Pancreas Cancer: An Epidemiologic Perspective

Paul K. Mills, Ph.D., M.P.H.Department of Internal Medicine

UCSF FresnoCancer Registry of Central California

Five Year Relative Survival With Pancreas Cancer in California, 2000-2008

Time Trends in Pancreas Cancer Incidence Rates in the U.S., 1973-2007, SEER data

Twelve Most Frequent Cancers in California, by Incidence Counts and Deaths, 2010

0

5000

10000

15000

20000

25000

Count

Cases

Deaths

Number of New Pancreas Cancer Cases and Deaths, 2009, by Location

Location New cases Deaths

SAMC, Fresno 40 31

Fresno County 80 65

California 3,881 3,543

United States 42,470 35,240

World ????? 227,000

Age Adjusted Pancreas Cancer Incidence Rates in California, 1988-2009 by Race/ethnicity and sex

Age –adjusted Pancreas cancer Mortality rates, Worldwide, 2008 (Globocan)

Age adjusted pancreas cancer mortality rates in the U.S., 2007, All races

Age adjusted pancreas cancer incidence rates, U.S., 2008, All Races

Age adjusted pancreas cancer incidence rates in California, 2005-2009, all race/ethnicities

Age adjusted pancreas cancer incidence among NH Blacks in California, 2005-2009

Age adjusted pancreas cancer mortality rates in California, NH Blacks, 2005-2009

Age specific incidence rates of Pancreas cancer in California, 1988-2008

Recent trends in cancer mortality rates in the U.S., 2003-2007

Joinpoint analysis of U.S. Panceas cancer incidence rates, 1975-2007

Endocrine vs. exocrine Incidence Rates, U.S., 1977-2005, SEER Data

Age Adjusted Incidence and Mortality Rates from Pancreas Cancer, California, 1988-2008

8.5

9

9.5

10

10.5

11

11.5

12

Rate/100,000

Year of Dx or Death

Inicdence Rate

Mortality rate

Pancreas cancer Stage at Diagnosis, 1988-2008, California

0

1

2

3

4

5

6

Localized Regional, direct extension only

Regional, regional lymph nodes only

Regional, direct extension and

regional lymph nodes

Distant Unstaged

Rate/100,000

Rate

Stage at Diagnosis, Pancreas Cancer, 1988-2008, by Race/Ethnicity, California

1995-2009 SAMC Pancreas CancerStage at Diagnosis by 5 Year Intervals

N=528

12%

55%

17%

8%7%

1%

9%

49%

16%20%

4%1%

5%

52%

10%

19%

13%

2%

0%

10%

20%

30%

40%

50%

60%

0 I II III IV Unk/NAStage at Diagnosis

1995-1999 2000-2004 2005-2009N=192N=164N=172

Molecular Genetics of Pancreatic Cancer

Gene Prevalence

K-ras2 mutation 80-95%

CDKN2 (P16) mutation, deletion or hypermethylation

85-98%

P53 mutation 50%

Smad4 homozygous deletions or mutations

55%

BRCA-2 mutations ??

Risk Factors for Pancreas Cancer

Risk factor Altered risk

Smoking 2-3 X

Caloric intake, physical activity, obesity ~2X

Chronic pancreatitis 2 X

Family Hx pancreas ca 7X

Diabetes 2-3X

Primary scherosing cholangitis

Hereditary pancreatitis 60X

Smoking—IARC Statement, (2004)

• “Cancer of the pancreas is causally associated with cigarette smoking. The risk increases with duration of smoking and number of cigarettes smoked daily. The risk remains elevated after allowing for potentially confounding factors such as alcohol consumption. The relative risk decreased with increasing time since quitting smoking”

Precursor Lesions for pancreas Cancer

Lesion Mechanism

Pancreatic intraepithial Neoplasia

Chronic inflammation

Prevention and Deterrence of Pancreas Cancer

• Smoking is the most significant reversible risk factor for pancreas cancer. Estimates indicate that smoking accounts for up to 30% of cases of pancreas cancer.

• A diet high in energy intake and low in fresh fruits and vegetables increases risk of pancreas cancer.

• Alcohol consumption does not increase risk of pancreas cancer unless it leads to chronic pancreatitis.

• Aspirin consumption????