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Pancreatic (Pancreas) Cancer Treatment and Diagnosis

Pancreatic (Pancreas) Cancer Treatment and Diagnosis

What are Pancreatic Cancer Treatments in Singapore?

Presenting treatments for stomach cancer in adults

OncoCare Breast Cancer Treatment Singapore

Pancreatic cancer may be treated with surgery, radiation therapy, chemotherapy, targeted therapy and immunotherapy.

Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Often, a combination of treatments is used to treat pancreatic cancer. When detected at an early stage, pancreatic cancer has a much higher chance of being successfully treated. However, there are also treatments that can help control the disease for patients with later stage pancreatic cancer to help them live longer and more comfortably.

Descriptions of the common types of treatments used for pancreatic cancer are listed below. 

 

Pancreatic Cancer Treatment: Surgery

Depending on the location and size of the tumour in the pancreas, surgery for pancreatic cancer includes removing all or part of the pancreas. An area of healthy tissue around the tumour is also often removed. This is called a margin. The goal of surgery is to have clear margins or negative margins. This means that there are no cancer cells in the edges of the healthy tissue removed.

There are different types of surgery performed for pancreatic cancer surgery.

  • Laparoscopy: During a laparoscopy, several small holes are made in the abdomen and a tiny camera is passed into the body while a patient receives anesthesia. During this surgery, the surgeon can find out if the cancer has spread to other parts of the abdomen. If it has, surgery to remove the primary tumour in the pancreas is generally not recommended.
  • Surgery to remove the tumour: Different types of surgery are used depending on where the tumour is located in the pancreas. In all of the surgeries shown below, nearby lymph nodes are removed as part of the operation.
  • Whipple Procedure: This surgery is also referred to as a pancreaticoduodenectomy. A Whipple procedure may be done if the cancer is located only in the head of the pancreas. This is an extensive surgery in which the surgeon removes the head of the pancreas, and the part of the small intestine called the duodenum, as well as the bile duct and stomach, or sometimes just part of the stomach. Then, the surgeon reconnects the digestive tract and biliary system. Temporary drains are usually put in the abdomen to help it drain and assist with patient recovery. Drains are usually placed during surgery and remain in place after surgery to drain any leakage of pancreas juice to the outside of the body. Drains are left in place for a variable period based on the amount and nature of their output, but they can be removed while still in the hospital and can stay in place for up to 2 to 3 months.
  • Distal Pancreatectomy: This surgery is commonly done if the cancer is located in the left side of the tail of the pancreas. In this surgery, the surgeon removes the tail and body of the pancreas, as well as the spleen.

Total Pancreatectomy:  If the cancer has spread throughout the pancreas or is located in many areas in the pancreas, a total pancreatectomy may be needed. A total pancreatectomy is the removal of the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, and the spleen.

Pancreatic Cancer Treatment: Radiation Therapy

Radiation therapy is the use of high-energy x-rays to destroy cancer cells. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body.

External-beam radiation therapy is the type of radiation therapy used most often for pancreatic cancer. A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. There are different ways that radiation therapy can be given:

  • Traditional radiation therapy: Also called conventional or standard fraction radiation therapy, it is made up of daily treatments of lower doses of radiation per fraction or day. It is given over 5 to 6 weeks in total and is generally given during the week with weekends off from treatment.
  • Stereotactic body radiation (SBRT): Also known as cyberknife, these are shorter treatments of higher doses of radiation therapy given over as few as 5 days. This is a newer type of radiation therapy that can provide more localized treatment in fewer treatment sessions.

Proton beam therapy: This is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. It also lessens the amount of healthy tissue that receives radiation. Proton beam therapy may be given for a standard amount of time or for a shorter time like SBRT.

Pancreatic Cancer Treatment: Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time, or a combination of different drugs given at the same time.

The goal of chemotherapy is to destroy cancer remaining before or after surgery, slow the tumour’s growth, or reduce cancer-related symptoms. It also may be combined with radiation therapy. Most chemotherapy treatments for pancreatic cancer are based on the following drugs:

  • Capecitabine (Xeloda)
  • Fluorouracil (5-FU)
  • Gemcitabine (Gemzar)
  • Irinotecan (Camptosar)
  • Leucovorin (Wellcovorin)
  • Nab-paclitaxel (Abraxane)
  • Nanoliposomal irinotecan (Onivyde)
  • Oxaliplatin (Eloxatin)
Pancreatic Cancer Treatment: Targeted Therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells and limits damage to healthy cells.

To find the most effective treatment, the doctor may run tests to identify the genes, proteins, and other factors in a patient’s tumour. Targeted therapy for pancreatic cancer includes:

  • Olaparib (Lynparza): This drug is for patients with metastatic pancreatic cancer associated with a germline (hereditary) BRCA mutation. This drug is taken as a pill orally by mouth, usually twice a day.

Larotrectinib (Vitrakvi) and Entrectinib (Rozlytrek): These are tumour-agnostic treatments that can be used for any type of cancer that harbours a specific genetic change called an NTRK fusion. This type of genetic change is found in a range of cancers, including pancreatic cancer, though it is rare. It is used as a treatment for pancreatic cancer that is metastatic or locally advanced and has not responded to chemotherapy. This drug is taken as a pill orally by mouth, usually once or twice a day. 

Pancreatic Cancer Treatment: Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body’s natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

Immune checkpoint inhibitors, which include anti-PD-1 antibodies such as pembrolizumab (Keytruda) and dostarlimab (Jemperli), are an option for treating pancreatic cancers that have high microsatellite instability (MSI-H) or mismatch repair deficiency (dMMR). Approximately 1% to 1.5% of pancreatic cancers are associated with high MSI-H.

Are there any Side Effects of Pancreatic Cancer Treatment?

Side Effects of Pancreatic Cancer Treatment: Surgery

Like all cancer treatments, surgery has benefits, risks, and side effects. After surgery, it is common to have some pain from the surgery’s effect on the body. Most patients will have at least some pain after the operation, which can usually be helped with pain medication, if needed.

