BMJ 2014;349:g5261 doi: 10.1136/bmj.g5261 (Published 4 September 2014)
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Pancreatic cancer should be treated as a medical emergency “The greatest oncological challenge” results partly from delays to diagnosis and treatment, writes J-Matthias Löhr J-Matthias Löhr professor of gastroenterology and hepatology and senior consultant, Karolinska Institutet and Karolinska University Hospital, Gastrocentrum, Stockholm, Sweden Outcomes for pancreatic cancer are poor, and the following case shows why. A 63 year old man presented to his general practitioner with abdominal pain and weight loss and eventually had diabetes diagnosed. He subsequently developed obstructive jaundice and was admitted to the emergency department of his local hospital on a Friday afternoon. Endoscopic retrograde cholangiopancreatography (ERCP) at the beginning of the next week helped identify a pancreatic tumour. It took two more weeks to complete high quality imaging and to send the scans to the regional cancer centre for evaluation. At the multidisciplinary team meeting, the tumour was deemed borderline resectable. Because the patient insisted on surgery, pancreatic resection combined with vascular resection and reconstruction was performed six weeks after the patient’s first visit to a physician. The delay was partly because of the holiday season.
Pathological examination confirmed the diagnosis of ductal adenocarcinoma, with microscopic margin involvement and spreading to multiple lymph nodes. The patient recovered well after surgery and started adjuvant chemotherapy six weeks later. Unfortunately, he tolerated gemcitabine poorly and his condition deteriorated. Routine multidetector computed tomography at three months showed multiple miliary liver metastases. He was unfit for second line chemotherapy and was given best supportive care, but he died one month later. The time from diagnosis to death was less than six months. In the final stage, the family also suffered.1
Pancreatic cancer increasingly presents as a medical emergency in that it is not diagnosed until the patient visits the emergency department, generally with obstructive jaundice requiring endoscopic decompression.2 Subsequent treatment depends on the level of service at the admitting hospital: referral without investigation at the local hospital (no ERCP capability), ERCP and referral (no specialised surgical expertise or multidisciplinary team), or full diagnosis and therapeutic
management (ERCP, multidisciplinary team discussion, surgery, chemotherapy). In reality, only a third of patients experience the third scenario, and most patients are seen initially at primary or secondary hospitals, particularly in countries with large rural areas. Once diagnosed, pancreatic cancer qualifies for fast track surgery in many European countries, and in the United Kingdom, and at our centre in, the disease also prompts fast track diagnosis.
In the UK, more than 90% of patients with cancer wait no more than 14 days between suspected diagnosis and specialist referral and two months to first definitive treatment.3 However, this measure is misleading for pancreatic cancer because stent placement in patients with jaundice is also regarded as a first definitive treatment.4 Delays to investigations before the multidisciplinary team meeting (including imaging, diagnosis, and staging) are common. Also, in most cases, the disease is probably systemic, given the long time before the cancer is clinically manifest.5 By the time the diagnosis is eventually confirmed the patient has to be treated as an emergency.
Patients who present early with a small tumour causing biliary obstruction are the exception rather than the rule.6 Patients with a preliminary diagnosis should be fast tracked for advanced diagnostics and surgery because it increases the chances of a quicker recovery.7 8 In addition, the time between surgery and the start of adjuvant chemotherapy should not be delayed unduly, although it is important that the patient has recovered fully after surgery.9 Twenty six years ago, R C N Williamson, director of surgery at London’s Hammersmith Hospital, referred in The BMJ to pancreatic cancer as “the greatest oncological challenge,”10 and, incredibly, the situation is worsening. Currently, pancreatic cancer ranks as the fourth highest cause of cancer related death in most European countries,11 but it will soon rank second, not because of increased incidence but because treatment for other solid cancers has become more effective.12
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
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BMJ 2014;349:g5261 doi: 10.1136/bmj.g5261 (Published 4 September 2014)
Page 2 of 2
VIEWS & REVIEWS
Research funding for pancreatic cancer lags behind that for other tumours. One reason is the lack of survivors (including celebrity spokespeople) to lobby for funding.13 The lack of funding is a particular problem because research is needed to develop new approaches to earlier diagnosis. In addition to innovative technologies, earlier diagnosis will require better communication between specialists and those in primary care.
