Pancreatic cancer: Improving outcomes

Pancreatic cancer has no early warning signs and the majority of people with this disease present with acute symptoms such as jaundice and weight loss.

In the vast majority of cases, pancreatic cancer is only diagnosed when it is already at an advanced stage. Resection or removal of the tumour is the only way to achieve a credible chance of remission. Historically, resection has often not been possible, with only between 5-10 per cent of patients reaching surgery. This has been a serious setback.

Locally advanced pancreatic cancer means that the disease has spread from within the organ itself to the surrounding blood vessels. As a result removing the tumour when this has happened is fraught with danger and can lead to massive haemorrhage.

Over the last decade, resection rates have increased to around 15 per cent because we now have better diagnostic imaging, specialist pancreatic units and a more effective combination chemotherapy agent known as Folfirinox.This treatment can help shrink the tumours of people with locally advanced pancreatic cancer until they can be removed safely by a surgeon and we are hoping this will help to push resection rates up to 20 per cent.

Another new treatment which can help to shrink the tumour is a new form of technology called the NanoKnife, or irreversible electroporation (IRE). IRE is a treatment that involves inserting needles around the cancer. These long needles (which are insulated except at the tip) are inserted through the skin, from the front, using computerized tomography (CT) guidance, without making an incision. High voltage electrical micro -currents are then passed between the needles. These currents damage and destroy the cancer cells but leave healthy cells relatively unscathed. We usually use up to four needles and a master needle, which ensures that the whole tumour is covered by the treatment. It also connects to a cardiac monitor and ensures that the electric currents are delivered between heart beats. If the shock was delivered at the same time as the heart muscle contracted, it could cause a fatal arrythmia. The complications of the procedure are low and the mortality is less than 1per cent. If the procedure is successful resection could be offered in a select group of patients, but the majority of patients treated will hopefully gain extended life.

Thanks to enhanced surgical techniques, mortality rates after surgery have dropped markedly in patients able to undergo a resection, from around 15 per cent of patients to just over one per cent of patients.

We also take care to choose patients who are most likely to survive any potential complications of surgery using tests including the CPex, which measures how much oxygen reaches their tissues when they are exerting themselves on an exercise bike. Those who have a low score may be able to receive prehabilitation to increase their cardiovascular fitness, but they are not offered surgery immediately since the likelihood of a positive outcome is very small.

Because pancreatic cancer is a disease with very few treatment options, it is vital that patients have access to all effective treatments, regardless of where they live. IRE is very promising but at the moment, it is only available at a few NHS centres to patients with pancreatic cancer because the current NICE guidance is that it should just be used for research purposes for this disease. There is also currently not enough evidence of its effectiveness as a treatment for pancreatic cancer. However, NICE opened a consultation into this treatment to see if IRE should be made widely available on the NHS in England for patients with pancreatic cancer. The first step we need to take in order to assess whether IRE should be widely available for this disease is to gather more evidence on its effectiveness in pancreatic cancer, and our research funded by Pancreatic Cancer UK is making a truly vital contribution to that. In time, it is also hoped that IRE costs will also come down as the technology becomes more mainstream. At the moment, the master needle costs around £2500 and other needles are around £250 each.

Pancreatic Cancer UK is calling on patients with pancreatic cancer with experience of IRE, and their families, to take part in a survey about the treatment here.