An international team of researchers has revealed how aggressive pancreatic cancer cells change their environment to enable easy passage to other parts of the body (or metastasis) – the main cause of pancreatic cancer related death. The researchers discovered that some pancreatic tumours produce more of a molecule called ‘perlecan’ to remodel the environment around them, which helps cancer cells spread more easily to other parts of the body, and also protects them against chemotherapy. In a mouse model, the researchers showed that lowering the levels of perlecan revealed a reduction in the spread of pancreatic cancer and improved response to chemotherapy.
Scientists studying a highly cancer-prone family have identified a rare, inherited gene mutation that dramatically raises the lifetime risk of pancreatic and other cancers. The discovery of the previously unknown mutation, reported in Nature Genetics by investigators from Dana-Farber/Brigham and Women’s Cancer Center, could lead to routine testing of individuals with a strong family history of pancreatic cancer to determine if they carry the mutation, occurring in the gene known as RABL3. If so, they could be screened to detect pancreatic cancer in an earlier, potentially more treatable stage. “There is evidence that catching pancreatic cancer through screening of high-risk individuals may improve outcomes,” said Sahar Nissim, MD, PhD, a cancer geneticist and gastroenterologist at Dana-Farber Cancer Institute and Brigham and Women’s Hospital, and first author of the study.
Leading the Way Through Research at our Four Dedicated Pancreatic Cancer Research Laboratories
Pancreatic cancer research is moving faster than ever before, and there has never been a more hopeful time for patients. Our Lustgarten-funded researchers are at the forefront of the most promising breakthroughs that are directly impacting patients and enabling some patients to live longer. In fact, the Foundation has directed close to $200 million to research to date, amounting to nearly two-thirds of the world’s private funding for pancreatic cancer research from organizations solely focused on this disease, and positioning the Foundation as the largest private funder of pancreatic cancer research in the world. We are making progress every day toward advancing early detection methods, discovering new treatments, and most importantly, creating a larger community of survivors.
To accomplish these breakthroughs and ensure more discoveries will follow, we have opened four dedicated pancreatic cancer research laboratories at Cold Spring Harbor Laboratory, Dana-Farber Cancer Institute, Johns Hopkins, and Massachusetts Institute of Technology, representing an investment to date of more than $25 million. United in the shared goal of improving patient outcomes, these laboratories are increasing collaboration between world-renowned pancreatic cancer researchers and are exploring new, promising avenues for understanding and treating this disease. Together, these facilities position the Foundation as the only non-profit in the world to have four labs devoted to pancreatic cancer research, which means more resources, time and talent are being put toward this disease, where they are urgently needed. Through these labs, the Lustgarten Foundation is ushering in a new era of research progress.
Cold Spring Harbor Laboratory: Focusing on Personalized Medicine
Dr. David Tuveson leads the Lustgarten Laboratory at Cold Spring Harbor Laboratory, designing new models of the disease and discovering novel therapeutic and diagnostic platforms to bring new options to patients more rapidly. Dr. Tuveson was the first scientist to develop a pancreatic cancer organoid – a three-dimensional cell culture system which reproduces a patient’s tumor in a dish to test it repeatedly with different drugs – and has started to demonstrate that organoids can accurately predict how a patient will respond to various therapies, offering the hope of personalized cancer treatments.
- Establish precision Clinical Laboratory Evaluation Program (CLEP)-certified testing of organoids to support clinical trials.
- Understand and inhibit therapeutic resistance to organoids.
- Conduct clinical trials to assess if treatment stratification will improve survival.
“There has never been a more exciting time in pancreatic cancer research. We are now taking our science into the clinic and impacting patient outcomes in real time. I want patients to know that we are making progress.”
Dana-Farber Cancer Institute: Advancing Translational Research
Under the leadership of Dr. Brian Wolpin, the Lustgarten Laboratory at Dana-Farber is a critical hub for advancing research from the laboratory to the clinic, a process known as translational research; initiating scientifically driven clinical trials; and identifying new approaches to early detection. This research will also capitalize on the large, multidisciplinary network of investigators working on pancreatic cancer, under the umbrella of Dana-Farber’s Hale Family Center for Pancreatic Cancer Research.
- Study the genetic composition and the driver pathways of pancreatic tumors, which will lead to personalized treatment options.
- Expand clinical trials for patients with metastatic pancreatic cancer using organoids, which allow multiple drugs to be tested in real time to identify the best course of treatment.
- Identify new blood-based and imaging markers for asymptomatic patients and new models for risk prediction to facilitate earlier detection.
“The work being done with the Foundation’s support is the main driver of progress in the field. It’s quite amazing that a single foundation can play such a transformative role. Our patients are and will be the beneficiaries of such vision and leadership.”
Massachusetts Institute of Technology: Merging Technology and Engineering
The Lustgarten Laboratory at MIT is leveraging its unparalleled expertise in cancer biology and engineering to advance pancreatic cancer research. Led by Dr. Tyler Jacks, the laboratory is studying the genetic events contributing to cancer development and examining the immune responses to the disease using molecular profiling to identify tumor mutations.
- Evaluate the immune system’s role in tumor development and disease progression to determine better therapies.
- Use cell profiling technologies to identify new targets for intervention.
