Global Rise in Pancreatic Cancer Deaths
Partly Preventable

Liam Davenport

October 28, 2019

BARCELONA, Spain — The global burden of pancreatic cancer has risen sharply since 1990, with the incidence increasing and death rates more than doubling to 2017, reports a new study that forms part of a comprehensive analysis of gastrointestinal diseases across the world.

The new data comes from the Global Burden of Diseases, Injuries, and Risk Factors Study.

The results were presented as a series of late-breaking abstracts at the United European Gastroenterology (UEG) Week Barcelona 2019, and were published simultaneously across several articles in The Lancet Gastroenterology & Hepatology.

"The recent increase in the global burden of pancreatic cancer will only continue given the ageing of the population and the projected rise in prevalence of many risk factors for this almost uniformly deadly cancer," writes Alison P. Klein, PhD, MHS, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, in an accompanying editorial.

"Policy makers need to prepare for the continued rise in pancreatic cancer incidence. Earlier diagnosis, improved treatments, and efforts to reduce modifiable risk factors are needed to help to reduce this growing cause of cancer mortality," she adds.

In the Global Burden study, researchers looked at pancreatic, colorectal, stomach and esophageal cancers, as well as inflammatory bowel disease, finding often stark differences between regions, despite the emergence of global trends linked to modifiable risk factors such as diet and smoking.

Coauthor Reza Malekzadeh, MD, Digestive Disease Research Institute, Tehran University of Medical Sciences in Iran, told Medscape Medical News that "the message of our study that we should now focus on is cancer prevention."

He emphasized around 50% of cancers are preventable via modifiable risk factors, adding that the other focus should be on early diagnosis, "because if you make early diagnosis, for pancreatic cancer, for colorectal cancer, for gastric cancer, it is possible to treat them."

"Therefore, policymakers in health should really focus on both these aspects, and also should spend more on research into prevention of these cancers," he added.

"Most Comprehensive Picture"

"This analysis provides the most comprehensive picture of the global burden of digestive disease to date," commented Herbert Tilg, MD, professor of internal medicine at the Medical University of Innsbruck in Austria, and chair of the UEG Scientific Committee.

"Examining these cross-populational trends offers vital information on the changing burden of disease and aids the correct allocation of resources to improve patient outcomes," he said in a statement.

For each of the diseases, the researchers used estimates from the Global Burden of Disease (GBD) 2017 dataset, which covered 195 countries and territories from 21 regions worldwide.

Vital registration, vital registration-sample, verbal autopsy, and cancer registry data were used to estimate the mortality, incidence, and disability-adjusted life-years (DALYs) of each condition for the period 1990 and 2017.

This analysis showed that, for esophageal cancer between 1990 and 2017, there was a decrease in age-standardized incidence (–22%), mortality (–29%), and DALY rates (–33%).

However, population growth and aging meant that there was an increase in the total number of new cases (52%), deaths (40%), and total DALYs (27%).

For stomach cancer, the picture was more mixed, with overall declines in age-standardized incidence, death, and DALY rates from 1990. However, there was a marked increase in age-standardized death rates in high-income Asia-Pacific countries and East Asia.

This prompted the researchers to urge that "specific local strategies should be tailored to each country's risk factor profile."

Doubling of Disease Burden in Pancreatic Cancer

However, when the researchers turned to pancreatic cancer, they found that the global burden of the disease had more than doubled during the study period.

Specifically, the age-standardized incidence rate was 5.0 per 100,000 person-years in 1990, increasing to 5.7 per 100,000 person-years in 2017, with 52% of incident cases occurring in men.

This was accompanied by a more than doubling (2.3-fold increase) in the number of deaths from pancreatic cancer, from 196,000 person-years in 1990 to 441,000 person-years in 2017.

The number of DALYs due to pancreatic cancer also doubled, increasing from 4.4 million in 1990 to 9.1 million in 2017.

The factors most commonly attributable to death from pancreatic cancer were smoking (accounting for 21.2% of the risk), high fasting plasma glucose (8.8%), and high body mass index (6.2%).

Malekzadeh explained that the issue with pancreatic cancer is that the "signs and symptoms appear very late, therefore we don't have any preventive measures."

He said that there is "a lot of research going on to find biomarkers, but the only thing is really to decrease the risk factors," emphasizing that risk factors such as alcohol, obesity, and diabetes are preventable. "And if we just control these factors, or decrease them, we may be able to decrease the incidence by up to 50%."

Malekzadeh added: "The time is now for preventing risk factors, and for investing more in research into early diagnosis."

Colorectal Cancer

For colorectal cancer, the researchers found that there was substantial variation in the burden of the disease across the world.

However, the general pattern was that the overall death rate from colorectal cancer was decreasing, despite the overall incidence rate increasing in most countries.

The age-standardized incidence rate of the disease increased by 9.5% between 1990 and 2017 to 23.2 per 100,000 person-years, while the age-standardized death rate decreased by 13.5% to 11.5 per 100,000 person-years in 2017.

From ages 64 through 80, the number of incident cases of and deaths was higher in males than females.

Colorectal cancer accounted for 18.9 million DALYs in 2017, which represented a 14.5% decrease since 1990.

The three largest contributors to DALYs were found to be a diet low in calcium (accounting for 20.5%), alcohol use (15.2%), and a diet low in milk (14.3%).

Malekzadeh underlined that, for colorectal cancer and even pancreatic cancer, "the first and very important point...is the fact that we are confronting an obesity epidemic."

He pointed out that the increase in daily calorie intake since the 1970s and the corresponding decrease in physical activity accounts for approximately 30% of the etiology of colorectal cancer.

This, Malekzadeh said, points to the need for more education "to convince the public" to engage in healthier lifestyles, and he argues that this includes the need to subsidize healthy foods.

Another issue is the need for improvement in care at all disease stages, argues Marianne Grønlie Guren, MD, PhD, K.G. Jebsen Colorectal Cancer Research Centre, Oslo University Hospital, Norway in an accompanying editorial.

She says that, while combination chemotherapy, targeted agents, and surgery have all improved the prognosis of metastatic colorectal cancer, "there are still only a few biomarkers to guide treatment selection in clinical practice for subgroups of patients who can benefit from targeted therapy or immune checkpoint inhibitors."

Guren emphasizes that dietary and lifestyle measures are needed to help prevent colorectal cancer, alongside screening for early detection in high-risk populations.

"Population-based cancer registries are important for monitoring the incidence of colorectal cancer and survival," she writes, as well as "access to high-quality health care for rapid diagnosis and appropriate treatment."

This should be coupled, Guren argues, with increased awareness of the disease, both for improved cancer care and research.

The study was funded by the Bill & Melinda Gates Foundation. Individual authors acknowledge support from numerous agencies and institutions.

European Gastroenterology (UEG) Week Barcelona 2019: Abstracts LB22, LB23, LB24, LB25, LB26. Presented October 22, 2019.

Lancet Gastroenterol Hepatol. Published online October 21, 2019.

Pancreatic cancer: Full text, Editorial

Stomach cancer: Full text, Editorial

Colorectal cancer: Full text, Editorial

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