The amount and location of the pain varies depending on the surgery. Factors that can affect the pain you experience include:

 

  • Location of the surgery
  • Size of incision, or surgical cut
  • Amount of tissue removed
  • If you had pain before surgery

Side effects of surgery include weakness, tiredness, and pain for the first few weeks after the procedure. Other side effects caused by the removal of the pancreas sometimes include difficulty digesting food and diabetes from the loss of insulin produced by the pancreas. Fatigue usually goes away gradually two to four weeks after surgery.

Side Effects of Pancreatic Cancer Treatment: Radiation Therapy

The possible side effects of radiation therapy depend on where the radiation is targeted. The common side effects include:

  • Skin irritation (in areas of radiation, ranging from redness, blisters, and peeling)
  • Hair loss
  • Fatigue
  • Nausea
  • Diarrhea
  • Lower blood cell counts
  • Increase risks of infections
  • Mouth and gum sores/difficulty swallowing/dry mouth
  • A type of swelling called lymphedema
Side Effects of Pancreatic Cancer Treatment: Chemotherapy

The side effects of chemotherapy commonly include the following:

  • Nausea and vomiting
  • Fatigue
  • Diarrhea
  • Constipation
  • Tiredness
  • Pain
  • Loss of appetite
  • Hair loss
  • Skin and nail changes
  • Numbness and tingling
  • Swelling
  • Low white blood counts, low red blood counts and low platelet counts
  • Risks of infections
  • Risk of infertility
Side Effects of Pancreatic Cancer Treatment: Targeted Drug Therapy

Depending on the targeted drugs used, the common side effects may include:

  • Low or High blood pressure
  • Increased blood sugar level or cholesterol
  • Low white blood counts, low red blood counts and low platelet counts
  • Blood clots
  • Fatigue
  • Nausea and vomiting
  • Diarrhea
  • Poor appetite and weight loss
  • Skin rash/Mouth sores
  • Swelling in the arms and legs (fluid build-up)

Constipation

Side Effects of Pancreatic Cancer Treatment: Immunotherapy

The side effects of immunotherapy may include:

  • Nausea and vomiting
  • Diarrhea
  • Constipation
  • Swelling of hands and feet
  • Rash and other skin changes
  • Itching
  • Vision problems
  • Muscle or joint pain
  • Loss of appetite
  • Shortness of breath

What do I need to do if I have Pancreatic Cancer?

OncoCare Breast Cancer Treatment: Radiation Therapy

The pancreas is a pear-shaped gland located in the center of the abdomen between the stomach and the spine. Doctors often say that pancreatic cancer is a “silent disease” because there are not many noticeable symptoms early on. Also, there are currently no specific tests that can reliably find the cancer for patients who do not have symptoms. When patients do have symptoms, they are often similar to the symptoms of other medical conditions, such as an ulcer or pancreatitis.

If you suspect that you or your loved one have Pancreatic Cancer, it is advisable to get the support you need. Early detection and diagnosis of Pancreatic Cancer is key to treating the disease.

Regardless of what stage your Pancreatic Cancer may be, you should schedule an appointment to see an oncologist specialising in Pancreatic Cancer as soon as possible. With the speed of developments in Pancreatic Cancer diagnosis and treatment, novel emerging treatment options could be explored by your medical oncologist.

Our cancer specialists at OncoCare specialise in treating late stage and advanced stages of Pancreatic Cancer, as well as earlier stages of the disease.

Operation Hours
8.30am – 5.30pm

Email Address
enquiries@oncocare.sg

Telephone Number
6733 7890

Who are the Pancreatic Cancer Specialists in Singapore?

Dr Akhil Chopra

https://oncocare.sg/specialists/dr-akhil-chopra/

MBBS (Delhi) – American Board Certified (Int Med) – American Board Certified (Hematology) –

American Board Certified (Med Oncology)

Before joining OncoCare Cancer Centre at Mount Elizabeth Hospital, Singapore, Dr Akhil Chopra was a Senior Consultant in Medical Oncology at Johns Hopkins Singapore, Tan Tock Seng Hospital and Adjunct Associate Professor at Lee Kong Chian School of Medicine.

Dr Chopra has experience treating multiple cancer types including breast cancer, lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers; as well as Stomach Cancers and chronic leukaemia’s/multiple myeloma. Besides his clinical and research work, he has been involved in teaching medical students from the Lee Kong Chian School of Medicine as well as medical residents and students from Johns Hopkins University, Baltimore in USA.

MEDICAL PROFILE

  • Graduated from Delhi in 2001
  • American Board Certified, Internal Medicine
  • American Board Certified, Medical Oncology
  • American Board Certified, Hematology
  • Fellowship Training at Hahnemann University Hospital/Drexel University College of Medicine in Philadelphia, USA

Cancer Specialities: breast cancer, lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers

Dr Benjamin Chuah

Senior Consultant, Medical Oncologist

MBBCH, BAO (Ireland) – MRCP (United Kingdom) – FRCP (Edinburgh) – FRCP (Medical Oncology)

Dr Benjamin Chuah, Senior Consultant Medical Oncologist at OncoCare Cancer Centre, was previously Consultant in the Department of Haematology-Oncology, National Cancer Institute Singapore, National University Hospital.

Graduating in medicine from Trinity College Dublin in 1998 where he was awarded the Professor Prize in Physic (Surgery) and the Arthur Ball Prize (2nd Place), Dr Chuah returned to Singapore and obtained his Membership of the Royal College of Physicians of the United Kingdom in 2002.

Prior to entering private practice, Dr Benjamin Chuah (patients often address him as Dr Ben Chuah) was actively involved in both post-graduate teaching and research. He was the Director for Postgraduate Medical Education (Medical Oncology) and was a Core Faculty for the Residency Program (Internal Medicine). For his efforts, he was awarded the National University Hospital Postgraduate Teaching Excellence Award in 2011. He was also involved in clinical and translational research for many years and was the principal or co-investigator in international trials involving the use of novel and targeted therapy drugs for colorectal and pancreatic cancer. He was awarded the NUH Innovative Grant for research in warfarin pharmacogenomics and was also honoured with the inaugural Kobayashi Foundation Award for work done on serial changes in the expression of breast cancer-related proteins in response to neoadjuvant chemotherapy. His research work has lead to several 1st author publications in high impact medical and oncology journals including Gastroenterology, GUT and Annals of Oncology.

