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Mr. Ross Carter - Interview 42

Brief Outline: Mr Ross Carter explains how symptoms of pancreatic cancer differ from symptoms of pancreatitis, how doctors treat symptoms of pancreatic cancer, which treatments might be appropriate, and how doctors manage pain and other symptoms if the cancer comes back.
Background: Mr Ross Carter is a consultant surgeon in upper gastrointestinal (GI) and pancreatico-biliary surgery at Glasgow Royal Infirmary.

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A consultant explains why some patients with pancreatic cancer first become jaundiced and why...

A consultant explains why some patients with pancreatic cancer first become jaundiced and why...

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And what are the symptoms of pancreatic cancer?
 
One of the challenges is that the symptoms, initially, can be very vague and patients often do not present with classical symptoms until they develop jaundice. Now, by far the commonest presenting symptom is jaundice. That’s where the skin goes a yellow colour. The whites of the eyes go a yellow colour and that’s due to a blockage of bile. Now, there are a number of other symptoms, particularly epigastric pain, that is pain just underneath the breast bone, discomfort on eating, being off your food, weight loss and general indigestion. And these, obviously, can be similar symptoms that you can get with ulcers or with other causes of indigestion and, usually, people first of all think of symptoms of indigestion rather than it being pancreatic cancer. 
 
And one of the challenges is always to have a very high index of suspicion that it could be a pancreatic cancer and look for it rather than waiting for the inevitable jaundice to appear. Now, about one third of pancreatic cancers do not affect the head of the gland. The gland of the pancreas is in two pieces. They’re in two areas. There’s the head of the gland and then a tail, a bit like a tadpole and two thirds of the gland is within the head and a third is in the tail. Similarly, you will get about a quarter to a third of pancreatic cancers that affect the body and tail that are away from the tubes from the liver and, therefore, they do not present with the classical jaundice. They often present with just epigastric pain within the epigastric area, weight loss, patients feeling generally unwell, and jaundice isn’t a feature and these are particularly, the really difficult types of patients to pick up.
 
So it’s quite complicated.
 
 

A consultant describes the symptoms of acute and chronic pancreatitis and explains how their...

A consultant describes the symptoms of acute and chronic pancreatitis and explains how their...

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There are two types of pancreatitis. There is acute pancreatitis and chronic pancreatitis and they present in different ways. Acute pancreatitis is a sudden onset illness, where the patients classically have very severe pain in the epigastrium, just underneath the breast bone, associated often with vomiting. And it can be an extremely severe pain. It’s classically one of the most severe pains you can have. The patient is often required to come to hospital and over a period of three to four days, in about eighty per cent of patients, they will settle relatively quickly. In those patients, the key to management is about preventing a further attack.
 
That’s usually looking for gall stones or avoiding other causes. Now, chronic pancreatitis is due to a scarring in the pancreas and it’s often due to recurrent mild attacks of pancreatitis that, over a period of years, result in the inflammation and scarring, which in those patients, they present with pain, episodes, which are not as severe, often requiring hospitalisation. But then they run into problems when the pancreas isn’t working so well.
 
So the digestive juices of the pancreas tend to reduce in quantity and they [patients] develop problems with their digestion, or sugar control can go off so they [patients] develop diabetes. They get weight loss and a variety of other symptoms. Now, the diagnosis is, again, often first of all thought to be an ulcer.
 
And it is only through investigation that it turns out to be chronic pancreatitis in those patients.
 
 
And the causes of pancreatitis and pancreatic cancer are quite unknown 
aren’t they?
 
Well, the causes of pancreatitis are, by far the most common cause is simple gall stones, where a gall stone falls out of the gall bladder, and blocks the pancreas tubes.
 
And results in acute inflammation. The second commonest cause is alcohol where often following a binge the patient can develop some inflammation within the pancreas and there are a number of other causes. Now, pancreatic cancer is not caused by gall stones or alcohol. The only real major contributory factor is smoking. There are a number of other minor contributory factors but the vast majority of patients who present with pancreatic pancreatic cancer, there isn’t an obvious cause as to why it has developed in that patient.
 
 

A surgeon explains that a raised CA 19-9 is likely to be associated with large tumours, and can...

A surgeon explains that a raised CA 19-9 is likely to be associated with large tumours, and can...

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Another factor with the blood, the blood test is it tends to be associated with a certain bulk of tumour and so it doesn’t present when the tumour is [small]. Very small tumours are much less likely to be associated with a rise in your CA 19-9 than more bulky tumours.
 