- Produce organoids more quickly and use them to examine genes that may be responsible for tumor development and explore DNA manipulations through screenings to examine disease progression.
“We are grateful for the Lustgarten Foundation’s investment in our work as it allows us to recruit new investigators from across MIT who have never worked in pancreatic cancer before but whose tools and approaches will help us develop new treatment paradigms for early diagnosis and intervention.”
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins: Furthering Early Detection and Therapeutics
Directed by Dr. Bert Vogelstein, the Lustgarten Laboratory at Johns Hopkins is leveraging its expertise in early detection to intercept pancreatic cancer at an earlier stage, when patients may be surgical candidates, and is developing new therapeutic approaches based on genetic alterations.
- Increase the sensitivity (ability to correctly identify those with the disease) of CancerSEEK, a blood test to detect pancreatic cancer and seven other cancers early, and bring this blood test to the clinic. CancerSEEK has received FDA “Fast Track” status for pancreatic cancer, accelerating the approval process.
- Advance the CompCyst test, which combines clinical, radiological, genetic and protein marker information to distinguish between pancreatic cysts that can become cancerous and those that will remain benign. The Lustgarten Laboratory at Johns Hopkins is working to further develop the CompCyst test into a clinically approved test for many people harboring pancreatic cysts, which can be common amongst the general population.
- Monitor the effectiveness of immunotherapy in patients being treated for cancer by examining specific T-cells.
“Early detection is how we are going to change the statistics for pancreatic cancer patients and create more long-term survivors. We are hopeful that our research will mean that deaths from pancreatic cancer will be less common, thanks to the Lustgarten Foundation’s support.”
Make a difference in patients’ lives by donating to the Lustgarten Foundation today and supporting pancreatic cancer research. We couldn’t accomplish all that we do without you
Unlike many other cancers, most pancreatic tumors are rock hard. “That’s one reason why pancreatic cancer is one of the most lethal types of cancer,” says Kenneth Olive, PhD, associate professor of medicine and pathology & cell biology at Columbia University Vagelos College of Physicians and Surgeons and a pancreatic cancer researcher at the Herbert Irving Comprehensive Cancer Center. “Pancreatic tumors recruit a thick layer of connective tissue called stroma that hardens the tumor and acts like a shield,” says Olive, whose previous research first uncovered how the stroma makes it difficult for chemotherapy drugs to reach malignant cells. “As a result, most chemotherapy drugs can’t build up to the levels needed to be effective.”
Charles S. Fuchs, M.D., MPH, is the Director of the Yale Cancer Center and the Physician-in-Chief of the Smilow Cancer Hospital. In this interview, he discusses why proper nutrition is important for patients with pancreatic cancer.
What is the main function of the pancreas and how does pancreatic cancer impact how the pancreas works?
The pancreas is responsible for aiding in digestion. When patients have pancreatic cancer, they may not have sufficient pancreatic enzymes being manufactured to help with digestion, or these enzymes are not getting into the intestinal tract. When that happens, doctors might recommend pills containing supplemental enzymes to improve digestion and make up for enzyme deficiencies that might occur as a result of having cancer. These issues can be caused by surgery for pancreatic cancer or by pancreatic function being diminished as a result of having pancreatic cancer.
In addition to aiding in digestion, the pancreas produces insulin and releases it into the bloodstream to control blood sugar. Adults with diabetes make a fair amount of insulin, but are typically insulin-resistant. That is, their bodies produce large amounts of insulin, but cannot make use of it, which creates high levels in the blood. High levels of insulin are thought to be a risk factor for pancreatic cancer. There are even rare cases where people may be diagnosed with diabetes in mid-life and it’s actually because they have undiagnosed pancreatic cancer.
Are there certain foods that may impact the risk for pancreatic cancer?
Foods with a high glycemic load, meaning that they are high in substances that increase blood sugar, may be linked to an increased risk for pancreatic cancer. Obesity is a major driver of the disease, and a sedentary lifestyle is also a factor. I recommend following a healthful diet and exercising regularly.
My research published in The New England Journal of Medicine (November 21, 2013) followed more than 118,000 healthy volunteers over three decades to assess their nut consumption and found that people who ate at least one ounce of nuts a minimum of seven times per week had a 20% lower death rate and fewer deaths due to cancer, heart disease and respiratory disease. Results also revealed that eating a one-ounce serving of nuts at least twice per week was associated with a lower risk of pancreatic cancer in women.
What is the latest research on the link between obesity and pancreatic cancer?
The number one cause of Type II diabetes, which impacts approximately 8% of Americans, is obesity. People with Type II diabetes are at an increased risk of developing pancreatic cancer. Obesity makes people insulin resistant, meaning that they have to make significantly more insulin than what is typically needed to control their blood sugar.
Why is it so important for pancreatic cancer patients to focus on proper nutrition?
Studies have shown that 75% of newly diagnosed cancer patients believe that there is a diet, food or supplement that can positively improve their outcome. Our recent studies of newly diagnosed cancer patients suggest that regular exercise and a balanced diet that avoids excessive carbohydrates can improve patient survival. Moreover, through proper nutrition, patients can maintain their muscle mass, which will help them perform activities of daily living, stay on a treatment plan, and improve overall quality of life.