Dr Ben Chuah’s subspecialty interest is in Gastrointestinal Cancers including oesophageal, gastric, biliary tract, pancreatic, liver (hepatocellular carcinoma), neuroendocrine cancers and colorectal cancers. As a clinical cancer specialist and researcher, his research work includes small cell gallbladder cancer with paraneoplastic hyponatremia, exploring the lack of somatic mutations in VEGFR-2 tyrosine kinase domain in hepatocellular carcinoma, renal cell carcinoma (kidney cancer) with bony metastases and use of the chemotherapy drug, docetaxel (Taxotere) with or without ketoconazole in breast cancer. He has published on screening in colorectal cancer and was involved in a randomized, phase 2 study of ganitumab or conatumumab in combination with FOLFIRI (5-FU, leucovorin, irinotecan) for second-line treatment of mutant KRAS metastatic colorectal cancer.

MEDICAL PROFILE

  • Graduated from Trinity College, University of Dublin, Ireland in 1998.
  • MRCP (UK), Royal Colleges of Physicians of the United Kingdom, 2002.
  • Awarded the Professor’s Prize in Physic (Surgery) 1998, Arthur Ball Prize (2nd place) 1998, NUH Innovative Grant 2007, the Kobayashi Foundation Award 2010 and NUH Postgraduate Teaching Excellence Award 2011.
  • He was the Director of Post Graduate Medical Education (Medical Oncology) and Core Faculty for the Residency Program (internal Medicine) at National University Hospital.

Dr Thomas Soh

MBBS (Singapore) – MRCP (United Kingdom)

Dr Thomas Soh is a Senior Consultant Medical Oncologist at OncoCare Cancer Centre.  He is also an accredited medical practitioner by the Office of the Public Guardian, to assist patients with making a Lasting Power of Attorney (LPA).

He was previously Consultant at the Department of Haematology Oncology at National University Hospital(NUH) and Visiting Consultant at Ng Teng Fong General Hospital.
He graduated from National University of Singapore in 2003 and received his Membership of the Royal College of Physician (United Kingdom) in 2007. He later completed his advance specialist training in Medical Oncology in 2012.

He was heavily involved in both undergraduate and postgraduate education, and was core faculty for the both the Internal Medicine Residency program and the Oncology Senior Residency program in the National University Hospital from 2012 to 2016.  He was recognised for his mentorship and a good teacher to junior doctors and medical students, with the Teaching Excellence Award in 2014, from National University Cancer Institute (NCIS), as well as the Best Tutor Award in 2015 for undergraduate teaching by the University Medical Cluster, NUH.

Dr Soh believes in the delivery of quality healthcare, and was the lead and co-lead in several healthcare improvement projects. He had received multiple awards for his involvement in the Clinical Practice Improvement Programmes that he had implemented in NUH. From 2013-2015, he contributed a leading role being the Honorary Secretary of the Executive Committee, Singapore Society of Oncology.

Dr Soh is actively involved in both research and education in cancer medicine. He had received funding for his work from the National Medical Research Council, Singapore, being awarded the Clinical Investigator Salary Support Program (CISSP) award 3 times. He had researched on drug response and toxicity in treating cancer, understanding how chemotherapy and targeted medications is absorbed and cleared in the body in relation to the pharmacokinetics and pharmacodynamics. He had published on genetic variants affecting chemotherapy in Asian breast cancer patients. His research publication in colorectal cancer involves working with cell free DNA,  chemotherapy drugs Regorafenib, FOLFIRI regimen (irinotecan, 5-fluorouracil and folinic acid).

He was the principal investigator in several multi-centre gastrointestinal cancer clinical trials and his research work has lead to more than 10 publications in high impact medical and oncology journals. He was the Principal Investigator for studies of circulating tumour cells, and was also doing trials in hepatocellular cancer (hepatoma) with drugs such as Sorafenib, Lenvatinib, Carbozantinib. The colorectal cancer trials involved drugs such as Cetuximab (Erbitux) with FOLFOX (Oxaliplatin, 5-fluorouracil and folinic acid), FOLFIRI regimens, Aflibercept and Y90 (Therasphere). In advanced pancreatic cancer, he was principal investigator for studies using Gemcitabine, Masitinib, and Abraxane. These experiences stand him in good stead to care for cancer patients and he is recognised for his dedication and expertise in these areas.

Dr Soh’s subspecialty interest is in Gastrointestinal (oesophageal, gastric, colon and rectal cancer) and Hepatobiliary Cancer (liver, pancreas, bile duct and gallbladder cancers). He is also a cancer specialist who looks after patients with neuroendocrine cancers. He speaks fluent English, Mandarin, Malay, Bahasa as well as Hokkien and has looked after many Indonesian and Malay patients. He has looked after many international patients, including Vietnamese, Myanmar, Banglahdeshi  and Cambodian patients as well, with the help of interpreters.

MEDICAL PROFILE

  • Graduated from the National University of Singapore in 2003
  • Obtained Membership of the Royal College of Physician (United Kingdom) in 2007
  • Awarded Teaching Excellence Award in 2014, NCIS
  • Awarded NUH UMC Undergraduate Teaching Best Tutor Award in 2015
  • Research funding from the National Medical Research Council (NMRC), Singapore, being awarded the Clinical Investigator Salary Support Program (CISSP) award 3 times
  • Research work was published in more than 10 publications relating to hepatocellular carcinoma, colorectal cancer, pancreatic cancer and other gastrointestinal cancers.
  • Sub-specialty oncology interest in gastrointestinal (oesophageal, stomach, colon and rectal cancers) and hepatobiliary cancers (liver, pancreas, bile duct and gallbladder cancers)

Dr Wong Nan Soon

MBBS (Singapore) – M.Med (Singapore) – MRCP (United Kingdom) – FAMS (Medical Oncology) – MHsc (Duke, USA)

Dr Wong Nan Soon is a Senior Consultant Medical Oncologist with more than 15 years of experience in the diagnosis and management of a wide range of cancers.

