2023-12-04 08:37:12
by Vera Martinella
It is possible to keep certain categories of people most at risk of developing pancreatic cancer under surveillance so as to discover it when treatments are most effective
Pancreatic cancer remains a difficult enemy to fight, which took away Gianluca Vialli at the beginning of the year, after having also marked the fate of other illustrious people, such as the tenor Luciano Pavarotti and the actor Patrick Swayze. In recent years, scientific research has made progress and life expectancy, which was mostly a few months, now exceeds three years for a growing number of patients who can now undergo surgery.
Late diagnosis
One of the biggest problems to be solved remains late diagnosis: Pancreatic cancer is insidious because in the early stage it does not give particular symptoms and the most obvious signs appear when it has started to spread to the surrounding organs or has obstructed the bile ducts – recalls Alessandro Zerbi , head of Pancreatic Surgery at the Irccs Humanitas Clinical Institute in Milan —. So 8 out of 10 people discover the disease when it is already in an advanced stage and the situation is very complicated.
Making matters worse is the fact that this neoplasm is particularly aggressive and that the pancreas is located in a delicate and difficult to reach area. This explains the survival rate five years after diagnosis which is much lower than, for example, that of the breast or prostate. Despite continuous efforts, so far researchers have not managed to develop tests capable of discovering the very first signs of the presence of a tumor, but they are already working on the people most at risk of getting sick to keep them under control.
Prevention
In addition to smoking, diabetes, obesity and a sedentary lifestyle, what increases the chances of developing pancreatic cancer is chronic pancreatitis, a permanent state of inflammation mostly due to chronic alcohol abuse – explains Zerbi -. Family history, then, is responsible for almost 10 percent of pancreatic tumors, which in some cases can be explained in the context of known genetically transmissible pathologies: Peutz Jeghers syndrome (more than 100 times risk), familial nevi syndrome multiple atypical and melanoma (20-30 times), Brca-2 gene mutation (3-10 times), hereditary pancreatitis (10 times) and Lynch syndrome.
Therefore, a fundamental first step is to limit the risks of getting ill, i.e. not smoking (3 out of 10 cases are caused by tobacco), following a healthy diet, staying away from extra pounds and maintaining moderate and constant physical activity. What else can be done? Some categories of people who are more at risk of developing a pancreatic neoplasm can be kept under surveillance because they belong to families where there are more cases of this disease or because they are carriers of mutations involved in its development – replies Silvia Carrara, president of the Italian Association for the Study of the Pancreas (Aisp) —. Aisp has promoted an Italian register which has the specific purpose of collecting data and information on how to best proceed in this direction.
The registry data
The first results of this strategy were published in the scientific journal The American Journal of Gastroenterology, the result of an Italian multicenter collaboration in which, among others and in addition to Humanitas, the San Raffaele Hospital in Milan and the Azienda Ospedaliera Universitaria Integrata participated of Verona. The study reports the results of surveillance conducted with magnetic resonance imaging and echoendoscopy for three years on 156 people with increased risk of pancreatic cancer enrolled in the Aisp registry. Thus, a pre-malignant lesion and 8 adenocarcinomas were identified, 5 of which were carriers of genetic mutations.
Of the 8 tumors, 3 were in an advanced stage already at the beginning of the screening, while 5 were found during surveillance at the first stage, when complete recovery can be aspired to – concludes Carrara, who is responsible for the Ultrasound Endoscopy Program at Humanitas -. an important message of hope: the identification of particular groups of people at risk and the surveillance conducted with the right means, with the correct timing, will lead to early diagnoses even in this “hostile” neoplasm and to better patient survival.
Research has made progress in recent years
Every year in Italy over 14,500 new cases of pancreatic cancer are recorded, the majority in people between 60 and 80 years old. And the numbers are increasing. We have arrived at some small-large conquests – says Massimo Falconi, director of pancreatic surgery and transplants at the Irccs San Raffaele Hospital in Milan -: in the last 20 years the effectiveness and safety of chemotherapy have improved thanks to the increase in available drugs and their use in combination. We understood and demonstrated which chemo to administer before surgery and for how long. We have shown that the operation should only be performed in centers with certain requirements, where more expert hands are concentrated, because mortality and complications are lower. And we discovered some types of people who are more at risk of getting sick, so we can “monitor” them. So we gained months of life.
Rely on centers with a lot of experience
Chemotherapy is still today the most important weapon in dealing with pancreatic cancer and, essentially, the chances of a definitive cure depend on its ability to destroy the invisible disease. Various studies have demonstrated, with numbers in hand, that specialized treatment centers are needed and that it is essential to turn to highly experienced hospitals, especially with regards to surgery which is particularly complex.
The treatment of this neoplasm is made complex by various factors – explains Alessandro Zerbi, head of Pancreatic Surgery at the Irccs Istituto Clinico Humanitas in Milan -: the “hidden” position of the pancreas compared to other organs; its proximity to large veins and arteries which makes surgery difficult except in 20-30% of cases; the initial diagnosis often in an advanced stage of the disease. Then there is the poor response to treatments which must include a multimodal approach with chemotherapy, surgery where possible, and possible radiotherapy.
The census
Of the 395 Italian hospitals surveyed by a research coordinated by San Raffaele and published in 2020, however, as many as 300 (77% of the facilities) had carried out on average only three pancreas operations per year. A number that is too low, considering that pancreatic surgery is the most complex of the entire abdominal area – underlines Massimo Falconi, director of the San Raffaele Pancreas Center -. The result is that mortality in the area varies from 3% in the most excellent and highest volume centers to over 25% in other less experienced centres, with disastrous results for patients. This is why for years specialists and patient associations have been calling for the creation of Pancreas Units (following the example of the certified Breast Units for breast cancer), to which they can entrust the entire process for the diagnosis and treatment of pancreatic cancer, with technological resources adequate and taken care of by a multidisciplinary team that encompasses all the specialist skills.
To date, there are few structures that have activated active surveillance protocols for subjects at increased risk of developing the pathology or standardized diagnostic-therapeutic care pathways (PDTA) – concludes Federica Valsecchi, president of Nadia Valsecchi Foundationwhich together with other realities such as Purple Hearted Friends, Beyond Research Association, Code Purple, My Everest e Purple Ribbon, for years has been involved in raising awareness among the population about prevention, supporting scientific research and assisting patients and families. There is a lack of resources and strategies dedicated to this by the National Health Service, just as the funds dedicated to scientific research on this pathology should be implemented at a European level. And then too little research is done on this tumor and it is almost entirely financed by associations created mostly by family members who have lost someone.
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December 4, 2023 (modified December 4, 2023 | 07:36)
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