What are some suggestions you have for patients who are trying to optimize their nutrition during treatment? For example, which foods should be avoided, and which foods are considered more nourishing and digestible and should be eaten as often as possible?
Pancreatic cancer patients who have difficulty consuming larger meals should try to eat 5-6 small meals or snacks throughout the day, as eating smaller amounts is easier for the body to digest and absorb and can minimize nausea. Patients should also eat foods that contain healthy fat and avoid greasy, fried foods. Eat as many fruits, vegetables, whole grains and lean proteins as possible and avoid excess sugar and sweets. Drink plenty of fluids to avoid dehydration and exercise frequently – even if it is just a short walk. For patients who are underweight, gaining or maintaining current weight is critical, so I recommend relaxing restrictions on low-cholesterol and low-fat foods. Otherwise, for patients with a relatively stable or healthy weight, maintaining weight with a balanced diet is preferred.
What do you advise patients who complain of a loss of appetite and problems digesting food?
This is a complex issue, as these problems can result from a physical problem in digestion related to pancreatic enzymes, or a deficiency in these enzymes. It could also reflect that the cancer is affecting the gastrointestinal tract in other ways, reducing the patient’s appetite. Additionally, pancreatic cancer can cause poor appetite, independent of these other factors.
Moreover, chemotherapy and recovery after surgery can both impair appetite. Patients should speak with their physicians if they are experiencing these problems while they’re going through treatment. Major medical centers typically have nutritionists on staff, and a nutritional consultation is invaluable. The goal is for each patient to remain as healthy as possible during treatment, and proper nutrition is key to making that happen.
What is the difference between malabsorption and cachexia (a condition characterized by progressive muscle wasting, loss of appetite, and unintentional weight loss)? How can cachexia be managed?
Pancreatic cancer has a unique ability to manipulate and rely on metabolic pathways and contribute to cachexia, which is a common condition in cancer patients that causes muscle wasting, loss of appetite, and unintentional weight loss. Cachexia occurs more often in pancreatic cancer patients than in patients suffering from other types of cancer.
In our current research, we have been measuring the blood from seemingly healthy patients who show no outward signs or symptoms of cancer, and we are finding pancreatic cancer signals in the blood years before patients exhibit any disease signs or symptoms. These patients’ metabolic screens are showing that they are subtly losing muscle. Moreover, our research team has confirmed this finding in mouse models. This breaking down of a muscle is an early sign of cachexia. We are trying to understand in both animal models and in our patient population which chemicals the pancreatic cancer is producing to cause cachexia and which chemicals the cancer is relying on for its survival so that we can block them. We can show biochemical evidence of muscle breakdown five years before people even know they have pancreatic cancer. Additional research is underway.
Patients showing signs of cachexia may benefit from appetite stimulants, omega-3 fatty acids, and/or other nutritional supplements. Cachexic patients would definitely benefit from working with a nutritionist to develop a customized nutritional plan.
Cachexia is very different from malabsorption, which occurs when a patient is actually taking food in but the nutrients are not being absorbed and are instead coming out in the stool. Malabsorption occurs when the pancreas does not make enough enzymes so patients can’t process the nutrients in their gastrointestinal tract, so that nutrients do not get absorbed. As a result, people will experience weight loss and sometimes diarrhea.
What dietary problems can some patients experience as a result of surgery? How quickly can most patients, if they do have surgery, resume a normal diet?
Patients should follow diet recommendations from their doctors. They will gradually resume a normal diet in terms of quantity of calorie consumption and dietary quality and variety. Following a Whipple procedure, which involves the surgical removal of part of the small intestine, pancreas and sometimes part of the stomach, patients should eat small, frequent meals; avoid high fat, high sugar and high fiber foods; eat foods high in protein to encourage healing; and limit liquid intake during meals, as significant liquid intake may impact how much food can be eaten.
What dietary problems can some patients experience when they’re going through chemotherapy and radiation?
The most common complaints are diminished appetite (sometimes related to nausea), complete loss of appetite, and change in taste. Luckily, these are all treatable. Typically, though, there’s not a clear rule of thumb for which foods patients can and can’t tolerate during treatment, as it varies from person to person.
Is vitamin D important for pancreatic cancer patients? Can patients benefit from eating food rich in vitamin D as well as from taking vitamin D supplements? Have there been any recent clinical studies that have demonstrated that taking vitamin D resulted in improved survival or a decrease in tumor size?
Vitamin D actually changes which genes are turned on and turned off, which then affects cancer development. Whereas other vitamins only impact simple metabolic pathways, vitamin D is technically really a hormone. The cell takes it into the nucleus and it affects the way we manage our DNA. It also changes which genes are overproduced.
Research into the potential benefit of vitamin D is extremely promising. Studies have found that people with higher levels of vitamin D have a lower risk of developing pancreatic cancer and that in people who already have the disease, people with higher levels of vitamin D have better outcomes.
In fact, The Wall Street Journal recently featured an article about how doctors, scientists and other experts are coming together to find breakthroughs for pancreatic cancer. One of the most exciting areas is the Lustgarten Foundation’s research with a synthetic form of vitamin D, which shuts down the stromal cells that surround the tumor and nurture the cancer cells. By shutting down the activity of the stromal cells, treatment is more effective.
