2480527 Pancreatic Cancer Jas

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment Running Head: PANCREATIC CANCER: CONSERVATIVE APPROACH VS. NONCONSERVATIVE APPROACH TO TREATMENT

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment [name of the writer] [name of the institution ] [name of the Professor] [Course] .

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Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment

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Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment Cancer Cancer happens when cells in a particular part of the body start growing out of control. Normal cells divide normally and grow in an orderly fashion, but for cancer cells that is not the case. They keep on growing and crowd out the normal cells. There are several types of cancer all have this out-of-control growth of cells common. Cancer is also known as carcinoma or malignant tumor. Cancerous cells are also termed as malignant cells. (Cancer. Health Guide. The New York Times) Occasionally cancer cells tend to break away from their cluster and reach other parts of the body by means of blood or lymph system. They then settle in those new places and start forming new tumors. This phenomenon is called metastasis. Cancer formed as a result of metastasis is called metastatic cancer. Even if cancer spreads to other parts of the body, it is still referred as the cancer of the part where it has started. If prostate cancer reaches the bones, it is still known as prostate cancer. If breast cancer reaches to the lungs, it is still called breast cancer. Sometimes cancer returns in a person who had been treated, a rare phenomenon called recurrence. (What is Cancer? American Cancer Society) Pancreas The pancreas is an important organ of the human body. It is located deep in the body, behind the stomach. It is similar to a fish in its shape. Its length is about 6 inches and width is less than 2 inches. It extends across the abdomen.

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Functions of Pancreas Pancreas performs three main jobs. First it has special cells called Islets of Langerhans that make Insulin that helps control blood sugar, lack of a body’s ability to produce Insulin cause a condition known as diabetes. This is called “endocrine function” of Pancreas. Second, the Pancreas has areas called acini that produce digestive enzymes. This is the “exocrine function” of the Pancreas. Third, duct cells of Pancreas produce a solution of Sodium bicarbonate, which helps in flushing the digestive enzymes out from the Pancreas. This solution when reaches the stomach neutralizes the acidic nature of the stomach and helps in protecting the internal cell lining of stomach. (PEaRL. (2006). Pancreas Education and Research Letter. Volume 2, Number 3. Winter 2006.) Pancreatic Cancer Both the exocrine and endocrine cells of Pancreas can form tumors. Relatively tumors arisen from the exocrine cells are more common. It should be kept in mind that all of the tumors are not necessarily cancer. Some are benign (Non-cancerous). It becomes important knowing which part of Pancreas has developed a tumor, the exocrine or the endocrine as each type of tumor has its signature signs and symptoms, has different diagnostic tests, different treatment and different prognosis. Exocrine tumors Exocrine tumors are more likely to be cancer. Most of these belong to a kind known as adenocarcinomas. Treatment of this type of cancer normally depends on the stage of the cancer, instead of its exact type. The stage here means how far the cancer has progressed.

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Ampullary cancer starts where the bile duct and the pancreatic duct open into the small intestine. Signs like yellowing of the skin and eyes (jaundice) make its detection possible at an earlier stage than most pancreatic cancers. Early detection means better chances of successful treatment. Endocrine Tumors Endocrine tumors are relatively less common. They are also termed as islet cell tumors and are of several sub-types. Most of them are benign, a few are cancerous. (What Is Cancer of the Pancreas? American Cancer Society) Incidence of the Disease According to The American Cancer Society’s prediction “in 2008, about 37,680 people in the United States will be found to have pancreatic cancer and about 34,290 will die of the disease.” The lifetime chances of having a pancreatic cancer are about 1 in 76. (How Many People Get Pancreatic Cancer? American Cancer Society) Risk Factors A risk factor may be anything that affects one's chance of getting a disease, cancer in this case. Some risk factors, like smoking, are under one’s control. Others, such as one's age, gender or race, can't be altered. Unfortunately, there is very limited knowledge about exactly what causes most cases of pancreatic cancer. Recent research shows that some of the risk factors listed below have an effect on the DNA of cells in the Pancreas, leading to abnormal cell growth causing tumors. One important thing that should always be kept in mind is that having one risk factor, or even more, does not guarantee that one will get the disease. And there are reported cases where people not having

