Epidemiology of Pancreatic Cancer in Connecticut

Vol. 55, No.6 Printed in U.S .A.

GASTROENTEROLOGY

Copyright© 1968 by The Williams & Wilkins Co.

EPIDEMIOLOGY OF PANCREATIC CANCER IN CONNECTICUT RAYMOND

E.

MoLDow, M.D., AND RoGER R . CoNNELLY

State of Connecticut, State Department of Health, Hartford, Connecticut

An estimated 18,000 deaths from pancreatic cancer will occur in the United States during 1968, 1 yet the etiology of the disease remains an enigma. Although various hypotheses have been suggested, such as chronic pancreatitis secondary to either alcoholism or biliary tract disease, none has been substantiated. The epidemiological approach to this type of problem has been rewarding in several cancer sites, but in pancreatic cancer the few comprehensive epidemiological studies have failed to reveal either an etiology or a common denominator warranting further evaluation. We attempted to obviate any bias introduced by the study of a disease within a given hospital by employing the Connecticut Tumor Registry 2 as the source of case selection. The Connecticut Tumor Registry is the only cancer registry in the United States that receives, codes, and analyzes reports of newly diagnosed cancer cases from essentially all hospitals within the state. Table 1 compares incidence and mortality rates for pancreatic cancer in Connecticut during the years 1955 to 1964 with rates for other sites within the digestive system. 3 Received March 11, 1968. Accepted May 22, 1968. Address requests for reprints to: Dr. Raymond E. Moldow, State of Connecticut, State Department of H ealth, 79 Elm Street, Hartford, Connecticut 06115 . Dr. Moldow is an Epidemic Intelligence Serl'ice Officer of the National Communicable Disease Center. Mr. Connelly is a biostatistician ll"ith the National Cancer Institute, National Institutes of Health. The authors are indebted to Henry Eisenberg, M .D., Chief, Chronic Disease Control Section, Connecticut State Health Department, for permission to utilize data from the Connecticut Tumor Registry. The authors also wish to thank Mrs. Barbara Hooper and Miss Arline DiMarzio for secretarial assistance. 677

Cancer of the pancreas accounted for 10.8% of all men and 8.5% of all women diagnosed with tumors of the digestive system. The incidence of the disease was greater than that for cancer of either the esophagus, small intestine, or biliary passages and liver. An indication of the poor prognosis for patients diagnosed with pancreatic tumors is found in the essentially identical rates of incidence and mortality for this disease. In contrast, mortality rates for cancer of the pancreas and cancer of the rectum are about the same but the incidence of rectal cancer, a disease with a better prognosis, is about twice that of pancreatic cancer. Since 1935 the incidence of the disease increased slightly among Connecticut men but remained stable among Connecticut women; average annual age-adjusted incidence rates were 6.9 cases per 100,000 men and 5.3 cases per 100,000 women during the years 1935 to 1939; in 1960 to 1964 these rates were 9.9 for men and 5.9 for women. No specific hypothesis was entertained in the present study, and we set out on a "fishing expedition," attempting to examine and evaluate all of the variables possible in a retrospective chart review. Material and Methods To assemble a series of patients for a case history study, all 865 cases of pancreatic cancer diagnosed in Connecticut residents between January 1957 and December 1963 and recorded by the Connecticut Tumor Registry as being confirmed microscopically were identified. After excluding 46 cases diagnosed in out-ofstate hospitals or inaccessible Connecticut institutions, we arranged the cases by hospital and date of diagnosis and took a systematic sample of every third case. A total of 269 cases were selected for inclusion in the study. Hospital reports for the study group originated from 38 Connecticut hospitals. All hos-

678

MOI,DOW AND CONAELD'

TABLE

Vol. 55, No . 6

1. Number of cases, percentage di stribution, incidence," and mortality" rates by p rimary site fo r cancer of the digestive system , Connectiwt, 1955 to 1964 Male

