said.

Dr O’Kane pointed out that the European Parliament held an awareness campaign last year on pancreatic cancer, with similar work being undertaken by the European Society for Medical Oncology (ESMO).

She also noted that the incidence of pancreatic cancer is particularly rising in women; “and we don’t know why this is.”

However, the biology of the disease is key, she said, noting that there are a number of modifiable and non-modifiable risk factors (genetics) to look out for.

“What we want, obviously, is to see people diagnosed earlier, as you can actually cure it in the earlier stages,” Dr O’Kane commented.

She citied data showing that pancreatic cancer survival rates are around 87.3 per cent if diagnosed at stage 1a, 1b,1c.

Discussing the current controversy around neoadjuvant treatment in pancreatic cancer, Dr O’Kane said she strongly advocates for neoadjuvant chemotherapy.

Looking at genomics, biomarkers, and screening in pancreatic cancer, she noted that it is driven by KRAS mutations in 90 per cent of cases, with other subtypes (RNA) also involved. Screening-wise, while not advised at a population level, it is recommended for those at high-risk, using endoscopic ultrasound and MRI.

Research on the role of metabolism and the microbiome in pancreatic cancer is increasing disease understanding, while the use of artificial intelligence is also showing promise in improving detection at an earlier stage. These advancements, coupled with promising early results for new treatments and a continuing improvement in surgical outcomes, mean that disease outcomes should continue to improve in pancreatic cancer in the coming years, Dr O’Kane concluded.

“There shouldn’t be such nihilism around pancreatic cancer,” she told the Medical Independent.

“We are making progress. When we detect pancreatic cancer early, we can cure it, especially in those stage 1 cancers, but even after surgery, adjuvant chemotherapy has really pushed the needle in terms of survival for patients of pancreatic cancer. In the advanced metastatic setting, a lot of people don’t even get referred for chemotherapy as there is a lot of nihilism around treatment for pancreatic cancer. 

“Yes, chemotherapy is the mainstay of medical treatment that we use, but if we can sequence patients there are subsets who can benefit from targeted therapies and that is where we need to be moving for all patients with pancreatic cancer, to avail of both germline testing; looking for hereditary genes; but also profiling of the tumour itself, so we can look for potential targets in the tumour itself.”