​Hepato-Pancreato-Biliary Cancers Doctor Q&A

Hepato-pancreato-biliary cancers comprise cancers in the liver, pancreas, gallbladder and bile ducts. In conjunction with World Pancreatic Cancer Day (on 21 Nov), Dr Lim Chiew Woon, Consultant from the Division of Medical Oncology at National Cancer Centre Singapore (NCCS), a member of the SingHealth group, answers your questions about hepato-pancreato-biliary cancers.

This As​k The Specialist forum has closed. Thank you for your interest and participation.

1. Question by v*******
Dear Dr Lim,
If a patient is diagnosed with multiple branch IPMN with no nodular solid components or restricted diffusion, what would be the recommended follow up required? Will taking probiotics or acidic food long term increase cancer risks?

Answered by Dr Lim:
At diagnosis of an IPMN, a hepatobiliary surgeon will review if the IPMN is at high risk of transforming into pancreatic cancer and advise if surgery is required. If IPMN is deemed low risk, we will usually repeat a MRCP or CT in one year. Subsequent interval of surveillance scan is dependent on the findings on MRCP/CT and other clinical factors. 

Currently, there is no conclusive data that suggests taking probiotics or acidic food increase cancer risks.

2. Question by L*******
Hi Dr, my father passed away from pancreatic cancer. Is this hereditery? Should I go for health screening for myself for this? Thank you.

Answered by Dr Lim:
Most pancreatic cancers are not hereditary. Only about 10-15% of pancreatic cancer is attributed to genetic causes. They are usually sporadic in nature and are due to a combination of risk factors. We do not usually recommend screening for pancreatic cancer for general population. However we do suggest screening for colon, breast and cervical cancer as per guidelines as these cancers are more prevalent and very curable when detected in early stage. 

3. Question by J****
Dear Dr Lim,
What are the common causes of liver cancer? Is it hereditary or because of lifestyle? Does having a fatty liver raise risk? How can I reduce my risk of liver cancer?

Answered by Dr Lim:
Dear J****, thank you for your question.
Common causes of liver cancer include hepatitis B and C, chronic alcohol-related liver disease, non-alcoholic fatty liver disease and cirrhosis of any cause. 

In Asia, liver cancer is a common cancer due to the high prevalence of chronic Hepatitis B. Hepatitis B is transmitted by an infected person via blood or body fluid. For example, from an infected mother to child during pregnancy, at birth or after birth or via sexual intercourse with an infected person. Singapore only started vaccination for Hep B for infants in the 1980s and therefore the older generation adults are at risk, especially if they have a family history of Hep B and liver cancer. Increasingly, patients are developing fatty liver disease due to increased incidence of diabetes and hyperlipidaemia hence lifestyle does play a contributory role in increased incidence of liver cancer. 

Fatty liver can increase the risk of developing non-alcoholic fatty liver disease and in turn, in the long run, increases the risk of developing liver cancer. Thankfully, fatty liver if diagnosed early, can be reversible with lifestyle modification.

Screening for Hepatitis B is important especially if there is a family history of Hepatitis B. Lifestyle changes are important such as moderation in alcohol intake and tobacco use. Exercise regularly and eat a healthy balanced diet to maintain a healthy weight to avoid diabetes and fatty liver disease. Practise safe sex. 

4. Question by A**
Dear Doctor,
Is pancreatic cancer more common in men than women? Also, is there a particular age group that is at greater risk? 
I read that pancreatic cancer is usually diagnosed at late stages, and survival rate after treatment is low. Is this true? Will we see more effective treatments soon? 
Can anything be done to lower risk of pancreatic cancer? Thank you!

Answered by Dr Lim:
Dear A**, thank you for your questions. 
Pancreatic cancer occurs in both men and women and is one of the leading causes of death in both genders. It is slightly more common in men than in women. It is rare before the age of 45, but the incidence rises sharply after. Mortality of pancreatic cancer also increases with increasing age. 