Primary si teb

No. of cases

%

Female Average annual ra te per 100,000 population

Ave rage annua l

:\ o. of cases

%

I ncidence Mortality

rate per 100,000 population Incidence Mortality

- --

- - - - --

Digestive systemc Esophagus Stomach Small intestine Large intestine Rectum Biliary passages and liver P a ncreas

12,032

100.0

93 .5

64 .4

10,219

100 .0

65.7

43 . 1

934 2,586 115 3,875 2, 373 672

7.8 21.5 1.0 32.2 19.7 5.6

7.4 20.1 1.0 30.1 18.5 5 .2

6.6 16 .6 0 .5 18 .1 9 .0 2.9

180 1,587 112 -!,568 1,934 766

1.8 15 .5 1.1 44.7 18.9 7.5

1.2 10 .1 0 .8 29.u 12.8 -! .9

0.9 8 .3 0.4 18 .1 5.4 3.5

1,295

10 .8

10 .1

9 .7

868

8.5

5.u

5.6

Age-adjusted to the total1950 population of the Con t ine ntal United States . International list numbers shown iu parentheses . c Includes 182 male and 204 female cases coded to either (156) liver, u nspecified whether prima ry or secondary, (157 ) peritoneum, or (158) other a nd unspecified digestive organs. a

b

pitals were visited and, except in those few instances when the record was not available, each study patient's medical chart was reviewed. When a chart was not available, records from the Connecticut Tumor R egistry for that patient were reviewed. On the basis of the abstracted information, 12 additional patients were excluded- 8 for lack of microscopic confirmation of the diagnosis and 4 because of a mistaken diagnosis; e.g., demonstration of a primary extrapancreatic site by autopsy. Thus '257 patients comprised the final study group. Although a hospi tal control group was not obtained in this study, it was possible to usc published data about Connecticut's population as the basis for comparing several demographic characteristics under investigation. The distribution by race, marital status, residence , and nativity of the Connecticut population at the midpoint of the study period, 1960, was ascertained from census reports.'- " Expected numbers of cases were calculated on the basis of the sex- and age-specific population distributions for each demogmphic characteristic. The expected numbers of cases were compared with the actua l numbers observed among the stud~· group. Tests of significan ce were performed at the 5% level using x" ana lyses .

R esults

Age and Sex The mean age of the study group was 64.4 years, with a range from 26 to 94

years. This mean age was simila r to that of 62.3 reported by Lazar et a!. 6 at Michael R eese Hospital a nd 63.2 observed by Sloan and Wha rton 7 at Los Angeles County hospita l. There were 153 men a nd 104 women, yielding a male to fema le ratio of 1.5: 1. The average age for women, 67.1 years, was significantly greater th an the an'rage age of 62.6 years for men. Race

T here were 246 Caucasians and 11 Negroes compared with expected numbers of 250.5 a nd 6.5, based on the sex- and agespecific racial distribution of the 1960 Connecticut population. Differences between the observed a nd expected numbers did not reach statistical significance (X 2 = 3.1, 0.07 < P < 0.09) . Howeve r, the indication of increased pancreatic cancer risk for Negroes is consistent with the higher incidence rates for Negroes found in past studies of 10 metropolitan a reas scattered throughout the United States 8 and in recent investigations within California's Alameda County.u On the other hand, only 4% of the patients were N egroes in Lowe a nd Palmer's study 10 at the East Orange Veterans Administration Hospital in New

D ecember 1968

()79

PAA CREATIC CANCER IN CONNECTICUT

Jersey, whereas the Negro admission rate was 25%. The ratio of N egro to Caucasian patients paralleled the general hospital admissions at Charity Hospital of Louisiana at New Orleans.U

Marital Status No significant differences were found between the observed and expected distributions by marital status (X~= 0.7, 0.85 < P < 0.88). Of the study group, 63.4% were married; 9.3% were single ; and 27.3% were widowed, separated, or divorced.