His subspecialty interests are in the field of breast cancer and gastrointestinal cancers (which include colon cancer, rectal cancer, anal cancer, biliary cancer, pancreatic cancer, liver cancer, GI stromal cancers (GIST) and neuroendocrine cancers.

In addition, he is also well versed in the treatment of a wide variety of cancers which include lung cancers kidney cancers, uterine, cervical and ovarian cancers.

He graduated from the Faculty of Medicine, National University of Singapore in 1994 and obtained the degrees of Master’s in Internal Medicine and Membership of the Royal College of Physicians of the United Kingdom in 2000.

In 2003, he completed advanced specialty training in general medical oncology.

This was followed by a 1 year clinical fellowship sub-specializing in breast medical oncology in Sunnybrook and Women’s Health Science Centre, Toronto, Canada where he trained under world renowned breast oncologists including Professor Kathleen Pritchard.

He was promoted to the position of consultant in 2006 and subsequently rose to the position of senior consultant and chief of breast team in the department of medical oncology, National Cancer Centre Singapore in 2009.

In 2009, he was awarded the prestigious Singapore National Medical Research Council overseas research fellowship to develop expertise in phase I clinical trials at Duke University, North Carolina, USA. During this year, he broadened his subspecialty interest to encompass gastrointestinal cancers, training under Professor Herbert Hurwitz. He also underwent further training in biostatistics and clinical research methodology, graduating with a master’s degree in health science research.

With this knowledge and experience in novel drug combinations, he is able to offer cutting edge medical treatment for both early stage cancers and also drug resistant difficult to treat advanced cancers.

MEDICAL PROFILE

  • Novartis Oncology Young Canadian Investigator Award 2005
  • Canadian Association of Medical Oncology Annual Meeting Best Poster Award 2005
  • Chairperson, Medical Treatment Fund Committee, Singapore Cancer Society 2007
  • Clinical teacher, Yong Loo Lin School of Medicine, National University of Singapore from 2006-2011
  • Adjunct Associate Professor in the Department of Clinical Sciences, Duke-National University of Singapore, 2011-2013
  • Visiting Senior Consultant, KK Women’s & Children’s Hospital, Singapore 2010-2011
  • Senior Consultant, Dept of Medical Oncology, National Cancer Centre Singapore 2009-2011
  • Visiting Consultant, Dept of Medical Oncology, National Cancer Centre Singapore 2012-2014
  • Committee member, Specialist Training Committee (Medical oncology), Ministry of Health from 2009 to 2012
  • Invited lecturer at Nanyang Polytechnic School of Health Sciences
  • Director of Public and Patient Education, National Cancer Centre Singapore 2008-2011
  • Deputy Director in the Division of Community Outreach and Philanthropy, National Cancer Centre Singapore
  • Vice President, Singapore Society of Oncology 2011-2012
  • Board Member, Chapter of Medical Oncologists of Singapore 2009-2012
  • Honorary Secretary, Chapter of Medical Oncologists, College of Physicians, Academy of Medicine, Singapore 2007-2008
  • Member, Clinical Trials Steering Committee, National Cancer Centre Singapore, 2008-2011
  • Member, Singapore Society of Oncology
  • Member, American Society of Clinical Oncology
  • Member, HepatoPancreatoBiliary Association of Singapore.
  • Chairman, Singapore Cancer Network Breast Cancer Workgroup since 2014
  • Involvement in more than 30 local and international pharmaceutical and investigator initiated clinical trials
  • Awardee of multiple institutional and national level research grants.
  • More than 60 abstracts and papers in both local and international oncology journals, including Journal of Clinical Oncology, Clinical Cancer Research and Annals of Oncology.

Faculty and lecturer at numerous national and international oncology conferences

DR. Angela Pang

Senior Medical Oncologist

MBBS (S’pore), Grad Dip (GRM), MRCP (UK), M Med (Internal Med)

Dr Angela Pang is a Senior Medical Oncologist at OncoCare Cancer Centre and also a visiting consultant at the National University Cancer Institute of Singapore (NCIS).

Prior to this, she was a Consultant with the Haematology-Oncology Department of National University Cancer Institute of Singapore (NCIS), National University Hospital (NUH) and Visiting Consultant at Ng Teng Fong General Hospital (NTFGH).

She had obtained her undergraduate degree from the School of Medicine, National University of Singapore (NUS). Thereafter, she obtained her postgraduate qualifications – Masters in Medicine (Internal Medicine) from NUS, and her Membership of the Royal College of Physicians (UK). Subsequently, she went on to complete her advanced specialist training in Medical Oncology in the National University Hospital (NUH), Singapore and was awarded the NCIS research scholarship for her Sarcoma research fellowship with Professor Robert G Maki in the Tisch Cancer Institute, Mount Sinai Hospital, New York. 

With a specific interest in the optimisation of care in elderly cancer patients, Dr Pang further pursued a Graduate Diploma in Geriatric Medicine with the Yong Loo Lin School of Medicine (YLLSOM). In order to integrate her expertise in both geriatrics and oncology, she also trained in Geriatric Oncology with Dr Beatriz Korc and Dr Stuart Lichtman in the Memorial Sloan Kettering Cancer Center, New York. 

Dr Pang’s main clinical interests are in bone/soft tissue sarcomas, gastrointestinal cancers and geriatric oncology. She was the co-lead for the Musculoskeletal oncology service in NCIS, and had set up of the multi-disciplinary Geriatric Oncology service in NCIS and NTFGH.

 She was also a principal investigator for several international multi-centre cancer clinical trials and also a recipient of several grants. Her research work has been published in peer reviewed journals including the Journal of Clinical Oncology (JCO), Journal of American Society of Medicine (JAMA) Oncology, Nature Communications, Clinical Cancer Research, British Medical Journal (BMJ) GUT, Oncogene, Oncotarget and others. 

She is a member of several professional bodies, including the American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), International Society of Geriatric Oncology (SIOG) and the Connective Tissue Oncology Society (CTOS).  

Dr Pang was also actively involved in both undergraduate and post graduate educations at the YLLSOM and NUH respectively. She has been awarded for teaching excellence and was previously appointed as Assistant Professor for Faculty of Medicine, YLLSOM and had served as core faculty of the undergraduate education (Medical Oncology) and Senior Residency (Medical Oncology) of NUH. 