Ronald Evans, Ph.D., of the Salk Institute for Biological Studies and a Lustgarten Foundation Distinguished Scholar, found that a synthetic derivative of vitamin D could potentially delay pancreatic cancer tumor growth when combined with chemotherapy in mice, resulting in a 57 percent increase in lifespan compared to chemotherapy alone. He is now conducting research to determine if late stage pancreatic cancer patients’ tumors have a vitamin D receptor in their metastases as well, which would make them eligible for treatment with synthetic vitamin D as part of their therapy.
Can pancreatic cancer patients benefit from increasing their consumption of foods/supplements containing vitamin A and vitamin C?
There’s no evidence that I know of that either vitamin A or vitamin C or any of the other vitamins influence pancreatic cancer development. The work with vitamin D is ongoing and there’s no harm in taking a vitamin D supplement.
Does pancreatic cancer deplete the body of certain nutrients, and how can these nutrients be replaced by supplements, including pancreatic enzyme supplements? How do these supplements work?
There’s not any particular nutrient that is affected more than another. Pancreatic enzyme supplements contain the pancreatic enzymes lipase, amylase and protease which help in the digestion of fat, carbohydrates and proteins. These enzymes may be needed if there is a blockage in the pancreatic duct or removal of part of the pancreas, which can cause a change in the amount and the flow of pancreatic juice. This juice contains enzymes that aid in digestion. There is a titration of these enzymes that can be very helpful, so that you can determine what concentration of each enzyme is necessary for each meal and snack. These supplements are available in both over-the-counter and prescription forms.
What advice would you give to pancreatic cancer patients who are searching for information on the diet that would be most appropriate for them during treatment?
Patients should speak with their physicians to determine what’s best for them and to identify reliable sources of information online that they can refer to for guidance. It’s alright if a physician says that he or she doesn’t have the answers but will connect you with a nutritionist who has more expertise. Speaking about nutrition is not necessarily common during oncology visits, as the conversation typically revolves around treatment plans. However, it is a very important topic, and patients should feel comfortable asking questions about how to optimize nutrition during treatment and advocating for a referral to a nutritionist.
What role does a nutritionist play in helping pancreatic cancer patients eat a well-balanced diet? When in the process should a patient seek out the help of a nutritionist?
The nutritionist is the best resource I have for when a patient asks, “What can I do to help myself?” Patients should speak with a nutritionist if they are experiencing side effects during treatment or after surgery that might require a change in diet. Nutritionists are also extremely helpful when there is continued weight loss without correction and there is no underlying medical reason for this. A nutritionist can create a customized eating plan that is specific to a particular patient and that takes into account the impact pancreatic cancer treatment has on digestion.
Ask the Nutritionist: Stephanie Meyers, M.S., R.D./L.D.N., C.N.S.D.
Stephanie Meyers, M.S., R.D./L.D.N., C.N.S.D., is a Senior Clinical Nutritionist/Registered Dietitian at The Dana-Farber Cancer Institute in Boston. She works in conjunction with the Leonard P. Zakim Center for Integrated Therapies, where she specializes in the nutritional care of cancer patients. Stephanie is also an adjunct faculty member in the Department of Nutrition at Boston University.
As a pancreatic cancer patient, you may face unique challenges to maintaining a balanced diet during treatment. You could experience unintentional weight changes, or you might find that despite a concerted effort to eat well, you are losing weight and muscle mass, or you may have less energy for activities of daily living. There isn’t a “one size fits all” diet for pancreatic cancer patients; a tailored approach is necessary. Nutritionists will help you develop a customized plan to take control of your diet and ensure you’re eating the best that you can – an empowering step towards optimizing your health and energy and minimizing treatment side effects.
There are calculations that nutritionists use to determine the number of calories, grams of protein and ounces of fluid needed per day. Once these amounts have been met, you know you don’t have to eat or drink anything else that day, and your caregivers can feel confident that you have received proper nourishment.
Below are some common issues encountered during treatment and some strategies for addressing them. Please note that the following information should not be used as a substitute for personal nutrition information from your registered dietitian or physician.
COPING WITH NAUSEA:
- Talk to your doctor about prescribing an anti-emetic medication to prevent nausea and vomiting.
- Eat small, frequent meals. Research has demonstrated that giving smaller food portions more frequently actually results in better oral intake than when given a plate of food with a pre-treatment sized portion on it. Eat from salad or dessert plates.
- Eat foods known to be beneficial for quelling nausea, including ginger and lemon (fresh, grated, or as an ingredient in other foods). In fact, even smelling a wedge of lemon has been shown to help with nausea; this is especially helpful when you’re out at a restaurant with family or friends.
- Eat high sodium foods that are coupled with potassium, such as a saltine cracker and a potato chip. Eating four or five dry, crunchy items is sometimes enough to settle gastric acid secretions in the stomach so you then feel well enough to have other more nutritious food options, such as a sandwich or soup.
- Eat cold foods.
- Avoid foods with a strong smell or odor.
COPING WITH CONSTIPATION:
- Take stool softeners or laxatives as recommended by your physician.
- Increase fiber intake via fresh fruits (including apples and berries) and vegetables (such as broccoli and salad), whole grains, nuts and seeds.
- Assure adequate fluid intake.
