Recently I witnessed an elderly lady in my local supermarket, fighting back the tears while her husband looked on blankly. The cause of her distress was and remains totally unknown to me. Maybe the couple had had a trivial argument over what brand of yoghurt to buy. But for some reason I was deeply moved by the scene, and it set me off thinking at a tangent.
Each of our lives is an unpredictable blend of joy and tragedy. To the elderly this is an especially real and immediate experience. Old age, if we ever reach it, is the time when we lose most of our friends and dear ones, witnessing their harrowing struggles with ill-health; each day looking ahead with foreboding or resignation to our own decline and death.
The next morning I heard the news of yet another celebrity succumbing to pancreatic cancer. The recent spate of such cases brought home how far we still have to go to defeat this awful disease. Almost one in 50 of us will develop pancreatic cancer, which means that hardly any extended family is untouched. Almost everyone knows someone afflicted, and hardly any of the victims survive beyond a matter of months following diagnosis. Although breast, prostate and colon cancer and leukaemia are as common or more so, these diseases typically take a different course, with the hope of at least medium-term survival with a decent quality of life and, for some, even the prospect of a complete recovery. But pancreatic cancer is a far more deadly disease. It is virtually symptomless until the stage at which is has spread beyond any effective intervention. Even at an earlier stage, the necessary surgery is traumatic and rarely succeeds fully.
During the twentieth century there was a relentless rise in the incidence of pancreatic cancer in Western countries, such that nowadays about three times as many cases are seen compared with a century ago. In recent decades this trends has levelled off, although the same rising curve is now evident in the rest of the world, especially in developing nations such as China. The reasons for this are debated, although one undoubted factor is globally increased life expectancy. More people are living to the age at which pancreatic cancer starts to become common.
Like all cancers, that of the pancreas has complex causes that remain poorly understood and that might take many years of research to disentangle, to the point that substantially better diagnostic tools and therapies can emerge. As is often pointed out, improvements in survival, even for some of the common cancers listed above, are almost entirely due to earlier diagnosis, in some cases helped by the emergence of genetic tests to identify individuals at high risk. In a nutshell, we don't know enough and we need to know a lot more.
Clearly the contribution of basic cell and molecular biology is crucial to this endeavour, not to mention clinical epidemiology, genetics and endocrinology. Yet research into pancreatic cancer is a relatively underfunded area. Only three projects specifically related to the disease are listed on the website of the EU's 7th Framework Programme (FP7), representing a minute slice of its total budget of €54 billion. Why is such a lethal disease so neglected in this manner?
There may be many answers to this question. One is undoubtedly that, while the human cost of the disease is devastating, it is a comparatively lighter burden in cruder economic terms. In the vast majority of cases it strikes individuals beyond normal working age. Purely palliative care is all that can be offered in most instances, which is obviously far less expensive than surgery or prolonged treatments with drugs or immunotherapy. Given also the rapid course of the disease, the cost of care per patient is much less than for breast cancer, diabetes, or Alzheimer disease. For this reason, it seems to figure only as a low priority on the radar of policy-makers. On the other hand, the only way it could be seriously combated, given present knowledge, would be to implement a prohibitively expensive population-based, invasive screening programme.
There are also few identified risk factors for the disease, apart from smoking, plus a minor contribution of obesity. Current data on the effects of diet are unclear, and in some cases contradictory. Health education programmes thus have little to contribute to raising awareness.
Another reason why the disease may be considered relatively invisible is that it does not have any specific lobby group of sufferers to speak up for more research and better care. It affects people of both sexes and all ethnic groups. There is no known connection with sexual orientation, sporting prowess or lifestyle, and rich and poor countries are both affected. The only major correlation is with age, and the elderly exercise little power in society. As a result of its ‘low profile’, those who lose a spouse, a close friend or a relative to this scourge, having witnessed their suffering, tend to feel alone in their grief, even when comforted by other family members.
Most likely, the elderly lady from the supermarket has sorted out whatever was upsetting her. But for millions, pancreatic cancer remains a cause of enormous grief. We need to put more effort into understanding its causes, so as to alleviate its human costs.