Dr Pang is fluent in English, Mandarin and Hokkien. She is able to converse in simple Malay/Bahasa. She has taken care of patients from many regional and overseas regions including Malaysia, Indonesia, Vietnam, Myanmar, China, Bangladesh, Sri Lanka, India, Canada and Mongolia.

Medical Profile

  • Graduated from the National University of Singapore with MBBS in 2005.
  • Obtained Membership of the Royal College of Physician (United Kingdom) and Masters in Internal Medicine (NUS) in 2009.
  • Awarded the NCIS scholarship (2015-2016) as a Sarcoma research scholar at The Tisch Cancer Institute, Mount Sinai Hospital with Professor Robert Maki.
  • Attended the Geriatric Oncology Program at the Memorial Sloane Kettering Cancer Centre (New York) in 2016.
  •  Co-lead for the Musculoskeletal Oncology (Sarcomas) service in NCIS
  • Built and served as the Program director of the Geriatric Oncology service in NCIS and NTFGH.
  • Assistant Professor Yong Loo Lin School of Medicine, National University of Singapore from 2017 – 2022.
  • Authored or co-authored publications in peer-reviewed international journals including Journal of Clinical Oncology (JCO), Journal of American Society of Medicine (JAMA) Oncology, Nature Communications, Clinical Cancer Research, British Medical Journal (BMJ) GUT, Oncogene, Oncotarget and others. 
  • Recipient of multiple teaching awards:  
    • NUHS Interprofessional teaching award in 2014.
    • NCIS Department Postgraduate teaching excellence award in 2015
    • NUHS Educator’s Day Collaboration Award in 2021.
  • Recipient of the Singapore Patient Engagement Initiative Award for the NCIS Dream Makers’ Program in 2021.
  • Recipient of several grants including Singapore Cancer Society Grant, Jurong Health Fund grant, NUHS bridging grant and the National Medical Research Council (NMRC) Clinician Investigator Salary Support Programme.
  • Member of several professional bodies including American Society of Clinical Oncology (ASCO), European Society of Medical Oncology (ESMO), International Society of Geriatric Oncology (SIOG) and the Connective Tissue Oncology Society (CTOS).  
  • Sub-specialty oncology interest in bone/soft tissue sarcomas, gastrointestinal cancers and geriatric oncology.

  Bibliography

1) Cancer physicians’ attitude towards treatment of the elderly cancer patient in a developed Asian country. Angela Pang, Shirlynn Ho and Soo-Chin Lee, BMC Geriatr. 2013 Apr 16;13:35. doi: 10.1186/1471-2318-13-35.

2) Hepatitis B virus reactivation risk varies with different chemotherapy regimes commonly used in solid tumours. Ling WH, Soe PP, Pang AS, Lee SC.Br J Cancer. 2013 May 28;108(10):1931-5. doi: 10.1038/bjc.2013.225. Epub 2013 May 7.

3) Lymphadenopathy and airway obstruction. Li A, Khoo KL, Tan CL, Pang A, Lee P. Am J Respir Crit Care Med. 2015 Jan 1;191(1): e1-3. doi: 10.1164/rccm.201409-1622IM.

 

4) Contemporary Therapy for Advanced Soft-Tissue Sarcomas in Adults: A ReviewAngela Pang, Mariana Carbini, Robert G. Maki. JAMA Oncol. 2016;2(7):941-947. 

5) Phase Ib/II randomized, open-label study of doxorubicin and cyclophosphamide with or without low-dose, short-course sunitinib in the pre-operative treatment of breast cancer. Andrea L.A. Wong, Raghav Sundar, Ting-Ting Wang, Thian-C Ng, Bo Zhang, Sing-Huang Tan, Thomas I.P. Soh, Angela S.L. Pang, Chee-Seng Tan, Samuel G.W. Ow, Lingzhi Wang, Jannet Mogro, Jingshan Ho, Anand D. Jeyasekharan, Yiqing Huang, Choon-Hua Thng, Ching-Wan Chan, Mikael Hartman, Philip Iau, Shaik A. Buhari, Boon-Cher Goh, Soo-Chin Lee Oncotarget. 2016 Sep 27; 7(39): 64089–6409

6) Carcinosarcomas and Related Cancers: Tumors Caught in the Act of Epithelial-Mesenchymal Transition. Angela PangMariana CarbiniAndre L. Moreira, Robert G. Maki. Journal of Clinical Oncology 2018 36:2210-216  

7) Longitudinal monitoring reveals dynamic changes in circulating tumor cells (CTCs) and CTC-associated miRNAs in response to chemotherapy in metastatic colorectal cancer patients. Karen Tan, Sai Mun Leong, Zizheng Kee, Patrick Vincent Caramat, James Teo, Michael Vito Martin Blanco, Evelyn S.C. Koay, Wai Kit Cheong, Thomas I-Peng Soh, Wei Peng Yong, Angela Pang. Cancer Letters, Volume 423, 1 – 8

8) Bromodomain and extraterminal proteins foster the core transcriptional regulatory programs and confer vulnerability in liposarcoma.

Chen Y, Xu L, Mayakonda A, Huang ML, Kanojia D, Tan TZ, Dakle P, Lin RY, Ke XY, Said JW, Chen J, Gery S, Ding LW, Jiang YY, Pang A, Puhaindran ME, Goh BC, Koeffler HP.Nat Commun. 2019 Mar 22;10(1):1353. doi: 10.1038/s41467-019-09257-z.

9) The treatment landscape of advanced angiosarcoma in Asia-A multi-national collaboration from the Asian Sarcoma Consortium.

Chen TW, Pang A, Puhaindran ME, Maw MM, Loong HH, Sriuranpong V, Chang CC, Mingmalairak S, Hirose T, Endo M, Kawai A, Farid M, Tan SH, Goh WL, Quek R, Chan JCH, Leung AKC, Ngan RKC.Cancer Sci. 2021 Mar;112(3):1095-1104. doi: 10.1111/cas.14793. Epub 2021 Feb 7.

