Is a nihilistic approach justifiable for pancreatic cancer ?

is reported as an aetiologic factor but new-onset diabetes may be a manifestation of PC [5]. Long-standing diabetes increases the risk of PC by 40-100%. Type 2 and type 1 DM increase the risk of PC with a latency period of more than 5 years [4]. Newonset diabetes (within 3 years) is associated with PC in nearly 50% of patients. Type 3 DM is an effect and harbinger of PC in 30% of patients [6]. Experimental studies have suggested that PC cell lines produce soluble factor(s) that can impair glucose metabolism in vitro and cause hyperglycaemia in vivo [7]. The dilemma of pancreatic carcinoma are the late and non-specific symptoms, no effective screening process and no specific high risk group [8,9]. The persistent dilemma in the management of pancreatic cancer is exacerbated by the preconceived knowledge of its poor prognosis [10,11].


The arguments
Although surgical resection is the most important factor that determines survival, the arguments for the nihilistic approach are that PC usually has an insidious presentation and physical signs of metastatic spread are commonly present at initial consultation.It is a disease of elderly patients and 50% are >70 years, many are unfit, weak, emaciated and suffer from other concomitant medical conditions [12].Endoscopic bypass is all that can be offered [10][11][12].A realist argument is that bypass procedures are all that can be offered in the vast majority.The palliation of biliary and gastric outlet obstruction is by surgical bypass (hepaticojejunostomy or gastrojejunostomy), if endoscopic/ Percutaneous methods fail and patient is fit for surgery.In some cases, resectability can only be defined intra-operatively, however.An unsuccessful resection for a carcinoma can result in a high mortality, a very high morbidity and an extremely costly period of treatment for the patient [10,11].The arguments for the activist are that PC is increasing in incidence and although it is considered a disease of the elderly more than 40% of men and 35% of women present under the age of 70 years as in this case [2].The use of modern diagnostic imaging techniques or protein markers especially glypican -1(PC1) can pick up tumours at an early stage [9,13].Even though the chances of cure are < 1%, the only hope for cure of early PC is by surgical resection [14].After a potentially curative R0 (no involved margins) resection in which all margins of the specimen are histologically tumor-free, median survival is 12 months, and 5-year survival rate is 15-

Introduction
Pancreatic ductal adenocarcinoma is the 13 th commonest cancer but the fourth most common cause of cancer-related death [1].The prognosis for patients with this disease is dismal.The overall worldwide incidence has increased over the past few decades such that over 265,000 cases are diagnosed annually and it is projected that it will be the leading cause of cancerrelated deaths in the USA by 2050 [2].The dismal overall median survival of 4.4 months and a five year survival of 5% is primarily due to the disease-specific symptoms occurring late in the course of the disease.As 50% present with metastatic disease and 35% present with locally advanced disease, only 10-20% with head and less than 3% of body/tail cancers are candidates for resection [3].Risk factors include age ( 80% of patients diagnosed age 70-80 years, 1% diagnosed age< 40years); sex ( more common in women than men); Race ( more common in African Americans, less common in Asian Americans than whites); hereditary ( 18-57 fold increased risk in relatives of familial pancreatic cancer (FPC) kindreds); hereditary pancreatitis ( 50-70 fold increased risk); smoking (10 fold increased relative risk if > 2 packs/ day); obesity; abdominal surgery ( 2-5 fold increased relative risk, prior partial gastrectomy, cholecystectomy;, occupational ( napthylamine, ethyl chloride, benzidine, metal-gas workers, chemists); chronic pancreatitis ( 5-15 fold increased risk) and diabetes mellitus (DM) ( 2-3 fold increased relative risk) [4,5].

Is a nihilistic approach justifiable for pancreatic cancer?
Copyright: © 2016 Weledji and sinju 26% [15].The resection ameliorates the diabetes in those who had diabetes preoperatively (new-onset) but not patients with long standing diabetes [6,16].This provides further evidence that PC induces glucose intolerance and recent-onset diabetes may not only define a high risk group for PC but a marker of early, asymptomatic cancer [17].Moreover, several studies have demonstrated the prevalence of diabetes in early stage PC which would favor the argument for the activist's resection approach [18,19].As nearly half the patients with early stage, resectable tumors have diabetes, PC-associated diabetes is not a contraindication for the surgical resection approach [20,21].The prompt diagnosis of type 3 DM (newly diagnosed diabetes mellitus) may allow detection of a tumour at a potentially curable stage.
Although widely viewed as a complex procedure associated with considerable perioperative morbidity and mortality, complete surgical removal of the pancreatic tumour is the most important factor that determines survival [10,11,14,15].The operative mortality has fallen to 5% or less in experience hands [10,22].The surgical procedure for tumour in head of pancreas is either a Whipple's pancreaticoduodenectomy (PD) or pyloruspreserving pancreaticoduodenectomy (PPPD) or PD with en bloc vascular resection and reconstruction and for tumour in body/ tail is either a distal pancreatectomy or a total pancreatectomy [10].If we excluded all patients from consideration for surgery we may also exclude patients suffering from cancer of the distal common bile duct, the duodenal mucosa and ampulla of Vata with these tumours having a 5 year survival rate of 30%.A nihilistic approach is therefore not justified, as in many cases resectability can only be defined intra-operatively.The favorable prognostic features are negative resection margin, negative lymph nodes, well/moderately differentiated carcinoma, primary < 2cm diameter and no perineural or lymphovascular invasion [10,23].Neoadjuvant and adjuvant chemotherapy or chemoradiotherapy improves the chance of cure for early PC [24,25].Screening for pancreatic cancer in high risk individuals including recentonset diabetics especially with the novel protein markers holds promise with regards improving long-term survival.
In conclusion, the persistent dilemma in the management of pancreatic cancer is not helped by the preconceived knowledge of its poor prognosis.A nihilistic approach is not justified.