T ABLE

2. Pancreatic cancer and nativity l\'o. of cases

Country of birth Observed

Expected

Austria, Hungary Canada Ge rmany Italy Norw ay, Sweden, Finland Poland Un ited Kingdom, Irela nd USS R Other foreign United States

5 15 5 18 5 8 9 9 14 169

4. 9 7.2 4.4 21.3 4.4 10. 8 11.0 6.0 12 .1 174.9

To ta l

'257

257.0

R esidence The data failed to show a ny significant geographic distribution of pancreatic cancer cases on the basis of residence in any of Connecticut's eight counties {X~ = 6.9, 0.42 < p < 0.45 ) . ·w hen the counties were ranked accordin g to the socioeconomic index developed by Stoc kw e ll,!~ no indication of a relationship between the incidence of pancreatic cancer and socioeconomic sta tus was apparent. This is consistent with other findin gs,l 3 • 14 although earlier studies of the white population of the United Statess revea led a greater pancreatic cancer risk a mong those with lower socioeconomic status.

Nativi ty and R eligion Table 2 demon strates the observed a nd l'xpcctcd in ciden ce of cases by country of birt h. The diffcrcncl'S between the ob::;cr\'cd and expected Ya lues a re not sta tistically significant (X~ = 12.3, 0.18 < P < 0.21) , Nativity studies based on death records from Connectieut, 1 '' New York City,tn. 17 and the eombined data from 35 stat es in the Uni ted States 1k haYe all shown the foreign bom patients to luwe a signifieantly higher risk of dy ing from pan ereatic cancer than the native born patients. We examined the cau"e of death as stated on the death certificate for those patients who had died to see if perhaps more native born than foreign hom patients were recorded as dying of causes other than pancreatic cancer. Just the opposite was true: 17.4% of the foreign born patients a nd 11.5% of the native born pa tients had something other than pan-

creatic cancer as the underlying cause of death on t he death certificate. Thus, no explanation was available of why the relationship between nativity and pancreatic cancer found in mortality studies was not observed in this morbidity study. Catholics accounted for 45% of the group (115 of 257) and Protestants for 33%. The remaining 22% were .Jewish (5%), Russian or Greek Orthodox (4%) , and unknown (13%) . The religious distribution of the population in the Northeast United States 19 was used for comparison. No significant deviations were observed according to stated religious preference. Studies based on mort ality data from New York City 16 • 17 indicate that pancreatic cancer is from 25 t o 50% more frequent among J ews than among Catholics or Protestants.

Symptoms The frequency of various presenting symptoms is demonstrated in figure 1. As others have noted, pain was the most frequent symptom, occurring in 62.6% of patients. Back pain, alone or with a n anterior a bdominal component, was observed in 21 % of patients with pain. Jaundiced persons (36%) had almost always recognized their condition at the time of admission . Weight loss, observed in as many as 70% of cases in other studies,G, 10 was noted in only 48%. Diarrhea, as a possible manifestation of inadequate pancreatic enzyme excretion, was noted in only 6% of ou r se-

MOLDOW AND CONNELLY

680

E

DIAR RHEA

The epigastric or left upper quadrant bruit, considered by Serebro 25 to be a helpful diagnostic sign in the diagnosis of pancreatic cancer, was not reported in any of our cases. Apparently, pancreatic tumor invasion of the splenic artery is responsible for the bruit.

6 . 2%

~CONSTIPATION

llol. 55, No. 6

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ries compared with 15 to 20% m other studies. 6 • 20 • 2 1

Radiological Findings An upper gastrointestinal series suggesting a pancreatic lesion was recorded in 31 % (61 of 167) of patients in whom this examination was performed. This percentage is similar to the 28% observed by :N"arielvala et al. 22 and to the 33% noted by Lazar, 6 but considerably lower than the 40 to 50% reported by Cliffton. 21 As might be expected, tumors located at the head of the pancreas were more frequently revealed by an upper gastrointestinal series. Of the 92 patients with pancreatic head cancers in which the X-ray examination was performed, 40% had a pancreatic lesion. For body and/ or tail tumors, the radiological findings were positive in only 22%. These data would suggest the value of the examination in lesions of the head and detract for those of the body and tail. In 18 patients (9%), the X-ray suggested intrinsic disease of the stomach, but this misinterpretation was less frequent than in other series, 6 • 22 where misdiagnosis occurred in about 25% of cases.