10) Outcomes of a phase II study of intraperitoneal paclitaxel plus systemic capecitabine and oxaliplatin (XELOX) for gastric cancer with peritoneal metastases.

Daryl Chia, Raghav Sundar, Guo Wei Kim, Jiajun Ang, Jeffrey Lum, Min En Nga, Chee Cheng Ean, Hon Lyn Tan, Jingshan Ho, Natalie Ngoi, Matilda Lee, Vaishnavi Muthu, Gloria Chan, Angela Pang, Yvonne Ang, Joan Choo, Joline Si Jing Lim, Asim Shabbir, Wei-Peng Yong, and Jimmy Bok Yan So. Journal of Clinical Oncology 2021 39:3_suppl, 165-165

 11) MNK1 and MNK2 enforce expression of E2F1, FOXM1 and WEE1 to drive soft tissue sarcoma Ke XY, Chen Y, Tham VY, Lin RY, Dakle P, Nacro K, Puhaindran ME, Houghton P, Pang A, Lee VK, Ding LW, Gery S, Hill J, Chen L, Xu L, Koeffler HP.Oncogene. 2021 Mar;40(10):1851-1867. doi: 10.1038/s41388-021-01661-4.

12) Targeting Glycolysis in Macrophages Confers Protection Against Pancreatic Ductal Adenocarcinoma.

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What is Pancreatic Cancer?

Definition of Pancreatic Cancer

Pancreatic cancer is a disease in which healthy cells in the pancreas stop working correctly and grow out of control. These cancerous cells can build up and form a mass called a tumour. A cancerous tumour is malignant, meaning it can grow and spread to other parts of the body. As it grows, a pancreatic tumour can affect the function of the pancreas, grow into nearby blood vessels and organs, and eventually spread to other parts of the body through a process called metastasis.

The pancreas is a pear-shaped gland located in the center of the abdomen between the stomach and the spine. It is made up of 2 major components:

  • The exocrine componentis made up of ducts and small sacs called acini on the end of the ducts. This part of the pancreas makes specialized proteins called enzymes that are released into the small intestine to help the body digest and break down food, particularly fats.
  • The endocrine componentis made up of cells lumped together in different locations within this part of the pancreas, called islets of Langerhans. These cells make specific hormones, the most important of which is insulin. Insulin is the substance that helps control the amount of sugar in the blood. This portion of the pancreas also makes other hormones, such as glucagon, somatostatin, pancreatic polypeptide (PP), and vasoactive intestinal peptide (VIP). Each of these hormones plays an important role in regulating the body’s metabolism.

Although pancreatic cancer accounts for less than 2% of cancers in Singapore, the incidence has increased over the past 40 years. Globally, pancreatic cancer is the eighth most common cancer in women and the tenth most common cancer in men. Incidence rates of pancreatic cancer have gone up by around 1% each year since 2000. Worldwide, an estimated 495,773 patients were diagnosed with pancreatic cancer in 2020.

What are the Signs and Symptoms of Pancreatic Cancer?

The most common symptoms of Pancreatic Cancer are:

 

Patients with pancreatic cancer may experience the following symptoms or signs. As the cancer grows, symptoms may include:

  • Yellow skin (including yellowing of the gums and inner lips) and/or eyes, darkening of the urine, itching, and clay-coloured stool, which are signs of jaundice caused by a blockage of the bile ducts
  • Pain in the upper abdomen, upper back, or arms
  • Painful swelling of an arm or leg due to a blood clot
  • Burning feeling in the stomach or other gastrointestinal discomforts
  • Stomach bloating
  • Floating stools with a particularly bad odour and an unusual colour due to the body not digesting fats well
  • Weakness
  • Loss of appetite
  • Nausea and vomiting
  • Chills and sweats
  • Fever
  • Unexplained weight loss

Screening for Pancreatic Cancer

Screening is used to look for cancer before you have any symptoms or signs.

Pancreatic cancer is a “silent disease” because there are not many noticeable symptoms early on. If pancreatic cancer is suspected, exams and tests will be needed to find out for sure. If cancer is found, other tests might then be needed to learn more about it.

 

Pancreatic Cancer screening tests include:

 If a doctor suspects that a person has pancreatic cancer, they will first ask about the person’s medical history and family history. Then, they will examine the person to look for signs of the disease. An appropriate and timely diagnosis is very important. The tests described below may be used when pancreatic cancer is suspected. However, the diagnosis will be confirmed with a sample of tissue from the tumour taken during a biopsy, fine needle aspiration, or surgery.

How Pancreatic Cancer is Diagnosed

There are many tests used for diagnosing pancreatic cancer. Not all tests described here will be used for every patient. The doctor may consider these factors when choosing a diagnostic test:

  • The type of cancer suspected
  • Signs and symptoms
  • Age, general health, and family history
  • The results of earlier medical tests

Tests to diagnose Pancreatic Cancer include:

