The population of urban areas faces a wide variety of acute health risks that need to be adequately addressed on a regular and consistent basis. One of the most notable among these is the need to address the growing incidence of and mortality rates due to pancreatic cancer.
Contemporary healthcare approaches gradually shift from the traditional approach to treating patients in an authoritative manner to informing and engaging them as partners in the prevention and treatment efforts (Nash et al., 2016). It means that evidence-based wellness models focused on proactive steps to reduce the problem become just as or even more important than treatment models that address the problem. For pancreatic cancer, the examples of these models would be combination immunotherapy and weight loss aiming at obesity prevention – and, while both approaches have evident strength, they are not devoid of significant limitations either.
Health Improvement Need
Pancreatic cancer is currently one of the most acute health improvement needs in the world. As of 2018, it was the 11th most common cancer in the world, with 458,918 cases reported in that year alone (Rawla et al., 2019). As such, it is a very prevalent malignancy, but its death rate is even more significant than its incidence in relative terms. According to Rawla et al. (2019), pancreatic cancer accounted for as many as 432,242 cancer-related deaths in 2018.
These numbers make it the 7th deadliest cancer in the world, as opposed to its 11th place in terms of incidence. The prevalence of pancreatic cancer and its mortality rates increases considerably with age, and the malignancy is also slightly more common in men than women. Pancreatic adenocarcinoma, which is the most common type of pancreatic cancer, has an extremely poor prognosis. Less than a quarter of patients live one year after the diagnosis, and only 9 percent live five years or more (Rawla et al., 2019). With this in mind, there can be no doubt that addressing pancreatic cancer is a crucial health need.
More importantly, still, pancreatic cancer is particularly prominent in developed nations as opposed to developing ones. For example, while it occupies 7th place by the number of cancer deaths worldwide, it is the 3rd most deadly cancer in the United States. According to Xu et al. (2018), approximately 50,000 new diagnoses are made each year, and more than 40,000 people die of it annually. Similar to the numbers on the global scale discussed above, mortality supersedes incidence in relative terms. While pancreatic cancer accounts for 3 percent of new cancer diagnoses in the United States each year, its share in the cancer death toll is 7 percent (Xu et al., 2019).
It makes this malignancy the third leading cause of cancer death in the country, with only lung and colorectal cancers being deadlier (Morrison et al., 2018). Moreover, the prevalence of pancreatic cancer consistently grows, and it is projected to overtake colorectal cancer in terms of absolute mortality rate by 2030 (Xu et al., 2019). Thus, urban communities in developed countries have a particular need for prevention and treatment options addressing this malignancy.
Salient Characteristics of the Affected Community
Urban communities differ from rural ones in their salient characteristics that pertain to population health. On the one hand, urban areas typically offer greater economic opportunities to increase healthcare access (Salgado et al., 2020). On the other hand, “urban segregation and heterogeneous socioeconomic characteristics” increase health inequalities (Salgado et al., 2020). Moreover, inefficient urban planning may contribute to greater pollution levels. Full-day jobs in urban environments can be a direct obstacle to healthy lifestyles in terms of nutrition and exercise (Salgado et al., 2020). These characteristics are directly relevant to addressing health needs emerging in urban populations.
The main social determinants related to the prevention and treatment of pancreatic cancer as a health need are diet-related. As of now, the precise otology of pancreatic cancer is still unclear, and the best medical science can do is to identify factors that correlate with increased incidence and mortality. One such determinant strongly associated with pancreatic cancer is nutrition. Dietary habits that include regular consumption of red meats increase mortality rates, while limited or no consumption of meat can decrease it by as much as 50 percent (Rawla et al., 2019). Conversely, there is some evidence that “frequent nut consumption significantly lowers the risk of pancreatic cancer in women” (Rawla et al., 2019, p. 17).
Moreover, research demonstrates that obesity is associated with an increase of 50 to 60 percent in the likelihood of pancreatic cancer (Xu et al., 2019). Thus, access to a healthy and balanced diet is the main social determinant related to pancreatic cancer incidence. As such, it is also indirectly related to economic stability and opportunity.
