Pancreatic Cancer
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PRIMER Pancreatic cancer Jorg Kleeff1,2, Murray Korc3, Minoti Apte4, Carlo La Vecchia5, Colin D. Johnson6, Andrew V. Biankin7, Rachel E. Neale8, Margaret Tempero9, David A. Tuveson10, Ralph H. Hruban11 and John P. Neoptolemos1 Abstract | Pancreatic cancer is a major cause of cancer-associated mortality, with a dismal overall prognosis that has remained virtually unchanged for many decades. Currently, prevention or early diagnosis at a curable stage is exceedingly difficult; patients rarely exhibit symptoms and tumours do not display sensitive and specific markers to aid detection. Pancreatic cancers also have few prevalent genetic mutations; the most commonly mutated genes are KRAS, CDKN2A (encoding p16), TP53 and SMAD4 — none of which are currently druggable. Indeed, therapeutic options are limited and progress in drug development is impeded because most pancreatic cancers are complex at the genomic, epigenetic and metabolic levels, with multiple activated pathways and crosstalk evident. Furthermore, the multilayered interplay between neoplastic and stromal cells in the tumour microenvironment challenges medical treatment. Fewer than 20% of patients have surgically resectable disease; however, neoadjuvant therapies might shift tumours towards resectability. Although newer drug combinations and multimodal regimens in this setting, as well as the adjuvant setting, appreciably extend survival, ~80% of patients will relapse after surgery and ultimately die of their disease. Thus, consideration of quality of life and overall survival is important. In this Primer, we summarize the current understanding of the salient pathophysiological, molecular, translational and clinical aspects of this disease. In addition, we present an outline of potential future directions for pancreatic cancer research and patient management. The normal pancreas consists of digestive enzyme- Pancreatic cancer is associated with an extremely secreting acinar cells, bicarbonate-secreting ductal cells, poor prognosis for several reasons3. It is usually diag- centro-acinar cells that are the geographical transition nosed at advanced stages, which is often due to non- between acinar and ductal cells, hormone-secreting specific and — in some cases — no symptoms, a lack of endocrine islets and relatively inactive stellate cells. The sensitive and specific tumour markers and difficulties majority of malignant neoplasms of the pancreas are in imaging early-stage tumours. Pancreatic cancer is adeno carcinomas; rare pancreatic neoplasms include aggressive, with perineural and vascular local growth neuroendocrine tumours (which can secrete hormones and early distant metastases that preclude curative sur- such as insulin or glucagon) and acinar carcinomas gical resection in most patients. Pancreatic cancer is (which can release digestive enzymes into the circula- character ized by a remarkable resistance (or tolerance) tion). Even less common neoplasms include colloid car- to most conventional treatment options, including cinomas, pancreatoblastomas and solid-pseudopapillary chemotherapy, radiotherapy and molecularly targeted neoplasms (FIG. 1). Specifically, ductal adenocarcinoma therapy. Finally, pancreatic cancer harbours multiple Correspondence to J.K. is the most common malignancy of the pancreas; this genetic and epigenetic alterations and have complex NIHR Pancreas Biomedical tumour (commonly and here referred to as pancreatic and dense tumour microenvironments. All of these fac- Research Unit, Department of cancer) presents a substantial health problem, with an tors result in an overall 5-year survival rate of <7%, with Molecular and Clinical Cancer Medicine, University of estimated 367,000 new cases diagnosed worldwide in almost all survivors at this time point being the 10–20% 1 Liverpool, Royal Liverpool 2015 and an associated 359,000 deaths in the same year . of patients who undergo surgical resection; for these and Broadgreen University Pancreatic cancer is currently the fourth highest cause of patients, the 5-year survival rate is ~15–25%4. Hospitals NHS Trust, Duncan cancer death in developed countries, and if outcomes are Although some areas of research and patient care Building, Daulby Street, Liverpool L69 3GA, UK. not improved, the disease is predicted to be the second have witnessed incremental progress (such as more- [email protected] leading cause of cancer-related mortality within the next effective combinatorial chemotherapeutic options, new decade2. Risk factors such as tobacco smoking, type 2 preoperative treatment strategies, better perioperative Article number: 16022 doi:10.1038/nrdp.2016.22 diabetes mellitus and chronic