What are the screening and treatment recommendations for pancreatic cancer in firefighters exposed to carcinogens?

Pancreatic Cancer in Firefighters

Screening Recommendations

Firefighters exposed to occupational carcinogens do not qualify for routine pancreatic cancer screening based on current guidelines, as they are not considered a high-risk group by established criteria. 1

Who Should Be Screened

Screening for pancreatic cancer is only recommended for individuals with specific genetic or familial risk factors, not occupational exposures 1:

• First-degree relatives from familial pancreatic cancer kindreds with at least two affected first-degree relatives 1
• Genetic syndrome carriers including:
  • Peutz-Jeghers syndrome 1
  • BRCA2 mutation carriers with ≥1 affected first-degree relative 1
  • p16 mutation carriers with ≥1 affected first-degree relative 1
  • Hereditary non-polyposis colorectal cancer (HNPCC) mutation carriers with ≥1 affected first-degree relative 1
  • Hereditary pancreatitis syndrome 1

Why Firefighters Don't Qualify for Screening

While firefighters have documented increased cancer risk from occupational exposures to polycyclic aromatic hydrocarbons (PAHs), per- and polyfluoroalkyl substances (PFAS), and other carcinogens 2, 3, there are no current screening programs that can be recommended in the general population or occupational exposure groups 1. The low incidence of pancreatic cancer in the general population makes population-based or occupation-based screening unfeasible 1.

Screening Modalities (If Criteria Met)

For individuals who do meet high-risk criteria, initial screening should include 1:

• Endoscopic ultrasound (EUS) and/or MRI/MRCP as first-line modalities 1
• CT scanning is NOT recommended for initial screening 1
• ERCP is NOT recommended for screening 1
• PET scanning has no role in pancreatic cancer diagnosis 4

Clinical Presentation to Monitor

Firefighters should be aware of symptoms that warrant immediate evaluation 1, 4:

• Jaundice (especially with head of pancreas tumors) 1
• Unexplained weight loss 1
• Persistent abdominal or back pain (especially with body/tail tumors) 1
• New-onset diabetes in up to 10% of cases 1
• Pancreatitis without obvious cause (no gallstones or alcohol abuse), particularly in elderly individuals 1

Diagnostic Approach When Symptoms Present

When pancreatic malignancy is suspected 4:

1. Initial imaging: Ultrasound of liver, bile duct, and pancreas without delay 4
2. Definitive staging: Multi-detector CT (MD-CT) or MRI plus MRCP 4
3. Chest imaging: MD-CT of chest to evaluate for lung metastases 4
4. Tissue diagnosis:
   • Biopsy restricted to cases where imaging is ambiguous 4
   • EUS-guided biopsy preferred over percutaneous sampling 4
   • Avoid percutaneous sampling in potentially resectable tumors due to risk of tumor seeding 4

Treatment Recommendations

Resectable Disease (Stage I and Some Stage II)

Radical surgery is the only curative treatment option 4:

• Pancreaticoduodenectomy (with or without pylorus preservation) for pancreatic head tumors 4
• Distal pancreatectomy with splenectomy for body and tail tumors 4
• Surgery must be performed at high-volume specialist centers to reduce morbidity and mortality 1, 4
• Postoperative chemotherapy: 6 months of gemcitabine or 5-fluorouracil 4, 5, 6

Borderline Resectable Disease

• Neoadjuvant chemotherapy or chemoradiotherapy may achieve tumor downsizing 4
• Patients who develop metastases during neoadjuvant treatment are not surgical candidates 4

Locally Advanced Unresectable Disease

• FOLFIRINOX protocol for patients with good performance status 4

Metastatic Disease (Stage IV)

Treatment options include 1, 4:

• FOLFIRINOX protocol for patients ≤75 years with performance status 0-1 and bilirubin ≤1.5 times upper limit of normal 1, 4
• Gemcitabine plus erlotinib, continuing erlotinib only if skin rash develops within first 8 weeks 1, 4, 5
• Second-line options: 5-FU and oxaliplatin after first-line gemcitabine failure 1

Palliative Management

Biliary Obstruction

• Endoscopic stenting preferred over surgical or percutaneous approaches 1, 4
• Metal stents for life expectancy >3 months 1, 4
• Plastic stents should be replaced every 6 months 1

Pain Management

• Opioids (morphine) as first-line for severe pain, oral route preferred 1, 4
• Celiac plexus blockade (percutaneous or EUS-guided) for patients with poor opioid tolerance 1, 4
• Hypofractionated radiotherapy may improve pain control 1

Duodenal Obstruction

• Expandable metal stents for proximal obstruction 1, 4
• Metoclopramide to speed gastric emptying 1

Follow-Up After Treatment

For patients with elevated preoperative CA19.9 1, 4:

• CA19.9 monitoring every 3 months for 2 years 1, 4
• Abdominal CT scan every 6 months 1, 4

For patients on chemotherapy 7:

• Toxicity assessment at each cycle 7
• Response evaluation with imaging every 8 weeks 7

Critical Pitfalls to Avoid

• Do not delay referral to specialist centers - this reduces resection rates and increases mortality 4
• Do not use percutaneous biopsy for potentially resectable tumors - risks tumor seeding 4
• Do not insert self-expanding metal stents in potentially resectable patients - complicates surgery 4
• Do not rely on occupational exposure alone as screening indication - current guidelines do not support this 1

Occupational Health Considerations for Firefighters

While not affecting screening eligibility, firefighters should implement decontamination practices to reduce carcinogen exposure 2, 3, 8:

• Immediate post-fire decontamination of skin and equipment 9
• Proper separation of clean and contaminated gear 8
• Avoiding eating or prolonged wear of contaminated PPE 8
• Regular laundering of fire hoods and protective equipment 8