MANAGING YOUR DIET FOLLOWING A WHIPPLE PROCEDURE:
- Eat small, frequent meals which include lean, high-quality protein, such as chicken or fish that is easy to digest.
- Limit intake of foods high in fat and sugar simultaneously to prevent dumping syndrome, which is the rapid movement of food from the stomach into the small intestine, which could result in discomfort. A nutritionist will be able to calculate exactly how many grams of fat and sugar you can eat and how they should be spread out over the day.
COPING WITH DIARRHEA:
- Take an anti-diarrhea medication as recommended by your physician.
- Follow a low-fiber, low-residue diet to limit foods that add residue, or undigested food, to the stool.
- Following the diet below should help control symptoms such as stomach cramping, bloating, gas and diarrhea:
- Minimize consumption of raw fruits and vegetables, nuts, whole grain breads and cereals, seeds, and cooked or canned fruits and vegetables with seeds.
- Eat white bread, plain crackers, cooked cereals, cold cereals, white rice, noodles and pasta, and cooked or canned fruits and vegetables without seeds (such as bananas, avocados, cooked potatoes without the skin, green beans, carrots and mushrooms).
- Eat vegetables that contain predominantly soluble fiber, like asparagus, that are better tolerated than vegetables like broccoli.
COPING WITH CACHEXIA (MUSCLE WASTING)
- Consider supplementation with anabolic steroids, appetite stimulants, omega-3 fatty acid and other nutritional supplements and certain medications.
- Exercise if possible to increase appetite and help slow down the decline in muscle mass.
- Eat small, frequent meals that are high in calories.
FINDING A NUTRITIONIST:
No matter what type of pancreatic cancer treatment you are receiving, it can be helpful to meet on a regular basis with a nutritionist. I follow a “chairside approach,” where I will consult with my patients while they’re in their infusion chairs receiving chemotherapy or hydration treatment.
This way, we can discuss which dietary modifications have and haven’t worked to manage and minimize symptoms. We can also strategize a new approach, as so much of nutrition is trial and error to develop an individualized plan.
In environments where oncologists have access to trained nutritionists who specialize in oncology, there is more recognition that there is a real benefit both in a quality of life standpoint and also potentially in terms of helping patients tolerate treatment better. You can also visit www.eatright.org, the website of the Academy of Nutrition and Dietetics, and search for a certified specialist in cancer/oncology nutrition by entering your zip code under the Find an Expert link.
Make a difference in patients’ lives by donating to the Lustgarten Foundation today and supporting pancreatic cancer research. We couldn’t accomplish all that we do without you.
Known as two of the most lethal cancers, ovarian and pancreatic cancer are often called silent killers since they rarely have early symptoms. As a result, they frequently go undetected until they’re too late to effectively treat.
Cancer scientists at Houston Methodist and The University of Texas MD Anderson Cancer Center have been vigilant about looking for more effective late-stage treatments and may have found one.
In a study published online July 22 in the journal Clinical Cancer Research, co-corresponding authors Stephen T.C. Wong, Ph.D., from Houston Methodist Cancer Center and Samuel Mok, Ph.D., from The University of Texas MD Anderson Cancer Center report that they have found a new type of immunotherapy to try in the fight against these two deadly malignancies.
Johns Hopkins Kimmel Cancer Center study coauthors Anne Marie Lennon, Simeon Springer, Marco Dal Molin, Christopher Wolfgang and Bert Vogelstein will participate in a press teleconference organized by the American Association for the Advancement of Science at 11 a.m. Tuesday, July 16. To RSVP, send an email to firstname.lastname@example.org. An audio recording and transcript will be available on the MedPak webpage (eurekalert.org/journls/scitransmed/) at the end of the teleconference.
In a proof-of-concept study, an international scientific team led by Johns Hopkins Kimmel Cancer Center researchers has shown that a laboratory test using artificial intelligence tools has the potential to more accurately sort out which people with pancreatic cysts will go on to develop pancreatic cancers.
Depression and anxiety are very common to find patients with pancreatic cancer who experience symptoms of both depression and anxiety. Read this interview with a pancreatic cancer expert here:
Q: What are depression and anxiety?
ALAN D. VALENTINE (ADV): Depression—a persistent feeling of sadness and loss of interest—is a mood disorder that runs along a wide spectrum, ranging anywhere from a mild adjustment disorder to major depressive disorder. An adjustment disorder with depressed mood, sometimes referred to as reactive depression, is usually a short-term condition brought on by stress and the inability to cope with certain situations. Major depressive disorder is a condition that tends to develop relatively slowly and can be very serious if it is not addressed. Anxiety is intense, excessive worry and fear about everyday situations.
Anxiety can also present as an adjustment disorder. Depression and anxiety are considered different conditions, but they are often related to one another.
Q: How common are depression and anxiety in patients with pancreatic cancer?
ADV: It is very common to find patients with pancreatic cancer who experience symptoms of both depression and anxiety. Depression is more common among cancer patients than in the general population, but not everyone who has cancer becomes depressed. Because the word “depression” is a loose term and is inclusive of different diagnoses, researchers use various methods to evaluate the condition. Therefore, the prevalence of depression among pancreatic cancer patients varies throughout different studies but is thought to range from around 33%–71%.