Physical Signs Figure 2 illustrates the frequencies of the various physical findings . Hepatomegaly and jaundice were exhibited with almost equal frequency (about 40%) at the time of diagnosis. Other investigators have frequently noted weight loss (rarely recorded as a physical finding in our study although obtained when the history was recorded in 48% of patients) and abdominal tenderness. An abdominal mass was detected in one-fourth of our patients, which is considerably less than the 55% reported by others. 22 - 24 A Courvoisier gall bladder was palpated in only 7% of all study patients, but more frequently (11.6%) in jaundiced persons.

Laboratory Tests The results of various laboratory tests and their correlation with the anatomical site of the pancreatic tumor are presented in table 3. The erythrocyte sedimentation rate and serum alkaline phosphatase were the laboratory tests most consistently abnormal, being elevated in 83.7% and 78.2%, respectively, of cases for which they were determined. Alkaline phosphatase and bilirubin were elevated in approximately 85% of cases in which the tumor was located in the head of the pancreas. However, in lesions of the body and tail, the alkaline phosphatase was elevated in only 58.5%, and the bilirubin was elevated in only 18.4%. These findings confirm the

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50

75

100

125

150

'

175

NO. OF CASES HAVING EACH SYMPTOM

Fro. 1. Symptoms on admission. Number of patients, 257.

fff~)cms C)

Jf.6I~ABLE

4.7%

GALL BLADDER

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25 50 75 100 125 NO. Of CASES HAVING EACH PHYSICAL FINDING

Fra. 2. Physical findings. Number of patients, 257.

TABLE

681

PANCREATIC CANCER IN CONNECTICUT

December 1968

3. Laboratory tests and correlation with anatomical site of pancreatic cancer" Abnormal laboratory tests

Anatomical site of pancreatic cancer

Alkaline phosphatase (n, 188)

Head/ head a nd body Body and/o r tail Head , body, and tail Not specified Total

Bilirubin (n, 187 )

blood Hemoglobin White cell count (n, 232) (n, 228)

Monocytosis

Erythrocyte

Cephalin

sedimenta- flocculation tion rate test (n, 86) (n, 125)

(n, 220)

Prothrombin time (n, 108)

%

%

%

%

%

%

%

%

89.7 58 .5 81.3 58.3

84.3 18.4 75.0 44.0

51.3 41.3 31.6 36 .4

34.5 39 .3 50.0 51.5

28.7 23. 7 43.8 36 .7

88.9 75.0 87.5 77 .8

11 .4 17.2 20.0 6.3

43 .1 62.5 37 .5 41.7

78.2

64.7

44.8

39.5

29.5

83.7

5.9

45.4

'

an, number of p atients.

expectation that lesions of the pancreatic head often produce biliary obstruction, while such obstruction is less frequently observed in tumors of the body or t ail. Although the ABO blood groups have been associated with upper gastrointestinal disease, no such association was demonstrated in the present study. For the 196 patients whose blood type was recorded, the distribution was as follows: 81 patients with type A, 29 with type B, 75 with type 0, and 11 with type AB. When this distribution was compared with published data on blood types in Connecticut residents,26 no significant differences were observed. Comparisons with recent data from the Connecticut R ed Cross likewise revealed no significant deviations from the expected. Aird and co-workers 27 found that cancer of the pancreas was more common in persons of type A t han in persons of types 0 or B. On the other hand, Buckwalter,28 of the Iowa Blood Type Disease Research Proj ect, reported an excess of type B (we expected 24 cases and observed 29) associated with his pancreatic cancer patients.