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any known risk factors get the disease. A few of the most important of these risk factors are listed below: Age: The risk of Pancreatic cancer increases with age. Nearly 90% of patients are 55 or above. The average age at the diagnosis time is 72. Gender: Men have a high incidence rate than women. Race: Probability in African Americans is more than whites. Smoking: The chances increases 2 to 3 times for smokers. Approximately every 2 to 3 out of 10 cases are linked with smoking. People using smokeless tobacco also are found to be more likely to get pancreatic cancer. Diet: There seems to be existing a link between the disease and high-fat diets including red meat, pork, and processed meat. Studies have shown diets richer in fruits and vegetables may help reduce the chances of the disease. Obesity and lack of exercise: Overweight people have more chances of developing pancreatic cancer, same goes for people abhorring exercise. Diabetes: Pancreatic cancer is more common in diabetic people. Exact reason is still unknown. Chronic Pancreatitis: It is a long-standing inflammation of the gland, linked with a somewhat higher chance of pancreatic cancer. Cirrhosis of the liver: Cirrhosis means scarring of the liver as a result of liver damage from hepatitis, alcohol use and things like that. People with cirrhosis tend to have a higher risk of pancreatic cancer.

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Work exposure: Heavy exposure at workplace to things like pesticides, dyes, and chemicals (some of which can be carcinogens) may elevate the chances of getting cancer of the pancreas. Family history: This cancer has some hereditary occurrences as well. Gene changes: Mutations of certain genes, passed from parent to child, may cause along with certain, other problems pancreatic cancers. The genes causing these problems have been identified by scientists and can be recognized by genetic testing. Stomach problems: Too much acidity in stomach or presence of bacteria called H. pylori in the stomach may also increase the risks of pancreatic cancer. (What Causes Pancreatic Cancer? American Cancer Society) Symptoms Due to the non-specific nature of symptoms, an early diagnosis of pancreatic cancer is very difficult. The symptoms of pancreatic cancer are seldom recognized until the cancer has progressed to an advanced stage and often spread to the other areas of the body. The symptoms in more advanced stages are yellowing of skin (jaundice), abdominal or back pain, unexplained weight loss, loss of appetite, pancreatitis, nausea and fatigue. Some times diabetes also appears 1-2 years prior to correct diagnosis. What makes diagnosis trickier is the fact that the same symptoms can occur as a result of several other diseases as well. (PEaRL. (2005). Pancreas Education and Research Letter. Volume 1, Number 3. Fall 2005.) A brief account of the major symptoms is as follows: Jaundice: Yellowing of eyes and skin is termed as jaundice. Its reason is build-up of bilirubin from the liver. Nearly half of the pancreatic cancer patients (and all of

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ampullary cancer) show signs of jaundice. But jaundice can also be caused as a result of certain other diseases like hepatitis. Pain: Abdominal or the back pain is a very common indication of advanced pancreatic cancer. Again, there are reasons other than cancer for this pain. Weight loss: Severe weight loss (without intent) over a period of months is a frequent observation in patients with this cancer. Loss of appetite and fatigue accompany weight loss usually. Digestive problems: If the tumors block the secretion of the pancreatic juice into intestine, patient may not be able to digest fat-rich diet. Stools may get pale, bulky, oily, and difficult to flush. Other complexities may include vomiting, nausea and pain that gets worse after eating. Swollen gallbladder: The doctor may discover that the gallbladder is swollen and enlarged. The doctor can feel the change and can also see it on imaging studies. Blood clots: Occasionally blood clots appear in the veins and may cause problems with fatty tissues beneath the skin. Sometimes these clots may travel to the lungs and cause dyspnea. But presence of blood clot does not mean that someone has cancer. The blood clots may appear as a result of several things other than cancer also. Diabetes: Pancreatic cancer may cause problems with sugar levels of the blood. Occasionally it may also lead to diabetes. (How Is Pancreatic Cancer Found? American Cancer Society)