Yes, unfortunately, pancreatic cancer is often diagnosed at late stages. At early stage, pancreatic cancer usually lack symptoms. A patient often presents at a late stage when he or she develops gradual onset of non-specific symptoms such as weight loss, abdominal discomfort, jaundice and tiredness. Most will present as a Stage 4 disease which is incurable and surgery is not an option. Treatment such as chemotherapy in this setting aims to palliate and prolong life, hence survival rate is low. 

Active research is ongoing for pancreatic cancer. We hope to improve treatment options such as chemotherapy and targeted therapy for patients in the future. 

Certain risk factors have been implicated in the risk of pancreatic cancer, such as smoking, diet, alcohol intake and high caloric intake. Do have a healthy lifestyle and diet, exercise regularly, stop smoking, moderate your alcohol intake and avoid excessive weight gain. 

5. Question by K****
Dear Dr Lim,
This is my first time hearing about cancers of the gallbladder and bile ducts. 
How common are they in Singapore? 
Is there a specific gender, race or age group that is more susceptible to these cancers? Is the risk greater there’s a family history of these disease? 
What are first signs to watch out for? Thanks for your advice.

Answered by Dr Lim:
Dear K****, thank you for your questions. 
Cancers of the gallbladder and bile ducts (cholangiocarcinoma) are rare and account for approximately 5% of all gastrointestinal cancers. However they present late and are almost always incurable at diagnosis. 

The incidence of these cancers increases with age. Cancer of the bile ducts or cholangiocarcinoma tends to be more common in men while gallbladder cancer tends to affect more women. These are related to the underlying risk factors of the cancers. Primary sclerosing cholangitis is a risk factor of cholangiocarcinoma and this is an inflammatory disorder of the biliary ducts that leads to fibrosis of the bile ducts. This condition tends to affect males predominantly. On the other hand, a history of gallstone disease is a strong risk factor for gallbladder cancer. Generally, most of these cancers are not hereditary. However if there is a significant family history of cancer, screening can be considered. 

Most patients with gallbladder cancer present with abdominal pain, loss of appetite, nausea and vomiting. While patients with cholangiocarcinoma present with symptoms related to biliary obstruction such as jaundice, generalised itch, dark urine and pale stools. Other common symptoms include abdominal pain, weight loss and fatigue.

6. Question by D****
Hi Dr Lim!
It’s been more than a year since my whipple and I am clear of cancer since my last scan. It's great that we have WPCR to raise awareness tomorrow. Early detection saved my life but it took a few tests before it could be confirmed.

Can you share with us how we can detect Pancreatic cancer early especially here in Singapore and what resources are available for those who discover they have it. 

Do we also have an organisation in Singapore that patients and ex-patients can assess new studies and treatment options or get more support on Pancreatic cancer? 
Thank you!

Answered by Dr Lim:
Dear D****, 
Congratulations on being a cancer survivor! 

Unfortunately, it is difficult to detect pancreatic cancer early. Most patients are diagnosed when they have advanced disease. The most frequent symptoms at diagnosis were poor appetite, loss of weight, abdominal discomfort, fatigue, jaundice and change in bowel habits. There are a small group of patients who are asymptomatic and their pancreatic tumours were picked up when they did scans for another reason. 

For a start, you can refer to NCCS website for further information. The link is https://www.nccs.com.sg/patient-care/conditions-treatments/pancreatic-cancer. At the bottom of the webpage, there are also various links to international resources about pancreatic cancer.

You can also refer to Singapore Cancer Society website (https://www.singaporecancersociety.org.sg/) to find out how you can cope with the diagnosis of cancer and links to various support groups for cancer patients and survivors. 

NCCS is an active clinical trial and research centre. For discussion of the most up-to-date treatment options and clinical trials, please approach your friendly medical oncologist.

About Dr Lim Chiew Woon

Dr Lim Chiew Woon is a Consultant with the Division of Medical Oncology at the National Cancer Centre Singapore.

Dr Lim obtained her membership with the Royal College of Physician (United Kingdom) in 2014 and subsequently completed her junior residency in Internal Medicine in 2015. She completed her senior residency in Medical Oncology in 2018. In 2016 and 2017, she was awarded the SingHealth Outstanding Resident Award.

Ref: M19