INTRODUCTION

OBJECTIVES:
 The goal of this concept map is to deeply understand the factors that
cause this disease and its management.

PANCREATIC CANCER

The pancreas is an organ that is located behind the stomach. It has two main functions:
●Making hormones, including those that regulate blood glucose (sugar) levels ("endocrine" function)
●Producing digestive juices that help the body break down food ("exocrine" function)

Pancreatic cancer is one of the leading causes of cancer-related death in the United States. Two types of
cancer can affect the pancreas:

●Pancreatic ductal adenocarcinoma – The most common type is cancer of the exocrine pancreas
that originates in the pancreatic ducts. The ducts are responsible for carrying pancreatic digestive juice
to the intestines. This type of pancreatic cancer, called "pancreatic ductal adenocarcinoma," is
discussed in this article.
●Pancreatic neuroendocrine tumors – Another type of cancer consists of a group of tumors that
originate from the cells that make hormones such as insulin. These tumors are called "pancreatic
neuroendocrine tumors" and are not discussed in this article.

Pancreatic cancer occurs when malignant cells develop in part of the pancreas. This may affect how the
pancreas works, including the functioning of the exocrine or endocrine glands. Pancreatic cancer can occur
in any part of the pancreas, but about 70% of pancreatic cancers are located in the head of the pancreas.
Exocrine tumours make up more than 95% of pancreatic cancers. The most common type,
an adenocarcinoma, starts in the cells lining the pancreatic duct. About 5% of pancreatic cancers are
pancreatic neuroendocrine tumours (NETs). These start in the endocrine cells. It is estimated that more than
4,500 people were diagnosed with pancreatic cancer in 2023. The average age at diagnosis is 72 years old

 Health statistics show that Pancreatic Cancer is at the lower end of the top 10
common cancers. However, it is the 4 t h leading cause of cancer deaths in the
world and in the Philippines.
 The pancreas (Lapay in Filipino) is an abdominal organ that is located behind the
stomach and is surrounded by other organs, including the spleen, liver and small
intestine. The pancreas is about 6 inches (15.24 centimeters) long, oblong and
flat. It plays an important role in digestion and in regulating blood sugar.
 The main functions of the pancreas are to produce Insulin (a hormone that lowers
a type of glucose, a type of blood sugar, in the blood) and to provide enzymes
used in digestion.
 SYMPTOMS

Most people with pancreatic cancer have abdominal pain and weight loss, with or without jaundice (yellowing
of the skin):

●Pain – Pain is a common symptom. It usually develops in the upper abdomen as a dull ache that
wraps around to the back. The pain can come and go, and it might get worse after eating.
●Weight loss – Some people lose weight because of a lack of appetite, feeling full after eating only a
small amount of food, or diarrhea. The bowel movements might look greasy and float in the toilet bowl
because they contain undigested fat.
●Jaundice – Jaundice causes yellow coloring of the skin and whites of the eyes. Bowel movements
may not be a normal brown color and instead have a grayish appearance, and the urine may be dark.
Jaundice is caused by blockage in the flow of bile through the ducts that come from the liver and
gallbladder to the intestine, where the bile assists in the digestion of food. The blockage is caused by
the cancer.

DIAGNOSIS

A. If you develop symptoms that raise suspicion for pancreatic cancer, your doctor or nurse will order
one or more tests. These might include:
B. ●Blood tests
C. ●Imaging tests – These may include an ultrasound, a computed tomography (CT) scan, or a
magnetic resonance imaging study (MRI).
D. ●Endoscopic procedures – Often, endoscopic, or interventional procedures of the gastrointestinal
tract may be performed including endoscopic ultrasound (EUS) and endoscopic retrograde
cholangiopancreatography (ERCP), are also performed.
E. The imaging and endoscopic tests can show if there is a mass (growth) in the pancreas if it is
involving neighboring structures, or if it has spread to other organs.
F. ●Biopsy – In most cases, your doctor will recommend a biopsy to confirm the diagnosis of cancer. A
biopsy involves removing a small piece of tissue from the mass. A clinician examines the tissue
under a microscope to see if there are signs of cancer.
G. To perform the biopsy, a doctor will use a CT scan or ultrasound to pinpoint the location of the mass,
then insert a needle into the mass and take a sample of tissue. A biopsy may also be obtained via
endoscopic procedures such as ERCP or EUS.

STAGING
Once pancreatic cancer is diagnosed, the next step is to determine its stage. Staging is a system used to
describe the spread of a cancer. A pancreatic cancer's stage is based on the size of the cancer and location
of the cancer in the body.

Staging is determined using the following tests:

●Imaging tests – Computed tomography (CT) scan, magnetic resonance imaging (MRI), or other
imaging tests to look for spread of cancer outside the pancreas.