In only 27 patients (11) was the disease process confined to the pancreas at the first hospital admission. In another 26% the tumor showed only local extension and/ or involved regional lymph nodes. The remaining 63% had remote spread at the time of diagnosis. The various sites of metastatic disease in the study group are listed in table 4. The relationship of anatomical site of the pancreatic tumor to the areas of metastases are also demonstrated in this table. As one might expect, lesions of the head are less frequently associat ed with metastases (83 %) than are diffuse lesions or those of the body and/ or tail (92%) . Lesions of the head are likely to produce early symptoms (parti cularly jaundice due to biliary obstruction) and thus the patient is more likely to be seen before metastasis occurs.

Site

Histological Type

The exact site of pancreatic involvement was not specified on the charts of 48 patients (19 %) . The head of the pancreas was involved in 60% (125 of 209) of cases for which a specific site was designated. This compares with a composite average of 71 % by seven authors. 22-24 · 29 -32 Body

No specific histological type was recorded in 13 cases which were diagnosed by direct observation of the pancreatic tumor at the time of surgery. Adenocarcinoma was the histological designation in 71% (174 of 244) of cases in which the histology was specified. Anaplastic carcinoma and

and/ or tail was the primary site in 31% (65 of 209) and diffuse involvement of the entire organ was reported in 9% ( 19 of 209).

Me tastases

682

MOLDOW AND CONNEL LY T ABLE

Vol. 55, No. 6

4. Metastatic sites and correlation with anatomical site of pancreatic cancer

I Anatomical site of pancrea tic cancer

Site of metastases

Loca l 1\o metas tases

Local ex tension

ex.ten-

Lymph

Liver

nodes

SIOTI

Lung and

Liver

and lymph

Peri-

nodes and tone urn lymph orexlocal tennodes

Peri-

li ver or

toneurn

peritoneum

and 1iver

sion

- - - --

Head/ head an d body Body and/ or tail Head, body, and t a il Not specified T otal

21 5 1

32 7 4 8

13 3 1 1

27

51

18

-

20 15 6 9

I

carcinoma, not further specified, were reported in 24% (58 of 244). I slet cell carcinoma, acinar and ductal carcinoma, cystadenocarcinoma, a nd epidermoid carcinoma accounted for the remaining 5% of histologica l di agnoses. A ssoc·ia tion s with Other D iseases

Almost half of t he study group (120 of 257) had no associated diagnoses at the time of first adm ission. Fifty-two pat ient s (20) had biliary tract disease (cholelithiasis, cholecystitis, or chol ecystectomy) diagnosed either prior to or during the admi,-sion for pancreatic cancer. As expected, more women than men had diagnosed bilia ry tract disease despite the L'i : 1 ma le to female ratio of the study group. In Yarious seria l autopsy studiesa:l-:! 0 the in cidence of biliary tract disease rangl'd from 10 to 40'7<-. When our inci dence of biliary t ract disease was compared vvith that of Lieber's, 3 " it was not found to be significantly different after adju:::t in g for sex a nd age differences. Twenty-seven patients (10) were desc ribed as having dia betes mellitus at the timl' of their pa ncreatic cancer diagnosis. Although hyperglycemia was noted on a number of charts, di a betes mellitus was not ab:::tracted unl ess the word appeared as a clinical diagnosis. Therefore, it is prolmble that 10% is a n underestimate of the true incidence of diabetes in our pancrea tic cancer group. In more than half ( 16 of the 27) dia betes had been diag-

50

---- 7 20 2 10 3 12 3 12

45

-

-

-

or lymph

Multiple sites

nodes -- --

Total

2

4 8 1 2

--127 63 19 -!8

11

15

257

3 3 1 7

4 4 3 3

3 6

14

14

nosed within t he 12 mon ths pnor to admission for pancreatic cancer. The finding of di a betes in 10% of the patients compares favorably with those of M ikal and CampbelFH a nd lVIarble, 37 but is considera bly less t han the 18% observed by N arielva la.2 ~ Thrombophlebit is a nd other thrombotic diso rd ers were rarely noted. P a ncreatit is wa:; part of the past medical hit'tory of only 4 patients. Seasonal l"aria tion