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Preventions There are no definite preventions against pancreatic cancer at this time. The best advice is refraining from smoking, one of the major risk factor one can control. Keeping good weight, taking good diet, and exercising regularly are also important. (Can Pancreatic Cancer be Prevented? American Cancer Society) According to two studies increased intake of vitamin D in diet and in form of pills reduces the chances of Pancreatic cancer by approximately 40%. (Skinner, H. G.; Michaud, D. S.; Giovannucci, E.; et al. (2006). Vitamin D intake and the risk for pancreatic cancer in two cohort studies. Cancer Epidemiol Biomarkers Prev 2006. Volume 15, Number 9.) Diagnosis As pancreas lies deep inside the body, the doctor cannot see or feel tumors during a routine physical checkup. For diagnosis of cancer and its size and exact location, the doctor may perform imaging tests like CT scan, ultrasound, PET scan, MRI, angiography, and ERCP. The only way to diagnose with surety is a biopsy. (Pancreatic Cancer) One of the relatively newer techniques of diagnostic approaches used for pancreatic cancer diagnosis is use of fine needle aspirate (FNA) using an endoscopic ultrasound (EUS). Another technique frequently used is endoscopic retrograde cholangiopancreatography (ERCP). Another method called “LOH Analysis” detects pre-cancerous and cancerous cells based on the loss of one or more tumor suppressor genes. (Khalid, A. (2005). The role of pancreatic cyst fluid molecular analysis in predicting cyst pathology. Clin Gastroenterol Hepatol 2005. Volume 3, Number 10, p. 967-73.)

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Currently, there are no tests (blood or other) that can find out this cancer in presymptomatic phase. Levels of tumor markers like Ca19-9, CEA, CA-50, SPAN-1, DUPAN2, elastase-1, tissue polypeptide antigen and tissue polypeptide-specific antigen and may be elevated than normal in patients with pancreatic cancer, but by the time the levels elevate the cancer is usually advanced. Tests for genes responsible for the genetic transfer in people with family history of the disease help predicting the level of risk. But a side effect is that if the results show higher risk the patients may not be able to get health insurance, or it may cost more. (How Is Pancreatic Cancer Found? American Cancer Society) Certain other tests, called imaging tests (that make pictures of the inside of the body) have got popularity these days. These are found to be useful especially in case of vital organs difficult to examine, such as pancreas. A brief idea of how these tests can be of any use is presented below: Computed Tomography (CT) Scan: It is a type of x-ray which creates detailed pictures of the inside organs of the body. It is useful in diagnosing cancer and estimating its spread, a process called staging the cancer. It may also be used to help guide a biopsy needle into the suspected cancerous place. CT scans are frequently used pancreatic cancer diagnosis, as it shows the pancreas clearly and often can guide about the location of cancer. These scans can also display the organs nearby, as well as lymph nodes and distant organs where the cancer might have spread. The CT scan may help the doctor to reach a decision about surgery as a treatment option.

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 10 Magnetic Resonance Imaging (MRI): MRI scans make use of radio waves and strong magnets in place of x-rays to take pictures. MRI scans are especially helpful for looking at the brain and spinal cord. Most doctors prefer CT scans for pancreas, but sometimes an MRI may give more information. Positron Emission Tomography (PET) Scan: PET scans need injecting a form of sugar into the blood that contains radioactive atoms. Cancerous cells tend to absorb large amounts of this sugar. A camera then shows the location of these cells. This test is useful to observe whether or not the cancer has reached the lymph nodes or other places. PET/CT Scan: This test combines the 2 types to even better pinpoint the tumor. This test is especially useful for locating cancer which has spread beyond pancreas and now can not be removed by surgery. It is also be useful for staging the cancer. It can even be able to diagnose early cancer. Ultrasound: It uses sound waves for imaging of the interior of the body. The pictures are then combined by a computer for a detailed image. This test is helpful in telling the type of tumor in the pancreas. Endoscopic ultrasound is performed with a probe inserted through the mouth or nose into the stomach. The probe is then pointed toward the pancreas, resulting in good picture and better diagnosis than CT scans for spotting small tumors. Patients are first sedated for this type of ultrasound. Endoscopic Retrograde Cholangiopancreatography (ERCP): Patients are first sedated and then a thin, flexible tube is inserted down the throat, all the way to the small intestine. The location of opening of common bile duct into the small intestine is traced and then a small quantity of harmless dye is then passed through the tube into the ducts. The dye outlines the ducts on x-rays. The pictures may show blocked or