●Laparoscopy – Sometimes, the staging of a pancreatic cancer also on what is found during surgery
or a special procedure known as a laparoscopy. This is a type of "minimally invasive surgery." During a
laparoscopy, a surgeon inserts a thin tube with a camera into small incisions in the belly to see the
organs inside the abdomen. In some centers, a laparoscopy is recommended before an attempt to
remove the cancer surgically to get more information on whether it has spread to the liver or other
parts of the abdomen.

GENETIC TESTING

Anyone with pancreatic cancer should be offered genetic testing, which may affect treatment options

●Germline mutations – "Germline" refers to the genes that a person received (inherited) from their
parents. The most common form of an inherited predisposition to pancreatic cancer is inheritance of
the BRCA genes (also known as the breast cancer genes). Other inherited conditions can also be
associated with the development of pancreatic cancer. Referral for genetic counseling may be
appropriate

●Somatic mutations – "Somatic" mutations refer to the genetic changes of the DNA in the tumor as
opposed to the DNA in healthy tissue. Identification of genetic changes unique to the tumor may allow
options for treatment with specific targeted therapies, including through clinical trials.

●Microsatellite instability – All pancreatic cancers should be tested for something called
"microsatellite instability." This involves looking at the tumor for loss of specific proteins involved in
repairing tumor cell DNA.

TREATMENT OF PANCREATIC CANCER

Pancreatic cancer can be treated with several approaches, depending upon the stage of the tumor and the
person's health. The main treatment options for pancreatic cancer include surgery, chemotherapy, and
radiation therapy (RT).

Early stage (surgically resectable) pancreatic cancer — The earliest stage pancreatic cancers (stages I or II)
can often be treated, and even cured, with surgery. However, few people are in the earliest stage when their
pancreatic cancer is found.
After surgery, most people often need further treatment, also called "adjuvant therapy,". This generally
includes chemotherapy and may include radiation therapy.

Some people whose tumors could be resected initially may be referred for initial chemotherapy and/or
radiation therapy to "downstage" or reduce the tumor and potentially improve outcomes from surgery.

Surgical approaches

Surgery for tumors in the head of the pancreas — The standard operation for tumors in the head of the
pancreas is called the Whipple procedure. This is also called a "pancreaticoduodenectomy."
In this procedure, the surgeon removes the pancreatic head, the duodenum (the first part of the small
intestine), part of the jejunum (the next part of the small intestine), the common bile duct, the gallbladder,
and part of the stomach. A modification of the Whipple procedure (called a "pylorus-preserving" Whipple
procedure) has been developed that preserves the part of the stomach (the pylorus) that is important for
stomach emptying. The Whipple procedure is a complex operation. Better treatment outcomes and less
postsurgical complications are more likely in hospitals that perform many Whipple procedures and when the
surgeon is experienced with the procedure. Surgery for tumors in the body or tail of the
pancreas — Because tumors in the body or tail of the pancreas do not cause the same symptoms as those
in the head of the pancreas, these cancers tend to be discovered at a later stage when they are more
advanced. If the tumor can be removed with surgery, a laparoscopy is usually done first to make sure the
cancer has not spread. If surgery is an option, part of the pancreas is removed, usually along with the
spleen.
Adjuvant therapy (treatment after surgery) — Adjuvant (additional) therapy refers to chemotherapy, radiation,
or a combination of both. Adjuvant therapy is recommended for people who are at high risk of having cancer
reappear (termed a "recurrence" or "relapse") after a tumor has been removed surgically.

Even if the tumor has been completely removed, tiny cancer cells may remain in the body and grow, causing
relapse after surgery. Adjuvant therapy can increase cure rates and prolong survival by eliminating the tiny
cancer cells before they have a chance to grow.

In people with completely resected pancreatic cancer, there are two ways to give adjuvant therapy after
surgery:

●Give chemotherapy alone

●Give a combination of chemotherapy and radiation therapy (this strategy is called "chemoradiation")

In the United States, after successful surgical removal of a pancreatic cancer, chemotherapy alone is
generally given. However, some people at high risk of local recurrence (ie, tumor coming back around the
site of surgery) will also receive chemoradiation.

Locally advanced pancreatic cancer — In locally advanced pancreatic cancer, the cancer has extended into
areas around the pancreas that make it difficult or impossible to remove it completely using surgery alone
but has not yet spread to distant locations. Using imaging studies and standard guidelines, some of these
cases may be classified as "borderline" resectable, while others are locally advanced and not resectable.

Chemotherapy — The best treatment for locally advanced pancreatic cancer is to start with systemic therapy
(specifically, chemotherapy). The purpose of the chemotherapy is to cause the tumor to shrink enough to
allow for surgery. Often, a person will receive radiation therapy after chemotherapy and prior to an attempt at
surgical removal.