Another important social determinant related to the health need in question is the physical environment. Research suggests that the exposure to and, hence, the gradual build-up of certain chemical elements in the pancreas may increase or decrease the risks of pancreatic cancer. Studies identified exposure to nickel, cadmium, and, to a lesser degree, arsenic as factors that correlate with a greater risk of pancreatic cancer (Rawla et al., 2019).
At the same time, selenium demonstrates an inverse association with the incidence of several cancers, including pancreatic one (Rawla et al., 2019). Considering this, one may list physical environment, particularly occupational exposure to certain chemicals, as yet another important social determinant affecting individuals related to this specific health need. At the same time, one needs to be aware that the studies on chemical exposure as related to pancreatic cancer are less numerous and conclusive than the ones concerned with nutrition and dietary choices.
Other Factors that May Impact the Health Need
Smoking is another factor that does not fall directly into the social determinants category but is, nevertheless, strongly associated with pancreatic cancer. Research suggests that it is “the most important environmental factor for pancreatic cancer in the world” (Rawla et al., 2019, p. 16). According to it, the duration of smoking and the average number of cigarettes smoked per day are directly related to the risk of pancreatic cancer. Specifically, smokers are almost twice as likely to develop it than non-smokers (Rawla et al., 2019). Moreover, passive smoking – that is, the exposure to tobacco smoke exhaled by others – also increases the likelihood of pancreatic cancer (Rawla et al., 2019). With this in mind, smoking is definitely a factor that requires consideration in terms of preventing and treating pancreatic cancer as a health need.
Addressing the health need in question may utilize different approaches relying on the treatment or wellness models. The treatment model focuses on the authoritative role of medical professionals in delivering treatment once the conditions manifest in patients, while the wellness model takes a more proactive approach and aims to prevent adverse conditions. For the case of pancreatic cancer in urban populations, this paper will examine combination immunotherapy and weight loss combined with obesity prevention as examples of treatment and wellness models, respectively.
Evidence-Based Treatment Model: Combination Immunotherapy
Immunotherapy has a relatively history in treating pancreatic cancer, and a number of approaches have been developed and tried to address it with varying but usually limited success. Immunity checkpoint blockade, which demonstrated significant results in melanoma and lung cancer, demonstrated little efficacy in treating pancreatic cancer (Morrison et al., 2018). Similarly, therapeutic vaccination did not generate robust antitumor responses in the immune system so far (Morrison et al., 2018). Research suggests that engineered T cells are exceptionally efficient in B-cell malignancies, but results with solid tumors, such as pancreatic cancer, remain elusive (Morrison et al., 2018).
Agonistic therapy takes another approach and seeks to increase the efficiency of the existing t-cells, but the evidence on immune memory creation in the trials conducted so far is limited (Morrison et al., 2018). Finally, stroma-modulating immunotherapies seem to improve survival rates, but the evidence from the trials conducted up to date is still limited if encouraging (Morrison et al., 2018). In short, a wide range of immunotherapeutic approaches for treating pancreatic cancer has been offered so far, and the results remain varied but usually modest.
Since single-agent immunotherapeutic interventions do not show remarkable progress in treating pancreatic cancer, the new approach offered is combination therapy. By design, it is intended to combine the positive effect of numerous solutions proposed and tested so far for a better overall result. In particular, Morrison et al. (2019) propose to combine “T cell activation through therapeutic vaccines with checkpoint blockade to prevent exhaustion and stromal modulation from improving T cell infiltration” (p. 423).
The best results are to be expected if a carefully selected combination of immunotherapies is combined with other treatments, most notably radiation and chemotherapy (Morrison et al., 2018). The trade-off between response and toxicity, as well as the development of the optimal dosing, remain the main challenges in developing combined therapies for pancreatic cancer. Thus, while certainly not a panacea, combined therapies represent a valid, evidence-based model for addressing the health needs discussed. Since it focuses explicitly on the treatment of the ailment after it is diagnosed, it may serve as a clear and unequivocal example of the treatment model, as opposed to the wellness model.
