Staging measures the extent of the disease and is a standardized way to classify a tumor based on its size, whether it has spread, and to where it has spread. Knowing the stage of your cancer will help your doctor determine which treatment options are right for you. The stage of your cancer is the most important factor in making the most appropriate treatment choices. Over half of patients with pancreatic cancer are diagnosed at Stage IV. Patients diagnosed with Stage IV pancreatic cancer should not be discouraged because there are several treatment options available. Most cancers are staged using the TNM system of classification, which uses 3 factors to evaluate cancer: tumor, node, and metastasis.
T stands for tumor and describes the size and location of the primary tumor, if and how far it has spread within the pancreas, and if it has spread to nearby structures that are close to the tumor, including the duodenum, bile ducts, or fat surrounding the pancreas.
N stands for node and describes evidence of metastases in the lymph nodes close to the pancreas; that is, whether or not the tumor has spread to the regional lymph nodes.
M stands for metastasis and describes evidence of distant metastases; that is, whether or not the cancer has spread to distant parts of the body.
Combining T, N, and M defines the stage of cancer. Each patient’s condition is evaluated for T, N, and M, and the descriptions are combined to form a stage. Some patients with borderline resectable or locally advanced cancer respond to therapy and are “down staged” and can undergo surgery. It is extremely important to seek out an experienced surgeon to see if surgery is possible.
|Stage||Description||Resectable or Borderline Resectable||Locally Advanced||Metastatic|
|0||Cancer is confined to ducts in the pancreas; also called carcinoma in situ||√|
|IA||Cancer is only in the pancreas and is 2 centimeters or smaller||√|
|IB||Cancer is only in the pancreas and is larger than 2 centimeters||√|
|IIA||Cancer has spread locally beyond the pancreas but has not spread to nearby lymph nodes, major blood vessels, or other parts of the body||√|
|IIB||Cancer either is limited to, or extends beyond, the pancreas, with spread to the lymph nodes but not to major blood vessels or other parts of the body||√|
|III||Cancer has spread to major blood vessels and possibly to the lymph nodes, but not to other parts of the body||√||√|
|IV||Cancer has spread to other parts of the body||√|
The Lustgarten Foundation recommends the National Comprehensive Cancer Network’s (NCCN) guidelines for staging cancer. This system divides cancers into groups based on whether or not the tumor can be removed surgically.
This type of pancreatic cancer can be surgically removed. These tumors may lie within the pancreas or extend beyond it, but there is no involvement of the critical arteries, and minimal involvement of veins, in the area. There is no evidence of any spread to areas outside of the tissue removed during a typical surgery for pancreatic cancer. Only 15-20 percent of patients have resectable or borderline resectable tumors at diagnosis.
Borderline Resectable Cancer
According to the NCCN guidelines, borderline resectable cancer is restricted to the pancreas, but the cancer approaches nearby structures, such as a major artery, vein, or severe symptoms are present. There is concern that the cancer might not be able to be surgically removed with clear margins.
Locally Advanced Cancer
The cancer is confined to the area around the pancreas, but cannot be surgically removed because the tumor may be intertwined with major blood vessels and may have invaded surrounding organs. No evidence to confirm that the cancer has spread to other areas of the body can be found. About 29 percent of patients with pancreatic cancer present with locally advanced disease.
The tumor has spread beyond the area of the pancreas and involves other organs, such as the liver or lungs, or other areas of the abdomen. Over half of all patients are diagnosed at this stage.
Choosing a Treatment Center
Choosing a treatment center is one of the most important decisions you will make during your pancreatic cancer journey. When selecting a treatment center, consider whether the center has a dedicated, interdisciplinary pancreatic cancer team with specific expertise in treating this disease. Patients should also consider how quickly they can be treated when choosing a treatment center. Typically, being seen within a few weeks of diagnosis is reasonable; longer than that is not.
There are 70 NCI-designated cancer centers located in 36 states and the District of Columbia in the United States, 66 of which treat patients.
There are many advantages to receiving treatment at a large cancer center. A center that treats a high number of patients with pancreatic cancer will have more experience in every aspect of your care, which includes diagnosing, staging, performing surgery, and managing side effects and potential complications. More experience usually means more expertise, which can improve the results of your treatment. For example, at an NCI-designated comprehensive cancer center, you may be able to have a type of surgery for pancreatic cancer that a small hospital may not be able to offer. Alternatively, another hospital may offer the procedure, but with limited prior experience. Ultimately, a patient wants to select a treatment center that he or she has confidence in that has significant experience in treating pancreatic cancer.