pancreatitis account for care and safer surgery), the overall effect on the progno- Published online 21 April 2016 approximately one-quarter to one-third of cases. sis of patients with pancreatic cancer has been marginal. NATURE REVIEWS | DISEASE PRIMERS VOLUME 2 | 2016 | 1 ©2016 Mac millan Publishers Li mited. All ri ghts reserved. PRIMER Author addresses the latest data show the incidence continuing to rise in the United Kingdom and in North America — prob- 1 NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer ably as a result of an ageing population3,8,9. Urban popu- Medicine, University of Liverpool, Royal Liverpool and Broadgreen University Hospitals lations tend to have higher rates than rural populations, NHS Trust, Duncan Building, Daulby Street, Liverpool L69 3GA, UK. reflecting the quality of diagnosis, although differences 2Department of General, Visceral and Pediatric Surgery, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany. in risk factors might also be involved. Studies suggest 3Departments of Medicine, and Biochemistry and Molecular Biology, Indiana University that first-generation migrants from low-risk areas who School of Medicine, the Melvin and Bren Simon Cancer Center, and the Pancreatic move to high-risk areas experience rates similar to Cancer Signature Center, Indianapolis, Indiana, USA. those of the country of migration after 15–20 years10, 4SWS Clinical School, University of New South Wales, and Ingham Institute for Applied indicating the importance of environmental factors on Medical Research, Sydney, New South Wales, Australia. pancreatic cancer aetiology. 5Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy. 6University Surgical Unit, University Hospital Southampton, Southampton, UK. Risk factors 7 Institute of Cancer Sciences, Wolfson Wohl Cancer Research Centre, University of Age is the major determinant of pancreatic cancer. Most Glasgow, Garscube Estate, Bearsden, Glasgow, Scotland, UK. patients are diagnosed at >50 years of age, with peak inci- 8QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia. 9UCSF Pancreas Center, University of California San Francisco — Mission Bay dence in the seventh and eighth decades of life. In terms Campus/Mission Hall, San Francisco, California, USA. of preventable risk factors, tobacco smoking is the most 10Cold Spring Harbor Laboratory, Cold Spring Harbor, New York, New York, USA. important and most studied. Smokers have a twofold to 11The Sol Goldman Pancreatic Cancer Research Center, Departments of Pathology threefold higher risk of developing pancreatic cancer and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. than non-smokers; a dose–risk relationship has been noted, as has a favourable effect of smoking cessation. The proportion of cases attributable to tobacco smok- Emerging strategies to treat pancreatic cancer include ing has been estimated to be 15–30% in various popu- identifying subgroups of patients for individualized lations11–13. Use of smokeless tobacco products can also therapies, developing molecularly targeted therapies increase the risk14. and immunotherapies, and focusing on the tumour Obesity and low physical activity are also linked microenvironment as a potential target. Additional to pancreatic cancer15,16. Some nutritional and dietary areas of intense investigation are early detection, tumour factors, including high intake of (saturated) fats, low marker validation and standardization of care. intake of vegetables and fruits and consumption of red In this Primer, we summarize key aspects of pancre- and processed meats, are also associated with risk17–19. atic cancer, from basic, translational and clinical points However, other dietary factors remain undefined and of view, and provide an outlook of the most important unquantified. Reports of an association between coffee challenges to tackling this deadly disease. consumption and pancreatic cancer risk20 have not been confirmed by subsequent studies. Furthermore, a pos- Epidemiology itive association with heavy alcohol consumption has Analyses of population-based data must consider geo- been observed, but no such association has been shown graphical and temporal variations in the quality of clin- with moderate drinking21,22. Heavy alcohol consump- ical diagnoses and in the proportion of histologically tion might be related to chronic pancreatitis, which verified cases of pancreatic cancer, which is rarely >50%5. increases the risk of pancreatic cancer by more than For example, differential access to health care, including tenfold, with little difference in attributable risk between advanced radiological tools, can influence the accuracy the alcoholic and non-alcoholic forms of pancreatitis. of reported pancreatic cancer