And so it often will be visible on a scan at the same time as it’s going to be visible on a blood test. One last problem with CA 19-9 as a screening test for pancreatic cancer is it can be raised in other causes of inflammation within the pancreas, for instance, chronic pancreatitis. So it’s specificity for being associated with cancer is not, by any means, a hundred per cent and, consequently, having a slightly raised CA 19-9 does not necessarily, mean that there is a tumour there at all.
 
 

A consultant explains that in his department doctors want to break bad news to patients with a...

A consultant explains that in his department doctors want to break bad news to patients with a...

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In an ideal situation, how should a patient be told about their diagnosis?
 
I don’t think you can be prescriptive because every person is very different. There is also a huge discrepancy in how much a patient takes in, on any one given situation after a discussion and whilst you can speak to a patient and you know you’ve told them certain aspects of their, certain facts, they will come back later and they won’t have taken that in. Now, what we do, within our own unit, is we try and break the diagnosis with a patient, if they’re willing, with their family and the consultant specialist, who is speaking to the patient, will also, will usually speak to the patient and relatives along with one of our specialist nurses, who will then, having discussed the diagnosis, will go over any areas that they’re unclear with and we’ll usually give them the opportunity of coming back and discussing aspects to their care. Now, at their initial discussion, we often keep the discussion relatively brief because the intricacies of discussing what possible treatments and the pros and cons of those, can be beyond their ability to take it in when they’re, initially, faced with a diagnosis.
 
So often giving them information over a number of episodes, also supplementing that with some written information so they can write it down and ask them to come with their own questions, can develop a better understanding from the patient about why certain aspects of treatment have been suggested.
 
 

A consultant explains why it is important to assess the situation carefully before inserting a...

A consultant explains why it is important to assess the situation carefully before inserting a...

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Treating the symptoms of pancreatic cancer depends largely on how it presents, and at what stage of disease it presents. When a patient develops jaundice, for instance, one of the areas where we have been trying to improve the patient pathway is to avoid the early introduction of stents before the patient has been properly assessed. In that there is some evidence that putting in stents before doing operations may actually have an adverse effect on the outcome. So what we try and do is to assess the patient relatively rapidly, when they present with jaundice, and make a decision whether surgery may be appropriate, or whether the patient would be better having a stent inserted first. Now, a stent is simply, either a plastic or a metal tube, which is used to hold the sides of the bile duct open, so that the bile from the liver can pass through the narrowed area of the pancreas and out into the intestine. And in allowing the liver to drain then, it allows the jaundice to resolve. The stents can be put in either by endoscopic routes, that’s with a telescope through the stomach and finding the lower end of the bile duct in the duodenum at the ampulla vater and inserting the tube from the bottom up, or alternatively, it can be done from the top down by, under local anaesthetic, putting a needle through the skin on the right hand side, through the liver and then down through the narrowed area into the intestine from the top down.

 

A consultant describes what types of surgery may be appropriate for patients with early-stage or...

A consultant describes what types of surgery may be appropriate for patients with early-stage or...

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So in every patient, what we need to do is to assess the stage of disease, and that’s usually done by a CT scan, and secondly, we have a number of tests where we look at the function of the heart and the lungs to try and get a gauge as to how fit the patient is and, therefore, how much of a stress an operation is going to put on their ability to recover from the operation.
 
It’s a big operation isn’t it?
 
Yes.
 
Can you summarise the different types of surgery that might be appropriate?
 
There is; the common types of surgery are either an attempt to remove the tumour itself and this is what we would call a pancreaticoduodenectomy or a Whipple resection, which is removing the head of the gland of the pancreas. Sometimes with a tumour in the tail of the pancreas we would perform removal of the tail of the pancreas, which is called a distal pancreatectomy. And, thirdly, occasionally, when we find at operation that the tumour is actually more advanced than was indicated on the pre-operative staging, in those patients we would perform a bypass operation, which is to allow the liver to drain into the intestine and the stomach to drain into the intestine without having problems with blockages of either the bile duct or the duodenum.
 
In that case, you’d leave the pancreas then?
 
Yes,
 
 

A consultant explains why the use of radiotherapy in pancreatic cancer is controversial.

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A consultant explains why the use of radiotherapy in pancreatic cancer is controversial.