Q: Is pancreatic cancer specifically associated with depression and/or anxiety?
ADV: Though somewhat controversial, pancreatic cancer has been linked with depression for many decades. It is thought that there are biological factors— hormones or neurochemicals, or an immunological response that produces inflammatory cytokines (a group of small proteins secreted by cell groups and involved in cell-to-cell communication)—associated with pancreatic cancer and other malignancies, and the first symptom it causes is an emotional change or even depressive syndrome. The first signs of disease that many patients with pancreatic cancer experience are changes in weight, feeling tired, or yellowing of the skin (jaundice), but they can sometimes experience emotional changes as well which may be due to elevated levels of proinflammatory cytokines.
Q: Why is it important to report symptoms of depression/anxiety to your doctor?
ADV: It is important for patients or caregivers to report symptoms to their oncologist or primary care provider because other medical considerations need to be evaluated. Some symptoms of depression or anxiety, such as insomnia, fatigue, and loss of appetite, are also side effects of chemotherapy, or a function of the disease process, which is why diagnosing depression— especially in cancer patients—can sometimes be difficult. For example, someone could be very anxious with his heart pounding at 140 beats per minute, not because he has an anxiety disorder but because he is anemic and therefore needs a different type of treatment. Additionally, the physical symptoms of pancreatic cancer that can cause depression, such as pain, loss of appetite, and weight loss, can also contribute to a person’s anxiety.
Q: What symptoms of depression/anxiety may be noticeable to others?
CINDY L. CARMACK (CLC): Patients with depression often lose interest in things that used to make them happy. You might find that someone with depression is not doing much with his or her day and not engaging in activities that used to be important. Although patients with cancer may be physically limited in their activities, someone struggling with depression may not be doing much of anything. When we assess patients, we ask, “Are there activities you are physically able to do that you’re not doing because you don’t have the motivation or desire to do them?”
Social isolation and irritability are also signs to look for in a patient who is depressed and should be mentioned to the patient’s healthcare team. Additionally, the patient may sleep a lot more than usual because of insomnia at night or hypersomnia, which are both symptoms of depression. Fatigue, difficulty concentrating, and feelings of hopelessness are other symptoms of major depressive disorder, which may develop slowly. At the same time, patients with pancreatic cancer going through treatment may experience fatigue and changes in sleep patterns as well. Patients should speak with their doctor to determine if symptoms are related to depression or to treatment. Patients with major depressive disorder may also have suicidal thoughts, and they may or may not express this to their loved ones. An evaluation of any patient’s mental health functioning should always include a suicide assessment.
Signs and Symptoms of Anxiety/Depression:
- Loss of interest in activities that were previously enjoyable
- Lack of motivation
- Feelings of worry, fear, or hopelessness
- Difficulty concentrating
- Social isolation
- Hypersomnia or insomnia (sleeping more or less often than usual)
- Eating more or less than usual
- Thoughts of suicide
Anxiety, on the other hand, tends to be more sudden and severe, so this may be noticed by others a little sooner. Patients with anxiety may also experience worry. It is common for someone to feel worried when he or she is diagnosed with cancer. However, if it reaches a point where the patient is feeling restless and constantly worrying, and it is interfering with his or her ability to concentrate or sleep, this should be discussed with a doctor. Fear is also a symptom of anxiety, although patients might not know what they are afraid of. If anxiety becomes severe, it can progress to full-blown panic.
Since depressive disorders tend to develop slowly, the patient may not even realize that he or she is depressed. Caregivers or someone close to the patient are often in the best position to notice a change in their loved one’s mood or behavior.
Q: How can caregivers help their loved one with pancreatic cancer get help for depression and anxiety?
ADV: If caregivers think their loved one is suffering from depression and/or anxiety, they should raise these topics by asking questions such as, “How are you doing emotionally?” or “You’re not yourself, and it’s not just that you have pancreatic cancer; this is extending to other things. How do you feel about this? Would you be willing to talk about it?”
It is understandable for patients with pancreatic cancer to feel sad and anxious sometimes, but if they are not adapting and their mood is interfering with their quality of life or causing other problems, then it is something that should be addressed. Being supportive is a really tough job, but honest, nonjudgmental, caring observation and comments are how I would suggest it be approached. Family and caregivers should not be scared of how their loved ones will react to them discussing their concerns. Depression and anxiety are conditions that need to be recognized and are not something to be afraid of.
Q: What challenges do caregivers face, and how do they get the support they need to help themselves and their loved ones cope with pancreatic cancer?
ADV: Emotional distress is more common among cancer caregivers than in the general population. Research shows that caregivers can be just as distressed as patients going through cancer. Caregivers are in a difficult position because they are also dealing with their own fears and emotions about what is happening to their loved ones. Being a caregiver is a difficult and honorable job, but caregivers cannot take care of their loved ones if they do not take care of themselves. It is important that caregivers know there is support available for them, including support groups both online and in person. Caregivers are encouraged to talk to their loved one’s doctor for more information about these useful resources.
Q: When should the doctor be informed of the patient’s depression and/or anxiety?
CLC: There should be some discussion between the patient and the doctor from the onset of symptoms. It is important to take care of the patient’s cancer, but it is equally important to take care of the patient’s emotional state. If a patient with pancreatic cancer is feeling ill or experiencing fatigue, pain, trouble concentrating, loss of appetite, and weight loss, it should raise concern about not only the pancreatic cancer but also concern that the patient may be experiencing depression or anxiety.