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 11 narrowed ducts as a result of pancreatic cancer. A small brush can also be put through the tube to remove cells for microscopic examination. ERCP may also be used to place a stent into the bile duct to keep it open if a tumor nearby is pressing on it. Angiography: It is a type of x-ray used to monitor blood vessels. The test show if the blood flow in an area is slowed or blocked by a tumor. It also shows whether there are any abnormal blood vessels. The results assist the doctor to decide if the cancer can be removed and also helps them plan the surgery. Biopsy: Biopsy is a tissue removal from the tumor for microscopic examination for cancerous cells. FNA (fine needle aspiration) biopsy is most frequently used method, though there are other biopsy methods as well. A thin needle is inserted, with the help of ultrasound, through the skin and into the pancreas to remove small pieces of tissue. This test rarely causes any side effects. Another method of biopsy samples often used is by doing 'keyhole surgery' (laparoscopy). The patient is sedated and the surgeon makes small incisions and inserts small, thin, telescope-like instruments into the abdominal cavity. One of the instruments is linked with a video screen. The surgeon looks at the tumor and observes its spread. Biopsy samples can also be taken in the process. Usually surgery is avoided unless it seems that the operation will surely remove all of the cancer. (How Is Pancreatic Cancer Found? American Cancer Society)

Treatment

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 12 Three main types of treatment can be used for pancreatic cancer: surgery, radiation therapy and chemotherapy. Decision to choose one or a combination depends upon the stage of the cancer. (Pancreatic Cancer) Surgery Two general kinds of surgery are used for pancreatic cancer: 

Potentially curative surgery: (also called the Whipple procedure) used when it seems possible to remove all the cancer.

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Palliative surgery: used when tumor is too widespread, it is done to relieve symptoms or to prevent certain problems, like blockage of the bile ducts or the intestine by the cancer.

Disadvantage Some studies have shown that removing only part of the cancer does not help patients to live longer. Pancreatic cancer surgery is one of the hardest operations for patients to have as there are frequent complications and recovery can take many weeks. The 5-year survival rate, for patients who opt for surgery, is about 20%. Radiation therapy Radiation therapy is done by using high energy rays (such as x-rays) to either kill or shrink cancerous cells. Treatment is given 5 times a week usually for a number of weeks or even months. Radiation (sometimes combined with chemotherapy) can also be used for treating tumors too widespread to be removed surgically. Disadvantages

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 13 Its side effects are skin changes that look like sunburn or suntan, upset stomach, loose bowels, weight loss, or fatigue. Chemotherapy Chemotherapy is the use of drugs to cure cancer. The drugs have an advantage over radiation and surgery that once the drugs enter the bloodstream, they reach to every organ of the body. This makes it useful for cancers spreading beyond the place they started. Chemotherapy may be used at any stage of pancreatic cancer, even in advanced stages. Disadvantages Its side effects depend on the type of drugs used, the dosage, and length of treatment. They may include diarrhea, loss of appetite, hair loss, nausea and vomiting and mouth sores. Low blood cell counts from treatment may result in increased chances of infection, bleeding or bruising after minor cuts, and fatigue. (How Is Pancreatic Cancer Treated? American Cancer Society) International statistics: Among cancer cases, the ranking of Pancreatic cancer’s incidence is 13th worldwide, with a fatality rank of 8th among cancer types. The average incidence of Pancreatic cancer in the world is 8-12 per 100,000 people, with Black males experiencing the highest rates amounting to 13 per 100,000 individuals. Similarly Korean, Czech, Latvian and New Zealand-Maori nationalities have the second highest incidence rates i.e. 11 per 100,000 people. India has the lowest incidence rate with 2 per 100,000 people plagued with the disease. American statistics: A disease which was expected to claim 37,680 people in the United States alone; with an expected death percentage of 91% explains the fatalistic nature of the disease. Europe

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 14 experiences almost 60,000 diagnosed cases of cancer each year. Almost 1 in 76 people experience Pancreatic Cancer with distribution between both the sexes discovered to be on an equal basis. A meager 5% patients are alive five years after initial diagnosis and complete recovery is even more circumspect. However, other factors do affect the incidence of this type of cancer and two major reasons are produced below: Age factor: The probability of Pancreatic Cancer is directly proportional to age and almost 90% of patients are above 55 years old. The average age is discovered to be 72 years. These facts reveal that as we get older we should pay greater attention towards avoiding such ailments and following medical advice in this regard. Sex: The probability of cancer is higher in males than in females which means that attention should be focused on finding the relevant reasons and providing preventive cure. The malefemale ratio is approximately 1.2-1.5:1. However, during the last two decades this statistic is slightly shifting in favor of the women due to changing smoking habits. The table on the side describes the risk factor for various cancer syndromes and major causes of cancer (mutations of Pancreatic cancer receive higher risk weightages): Causes: With respect to probable causes of cancer almost 40% of the cases are sporadic in nature and among the rest 30% are attributed to smoking and 20% cases are related to dietary factors, the remaining 5-10% is hereditary in nature.