Sea:;o nal variation in the onset of discase has been noted in certain ma lignant disease::;, e.g., childhood leukemia, and in the present study there was a statistically significant monthly variation according to the month of on:;ct of ,.;ymptoms. Tht> Yariation conform::; to a bimoda l pattcm with peaks in May and August. No abnormal variation was detected according to month of diagno:;i,;. Figure 3 illust rates thl' distribu tion of case:,; by month of diagno:>is and month of onset of ::;ymptoms. M or! es of Th erapy ,'lurgery . Thirty-fiye patients underwent no surgica l procedure; the histo logi cal diagnosi:,; in t hese cases was made at autopsy. Exp loratory laparotomy alOJH' was performed in 110 patients. P a lliatin surgery ( con::;isting of 10.5 biliary and/ or gastroin te:stin a l bypass procedures) accounted for the vast majority of definitive

68:)

PANCREATIC CANCER I N CONNEC TICUT

D ecem ber 1968 30

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Vl <(

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ci

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- - ONSET MONTH O f SYMPTOMS (N · -

-

· MONTH Of DIAGNOSIS ( N

= 24b)

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0 ~---r--~----~--~---r--~----r---~---r--~----.

JAN

fEB

MAR

APR

MAY

JUN JUL MONTH

AUG

SEP

OCT

NOV

DEC

Fro. 3. Seasonal variation in pancreatic cancer.

procedures. Only 7 patients underwent :;urgical treatment for cure. Chemo therapy and radiation. Twentyseven patients received chemotherapy or X -ray treatment. Chemotherapy with .5-FU, ni trogen mustard, Thiotepa, actinomycin D , or steroids was employed in 19 patients. Only 9 patients received either chemotherapy or radiation as sole treatment; the remainder received it as an adjunct to palliative surgery or curative surgery.

Survival Prognosis was extremely poor: a ll but 4 of the 257 patient:; were dead at the time of t his analysis. Two patients were lo:;t to follow-up after 1 month and 47 mon th:; of surviva l from t he time of diagnosis. The other 2 patients were alive at last contact, with 38 and 63 months of surviva l, respectively. The latter was the only .5-year survivor in t he entire study group. Only 24, or 9.3%, of the 257 patients suJTind 1 year (counting as a death the patient ]oo;t to follo w-up after 1 month). Th e nseragc surviva l was 4.3 months when measured from the time of diagnosis (and 7.8 mon ths when measured from the onset of first symptom). These figures, a lthough disma l, arc somewhat better than those recently reported by Smith et a!Y for 600 pa tients t reated during the years 1948 to 1962 at Cha rity Hospital of Lou-

isiana at New Orleans ; 5.2% of t hem survived 1 year after diagnosis, and the average survival was 3.2 months. The 1-year survival rate of 9.3% fo r the study group was lower t han that of 12.5% for all 1472 pancreatic cancer patients reported t o the Connecticut Tumor Registry during t he years 1955 to 1963. The registry data 38 also indicate some improvement in prognosis sin ce 1935. For 2747 patients reported to the California Tumor Registry 39 durin g t he years 1942 to 1946, t he 1-year survival rate was 7.1 %. Seven of the 27 patients with loc ali zed disease (25.9% ) survived 1 year in contrast to 14.1% of the 78 patient:;; with local invasion and/ or regional lymph node involvement who Jived that lon g. Only 3.9% of the 152 patients with di~tant metastases survived 1 year from the t ime of diagnosis. Survival for patienb with tumors of the pancreatic head (12.7 ~( at 1 year) was higher than for patient::< with tumors involvin g t he body and/ or tail of the pancreas (7.5% ). This was not ;;mprising because distant metastase;; wen• less frequ ently associated with tlw fo rmer group than with t he latter. Neither t he sex nor mari tal sta tu~ of the patient nor t he histologica l ty pe of the t umor were found to influence t he prognosis to any great extent . On e demographic characteristic, nativity, '"as related to surviva l ; only 3 of t he 88 fore ign