The choice of regimen is based on several factors, including how healthy a person is before starting therapy,
and involves discussion with the treating clinician. Two common regimens used to treat pancreatic cancer
include:

●FOLFIRINOX (fluorouracil, leucovorin, irinotecan, and oxaliplatin)

●Gemcitabine plus nab-paclitaxel

Radiation therapy — Radiation therapy is often included in the treatment of locally advanced pancreatic
cancer. Radiation therapy is delivered while the person lies on a table underneath or in front of the machine.
The treatment takes only a few seconds, similar to having an x-ray.

The choice of radiation therapy delivery depends on tumor anatomy (ie, size, shape, contact with important
internal structures) and the experience of the radiation oncologist. The radiation therapy schedule depends
on whether the goal is to shrink the tumor and increase the chances of surgical removal, or to treat the tumor
completely without surgery.

Radiation therapy can be delivered in several ways

●Chemoradiation – Chemoradiation combines radiation therapy with chemotherapy. Most people

receive radiation therapy five days per week typically for five to six weeks, although the treatment
duration could be as short as two to three weeks. Chemotherapy (administered either oral or
intravenously) is also administered at the same time with radiation therapy to make it more effective.

●Stereotactic body radiotherapy – Stereotactic body radiation therapy (SBRT) is an alternative

option for radiation therapy delivery. SBRT involves a shorter treatment course of five days and is
given without chemotherapy.

Depending on the specific kind of cancer and its genetic makeup, some people may be candidates for other
types of treatment, such as:
●Immunotherapy – Immunotherapy refers to drugs that stimulate or unleash your immune system to
attack and kill the cancer cells. "Immune checkpoint inhibitor" drugs, though not broadly effective in
pancreatic cancer, can be used to treat certain rare subtypes of pancreatic cancer that show mismatch
repair deficiency (also known as microsatellite instability).

●Poly adenosine diphosphate-ribose polymerase (PARP) inhibitors – For people with a mutation
in the BRCA1, BRCA2, or PALB2 genes (which are associated with an increased risk of certain types
of cancer, including pancreatic cancer), a PARP inhibitor drug such as olaparib may be recommended
if the cancer did not progress after a period of chemotherapy.

These therapies do not cure metastatic pancreatic cancer, but they can relieve symptoms, slow the spread
of the cancer, and prolong life. Talk to your doctor about the benefits and risks of chemotherapy. Your doctor
might suggest participating in a clinical trial that compares new chemotherapy medicines or new
combinations of treatment.

DISCHARGE PLANNING:
Home care after surgery Here’s what to do at home after surgery for pancreatic cancer:

 Follow the diet you discussed with your healthcare provider.

 Use pain medicines as needed.
 Check your temperature every day for a week after your surgery.
 Increase your activity slowly. Start with short walks on a level surface. Don’t overdo it. If you get
tired, rest. Shower as needed.
 Ask a friend or family member to stay close by in case you need help. Limit stair climbing to once
or twice a day. Go slow and stop to rest every few steps.
 Do deep breathing and controlled coughing exercises. Ask your healthcare provider for
guidelines.
 Don’t lift anything heavier than 5 pounds (2.27 kg) for 4 to 6 weeks after surgery.
 Don’t mow the lawn or push a vacuum cleaner.
 If you ride in the car for more than short trips, stop often to stretch your legs. Don’t drive until
your healthcare provider says it’s OK.
 XAsk your healthcare provider when you can expect to return to work.

Home care after chemotherapy

Here’s what to do at home after chemotherapy for pancreatic cancer:

Prevent or manage mouth sores

Many people get mouth sores during chemo. So, don’t be discouraged if you do, even if you're
following all your healthcare provider’s instructions. Do these things to help prevent mouth sores
or to ease discomfort.

 Brush your teeth with a soft-bristle toothbrush after every meal and at bedtime.
 If your platelet count is low or if your gums are inflamed, flossing may cause gum bleeding.
 You may need to limit flossing.
 Use an oral swab or special soft toothbrush if your gums bleed during regular brushing.
 Use any mouthwashes given to you as directed.
 Don't use mouthwash that contains alcohol. Keep your mouth moist. Use salt and baking soda to
clean your mouth.
 Mix 1 teaspoon (s) of salt and 1 teaspoon (s) of baking soda into an 8-ounce glass of warm
water. Swish and spit.
 Watch your mouth and tongue for white patches. This can be a sign of fungal or yeast infection,
common side effects of chemo.
 Be sure to tell your healthcare provider about these patches. You may need medicine to help
you fight the fungal infection.
 If you have dentures, keep them clean and limit the time you wear them.