Much can be done in the meantime to prolong survival—for example, improved coordination between the managers of patient pathways would help to speed patients’ progress through the investigations before multidisciplinary team meetings. And a suspected diagnosis of pancreatic cancer in other medical emergencies should automatically trigger fast track diagnostics and treatment. Moreover, the interval between diagnosis and surgery could be used for neoadjuvant therapy. Evidence is emerging that this may be advantageous even in patients with operable or borderline operable disease.14
For some years now, our centre has had allocated time slots for magnetic resonance imaging and multidetector computed tomography so we can offer fast track, high quality imaging. And a dedicated coordinator ensures access to imaging and evaluation at multidisciplinary team meetings. If the slots are not needed for pancreatic cancer patients, they are used for other patients who require urgent imaging. Multidisciplinary team meetings occur twice a week to expedite decision making. Management decisions are entered in the electronic patient record, and patients and colleagues are informed by telephone or outpatient clinic visits on the day of the decision. Twenty six years ago, Williamson wrote that “small but worthwhile gains in survival may come from an alert general practitioner or gastroenterologist who refers patients for a surgical opinion early.”10 Today it seems clear that pancreatic cancer must be considered a medical emergency.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent not required (patient anonymised, dead, or hypothetical). 1 2 3
4 5 6 7 8 9 10 11 12 13 14
McPherson T. My mum wanted assisted dying but we watched her die slowly and in pain. BMJ 2012;344:e4007. Pancreatic Cancer UK. Policy briefing: every life matters: the real cost of pancreatic cancer diagnoses via emergency admissions. www.pancreaticcancer.org.uk/media/450955/elm_ policybriefing_final.pdf. Aveyard E, Pottage C, McDonnell P, Svenson M. Waiting times for suspected and diagnosed cancer patients. 2012-13 Annual report. London: NHS, 2013. www.england. nhs.uk/statistics/wp-content/uploads/sites/2/2013/07/Cancer-Waiting-Times-AnnualReport-2012-13-amended.pdf. NHS. Cancer waiting times. A guide. Version 7.0, 2013. www.nwlcn.nhs.uk/Downloads/ Cancer%20Intelligence/Going%20Forward%20on%20Cancer%20Waits%20A%20Guide% 20Version%207.0.pdf. Luebeck EG. Cancer: genomic evolution of metastasis. Nature 2010;467:1053-5. Birk D, Fortnagel G, Formentini A, Berger HG. Small carcinoma of the pancreas. Factors of prognostic relevance. J Hepatobiliary Pancreat Surg 1998;5:450-4. Balzano G, Zerbi A, Braga M, Rocchetti S, Bebeduce AA, Di Carlo V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 2008;95:1387-93. Hall TC, Dennison AR, Bilku DK, Metcalfe MS, Garcea G. Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review. Ann R Coll Surg Engl 2012;94:318-26. Valle JW, Palmer D, Jackson R, Cox T, Neoptolemos JP, Ghaneh P, et al. Optimal duration and timing of adjuvant chemotherapy after definitive surgery for ductal adenocarcinoma of the pancreas: ongoing lessons from the ESPAC-3 study. J Clin Oncol 2014;32:504-12. Williamson RC. Pancreatic cancer: the greatest oncological challenge. BMJ 1988;296:445-6. Bond-Smith G, Banga N, Hammond TM, Imber IC. Pancreatic adenocarcinoma. BMJ 2012;344:e2476. Malvezzi M, Bertuccio P, Levi F, La Vecchia C, Negri E. European cancer mortality predictions for the year 2014. Ann Oncol 2014;25:1650-6. Löhr M. Is it possible to survive pancreatic cancer? Nat Clin Pract Gastroenterol Hepatol 2006;3:236-7. Christians KK, Tsai S, Mahmoud A, Ritch P, Thomas JP, Wiebe L, et al. Neoadjuvant FOLFIRINOX for borderline resectable pancreas cancer: a new treatment paradigm? Oncologist 2014;19:266-74.
