November 1, 2010
Surprise finding: Pancreatic cancers progress slowly
Pancreatic cancer develops and spreads much more slowly than scientists have thought, according to new research from Johns Hopkins investigators. The finding indicates that there is a potentially broad window for diagnosis and prevention of the disease.
“For the first time, we have a quantifiable estimate of the development of pancreatic cancer, and when it would be best to intervene, so there is potentially a very broad window for screening,” said Christine Iacobuzio-Donahue, associate professor of pathology and oncology at Johns Hopkins’ Sol Goldman Pancreatic Cancer Research Center. Right now, however, she added, “pretty much everybody is diagnosed after that window has closed.”
Pancreatic cancer is notoriously difficult to detect in its early stages because there are frequently few symptoms, and current imaging techniques are not specific for cancer.
Bert Vogelstein, professor and director of the Ludwig Center for Cancer Genetics and Therapeutics at the Johns Hopkins Kimmel Cancer Center and an investigator at the Howard Hughes Medical Institute, said that the results of the new study show that “many pancreatic cancer cases have a long lag time before they are detected through conventional tests. This leaves room to develop new early diagnostic tools and intervene with potentially curative surgery.”
The Johns Hopkins work, published in the Oct. 28 issue of the journal Nature, suggests that it takes at least a decade for the first cancer-causing mutation that occurs in a cell in a pancreatic lesion to turn into a full-fledged cancer cell. At this point, the lesion is called “high grade” and should be removed, much like polyps are removed from the colon.
After the first cancer cell appears, it takes an average of nearly seven years for that cell to turn into the billions that make up a cancerous tumor the size of a plum, after which at least one of the cells within the tumor has the potential and ability to spread to other organs. Patients die an average of two and a half years after this metastasis.
The results contradict the idea that pancreatic cancers metastasize very early in their development, Iacobuzio-Donahue said.
For the study, scientists collected tissue samples during autopsies of seven patients who died from pancreatic cancer that had metastasized to other organs. Because the tissue samples were taken within six hours of each patient’s death, the scientists were able to keep some of the cells alive long enough to extract the DNA and sequence the series of chemical “letters” that form genes.
In all patients, metastatic deposits were found in two or more sites in the body, most often the liver, lung and peritoneum (lining of the abdomen). The researchers found similar mutations present in both the areas of metastasis and in the primary pancreatic tumors from which the metastases arose.
They also identified and classified the types of mutations—ones that occur before metastasis and others that happen after the cancer has spread. Both types of mutations were present within the primary tumor years before the metastases became clinically evident, Iacobuzio-Donahue said.
Using mathematical models to study the timing of pancreatic cancer progression, the scientists conservatively estimated an average of 11.7 years before the first cancer cell develops within a high-grade pancreatic lesion, then an average of 6.8 years as the cancer grows and at least one cell has the potential to spread and, finally, an average of 2.7 years from then until a patient’s death.
The Johns Hopkins scientists said that the goal is to develop a pancreatic cancer screening method similar to the protocol used for breast and colon cancers. Though early stages of pancreatic cancer cause no symptoms, Iacobuzio-Donahue said that perhaps at a certain age people should undergo an endoscopy to screen for pancreatic cancer. Endoscopy is a procedure allowing doctors to look inside the body through the use of an instrument that has a tiny camera attached to a long thin tube.
Another study published in the same issue of Nature, directed by British researchers at the Wellcome Trust Sanger Institute in collaboration with Iacobuzio-Donahue, used cell lines and tissue samples from the same pancreatic cancer patients as the Johns Hopkins study to look for rearrangements of genetic material. The scientists found that more than half of specific rearrangements occurred in all metastases and primary tumors.
The genome sequencing work was supported by the National Institutes of Health, Bill and Melinda Gates Foundation, Uehara Memorial Foundation, AACR-Barletta Foundation, John Templeton Foundation, Sol Goldman Pancreatic Cancer Research Center, Michael Rolfe Pancreatic Cancer Foundation, George Rubis Endowment for Pancreatic Cancer Research, Joseph C. Monastra Foundation for Pancreatic Cancer Research, Alfredo Scatena Memorial Fund, Sigma Beta Sorority, Skip Viragh Foundation, Virginia and D.K. Ludwig Fund for Cancer Research, Joint Program in Mathematical Biology and J. Epstein.
Other scientists involved in the research were Shinichi Yachida, Sian Jones, Rebecca Leary, Baojin Fu, Mihoko Kamiyama, Ralph H. Hruban, James R. Eshleman, Victor E. Velculescu and Kenneth W. Kinzler, all of Johns Hopkins; Ivana Bozic and Martin A. Nowak, both of Harvard University; and Tibor Antal, of Harvard and the University of Edinburgh, Scotland.
The Sol Goldman Pancreatic Cancer Research Center at Johns Hopkins