Pancreatic carcinoma following gastric resection. A case-control study based on 21,660 consecutive clinical necropsies at Malmö University Hospital

The risk of pancreatic cancer in patients with gastric or duodenal ulcer disease

Although Helicobacter pylori (H. pylori) seropositivity is linked to an excess risk of pancreatic cancer, the biologic mechanism is unknown. Gastric ulcer is primarily associated with corpus colonization of H. pylori, atrophic gastritis and formation of N-nitrosamines. Duodenal ulcer is a marker of antral colonization, hyperacidity and uninhibited secretin release. We estimated relative risks for pancreatic cancer among patients with gastric or duodenal ulcer, based on a register-based retrospective cohort study with 88,338 patients hospitalized for gastric ulcer and 70,516 patients for duodenal ulcer recorded in the Swedish Inpatient Register between 1965 and 2003. Following operation, the 14,887 patients who underwent gastric resection and 8,205 with vagotomy were analyzed separately. Multiple record-linkages allowed complete follow-up and identification of all incident cases of pancreatic cancer until December 31, 2003. Standardized incidence ratios (SIRs) estimated relative risks. During years 3-38 of follow-up, we observed a 20% excess risk (95% confidence interval [CI] 10-40%) for pancreatic cancer among unoperated gastric ulcer patients. The excess increased to 50% (95% CI 10-110%) 15 years after first hospitalization (p for trend = 0.03). SIR was 2.1 (95% CI 1.4-3.1) 20 years after gastric resection. Unoperated duodenal ulcer was not associated with pancreatic cancer risk, nor was vagotomy. Our results lend indirect support to the nitrosamine hypothesis, but not to the hyperacidity hypothesis in the etiology of pancreatic cancer.

Pancreatic carcinoma incidence and survival in Sweden in 1980-2000: a population-based study of 16,758 hospitalized patients with special reference to different therapies

AIMS

The purpose of this study was to analyze the incidence and survival of pancreatic carcinoma in Sweden during 1980-2000.

METHODS

In this population-based study the patients were identified in the Swedish Hospital Discharge Register and Cancer Register. Data were matched with those in the Register of Causes of Death in Sweden, and 16,758 patients were identified.

RESULTS

During the studied period, 1819 patients underwent pancreatic resection, 7457 were treated with palliative procedures and, in 7482, no intervention was carried out. The incidence of pancreatic carcinoma in Sweden for men dropped from 16 per 100,000 at the beginning of the period to 8 per 100,000 in the year 2000. Corresponding figures for women were 12 and 7, respectively. Patients who underwent pancreatic resection had significantly longer survival compared to the palliative procedure or no-intervention groups (p<0.001). After 12 months 49.7% of the resected patients were alive while the corresponding survival in the palliative procedure and no-intervention groups were 13.6% and 11.9%, respectively. The five-year survival rate after resection was 10.8%. In the resection group survival improved over time (p<0.001) and women survived longer than men (p<0.01), which was not the case in the palliative procedure or no-intervention groups.

CONCLUSIONS

During the study period, the incidence of pancreatic carcinoma in Sweden decreased markedly. The resection rate increased and only in this group of patients an improved survival was noted over time. The survival was the same for patients who underwent palliative interventions as for those who only received supportive care.

Pancreatic cancer in sweden 1980-2000: a population-based study of hospitalized patients concerning time trends in curative surgery and other interventional therapies

Progress has been made during the last few decades in the treatment of patients with pancreatic cancer. In this population-based study, the time trends in curative surgery and the choice of palliative invasive therapies in Sweden over two decades are analyzed. Patients treated for pancreatic carcinoma in Sweden during 1980-2000 were identified in the Swedish Hospital Discharge Register and the Cancer Register. These data were matched with those in the Register of Causes of Death in Sweden. Data were identified and analyzed for 16,758 patients for three periods: 1980-1986 (n = 5775), 1987-1993 (n = 6096), and 1994-2000 (n = 4887). The rate of pancreatic resection increased 7.2%, 10.9%, and 15.1% (P < 0.0001) during the three respective periods. Palliative interventions decreased from 46.8% in the first period to 41.7% in the last period. On comparing the first and the last periods, biliary bypass operations were found to decrease (from 45.9% to 18.1%), as well as gastric bypass procedures (from 33.8% to 22.8%; P < 0.0001). Interventions by percutaneous transhepatic cholangiography (PTC) remained constant (10%-11%). Endoscopic therapy increased from 10.8% to 49.0%, as did the number of procedures per patient, from 1.3 to 1.7 (P < 0.0001) in the first and last periods, respectively. In 1980, the mean hospital stay was 40 days after resection and 30 days after palliative intervention. In 2000, the corresponding numbers were 26 days and 18 days (P < 0.001), respectively. During the past two decades, the rate of pancreatic resections in Sweden increased significantly. There was also a dramatic drop in palliative open surgery and a simultaneous increase in endoscopic interventions. Hospital stays decreased by more than a third.

Epidemiologic and etiologic factors of pancreatic cancer

Ranking fourth as a cause of death from cancer for men and women in the United States, pancreatic cancer represents a significant challenge for physicians and surgeons. In addition to the elderly, high-risk groups include blacks, men, smokers, and patients with certain preexisting diseases such as pancreatitis and long-standing diabetes. Various inherited genetic disorders cause approximately 5% to 10% of the total cases of pancreatic cancer. Smoking doubles the risk of pancreatic cancer. Control of smoking offers the best available strategy for reducing the incidence of this disease. Dietary measures to reduce the risk of pancreatic cancer include maintenance of normal body weight and consumption of a well balanced diet with adequate amounts of fruits and vegetables. Chronic pancreatitis caused by heavy alcohol consumption or, rarely, by an underlying inherited disorder is another strong risk factor, but because this benign disease is uncommon, elimination of this underlying cause would have minimal impact on the frequency of pancreatic cancer.

Survival following pancreatic carcinoma: a follow-up study of all cases recorded in Malmö, Sweden, 1977-1991

BACKGROUND

The aim of this follow-up study was to assess whether there has been any increase in the percentage of patients offered attempted curative surgery for pancreatic carcinoma and whether the overall survival rate has improved, during the time period 1977-1991.

METHODS

Details of new cases of pancreatic carcinoma arising in the population of Malmö during the study period were retrieved from the Local Tumour Register in Lund, Sweden. In all, 740 patients were found; 575 of these were diagnosed before death. Kaplan-Meier analysis was used to calculate overall survival rates, and Cox regression analysis was used to assess survival in relation to year of diagnosis after adjustment for sex, age at diagnosis and stage of disease.

RESULTS

Cytological or histopathological evidence of the disease was given in 95 per cent of cases. The overall 5-year survival rate was 0.5 per cent (three of 575). Curative surgery was attempted in 24 patients (4.2 per cent); the proportion undergoing curative surgery increased in the last part of the study. Two of the 24 patients in this group survived for 5 years.

CONCLUSION

The prognosis in pancreatic carcinoma remains dismal. Attempted curative surgery still is the only hope for cure, but the group of patients that can be offered this possibility is very limited. In this study, an increase was found in the proportion of patients who were offered attempted curative surgery, but there was no statistically significant increase in the 5-year survival rate following surgery.