Cite this as: BMJ 2014;349:g5261 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Views & Reviews
VIEWS & REVIEWS PERSONAL VIEW
Pancreatic cancer should be treated as a medical emergency “The greatest oncological challenge” results partly from delays to diagnosis and treatment, writes J-Matthias Löhr J-Matthias Löhr professor of gastroenterology and hepatology and senior consultant, Karolinska Institutet and Karolinska University Hospital, Gastrocentrum, Stockholm, Sweden Outcomes for pancreatic cancer are poor, and the following case shows why. A 63 year old man presented to his general practitioner with abdominal pain and weight loss and eventually had diabetes diagnosed. He subsequently developed obstructive jaundice and was admitted to the emergency department of his local hospital on a Friday afternoon. Endoscopic retrograde cholangiopancreatography (ERCP) at the beginning of the next week helped identify a pancreatic tumour. It took two more weeks to complete high quality imaging and to send the scans to the regional cancer centre for evaluation. At the multidisciplinary team meeting, the tumour was deemed borderline resectable. Because the patient insisted on surgery, pancreatic resection combined with vascular resection and reconstruction was performed six weeks after the patient’s first visit to a physician. The delay was partly because of the holiday season.
Pathological examination confirmed the diagnosis of ductal adenocarcinoma, with microscopic margin involvement and spreading to multiple lymph nodes. The patient recovered well after surgery and started adjuvant chemotherapy six weeks later. Unfortunately, he tolerated gemcitabine poorly and his condition deteriorated. Routine multidetector computed tomography at three months showed multiple miliary liver metastases. He was unfit for second line chemotherapy and was given best supportive care, but he died one month later. The time from diagnosis to death was less than six months. In the final stage, the family also suffered.1
Pancreatic cancer increasingly presents as a medical emergency in that it is not diagnosed until the patient visits the emergency department, generally with obstructive jaundice requiring endoscopic decompression.2 Subsequent treatment depends on the level of service at the admitting hospital: referral without investigation at the local hospital (no ERCP capability), ERCP and referral (no specialised surgical expertise or multidisciplinary team), or full diagnosis and therapeutic
management (ERCP, multidisciplinary team discussion, surgery, chemotherapy). In reality, only a third of patients experience the third scenario, and most patients are seen initially at primary or secondary hospitals, particularly in countries with large rural areas. Once diagnosed, pancreatic cancer qualifies for fast track surgery in many European countries, and in the United Kingdom, and at our centre in, the disease also prompts fast track diagnosis.
In the UK, more than 90% of patients with cancer wait no more than 14 days between suspected diagnosis and specialist referral and two months to first definitive treatment.3 However, this measure is misleading for pancreatic cancer because stent placement in patients with jaundice is also regarded as a first definitive treatment.4 Delays to investigations before the multidisciplinary team meeting (including imaging, diagnosis, and staging) are common. Also, in most cases, the disease is probably systemic, given the long time before the cancer is clinically manifest.5 By the time the diagnosis is eventually confirmed the patient has to be treated as an emergency.
Patients who present early with a small tumour causing biliary obstruction are the exception rather than the rule.6 Patients with a preliminary diagnosis should be fast tracked for advanced diagnostics and surgery because it increases the chances of a quicker recovery.7 8 In addition, the time between surgery and the start of adjuvant chemotherapy should not be delayed unduly, although it is important that the patient has recovered fully after surgery.9 Twenty six years ago, R C N Williamson, director of surgery at London’s Hammersmith Hospital, referred in The BMJ to pancreatic cancer as “the greatest oncological challenge,”10 and, incredibly, the situation is worsening. Currently, pancreatic cancer ranks as the fourth highest cause of cancer related death in most European countries,11 but it will soon rank second, not because of increased incidence but because treatment for other solid cancers has become more effective.12
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;349:g5261 doi: 10.1136/bmj.g5261 (Published 4 September 2014)
Page 2 of 2
VIEWS & REVIEWS
Research funding for pancreatic cancer lags behind that for other tumours. One reason is the lack of survivors (including celebrity spokespeople) to lobby for funding.13 The lack of funding is a particular problem because research is needed to develop new approaches to earlier diagnosis. In addition to innovative technologies, earlier diagnosis will require better communication between specialists and those in primary care.