  • Physical Examination: The doctor will examine the patient’s skin, tongue, and eyes to see if they are yellow, which is a sign of jaundice. Jaundice can be from a tumour in the head of the pancreas that is blocking the normal flow of a substance called bile, which is produced in the liver. However, many patients with pancreatic cancer do not have jaundice when the cancer is diagnosed. The doctor will also feel the abdomen for changes caused by the cancer, although the pancreas itself, which is located in the back of the upper abdomen, can rarely be felt. An abnormal buildup of fluid in the abdomen, called ascites, may be another sign of cancer. The doctor will also examine the abdomen to determine if the patient have pain in the upper portion of the abdomen just below the breastbone.
  • Blood test: The doctor may take samples of blood to check for abnormal levels of bilirubin and other substances. Bilirubin is a chemical that may reach high levels in people with pancreatic cancer due to blockage of the common bile duct by a tumour. Carbohydrate antigen 19-9 (CA19-9) is a tumour marker. A tumour marker is a substance produced by a tumour that may be found at higher levels if cancer is present and can be measured in the blood. CA19-9 levels are often increased in people with pancreatic cancer, although some patients have normal CA19-9 levels. CA19-9 levels often become higher as the cancer grows or spreads.
  • CT or CAT Scan: A CT scan takes pictures of the inside of the body using x-rays taken from different angles. A computer combines these pictures into a detailed multi-dimensional scan (typically 3-dimensional or more) image that shows any abnormalities or tumours. A CT scan can be used to determine the size and location of the primary tumour and evaluate the possibility of spread to lymph nodes or other parts of the body.
  • PET or PET-CT scan: A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.
  • Endoscopic retrograde cholangiopancreatography (ERCP): The doctor will put a thin, lighted tube called an endoscope through the mouth and stomach into the small intestine. Then, a smaller tube called a catheter is passed through the endoscope and into the bile ducts and pancreatic ducts. Dye is injected into the ducts, and the doctor takes x-rays that can show whether a duct is compressed or narrowed. Often, a plastic or metal stent can be placed across the obstructed bile duct during ERCP to help relieve any jaundice. Samples of the tissue can be taken during this procedure and can sometimes help confirm the diagnosis of cancer. The patient is lightly sedated during this procedure. ERCP is generally used to place bile duct stents and not commonly used for diagnosis.
  • Ultrasound: An ultrasound uses sound waves to create a picture of the internal organs. There are 2 types of ultrasound devices:
  • A transabdominal ultrasound deviceis placed against the outside of the abdomen and is slowly moved around by the doctor to produce an image of the pancreas and surrounding structures.
  • An endoscopic ultrasound (EUS) device is a thin, lighted tube that is passed through the patient’s mouth and stomach and down into the small intestine. It is slowly moved around the area to take a picture of the pancreas.EUS is generally done under sedation, so the patient sleeps through the procedure. A biopsy may also be done at the same time as this procedure.
  • Percutaneous transhepatic cholangiography (PTC):In this x-ray procedure, a thin needle is inserted through the skin and into the liver. A dye is injected through the needle, so the bile ducts show up on x-rays. By looking at the x-rays, the doctor can tell whether there is a blockage of the bile ducts.
  • Magnetic resonance imaging (MRI):An MRI uses magnetic fields to produce detailed images of the body. MRI can be used to measure the tumour’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye is usually injected into a patient’s vein.
  • Biopsy: This is the removal of a small amount of tissue for examination under a microscope. There are a couple of different ways to collect a tissue sample:
  • Fine needle aspiration (FNA): An FNA uses a thin needle that is inserted into the pancreas to suction out cells. This is typically done by EUS or through the skin, called percutaneously, guided by a CT scan.
  • Core Needle Biopsy: This is used to collect a larger piece of tissue, which may be helpful for biomarker or genetic testing of the tumour.
  • Molecular or biomarker testing of the tumour: The doctor may recommend additional molecular tests to be performed on the tumour sample to identify specific mutations, genetic alterations, expression of certain proteins, and other molecular features unique to the tumour.
  • Germline testing: It is now recommended that all patients with a diagnosis of pancreatic cancer be considered for germline testing. This means testing a blood or saliva sample to look for mutations in a person’s DNA that may indicate a hereditary predisposition to cancer. If a patient is found to be a carrier for particular genetic mutations, this may help guide the treatment decisions if pancreatic cancer is diagnosed.

 

What are the Causes and Risk Factors of Pancreatic Cancer?

The following factors may increase the risk of Pancreatic Cancer:

  • Age: The risk of developing pancreatic cancer increases with age. Most patients who develop pancreatic cancer are older than 45. In fact, 90% are older than 55 and 70% are older than 65.
  • Gender: More men are diagnosed with pancreatic cancer than women.
  • Smoking: Patients who smoke tobacco are 2 to 3 times more likely to develop pancreatic cancer than those who don’t.
  • Obesity, diet and alcohol: Regularly eating foods high in fat is a risk factor for pancreatic cancer. Research has shown that obese and even overweight patients have a higher risk of being diagnosed with and dying from pancreatic cancer. Chronic, heavy alcohol use can also increase the risk of pancreatic cancer, most likely by causing recurrent pancreatitis, which is repeated inflammation of the pancreas.
  • Diabetes: Many studies have indicated that diabetes increases the risk of developing pancreatic cancer, especially when a patient has had diabetes for many years. In addition, suddenly developing diabetes later in adulthood, sometimes called new-onset diabetes, can be an early symptom of pancreatic cancer.

Family History: Pancreatic cancer may run in the family and/or may be linked with genetic conditions that increase the risk of other types of cancer.

What are the Types of Pancreatic Cancer?

Pancreatic cancer types can be divided into two larger categories: exocrine pancreatic cancer, which includes adenocarcinoma, and neuroendocrine pancreatic cancer. Each category has several cancer types that may vary in their symptoms and prognosis.

  • Exocrine (Nonendocrine) Pancreatic Cancer: Exocrine pancreatic cancer develops from exocrine cells, which make up the exocrine gland and ducts of the pancreas. The exocrine gland secretes enzymes that help break down carbohydrates, fats, proteins and acids in the duodenum. The various types of exocrine pancreatic cancers make up more than 95 percent of all cancers of the pancreas. They include the following:
  • Adenocarcinoma: Also called ductal carcinoma, this is the most common type of pancreatic cancer, accounting for more than 90 percent of pancreatic cancer diagnoses. This cancer occurs in the lining of the ducts in the pancreas.
  • Squamous Cell Carcinoma: This extremely rare nonendocrine cancer of the pancreas forms in the pancreatic ducts, and is made purely of squamous cells, which are not typically seen in the pancreas. Studies have reported that it has a very bad prognosis due to most cases being discovered after metastasis.
  • Adenosquamous Carcinoma: This rare type of pancreatic cancer represents 1 percent to 4 percent of exocrine pancreatic cancers. Compared with adenocarcinoma, adenosquamous carcinoma is a more aggressive tumour with a poorer prognosis.
  • Colloid Carcinoma: Another rare type, colloid carcinomas account for 1 percent to 3 percent of exocrine pancreatic cancers. These tumourous tend to develop from a type of benign cyst called an intraductal papillary mucinous neoplasm (IPMN). Because the pancreatic colloid tumour consists of malignant cells that float in a gelatinous substance called mucin, it is not as likely to spread and is easier to treat than other pancreatic cancers. It also has a much better prognosis.
  • Neuroendocrine Pancreatic Cancer: Pancreatic neuroendocrine tumours (NETs) develop from cells in the endocrine gland of the pancreas, which secretes the hormones insulin and glucagon into the bloodstream to regulate blood sugar. Also known as endocrine or islet cell tumours, neuroendocrine cancers are rare, making up less than 5 percent of all pancreatic cancer cases.
  • Benign Precancerous Lesions: Cysts and other benign tumours can form in the pancreas, and some can be precursors to pancreatic cancer, including intraductal papillary-mucinous neoplasms (IPMNs). Often, IPMNs and other benign lesions are found when a patient is being scanned for an unrelated medical reason. Depending on the location and type of the growth, the doctor may want to either surgically remove the lesion or continue monitoring it to ensure that it does not become malignant.

