Pancreatic cancer is a nasty, stubborn killer that has thus far defied medicine’s best
efforts at early diagnosis and curative treatment. In November, it claimed the
life of my friend Peter Zimroth, a 78-year-old New York City attorney who was
devoted to public service and who most recently oversaw the decline in the
Police Department’s stop-and-frisk strategy.
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Zimroth had been
on my “most admired” list even before he married esteemed actress Estelle
Parsons, who was 16 years his senior. Even during his yearlong, albeit losing,
fight against cancer during the
pandemic, Zimroth remained devoted to the
public good, designing a brightly colored T-shirt and cap bearing an urgent
plea, “Smash the Virus! Get the Shot,” and raising more than $73,000 to support
research at Memorial Sloan Kettering Cancer Center, where doctors tried
valiantly to buy him more time.
Zimroth was fit
and active and in otherwise good
health before symptoms developed — in his
case, stomach pains and constipation. By that time, the cancer had spread and
it was too late to operate. His death follows that of several other well-known
people who have succumbed to the same disease: Supreme Court Justice Ruth Bader
Ginsburg,
US Rep. John Lewis, “Jeopardy!” host Alex Trebek and Apple co-founder
Steve Jobs.
Although
pancreatic cancer is a relatively rare cancer, it is so deadly that it is now
on track to become the country’s second leading cause of cancer-related deaths
by 2040. Currently, it accounts for about 3 percent of all cancers and 7
percent of cancer deaths. Overall, only 1 in 10 people diagnosed with
pancreatic
cancer survive five years. A cure is almost always a lucky accident,
when the cancer is detected at an early, symptom-free stage during an unrelated
abdominal scan or surgery and the tumor can be surgically removed.
Dr. Brian Wolpin,
director of the gastrointestinal cancer center at the
Dana-Farber Cancer Institute in Boston, told me that this is such a hard cancer to find early
because “it’s relatively uncommon in the population and the symptoms it causes,
like weight loss, fatigue and abdominal discomfort, are nonspecific and more
likely due to other conditions.” As a result, he said, “when 80 percent of
patients walk through my door for the first time, I know that we are highly
unlikely to cure their cancer.”
Risk factors for
pancreatic cancer
Still, there are several major risk factors for developing pancreatic
cancer. Smoking doubles the risk and accounts for about one-quarter of all
cases. Being obese, gaining excess weight as an adult, and carrying extra
weight around the waist, even if not otherwise very overweight, also increase
one’s risk.
That may be why
type 2 diabetes, which is most often related to being overweight, is an
important risk factor as well. Other risks include chronic pancreatitis, a
persistent inflammation of the pancreas often linked to heavy alcohol
consumption and smoking, and workplace exposure to certain chemicals, including
those used in dry cleaning and metal work industries.
Older age is also
a risk factor — about two-thirds of cases occur in those 65 and older. And
family history may also play a role, including inherited genetic conditions
such as mutations in the BRCA1 or BRCA2 genes that are most often associated
with breast and ovarian cancers.
Diabetes as an early
warning sign
It has long been known that
the best chance of surviving most cancers results from early detection, when
the malignancy is totally confined to the organ or tissue in which it
originates. (
Blood cancers present different issues.) The pancreas is a rather
small, carrot-shaped organ — about 6 inches long and less than 2 inches wide —
that lies well hidden between the ribs and the stomach.
An early cancer in the pancreas doesn’t produce a
lesion that can be felt, and it rarely causes symptoms that might prompt a
definitive medical workup until it has escaped the confines of the pancreas and
spread elsewhere.
But scientists are studying one possible early
warning sign: a link between pancreatic cancer and newly developed Type 2
diabetes. Diabetes, too, arises in the pancreas, which contains specialized
cells that produce the hormone insulin that regulates blood-sugar levels. And
although it’s not yet known which comes first, diabetes or cancer, some
research suggests that the recent development of Type 2 diabetes may herald the
existence of cancer hidden in this organ.
An early study from 2005 of 2,122 residents of
Rochester, Minnesota, by Dr. Suresh Chari, now a gastroenterologist at the
University of Texas MD Anderson Cancer Center, found that within three years of
receiving a diagnosis of diabetes, people were six to eight times more likely
than the general population to have pancreatic cancer. He, along with
colleagues at the Mayo Clinic, also identified a gene called UCP-1 that may predict
the development of this cancer in people with diabetes.
More recently, Dr. Maxim Petrov, a professor of
pancreatology at the University of Auckland School of Medicine, led a September
2020 study in New Zealand of nearly 140,000 people with Type 2 diabetes or
pancreatitis, or both, who were followed for up to 18 years. The findings
revealed that those who developed diabetes after an attack of pancreatitis were
seven times more likely to get pancreatic cancer than others with Type 2
diabetes.
In 2018, the
National Cancer Institute launched a
study that is in the process of enrolling 10,000 people ages 50-85 with newly
diagnosed diabetes or elevated blood-sugar levels. Participants will donate
blood and tissue samples, and researchers will follow them in the hopes of
identifying clues to early detection among those who develop pancreatic cancer.
Another effort begun last summer by the
Pancreatic Cancer Action Network, called the Early Detection Initiative for Pancreatic
Cancer, will enroll more than 12,000 participants with elevated blood-sugar
levels and new-onset diabetes. Half will have periodic blood tests and undergo
abdominal imaging based on their age, body weight and blood-glucose levels to
look for evidence of early pancreatic cancer, while the others will serve as
controls.
The goal of such studies is to identify biological
markers, such as certain genes or proteins excreted by the tumor, that could be
used in screening tests to indicate the presence of cancer when it could still
potentially benefit from surgery. Alas, the results are not likely to be known
before 2030, if then.
Meanwhile, Wolpin said doctors should consider “a checklist”
of warning signs that might alert them to the presence of an early, curable
cancer. Among things to consider, he said, are whether a patient’s glucose
level is rising rapidly and is difficult to control with diabetes medication;
whether patients with diabetes are losing weight with no explanation like a
change in diet or exercise; or if patients have been fine for years and then
suddenly in their early 70s get diabetes and it’s not clear why.
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