Home care after radiation therapy

Here’s what to do at home after radiation therapy for pancreatic cancer:

Skincare Do's and don'ts include:

 Don’t scrub the treated area. Do ask your therapy team which lotion to use. Don't get sun on the
treated area.
 Ask your therapy team about using sunscreen.
  Don’t remove ink marks unless your radiation therapist says it’s OK.
 Do protect your skin from heat or cold. Don't use hot tubs, saunas, heating pads, or ice packs.
 Do wear soft, loose clothing to keep your skin from rubbing. Don’t be surprised if your treatment
causes slight burns to your skin.
 Some medicines used in high doses can cause this to happen.
 Ask for a special cream to help relieve the burn and protect your skin.

When to call your healthcare provider

Call your healthcare provider right away if you have any of the following:

 Any chest pain Fever of 100.4° F (38.0°C), or as directed by your healthcare provider Chills
 Any unusual bleeding Signs of infection around the incision (redness, drainage, warmth, pain)
 Incision that opens up or pulls apart Cloudy thinking or trouble concentrating
 Ongoing fatigue Shortness of breath, especially at rest
 Trouble breathing Rapid, irregular heartbeat; chest pain Dizziness or lightheadedness
 Constant feeling of being cold new or unusual lumps, bumps, or swelling Yellowing of the skin or
eyes; light-colored stools
 Persistent nausea or vomiting Persistent diarrhea new redness, pain, swelling, or warmth in your
leg(s) or arm(s)

DIAGRAM

5 YEAR RELATIVE LATE DIAGNOSIS- HIGH RECCURENCE

SURVIVABILITY ADVANCED RATE AFTER
RATE: 8% TUMORS SURGERY

MEDIAN PANCREATIC UNSPECIFIC

SURVIVAL-9 CLINICAL
CANCER SYMPTOMS
MONTHS

EXTENSIVE POOR RESPONSE TO

DESMOPLASIA LACK OF SYSTEMIC
BIOMARKERS THERAPIES
RELATED NURSING THEORY:

Patients who are suffering from pancreatic cancer have numerous problems. Watson's Theory of
Human Caring seems to be proper in caring for these patients. This theory stresses the
humanistic aspects of nursing as they interfere with scientific knowledge and nursing practice.
The process of the study was done in five stages. After the implementation of Watson's theory in
a five-step interview, the patient's disappointment and despair were reduced and the patient
agreed to continue the treatment process. Watson's theory of caring is likely to bring love and
hope back to patients with pancreatic cancer in bad physical and mental conditions. By applying
10 caring factors of this theory, a humanitarian relationship is established with the patient; this
relationship is based upon love and hope. The patient is able to express feelings and continue
the treatment process by trusting God, applying spirituality, and gaining support from family and
friends.

REVIEW OF RELATED STUDIES/LITERATURE

Pancreatic adenocarcinoma is a lethal condition with a rising incidence, predicted to become the second
leading cause of cancer death in some regions. It often presents at an advanced stage, which contributes to
poor five-year survival rates of 2%-9%, ranking firmly last amongst all cancer sites in terms of prognostic
outcomes for patients. Better understanding of the risk factors and symptoms associated with this disease
is essential to inform both health professionals and the general population of potential preventive and/or
early detection measures. The identification of high-risk patients who could benefit from screening to detect
pre-malignant conditions such as pancreatic intraepithelial neoplasia, intraductal papillary mucinous
neoplasms and mucinous cystic neoplasms is urgently required, however an acceptable screening test has
yet to be identified. The management of pancreatic adenocarcinoma is evolving, with the introduction of
new surgical techniques and medical therapies such as laparoscopic techniques and neo-adjuvant
chemoradiotherapy, however this has only led to modest improvements in outcomes. The identification of
novel biomarkers is desirable to move towards a precision medicine era, where pancreatic cancer therapy
can be tailored to the individual patient, while unnecessary treatments that have negative consequences on
quality of life could be prevented for others. Research efforts must also focus on the development of new
agents and delivery systems. (McGuigan et al., 2018)

REFERENCES

https://www.cancer.org.au/cancer-information/types-of-cancer/pancreatic-cancer

https://www.themedicalcityclark.com/cancer-of-the-pancreas/

https://www.uptodate.com/contents/pancreatic-cancer-beyond-the-basics

https://mountnittany.org/wellness-article/pancreatic-cancer-discharge-instructions-for-after-
treatment#:~:text=Eat%20foods%20high%20in%20protein,in%20the%20area%20being
%20treated.
https://www.redlandshospital.org/nursing-excellence/jean-watsons-theory-of-human-caring/
#:~:text=According%20to%20Watson%20(1997)%2C,interpersonal%20process%20between
%20the%20care

McGuigan, A., Kelly, P., Turkington, R. C., Jones, C., Coleman, H. G., & McCain, R. S. (2018). Pancreatic

cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World Journal of

Gastroenterology, 24(43), 4846–4861. https://doi.org/10.3748/wjg.v24.i43.4846