What are the Stages of Pancreatic Cancer?

           Doctors use several systems to stage pancreatic cancer. The method used to stage other cancers, called the “TNM classification,” is not often used for pancreatic cancer. However, for completeness, it is discussed further below.

The more common way to classify pancreatic cancer is to classify a tumour into 1 of the following 4 categories, based on whether it can be removed with surgery and where it has spread:

  • Resectable (localised): This type of pancreatic cancer can be surgically removed. Surgery is often done right after diagnosis. Sometimes, additional treatment may be recommended before surgery. The tumour may be located only in the pancreas or extend beyond it, but it has not grown into important arteries or veins in the area.
  • Borderline Resectable: This category describes a tumour that may be difficult or not possible to remove surgically when it is first diagnosed, but if chemotherapy and/or radiation therapy is able to shrink the tumour first, surgery may be possible to remove the tumour later with negative margins. A “negative margin” means that no visible cancer cells are left behind in the body.
  • Locally Advanced: This type of pancreatic cancer is still located only in the area around the pancreas, but it cannot be surgically removed because it has grown into or close to nearby arteries, veins, or organs. This means that it cannot be removed with surgery because the risk of damaging these nearby structures is too high.
  • Metastatic: The tumour has spread beyond the area of the pancreas and to other organs, such as the liver, lungs, or distant parts of the abdomen.

 

Staging is a way of describing where the cancer is located, or if it has spread and whether it is affecting other parts of the body. The tests and scans used to diagnose the patient’s cancer will give some information about:

  • the type of cell the cancer started in and where it began
  • how abnormal the cells look under the microscope (the grade)
  • the size of the cancer and whether it has spread (the stage)

<h3> Stage 0 Pancreatic Cancer

 

Stage 0: Refers to cancer in situ, in which the cancer has not yet grown outside the duct in which it started (Tis, N0, M0).

 

<h3> Stage 1 Pancreatic Cancer

  • Stage IA: The tumour is 2 cm or smaller in the pancreas. It has not spread to lymph nodes or other parts of the body (T1, N0, M0).
  • Stage IB: A tumour larger than 2 cm is in the pancreas. It has not spread to lymph nodes or other parts of the body (T2, N0, M0).

<h3> Stage 2 Pancreatic Cancer

 

  • Stage IIA: The tumour is larger than 4 cm and extends beyond the pancreas. It has not spread to nearby arteries, veins, lymph nodes, or other parts of the body (T3, N0, M0).
  • Stage IIB: A tumour of any size has not spread to nearby arteries or veins. It has spread to 1 to 3 regional lymph nodes but not to other parts of the body (T1, T2, or T3; N1; M0).

 

<h3> Stage 3 Pancreatic Cancer

 

Stage III may be either of these conditions:

  • A tumour of any size that has spread to 4 or more regional lymph nodes but not to nearby arteries, veins, or other parts of the body (T1, T2, or T3, N2, M0).
  • A tumour that has spread to nearby arteries and veins and may

<h3> Stage 4 Pancreatic Cancer

 

Stage IV: Any tumour that has spread to other parts of the body (any T, any N, M1).

 

<h3> TNM Staging System

Depending on the cancer specialist, a different staging system may be used to describe the progression of the Pancreatic Cancer. This is called the TNM staging system:

  • T describes the size of the tumour
  • N describes whether there are cancer cells in the lymph nodes
  • M describes whether the cancer has spread to a different part of the body (M is an acronym for metastasis)

Tumour (T)

Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumour. Tumour size is measured in centimeters (cm). A centimeter is roughly equal to the width of a standard pen or pencil.

The tumour stage helps the doctor develop the best treatment plan for each patient. Specific tumour stage information is listed below.

  • TX: The primary tumour cannot be evaluated.
  • T0 (T plus zero): No evidence of cancer was found in the pancreas.
  • Tis: Refers to carcinoma in situ, which is very early cancer that has not spread.
  • T1: The tumour is in the pancreas only, and it is 2 centimeters (cm) or smaller in size. This stage may be further divided into T1a, T1b, and T1c based on the size of the tumour.
  • T2: The tumour is in the pancreas only, and it is larger than 2 cm but not larger than 4 cm.
  • T3: The tumour is larger than 4 cm and extends beyond the pancreas. It does not involve the major arteries or veins near the pancreas.
  • T4: The tumour extends beyond the pancreas into major arteries or veins near the pancreas. A T4 tumour cannot be completely removed with surgery.

Node (N)

The “N” in the TNM staging system is for lymph nodes. These small, bean-shaped organs located throughout the body help fight infection and disease as part of the body’s immune system. In pancreatic cancer, regional lymph nodes are those lymph nodes near the pancreas, and distant lymph nodes are those lymph nodes in other parts of the body.

  • NX: The regional lymph nodes cannot be evaluated.
  • N0: Cancer was not found in the regional lymph nodes.
  • N1: Cancer has spread to 1 to 3 regional lymph nodes.
  • N2: Cancer has spread to 4 or more regional lymph nodes.

Metastasis (M)

The “M” in the TNM system describes whether the cancer has spread to other parts of the body, called metastasis.

  • M0: The disease has not spread to other parts of the body.

M1: Cancer has spread to another part of the body, including distant lymph nodes. Pancreatic cancer most commonly spreads to the liver, the lining of the abdominal cavity called the peritoneum, and the lungs.

    More about Pancreatic Cancer (provided by OncoCare)