Much can be done in the meantime to prolong survival—for example, improved coordination between the managers of patient pathways would help to speed patients’ progress through the investigations before multidisciplinary team meetings. And a suspected diagnosis of pancreatic cancer in other medical emergencies should automatically trigger fast track diagnostics and treatment. Moreover, the interval between diagnosis and surgery could be used for neoadjuvant therapy. Evidence is emerging that this may be advantageous even in patients with operable or borderline operable disease.14
For some years now, our centre has had allocated time slots for magnetic resonance imaging and multidetector computed tomography so we can offer fast track, high quality imaging. And a dedicated coordinator ensures access to imaging and evaluation at multidisciplinary team meetings. If the slots are not needed for pancreatic cancer patients, they are used for other patients who require urgent imaging. Multidisciplinary team meetings occur twice a week to expedite decision making. Management decisions are entered in the electronic patient record, and patients and colleagues are informed by telephone or outpatient clinic visits on the day of the decision. Twenty six years ago, Williamson wrote that “small but worthwhile gains in survival may come from an alert general practitioner or gastroenterologist who refers patients for a surgical opinion early.”10 Today it seems clear that pancreatic cancer must be considered a medical emergency.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare. Provenance and peer review: Not commissioned; externally peer reviewed. Patient consent not required (patient anonymised, dead, or hypothetical). 1 2 3
4 5 6 7 8 9 10 11 12 13 14
McPherson T. My mum wanted assisted dying but we watched her die slowly and in pain. BMJ 2012;344:e4007. Pancreatic Cancer UK. Policy briefing: every life matters: the real cost of pancreatic cancer diagnoses via emergency admissions. www.pancreaticcancer.org.uk/media/450955/elm_ policybriefing_final.pdf. Aveyard E, Pottage C, McDonnell P, Svenson M. Waiting times for suspected and diagnosed cancer patients. 2012-13 Annual report. London: NHS, 2013. www.england. nhs.uk/statistics/wp-content/uploads/sites/2/2013/07/Cancer-Waiting-Times-AnnualReport-2012-13-amended.pdf. NHS. Cancer waiting times. A guide. Version 7.0, 2013. www.nwlcn.nhs.uk/Downloads/ Cancer%20Intelligence/Going%20Forward%20on%20Cancer%20Waits%20A%20Guide% 20Version%207.0.pdf. Luebeck EG. Cancer: genomic evolution of metastasis. Nature 2010;467:1053-5. Birk D, Fortnagel G, Formentini A, Berger HG. Small carcinoma of the pancreas. Factors of prognostic relevance. J Hepatobiliary Pancreat Surg 1998;5:450-4. Balzano G, Zerbi A, Braga M, Rocchetti S, Bebeduce AA, Di Carlo V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 2008;95:1387-93. Hall TC, Dennison AR, Bilku DK, Metcalfe MS, Garcea G. Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review. Ann R Coll Surg Engl 2012;94:318-26. Valle JW, Palmer D, Jackson R, Cox T, Neoptolemos JP, Ghaneh P, et al. Optimal duration and timing of adjuvant chemotherapy after definitive surgery for ductal adenocarcinoma of the pancreas: ongoing lessons from the ESPAC-3 study. J Clin Oncol 2014;32:504-12. Williamson RC. Pancreatic cancer: the greatest oncological challenge. BMJ 1988;296:445-6. Bond-Smith G, Banga N, Hammond TM, Imber IC. Pancreatic adenocarcinoma. BMJ 2012;344:e2476. Malvezzi M, Bertuccio P, Levi F, La Vecchia C, Negri E. European cancer mortality predictions for the year 2014. Ann Oncol 2014;25:1650-6. Löhr M. Is it possible to survive pancreatic cancer? Nat Clin Pract Gastroenterol Hepatol 2006;3:236-7. Christians KK, Tsai S, Mahmoud A, Ritch P, Thomas JP, Wiebe L, et al. Neoadjuvant FOLFIRINOX for borderline resectable pancreas cancer: a new treatment paradigm? Oncologist 2014;19:266-74.
Cite this as: BMJ 2014;349:g5261 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