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The use of radiotherapy in pancreatic cancer is controversial. Some of this arose as a result of, a surprising result in the ESPAC one study, performed in the late nineteen nineties, where patients who have radiotherapy following resection of pancreatic cancer actually did not so well as those that did not have the radiotherapy. 
 
On the other side of the Atlantic in America, however, there is a groundswell of opinion that using a multi-modal approach of chemotherapy, radiotherapy plus or minus surgery is the mainstay of their treatment programmes. And within the UK there are a number of studies looking at the role of radiotherapy in the patient who has not presented early enough to consider surgery, so in a palliative setting. At present, there is insufficient evidence to be dogmatic as to whether radiotherapy is the correct type of treatment to be used in pancreatic cancer but it’s certainly an area where a lot of work is being done on at present.
 
 

A consultant explains that CyberKnife is focused radiotherapy, and that it has some potential...

A consultant explains that CyberKnife is focused radiotherapy, and that it has some potential...

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Cyberknife is really just focused radiotherapy and I think it’s important that, the concept of the name, it is not surgery, it is not removing the tumour in any way, it is no more effective in damaging the tumour than normal radiotherapy but the principle advantage of stereotactic or targeted radiotherapy is that a dose can be, a given dose can be administered more quickly so you’ll get a dose in two to three days that would otherwise take three to four weeks. 
 
And the effect on other organs around the target area may be reduced slightly. So there is a potential advantage of focused radiotherapy in terms of reducing the side effects that you might get from the standard radiotherapy but in terms of actually being more effective in damaging the tumour, it is not going to make any miraculous change to the effect of radiotherapy, standard radiotherapy alone.
 
 

A consultant explains that people who have part of their pancreas removed are likely to develop...

A consultant explains that people who have part of their pancreas removed are likely to develop...

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When, in all patients who have pancreatic disease, there are, the pancreas may not function quite as well as it did in health and each aspect of the function of the pancreas is an area where, which may require to be helped through improving its function by medicines. Patients who have had part of their pancreas removed, part of their body’s insulin producing cells have also been removed, and there is an increased risk or an increased incidence of diabetes following resection.
 
So a number of patients require to have a degree of diabetic control following a pancreatic resection. Contrary to many other diabetic patients, they also often have a requirement for a relatively high calorific intake because they’re trying to recover from an operation.
 
And so the advice, the standard diabetic advice regarding your diet may need to be altered by a specialist dietician to try and get a balance between your glucose control and your diabetes management.
 
And your nutritional recovery from your surgery.
 
 

A consultant explains that many people with pancreatic cancer will need medicines such as Creon...

A consultant explains that many people with pancreatic cancer will need medicines such as Creon...

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Now, just as those patients have had a reduction in their insulin production, they’ve also often had a reduction in their digestive juice output of the pancreas, be that either from a resection or even just from, in those patients who haven’t had a resection, due to a blockage of the pancreatic duct. And in these patients they tend not to digest their fat nearly as well as they should.
 
Adding in a pancreatic enzyme supplement of lipase, the commonest one within the UK being Creon, but there are others such as Pancrex, can help the symptoms of fat mal-absorption, which tend to be a feeling of bloatedness, often with a loose, rather than true diarrhoea type stool, and the key feature of it is that it’s quite difficult to flush away.
 
And if you’re needing to flush your toilet a couple of times then the likelihood is you may well have some, what we would call, steatorrhoea, and you should be on pancreatic exocrine supplementation as this can often help, greatly, your symptoms.
 
 

A consultant explains why doing routine CT scans after treatment has finished may be a mixed...

A consultant explains why doing routine CT scans after treatment has finished may be a mixed...

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How would a patient, or how would that present, how might recurrence present? 
 
There’s, recurrence is often difficult. Recurrence can present in a number of different ways. There’s no such thing as an average patient and every patient can develop symptoms which are relatively specific to themselves. It often presents with the patient just not feeling as well as they had done three four months previously and it’s a non-specific change in their well-being that they complain of when they come back to the clinic. A number of patients, particularly those that are undergoing trials, may have a recurrence identified on interval scanning, follow-up scanning, whilst they otherwise feel very well.
 
And in these patients, it can often be quite difficult where there is evidence that the tumour has come back but the patient is otherwise very well. And a number of clinicians, consequently, are more inclined to perform scans based on patients’ symptoms rather than just routinely doing a scan, which may cause the patient a great deal of distress before, during and after waiting for a result.
 
