Biology and management of pancreatic cancer.

Correspondence to: Professor J P Neoptolemos, School of Cancer Studies, Division of Surgery and Oncology, University of Liverpool, 5th Floor UCD Building, Daulby Street, Liverpool L69 3GA, UK; j.p. [email protected] __________________________ P ancreatic cancer continues to pose an enormous challenge to clinicians and cancer scientists. With a more affluent world the global incidence of pancreatic cancer is rising. For the first time significant advances are now being made into the management of the disease. There is a more sophisticated approach to palliative care and the centralisation of pancreatic cancer services is leading to greater tumour resection rates. Newer adjuvant modalities are also greatly increasing the 5 year survival rates. The molecular basis of pancreatic cancer is now better understood than ever before, leading to the development of new diagnostic approaches and the introduction of mechanistic based treatments. Technical advances in imaging and great improvements in conventional and molecular pathology have led to a deeper understanding of the pathological variables of the disease. This is now an important time for making big inroads into what still remains the most lethal of the common cancers. Pancreatic ductal adenocarcinoma remains one of the most difficult cancers to treat. It is the commonest cancer affecting the exocrine pancreas. In 2000, there were 217 000 new cases of pancreatic cancer and 213 000 deaths world wide and in Europe 60 139 new patients (10.4% of all digestive tract cancers) and 64 801 deaths. In 2002 there were 7152 new cases in the UK, with similar numbers in men and women. In the USA in 2006 there were 33 730 new cases and 32 300 deaths. Without active treatment, metastatic pancreatic cancer has a median survival of 3–5 months and 6–10 months for locally advanced disease, which increases to around 11–15 months with resectional surgery. The late presentation and aggressive tumour biology of this disease mean that only a minority (10–15%) of patients can undergo potentially curative surgery. Major advances in the past decade have included improvements in operative mortality and morbidity through the development of specialist regional centres and improved survival using systemic chemotherapy. 5 Significant progress has been made in unravelling risk factors and key molecular events in pancreatic carcinogenesis, leading to potentially exciting new developments in diagnosis, screening of high-risk groups and mechanistic based treatments (MBTs).