684

MOLDOW AND CONNELLY

born patients survived 1 year (3.5%) compared with 12.4% of the native born patients. Of the 7 patients who had curative surgery, all but 1 survived more than 1 month. Two patients died within 6 months of diagnosis, and the remaining 4 patients survived 12, 13, 19, and 63 months. The average survival time of 16.4 months is only slightly less than results of 18.1 months reported by the Portland Surgical Society 40 for 27 curative resections and is substantially more than that of 8.9 months reported by Smith et alP for 79 patients who had curative treatment. Of 105 patients who had palliative treatment, 78% survived 1 month following the diagnosis of the disease. There were 12 1-year survivors for a rate of 11%. The average survival time of 4.6 months is similar to results of 5.440 and 4.7 11 months reported in other large studies. Of the 110 patients undergoing only exploratory laparotomy, 65% survived 1 month and 8 patients or 7% survived 1 year. Twelve of these patients also received supportive therapy, but none survived 1 year. The average survival time of 3.5 months is only slightly longer than t he 3.040 and 2.6 11 months reported by others. The 35 patients who had no operative procedures had the poorest survival rate: 23% survived 1 month, but none lived as long as 6 months. Summary

During recent years in Connecticut, pancreatic carcinoma accounted for 10% of all digestive system tumors. A retrospective study, based on a sample of pancreatic cancer cases reported by 38 hospitals to the Connecticut Tumor Registry between January 1957 and December 1963, was undertaken. The study group of 257 patients had an average age of 64.4 years. There were 153 men and 104 women, the latter being significantly older at the time of diagnosis. Negroes, although only accounting for 11 of the cases in the study, appeared to be at greater risk of developing the disease. A significant seasonal variation, with

Vol. 55, No. 6

peaks in May and August, was noted according to the month of onset of symptoms. M arital status, religion, nativity, and residence demonstrated no significant relationship to the disease. Pain was the most frequently occurring symptom: hepatomegaly and jaundice were the most frequent physical findin gs. An upper gastrointestinal series suggested pancreatic lesion in 40% of cases in which the tumor was located in the pancreatic head. Serum alkaline phosphatase and erythrocyte sedimentation rate were the most consistently abnormal laboratory tests, being elevated in about 80% of cases. The cancer involved the head of the pancreas in 60% of cases in which the tumor site was specified; body and/ or taii was involved in 30%. Seven of every 10 cases with known histological type were adenocarcinomas. The tumor confined itself to the pancreas in only 11 % of patients at the time of diagnosis; 26% demonstrated local invasion or regional lymph node spread , and the remaining 63% exhibited distant metastases. Distant metastases were associated less frequently with cancer of the pancreatic head than with tumors of other pancreatic sites. Biliary tract disease was a secondary diagnosis in 20% of all patients; a history of diabetes mellitus was obtained in 10%. Seven patients underwent curative surgery, but the vast majority of definitive procedures (105) were performed for palliation. Chemotherapy and X-ray treatment were employed only rarely. Prognosis was extremely poor: only 9% of the study group survived 1 year. The average survival from diagnosis to death was 4.3 months. Only 3 of the 88 foreign born patients survived 1 year. Patients with palliative therapy had a better prognosis than those not t reated, but the only 5-year survivor was among the 7 patients treated by pancreatectomy. REFERENCES 1. Statistics on cancer: 1968 facts and figures.

American Cancer Society, New York, 1968. 2. Campbell, P. C. 1963. The Connecticut Tu-

December 1968

3.

4.

5.

6.

7.

8.

!J.

10.

11.

12.

13.

14.

15.

16.

J'ANCUEATIC CANCER I N CONNECTIC UT

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38. Eisenberg, H., P. D. Sulli van, and F. M. Foote. 1967. Trends in survival of digestive system cancer patients in Connecticut, 1935 to 1962. Gastroenterology 53: 528-546. 39. Cancer regi:;tration and sun·ival in Ca lifornia. 1963. California Tumor Registry, State of

California Department of Public Health

Berkele~'·

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40. The Portland Smgical Society. 1967. A ten-

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