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 15 The disease is the third most common malignancy where cancers belonging to the gastrointestinal tract are concerned and ranks as the fifth leading cause of cancer deaths. This disease can arise from both the endocrine and exocrine portions of the pancreas with diagnosis difficult in the early stages. The exocrine portion accounts for 95% of the pancreatic tumors, most probably from the ductal epithelium and connective tissues. Approximate figures indicate that 75% of the tumor originates from the pancreatic head and neck, 15-20% in the body and 5-10% occurs in the tail. Survival statistics: True long-term cures are extremely rare in this form of cancer, with most individuals eventually succumbing to the disease. Pancreatic adenocarcinoma has a higher fatality rate than endocrine and cystic neoplasms. As discussed before, only 5% of patients survive after 5 years and the median survival age is in the range of 4-6 months. In the event of successful curative therapy, which is realized by 20% of the patients, the median survival age increases to 12-19 months and the 5 year survival rate becomes 15-20%. The survival rate for people exceeding one-year life after diagnosis is 2 out of 10 cases. Five year survival rates are used for comparative analysis, with respect to people who have cancer to those who don’t have it. This analysis reveals how many people die due to the type of cancer in question. The numbers are meant to provide a comprehensive overview and situational characteristics have significant bearing on the impact of a particular individual’s situation. A table describing the relationship between stages of cancer and the associated survival rates is reproduced below:

5-year relative survival for pancreatic cancer by stage Stage IA:

37%

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 16 Stage IB

21%

Stage IIA

12%

Stage IIB

6%

Stage III

2%

Stage IV

1%

Statistical analysis summary: With overall highest incidence rates found in males and especially Black Americans, Pancreatic Cancer is a fatal disease that has a low detection probability and even lower survival rate. Few success stories are found and statistically speaking a full recovery is an extremely rare event. The stage of Pancreatic cancer progression has a significant impact on recovery and to what extent the disease can be cured. Among the identified factors, smoking and dietary trends received a combined weightage of approximately 50%, with a significant portion of the American population already ranked as obese. Long-term recovery rates do not even rank in double figures which explains the alarming significance of the situation. Role of Nurses Nurses perform a godly duty of helping people, making them feel and stay comfortable and maintaining a standard of post-operative care and treatment, which is of utmost importance in treating pancreatic cancer. There are a number of areas where nurses can play their part. A few of them are presented below: Nutrition Besides possible bile duct blockage, patients of pancreatic cancer tend to lose their appetite and suffer weight loss and fatigue. The symptoms may be a result of treatment or the cancer itself. When possible, nurses can advise patients to try taking high-energy diet and food supplements. Many patients have to take pancreatic enzymes in form of a tablet for

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 17 assistance in absorbance of digested food. For some patients the doctors may put a feeding tube into the stomach to improve nutrition and energy levels, usually temporarily, here the role of nurses increase manifolds. Pain Abdominal or back pain can become a major nuisance for people with pancreatic cancer. Treatment is there to help relieve this pain. There are many ways of relieving pain from pancreatic cancer, including combinations of medicines and endoscopy or surgery. Cutting some of the nerves that carry pain sensations or injecting alcohol into these nerves can provide relief. Morphine or other similar medicines (opioid agents) reduces pain significantly for most patients. Pain medicines work best when they are given regularly on a schedule, this is where nurses step in. (Palliative and Supportive Care. American Cancer Society) Pain management is one of the most important aspects of treatment of pancreatic cancer. A multitude of pharmacological and non-pharmacological therapies could be administered to manage the symptoms. Identifying the type of pain (nociceptive or neuropathic) is vital for proper treatment. The treatments currently available are ample, they include adjuvant analgesics, non-steroidal anti-inflammatories, and opioids that are customized to the patient’ needs. When relief is below the desired level with pharmacological interventions, celiac block and other interventions could be considered. (Cruciani, R. A.; Jain, S. (2008). Pancreatic Pain: A Mini Review. Pancreatology. Volume 8, Number 3, p. 230235.)