The use of some kind of standardized distress screening tool may prove useful. If depression and/or anxiety are consistently interfering with a patient’s ability to function or participate in his or her own treatment, it should be brought to the doctor’s attention. Patients with pancreatic cancer may have one or two bad days with pain where they seem really depressed and are not interested in doing anything, but it is a red flag if they continue to feel down once the pain is addressed and managed. It is important for patients and their loved ones to learn how cancer can affect them emotionally, so they can be aware and catch the problem before it becomes severe.
Patients and their families should be assured that it is okay to discuss these issues and describe what they are experiencing. For example, patients may express sentiments such as, “I am really feeling down,” “I don’t feel like I normally do; I feel different,” “I’m so nervous that I cannot sleep at night,” “I can’t concentrate on my work,” or “When I’m supposed to be looking after my kids, I’m not paying attention to them.” Importantly, the healthcare team should be informed of any patient’s expressed desire for self-harm.
Q: Why should patients seek treatment for depression and anxiety?
ADV: It is important for patients and caregivers to understand that depression and anxiety are treatable disorders, and they do not have to live with these conditions. We do not want anyone to be in emotional pain any more than we would want them to be in physical pain. Patients should know there are treatment options available for their emotional symptoms.
There is an automatic assumption that patients with cancer will get depressed and that nothing needs to be done about it. There is also a stigma associated with mental health disorders in general, so patients and families may be ashamed to bring up the subject. Between the stigma and this idea that it is normal to feel depressed or anxious, patients (and sometimes doctors) may decide not to take action. However, a lot of pain can be avoided if patients and their families inform the doctor of any signs of depression or anxiety.
Patients and their families should know these feelings are common and are nothing to be ashamed of. Left untreated, depression and anxiety can interfere with the patient’s ability to cope and adhere to treatment. Some studies even suggest an adverse effect on survival. Patients should seek treatment when symptoms interfere with their ability to cope or problem solve, or when it becomes difficult to handle everyday tasks, which could be educational or work-related, or when it becomes a challenge participating in their own care as cancer patients. Treatment should be started any time a patient is suffering.
Q: What kinds of treatments are used to treat depression and anxiety?
ADV: Commonly used therapies are psychotherapy and medications. Psychotherapy can be done in a group setting or one-on-one between an individual and a mental health professional. Sometimes a few brief therapy sessions can be effective in preventing mild anxiety or depression from progressing to full-blown major depression.
Antidepressants are also commonly used for depression and sometimes for maintenance therapy of anxiety disorders. Medications may not be adequate by themselves. At least for major depression, a combination of psychotherapy and medication typically works better than either one alone, even though psychotherapy or medication alone can be effective.
Q: Are there any concerns about overmedicating patients?
ADV: Yes, always, in any setting. Otherwise the risks are mostly related to drug–drug interactions. I encourage patients and/or family members to ask, “Is this antidepressant going to interfere with any other drugs? What are the side effects?” Our goal is to educate our patients and their caregivers so they are knowledgeable about all prescribed medications.
Q: How can a pancreatic cancer patient or caregiver find a good mental health provider?
CLC: A good start would be to ask the oncologist and begin with an in-house mental health provider located where the patient is receiving cancer care. If counselors are unavailable at the patient’s treatment center, it is also okay to find a provider in the community. While it is convenient for patients to coordinate a psychiatry visit when they meet with their oncologist, they might also need to see a psychologist or counselor more frequently, so finding a provider closer to home might be helpful if they are not available at their treating oncology center. Cancer centers that are associated with medical schools often have very good oncology and psychiatry/ behavioral health departments.
Q: What are some techniques for managing depression and anxiety?
ADV: I am a big fan of distraction. I suggest that patients try to focus on something that takes their mind off of their depression or anxiety, preferably activities that the patient previously enjoyed doing, although that is sometimes easier said than done.
I also suggest exercise for all my depressed patients, as exercise is an activity that patients can do to contribute to their own physical and emotional health and a way for them to take part in their own care and recovery. In fact, studies indicate it is the best treatment for cancer-related fatigue. For patients who are physically able, exercise also helps relieve depression and anxiety, serving as a distraction technique, as well as providing a sense of personal accomplishment. Also, being physically stronger can help patients withstand the side effects of treatment.
If patients are uncomfortable about exercise, especially if they are out of shape, occupational therapists, physical therapists, and rehabilitation medical doctors can be helpful. It is more important for exercise to be regular than to be intense. If my patients are physically able, I suggest walking as a form of exercise, especially because it can be done at the patient’s own pace and family members or friends can also participate. Water aerobics are also helpful for some patients. For other patients, Tai Chi, self-hypnosis, or relaxation training works well.
Ways to cope with anxiety/depression:
- See a doctor if symptoms are interfering with your life
- Find a therapist you trust and with whom you are comfortable speaking
- Take the medications the doctor prescribes
- Get plenty of sleep and adequate exercise
- Eat a well-balanced diet
- Meditate and do relaxation exercises (deep breathing, yoga, Tai Chi, etc.)