Especially, when they are feeling otherwise very well.
 
There’s really nothing dramatic you can do if it has come back?
 
Well, if a tumour comes back, there is no proven evidence that giving chemotherapy early in those patients is any better than giving the chemotherapy when the patient develops symptoms and, consequently, knowing that there may be a recurrence two to three months earlier than any symptoms and, thereby, giving the patients chemotherapy early, may not be any advantage to the patient and they, actually, reduce their quality of life during that period.
 
So there is a balance often to be met with the expectations of the patient and what they would wish to have regarding their follow-up and also the clinician and how they are following the patient up as part of their general practice.
 
So doing routine scans can be a mixed blessing in this in this circumstance.
 
 

A consultant explains that a cancer of the pancreas often spreads to the liver or to the lungs....

A consultant explains that a cancer of the pancreas often spreads to the liver or to the lungs....

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If the cancer comes back in other areas, where is it most likely to recur?
 
The commonest site for recurrence is within the liver but also metastases or satellite lesions can appear within the lungs.
 
Or within often within the glands around the back of the stomach in the region of where the pancreas previously was. It can, occasionally, affect other areas such as bone but they’re much less common than the liver and the lungs.
 
 

A consultant explains that pain relief medicines follow a ‘ladder’ of increasing strength.

A consultant explains that pain relief medicines follow a ‘ladder’ of increasing strength.

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Now, as a general principle, simple treatments are better than more complex ones and so most people would follow a standard analgesic ladder, where you work up a number of steps of increasing strengths of painkiller, moving from simple paracetomol to non-steroidal drugs and then moving on to opiate type morphine type substitutes, to control discomfort. And in the vast majority of patients good control of pain is achievable through simple means. Side effects with increasing drug dosages, however, can be a problem.
 
And in those patients who are having their quality of life affected by the side effects of the necessary painkillers, there are a number of other methods we can use to help control the pain. And they can either be through injecting the nerves around the pancreas, and that’s called a coeliac plexus block, and that can be done either through the skin under x-ray control or using a telescope using endoscopic ultrasound control or alternatively, you can cut the nerves using a keyhole operation in the chest to divide the nerves so that the pain stimulus from the pancreas doesn’t reach the brain.
 
And that keyhole operation in the chest is called a thoracoscopic splanchnicectomy. These can greatly improve patients who are otherwise finding the side effects of the drugs they’re required to take disabling and in, particularly, in the fitter patients who are wanting to carry out, have a very normal lifestyle but find that they’re quite drowsy through the painkillers etcetera. They can get a great deal of benefit from a surgical or radiological approach to their pain.
 
 

A consultant explains that people with pancreatic cancer often die of a secondary medical problem...

A consultant explains that people with pancreatic cancer often die of a secondary medical problem...

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What about end of life? Sometimes people say, “How will I die?”
 
Yes….. End of life care in pancreatic cancer can be very variable and one of the keys is to be working, and, hopefully, dealing with every issue of a patient coming to their end of their life, through the management team that they have been dealing with throughout their care.
 
Certainly within our own practice, we actually try and involve our palliative team at a very early stage, well before they have got anywhere near the end of life care, because they are experts in the management of symptom control, and often patients, when we introduce this initially, feel that we are perhaps premature, but it’s trying to look at the patient’s overall management, and not just introduce the palliative consultants towards the end of life. For those patients who are approaching the end of life, pancreatic tumours and tumours in general, how they tend to catch up with you is by making you generally weak and your ability to deal with another medical problem reduces with time.
 
So that when you develop a chest infection, for instance, that you would normally be able to brush off, you’re just unable to manage to do so. The majority of patients, we would hope, would be extremely comfortable. They would be in an environment which suits both them and their family.
 
And we work hard to try and make sure that both patients that wish to be at home with their family can be. Those that would rather be within a hospice environment can be, or even within the hospital environment, with people they know and making sure that their symptoms are well controlled. 
 
A lot of patients ask questions as to how long they’re going to have before the tumour catches up with them and there is no way of predicting this, although we can have ideas that the patient’s general condition is deteriorating, because it is often the development of a secondary medical problem, such as a chest infection, that eventually is too much for them, none of us know when we’re next going to get our next cold.
 
And, consequently, we need to try and be dealing with each day as it comes and making sure that the symptom control for that day, for that week, for that month, is as good as we possibly can even though the general condition of the patient is reducing.
 
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