A DOCTOR WRITES: There is no medical reason why Brian Lenihan should not continue to work, writes DR MUIRIS HOUSTON
BRIAN LENIHAN’S statement yesterday that he has been diagnosed with “cancerous tissue at the entrance to the pancreas” and that he will begin chemotherapy later this week represents a very open and honest sharing of personal health information with the public.
His commitment to be positive about his illness while continuing to work as Minister for Finance is both brave and admirable.
Pancreatic cancer characteristically does not cause symptoms until it has reached an advanced stage, which is the case for 80 per cent of people diagnosed with the disease. Unfortunately, most patients are not suitable for surgical treatment, due to the cancer having spread locally in an area that contains a number of vital blood vessels. Some two-thirds of cancers are found in the head or entrance of the pancreas, with about a third developing in the tail of the gland.
The pancreas is a gland located behind the stomach at the back of the abdominal wall. Extending horizontally, it is shaped like a fish. Some six inches long, the gland has a wide head tapering to a narrow pointed tail. The pancreas contains two separate parts: the exocrine and endocrine glands. The exocrine part produces a cocktail of enzymes that help us digest fat, proteins and carbohydrates in food. Exocrine glands and ducts make up more than 95 per cent of the cells in the pancreas and are the source of the commonest type of pancreatic cancer. Just a small percentage of pancreatic cells, arranged in clusters, are called endocrine cells and it is these which manufacture the sugar-regulating hormone insulin.
What are the risk factors for developing cancer of the pancreas? By far the biggest is cigarette smoking. Almost 30 per cent of cases are thought to result directly from smoking. Age is another factor; pancreatic cancer is rare under the age of 50. Men are 20 per cent more likely than women to develop the cancer. Being overweight is a risk factor.
In terms of symptoms and signs of the disease, they are non-specific and manifest themselves late. The most common presenting symptoms are jaundice and weight loss. Tummy pain, when it occurs, is non-specific in nature, although it may radiate to the back. Other symptoms include weakness, loss of appetite, nausea and vomiting. The most accurate tests for making a diagnosis are a dedicated type of Cat scan or the use of a local ultrasound probe passed into the intestine. Unfortunately, there is no accurate blood or screening tests for cancer of the pancreas.
Jaundice is the result of a blockage in the common bile duct that is pressed on by the cancer developing in the adjacent pancreatic duct at the head of the gland. As a result, a substance called bilirubin accumulates in the tissues and the blood, leading to yellow eyes and skin.
If the person is lucky, jaundice occurs early in the growth of the cancer, leading to an early diagnosis. Potentially curative surgery – a Whipple procedure – can succeed in removing the entire cancer and reconnecting the bile duct to the small intestine. More commonly, a small tube (stent) is placed in the bile duct via a flexible telescope to resist compression from the surrounding tumour and prevent unpleasant symptoms later in the illness.
Chemotherapy is used to treat most patients with pancreatic cancer. The standard chemotherapy drug is gemcitabine, but other drugs such as cisplatin and 5-fluorouracil may be used. Chemotherapy is given in cycles, two weeks apart. The most common side-effects are nausea and tiredness; because of its effect on the immune system, the patient carries a higher risk of developing infection.
In this context it makes sense for the Minister to curtail his public engagements. But he is absolutely correct to continue to work; there is no medical reason for him not to do so. Indeed, from the point of view of coming to terms with his illness, the Lenihan family will benefit from as normal a routine as possible.
A diagnosis of cancer is the beginning of a personal journey. Brian Lenihan deserves the space and privacy to undertake this journey at his own pace.