Many patients live a manageable distance from a major cancer center. Up to half of the patients who are seen at major cancer centers are seen for only one visit. Doctors from top cancer centers often plan patients’ chemotherapy treatment regimens then refer them to doctors closer to home who will carry out the treatment plan.
SOME QUESTIONS TO ASK WHEN LOOKING FOR A TREATMENT CENTER
- Has the facility been rated by the state, consumer, or other groups for its quality of care?
- Has the facility been approved by a nationally recognized accrediting body, such as the American College of Surgeons and/or the Joint Commission on Accreditation of Healthcare Organizations?
- How many pancreatic cancer patients do you typically treat a year?
- How many pancreatic cancer surgeries do you typically perform a year?
- Does the facility explain patients’ rights and responsibilities? Are copies of this information available to patients?
- Does the treatment facility offer support services to help with day-to-day obstacles such as obtaining medical equipment and supplies, arranging transportation for treatment, or handling the emotional, psychological, or financial issues that go along with having cancer?
- Does the treatment facility offer multidisciplinary care?
- Do I have confidence in the facility?
- Do I feel comfortable at this facility?
- How far is it from home?
- Do I want the “standard of care” (surgery, chemotherapy, and/or radiation therapy) or am I interested in participating in a clinical trial?
- Does the center accept my insurance? If not, how much financial responsibility will I have for my treatment?
Multidisciplinary Clinics Dedicated to Pancreatic Cancer
Today, more cancer centers have multidisciplinary clinics specifically dedicated to pancreatic cancer, with the goal of providing the highest quality of care. Because highly experienced pancreatic cancer clinicians and specialists are available at these clinics, the most advanced treatments are offered. These clinics also provide patients with the infrastructure, coordinated services, and team approach needed to carefully walk them through all phases of treatment. Many of these centers also have the ability to arrange for a patient’s blood and tumor to be genetically sequenced. One doctor will be in charge of your care, but an entire team may be involved in creating and implementing your treatment plan. These specialists may include:
- Surgeons: doctors with experience in pancreatic surgery and in managing potential complications of surgery.
- Medical oncologists: doctors with specialized training in diagnosing and treating cancer and who prescribe anticancer medications. This specialist can act as a main health care provider and also coordinates treatment given by other specialists.
- Radiation oncologists: doctors who specialize in treating cancer with radiation.
- Gastroenterologists: doctors who specialize in disorders of the digestive system.
- Endocrinologists: doctors who specialize in disorders of glands of the endocrine system.
- Pathologists: doctors who look at microscope slides prepared from tissues to establish a diagnosis.
- Radiologists: doctors who perform and interpret imaging of your body.
Other healthcare personnel may also be involved in your care, including:
- Advanced Practice Providers: These are comprised of nurse practitioners and physician assistants. Both types of providers have had advanced education and special training in managing the treatment and care of patients with cancer. In some institutions, you may be seen periodically by an Advanced Practice Provider.
- Nurse Navigators: These are experienced nurses who expedite and coordinate patient care. They also educate and advocate on behalf of patients.
- Oncology nurses: Oncology nurses have special training in managing the treatment and care of patients with cancer. Among their duties are administering chemotherapy drugs, helping to manage side effects, and providing patient education.
- Oncology social workers: Oncology social workers are professionally trained to counsel patients who have cancer and to help provide practical assistance. These professionals can help find support groups, locate community services, and assist with finding financial assistance.
- Dieticians and nutritionists: These professionals can help develop food and nutrition plans to help maintain energy, weight, and muscle mass during treatment.
QUESTIONS TO ASK AFTER DIAGNOSIS
Asking good questions will help you get the best care possible for pancreatic cancer. You have a right to have all questions answered to your satisfaction.
- What type of pancreatic cancer do I have, and what is the stage (resectable, borderline resectable, locally advanced or metastatic)?
- Should I have any additional tests to more accurately stage my cancer?
- What is the treatment plan that you recommend?
- What are the potential benefits, risks, and side effects of that treatment?
- Where will the treatment be given, and how often?
- How will I know if the treatment is working?
- Who will be part of my care team?
- Are clinical trials available for my type and stage of pancreatic cancer?
- If surgery is recommended, is the center that will perform my surgery a high-volume one?
- If I have border-line resectable or locally advanced pancreatic cancer, what will your institution do to try to make my cancer resectable?
- Should I have my tumor or my blood (germline) genetically sequenced?
- Can you estimate the amount of time I may need to recover from surgery?