Evidence-Based Wellness Model: Weight Loss and Obesity Prevention
As mentioned above, obesity is a notable risk factor for pancreatic cancer, meaning that weight loss should be one of the primary areas of attention in any prevention effort. One possible approach within this strategy is calorie reduction. Research demonstrates that reducing the calorie intake decreases cancer incidence among women, including but not limited to pancreatic cancer specifically (Xu et al., 2019).
Studies in animals also demonstrated that calorie reduction impedes pancreatic cancer growth and development (Xu et al., 2019). At the same time, the usefulness of this particular option is limited because patients often have a hard time adhering to a strict diet in the long term. In the majority of cases, the patients eventually gain back the weight they lost, thus negating the positive impact of calorie restriction (Xu et al., 2019). Fortunately, it is not the only possible approach for weight reduction.
Biologically based interventions have significant potential in reducing excessive weight and preventing obesity, which makes them a feasible choice when calorie restriction is unlikely to produce a sustainable result. First of all, anti-obesity drugs have proven reasonably effective in reducing weight and, by extension, pancreatic cancer risks (Xu et al., 2019). Similarly, bariatric surgery ensures stable weight loss in the long term, which also has positive implications for the potential risk of cancer. As noted by Xu et al. (2019), “retrospective clinical studies have shown that bariatric surgery reduced the incidence of multiple cancers including breast, endometrial, colorectal, melanoma and non-Hodgkin lymphoma” (p. 159). At the same time, evidence for pancreatic cancer specifically is less compelling (Xu et al., 2019).
That being said, obesity prevention is, nevertheless, a viable approach to addressing pancreatic cancer prevention as a health need. Since it focuses on proactive steps intended to decrease the risk of the condition before it develops, it is an evident example of the wellness model, as opposed to the treatment model.
Advantages and Disadvantages Comparison
An important advantage of combination immunotherapeutic interventions is that they address specific biological mechanisms directly involved in the development of pancreatic cancer. For instance, immunity checkpoint blockade may increase the efficiency with which the immune system operates, while stromal modulation can improve intratumoral blood flow and decrease the obstacles to efficient immune response (Morrison et al., 2018).
However, immunotherapies as a treatment model involve a tricky balancing act between dosage and response, as better response almost invariably means higher toxicity (Morrison et al., 2018). Another weakness of the treatment model is that it only addresses the condition after it has manifested, meaning the best it can do is mitigate the effects of pancreatic cancer and slightly improve life expectancy.
As for the wellness model, it has the advantage of being proactive and, thus, preventing the condition from ever developing in the first place. As mentioned above, weight loss and obesity prevention through anti-obesity drugs, bariatric surgery, and, to a lesser degree, calorie restriction decreases the likelihood of pancreatic cancer (Xu et al., 2019). It is also not nearly as costly as some of the immunotherapeutic interventions listed above, most notably the use of engineered T cells (Morrison et al., 2018). However, some forms of bariatric surgery, such as gastric band, have a high long-term complication rate (Xu et al., 2019).
Additionally, the effect of weight loss on pancreatic cancer likelihood only demonstrates notable effects in women (Xu et al., 2019). This is a serious limitation because men constitute the majority of patients (Rawla et al., 2019). Finally and most importantly, pancreatic cancer’s etiology is still unclear. It means that all preventive treatments that fall within the wellness model are based on more or less educated guesses rather than accurate knowledge.
To summarize, addressing pancreatic cancer is an acute health need due to its growing prevalence and significant death rate. Communities in developed countries with limited access to healthy nutrition options and increased environmental exposure to a number of chemical elements are at particular risk. Combined immunotherapies as an evidence-based treatment model address specific biological mechanisms to improve immune system response and increase life expectancy but are costly, reactive, and involve the risk of high toxicity. Weight loss and obesity prevention as a wellness model is proactive and more accessible but can have long-term complications, mainly benefits the smaller female subset of patients, and is largely based on educated guesses. Thus, while both models have a potential worth considering, there is currently no optimal solution to the health need presented.
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Xu, M., Jung, X., Heins, O. J., Eibl. G., & Chen, Y. (2018). Obesity and pancreatic cancer: Overview of epidemiology and potential prevention by weight loss. Pancreas, 47(2), 158-162. Web.