Pancreatic cancer

What is it?

According to the NCI: pancreatic cancer begins in the pancreas, a pear-shaped organ in the abdomen behind the lower part of the stomach. It can arise from exocrine or endocrine cells. Exocrine tumours account for about 95% of cases, and pancreatic ductal adenocarcinoma (PDAC) about 90% of all cases, while neuroendocrine tumours are much less common and generally have a better outlook.

The NHS defines it as cancer found anywhere in the pancreas.

Causes

A specific cause is not always known, and anyone can be affected (NHS). It is linked to increasing age: it is most common after 65 and uncommon before 40, and to conditions such as chronic pancreatitis and a family history of pancreatic cancer.

Risk factors

Modifiable factors according to the NHS: obesity and being overweight, a lot of red and processed meat, excessive alcohol, and smoking. The NHS explains that the disease cannot always be prevented even with healthy changes.

According to SEER: the median age at diagnosis is 71; the rate is higher in men (15.7 per 100,000) than in women (12.4 per 100,000); and the lifetime risk is about 1.7% in the United States.

Symptoms

According to the NHS: yellowing of the whites of the eyes and skin (jaundice), which may come with itching, dark urine and pale stools; loss of appetite or unintentional weight loss; tiredness; and a high temperature or shivering. Digestive symptoms include nausea, a change in bowel habits, abdominal and back pain (which may worsen after eating or when lying down) and bloating.

The NHS stresses that having these symptoms does not necessarily mean pancreatic cancer, as they are common in other conditions. See a doctor for marked weight loss, or digestive symptoms that do not improve or worsen after two weeks.

How is it diagnosed?

According to the NHS, the following are used: blood tests, imaging (CT, MRI, ultrasound and sometimes from inside the body by endoscope, and PET), a biopsy (taking a sample of cells), ERCP, and laparoscopy. The results are then used to determine the size of the tumour and how far it has spread (the stage).

The NCI points to the importance of molecular testing of the tumour to determine eligibility for targeted and immune therapy.

Stage at detection in the United States according to SEER: localised 15% of cases, regional 28%, and distant (spread) 51%.

Treatment

The treatment categories usually used are listed here; this is not a prescription. The doctor chooses the plan according to each person's condition; do not change any medicine or dose without a specialist.

The NCI says surgery, when it can remove the whole tumour, offers the best chance of long-term survival. Types include the Whipple procedure (pancreaticoduodenectomy) for tumours of the head of the pancreas, distal pancreatectomy for tumours of the body and tail, and procedures to relieve symptoms such as endoscopic stents and gastric bypass.

Chemotherapy is most commonly given as two combinations: FOLFIRINOX, or gemcitabine with nab-paclitaxel (NCI). It is used before surgery to shrink the tumour or after it to limit recurrence, and may be combined with radiotherapy, which is "not often used" according to the NHS. Targeted therapies and immunotherapy are available for tumours with specific molecular features (NCI).

Supportive and palliative care: enzyme replacement tablets to improve digestion, pain relief, anti-sickness medicines and nutritional support; they ease weight loss, weakness and pain (NCI, NHS). The NCI says many experts think it is important for every patient to join a clinical trial. The NHS states that the disease can be hard to treat, and that when a cure is not possible, treatment aims to limit the tumour and its symptoms and prolong life.

Follow-up

The follow-up plan is determined by the stage and the treatment, and the multidisciplinary team draws up the plan after test and imaging results (NHS). Ask your team about the schedule of tests and how to contact them when new symptoms appear.

Complications

Note: the figures below are statistics for populations in the United States; they do not predict the outlook of any individual, and the outlook varies with the stage, general health and treatment options. Discuss them with your treating team. According to SEER (data 2016 to 2022): the 5-year relative survival is 13.7% for all stages; 43.6% for localised disease, 17.0% for regional, and 3.4% for distant.

Common questions