Reference

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 18 American Cancer Society (Corporate Author, Editor); Pierce, M. (Ed.); Walker, C. L. (Ed.); Ades, T. B. (Ed.); Varricchio, C. G. (Ed.). (1997). A Cancer Source Book for Nurses. Jones & Bartlett Publishers; 7th edition Barton-Burke, M.; Wilkes, G. M. (2006). Cancer Therapies. Jones & Bartlett Publishers. Can Pancreatic Cancer be Prevented? American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_Can_pancreatic_cancer_be _prevented_34.asp?sitearea= Cancer. Health Guide. The New York Times. Retrieved November 18, 2008 from http://health.nytimes.com/health/guides/disease/cancer/overview.html Cruciani, R. A.; Jain, S. (2008). Pancreatic Pain: A Mini Review. Pancreatology. Volume 8, Number 3, p. 230-235. Erickson, R. A. (2005). Pancreatic Cancer. eMedicine from WebMD. Etemad, B.; Whitcomb, D. C. (2001). Chronic Pancreatitis: Diagnosis, Classification, and New Genetic Developments. Gastroenterology. Volume 12, p. 682–707. Gold, E.B.; Diener, G. L. et al. (1985). Diet and other risk factors for cancer of the pancreas. Cancer. Volume 55, p. 460-467. Groenwald, S. L. (Ed.); Frogge, M. H. (Ed.); Goodman, M. (Ed.); Yarbro, C. H. (Ed). (1997). Cancer Nursing: Principles and Practice. Jones & Bartlett Publishers. Hayes, C. (2006). Pancreatic cancer: an overview for allied healthcare practitioners. Gastrointestinal Nursing. Volume 4, Issue 8, p. 12 – 21.

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 19 How Is Pancreatic Cancer Found? American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_How_is_pancreatic_cancer _found_34.asp?sitearea= How Is Pancreatic Cancer Treated? American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_2_4X_How_Is_Pancreatic_Cance r_Treated_34.asp?sitearea= How Many People Get Pancreatic Cancer? American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_2_1X_How_many_people_get_p ancreatic_cancer_34.asp?sitearea= Khalid, A. (2005). The role of pancreatic cyst fluid molecular analysis in predicting cyst pathology. Clin Gastroenterol Hepatol 2005. Volume 3, Number 10, p. 967-73. Klapman, J.; Malafa, M. P. (2008). Early Detection of Pancreatic Cancer: Why, Who, and How to Screen. Cancer Control. Volume 15, Number 4, p. 280- 287. ©2008 H. Lee Moffitt Cancer Center and Research Institute, Inc. Lomberk, G. (2008). Pain Management. Pancreatology. Volume 8, p. 542–543. Palliative and Supportive Care. American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_Palliative_and_Supportive _Care_34.asp?sitearea=

Pancreatic Cancer: Conservative Approach Vs. Non-Conservative approach to Treatment 20 Pancreatic Cancer. Retrieved November 18, 2008 from http://www.cancer.com/cancer/pancreatic_cancer.html PEaRL. (2005). Pancreas Education and Research Letter. Volume 1, Number 3. Fall 2005. PEaRL. (2006). Pancreas Education and Research Letter. Volume 2, Number 3. Winter 2006. Skinner, H. G.; Michaud, D. S.; Giovannucci, E.; et al. (2006). Vitamin D intake and the risk for pancreatic cancer in two cohort studies. Cancer Epidemiol Biomarkers Prev 2006. Volume 15, Number 9. What Causes Pancreatic Cancer? American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_2_2X_What_causes_pancreatic_c ancer_Can_it_be_prevented_34.asp?sitearea= What Is Cancer of the Pancreas? American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_2_1X_What_is_pancreatic_cance r_34.asp?sitearea= What is Cancer? American Cancer Society. Retrieved November 18, 2008 from http://www.cancer.org/docroot/CRI/content/CRI_2_2_1x_What_Is_Cancer.asp? sitearea=