Pancreatic cancer options
How do doctors determine whether or not chemotherapy or surgery is appropriate for treating pancreatic cancer? Why do some people with a late-stage diagnosis have treatment, while others are told treatment will not help their situation?
The treatment plan for each individual with pancreatic cancer is unique to that person's situation and the stage of the disease when it is diagnosed. Where in the past many people were advised that no treatment was available when cancer had spread outside the pancreas, today improved chemotherapy offers new treatment possibilities for this difficult cancer.
Pancreatic cancer is uncommon compared with other kinds of cancer. Symptoms are relatively nonspecific and can include abdominal or back pain, weight loss, new onset or worsening diabetes and jaundice or yellowing of the skin. Smoking is the only known significant risk factor, and although a small fraction of patients have a genetic predisposition, the majority of causes are unknown. The lifetime risk of developing the disease for people in the general population is about 1 percent. Unfortunately for those who do get it, pancreatic cancer is one of the hardest kinds of cancer to successfully treat. The five-year survival rate now is just over 7 percent.
The reason pancreatic cancer is so devastating is twofold. First, there's no early screening for it. Many cases are diagnosed at an advanced stage when cancer has already spread from the pancreas to other organs. The second reason has to do with the biology of the cancer. It's very aggressive and has a high tendency to spread to other sites. That means that for many people, the disease comes back after treatment.
In people diagnosed before cancer has spread outside the pancreas, treatment may include surgery to remove the tumor followed by chemotherapy. But that group is in the minority and only includes about 15 percent of patients at diagnosis. In up to 50 percent of patients, the cancer has spread to other sites outside the pancreas, making surgery ineffective. In about 35 percent of patients, the tumors involve vascular structures around the pancreas, so the cancer traditionally was felt to be surgically inoperable.
It's in this second group of patients that a new approach to treatment has been helping over the last several years. With the advent of improved chemotherapy and radiation therapy, it is now possible to give treatment to those individuals that may, in a significant number of cases, reduce the cancer to a point that surgery is a viable option for long-term survival and even cure.
The advances in chemotherapy for pancreatic cancer have been particularly positive. Whereas the response rates to traditional chemotherapy in people with pancreatic cancer used to be about 9 percent, that rate has almost tripled with the new chemotherapy regimens available today. It's even higher in patients whose tumors have not spread to other sites.
Additionally, the surgery used to remove pancreatic cancer has improved. Historical data suggest that about one in four patients had some cancer remaining in the pancreas after surgery. With preoperative chemotherapy and subsequent radiation therapy, along with updated surgical techniques, we have improved those percentages and increased the odds that all cancer cells will be removed. This strategy and improved care after surgery have also decreased the number of postsurgical complications.
A diagnosis of pancreatic cancer can be very frightening. But for many people, modern treatment options are available. If you are diagnosed with pancreas cancer and you aren't given any treatment choices, get another opinion. Talk to an oncologist or to a surgeon who specializes in pancreatic cancer at a center that does a high number of surgeries.
Mark Truty, M.D., Surgery, Mayo Clinic, Rochester, Minn.
Changes in menstruation
I am 41 and have had regular periods my entire life, until recently, when I didn't have a period for more than two months. It was heavy and lasted much longer than is typical for me. Should I be concerned? Do I need to see my doctor?
This is a very common situation for women your age. One episode of an irregular period usually isn't cause for concern. But from this point on, keep track of your periods. If they continue to be unpredictable or unusually heavy, or if you start to have other symptoms, such as pain or hot flashes, make an appointment to see your health care provider.
Even though the average age of menopause is around 51, it's not uncommon for women to experience menstrual irregularities in the decade before menopause, most often during their 40s. Once you notice a change in your period, it's a good idea to start monitoring it. Write down when they happen, how often they last and how heavy they are in terms of how many pads or tampons you use in 24 hours.
If after four to six months your periods are still irregular, then an assessment is in order. Your primary care provider is the best place to start. He or she can do a physical exam, order any needed testing and check for possible underlying medical conditions.
Two common causes of menstrual irregularity are thyroid disorders and endometrial hyperplasia, in which the lining of the uterus thickens. Noncancerous growths of the uterus, known as uterine fibroids, may also lead to changes in your periods. Your health care provider may also check you for anemia, a common side effect of heavy menstrual blood loss.
As you monitor your cycles over the next several months, if you have very heavy bleeding that is saturating a maxi pad or tampon in one hour or less, for more than two hours, or if you have bleeding that lasts for more than 10 days, contact your health care provider right away. Do the same if you notice other new symptoms.
Also, if you have factors that raise your risk for endometrial hyperplasia, including obesity, high blood pressure and diabetes, and the irregularity continues, the amount of time you monitor your condition before you call your provider is shorter. If you are at increased risk of endometrial hyperplasia and irregularity persists for two to three months, contact your provider.
Although an underlying condition can lead to menstrual irregularities, in many premenopausal women your age, period changes are a result of reproductive aging, not a sign of a problem. In those cases, a variety of treatments is available, including nonsteroidal anti-inflammatory drugs and oral contraceptives.
Petra Casey, M.D., Obstetrics and Gynecology, Mayo Clinic, Rochester, Minn.
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