Meet Our Experts:
Alan D. Valentine, M.D., is a Professor and Chair of the Department of Psychiatry at The University of Texas MD Anderson Cancer Center.
Cindy L. Carmack, Ph.D., is a licensed clinical psychologist and Associate Professor in the Department of Palliative Care, Rehabilitation and Integrative Medicine at The University of Texas MD Anderson Cancer Center.
Strengthening Resolve Through Support Groups
Meet Our Expert: Randy Hight, LCSW, OCW-C, is the Director of the Nancy Marx Cancer Wellness Center (NMCWC) at the Sid Jacobson Jewish Community Center in Roslyn, NY. At NMCWC, she collaborates with doctors, social workers, nurses and local hospitals to provide programs that help improve the emotional and physical health of participants.
One of the most overlooked areas of a pancreatic cancer diagnosis is the isolation that patients feel, which can lead to depression. Patients often spend the majority of their time going to doctor appointments, having and recovering from surgery, and/or undergoing chemotherapy treatment; they have so much emotional distress that they distance themselves from their loved ones, activities, hobbies, and work they enjoy. One of the best steps patients can take is to reach out to others by attending cancer support groups where they share their feelings without fear of being judged, among a group of people who can uniquely empathize with their experiences. Patients socialize, offer comfort and encouragement, and discuss new treatments, research and clinical trials, and strategies to manage cancer pain and deal with side effects including hair loss and neuropathy.
Most importantly, groups help to universalize what people are going through so that they can draw strength from others who have a similar experience. Survivors often attend and serve as role models, recommending that patients infiltrate back into life, despite a devastating cancer diagnosis, and that every day, they set small goals for themselves, even if it’s simply getting dressed and getting the mail.
Patients can find support groups at their hospitals, or by contacting CancerCare® if they need phone conversations and online groups because they’re not well enough to travel. Cancer Hope Network also connects patients with another person who has gone through a similar cancer experience to serve as a support system. It is crucial that social workers and other therapists let their patients know if they feel patients need additional treatment to complement talk therapy, such as medication.
Attending a support group can help patients stay present, appreciate life’s gifts, and help them find hope while living with a diagnosis of pancreatic cancer. That’s why every step towards reconnecting with the outside world and with other people in a group setting matters. At any given moment, there is the potential for a new treatment around the corner, and that possibility should bring hope and comfort to patients.
Make a difference in patients’ lives by donating to the Lustgarten Foundation today and supporting pancreatic cancer research. We couldn’t accomplish all that we do without you.
Pancreatitis is an inflammation of the pancreas that accounts for 275,000 hospitalizations in the United States annually. Patients who suffer from hereditary pancreatitis have a 40 to 50 percent lifetime risk of developing pancreatic cancer. Dannielle Engle, a former Cold Spring Harbor Laboratory (CSHL) Cancer Center postdoctoral fellow who was recently appointed Assistant Professor at Salk Institute, studies the progression of pancreatitis to pancreatic cancer. She has focused on a potentially powerful biomarker, a chemical structure created by complex sugar molecules called CA19-9, since CA19-9 is elevated in patients with pancreatitis and pancreatic cancer.
Follow the Lead of “Jeopardy! James”
We all watched in disbelief as Alex Trebek shared in March that he was suffering from Stage IV pancreatic cancer. This news hit Naperville, IL Walk leader Ann Zediker especially hard, as she lost her own father to the disease in 2010, just five months after he was diagnosed. She watched a man who loved life deteriorate during treatment. Now, Ann is fighting for continued research and a cure.
This year, Jeopardy! champion James Holzhauer, who won an impressive 32-straight games, caught her attention. After seeing him on the show, she learned that he was born and raised in Naperville, and she invited him to attend this year’s walk on Saturday, July 14th. While he couldn’t attend, he has added his support to the Naperville Walk in honor of Alex Trebek and all the other survivors. His generous donation of $1,109.14 represents his daughter’s birthday (November 9, 2014).
We encourage you to follow James’ example and donate amounts corresponding to your birthday, in honor or in memory of a loved one, or in support of Alex Trebek.
Your contribution will make a difference in detecting the disease earlier, developing better treatments and eventually finding a cure! And, thanks to separate funding to support administrative expenses, 100% of your donation goes directly to pancreatic cancer research.
NBC: ‘Jeopardy!’ champ James Holzhauer makes pancreatic cancer donation in Alex Trebek’s name
CBS: “Jeopardy James” Holzhauer donates to pancreatic cancer research to honor Alex Trebek
Fox News: “Jeopardy!’ champ James Holzhauer donates to pancreatic cancer charity walk in Trebek’s honor
CNN: “Jeopardy!” Champion James Holzhauer donated to a cancer walk in Alex Trekek’s name
ABC Chicago: “Jeopardy! James” Holzhauer donates $1K to Naperville pancreatic cancer research walk
Chicago Tribune: ‘Jeopardy!’ champ James Holzhauer makes donation in Alex Trebek’s name to Naperville pancreatic cancer walk
Yahoo: ‘Jeopardy!’ champion James Holzhauer donates to pancreatic cancer walk in Alex Trebek’s name
Survivornet: As Alex Trebek continues his journey with pancreatic cancer “Jeoparty James” contributes part of his fortune to finding its cure