Pancreatic cancer



Last Review Date: March 6, 2017


What is it?

For an explanation of the pancreas and the words exocrine and endocrine, please see the description under "What is the pancreas?" in Pancreatic diseases.

Cancer is an uncontrolled growth of abnormal cells that form tumours, damage normal tissue, and eventually metastasise (spread throughout the body). Most (95 per cent) pancreatic cancers are adenocarcinomas that develop in the ducts and sometimes in the enzyme producing cells of the exocrine tissue. Endocrine tumours are usually less aggressive than exocrine tumours and are much more rare. They may be benign tumours (those that do not metastasise, such as insulinomas) or malignant (a group of cancers called islet cell cancers). Endocrine tumours are usually detected earlier than exocrine cancers because they tend to produce excessive amounts of the hormones insulin and glucagon that frequently result in symptoms.

Because they are more common and aggressive, the remainder of this discussion focuses on exocrine cancer. Unfortunately, these are hard to detect at an early stage. Since the pancreas is deep in the body, tumours usually cannot be seen or felt during a physical examination and, by the time symptoms develop, the cancer often has spread throughout the pancreas and beyond. One exception to this is a cancer that forms where the pancreatic and bile duct empty into the duodenum, ampullary cancer. Since ampullary cancer often obstructs the flow of bile from the bile duct and causes jaundice, it has the potential of being detected earlier than most exocrine cancers.

In the year 2012 in Australia 1451 males and 1374 females were diagnosed with pancreatic cancer. It was the 11th most commonly diagnosed cancer in Australia in 2012. In 2008–2012 in Australia, individuals diagnosed with pancreatic cancer had a 7% chance of surviving for 5 years compared to their counterparts in the general Australian population.


Signs and Symptoms

Early symptoms of pancreatic cancer are often either absent or subtle. They include abdominal pain, back pain, nausea, loss of appetite, unexplained weight loss and, less commonly, jaundice. Since these symptoms are seen in other conditions besides cancer, they may be ignored or missed in the early stages. By the time chronic pain, vomiting, impaired digestion of food and problems with blood sugar control, appear and are recognised, the pancreatic cancer usually has become firmly established.


Tests

Unfortunately, there are no laboratory tests available for the early detection or diagnosis of pancreatic cancer. Diagnosis usually is made after the cancer has already spread, using imaging tests and biopsy.

Laboratory tests that are useful with pancreatic cancer include:

  • CA 19-9 (Cancer antigen 19-9): a tumour marker that can be used for monitoring response to treatment. It is not useful for detection or diagnosis because it is not elevated in all cases and it is not specific for pancreatic cancer (it may be elevated as a result of other conditions). If it is elevated at diagnosis it may then be used to monitor the treatment or recurrence.
  • CEA (Carcinoembryonic antigen): used as a monitoring tool
  • Other tests, such as liver function tests, amylase and lipase may be helpful to determine the effects of the cancer

Non-laboratory tests that may be used:

  • CT (computed tomography) scan: useful for detecting pancreas masses and checking for metastasised cancer
  • ERCP (endoscopic retrograde cholangiopancreatography): may be used to introduce a dye for X-rays or to place a stent (a metal or plastic tube that can help keep a duct open and functioning)
  • Transabdominal ultrasound
  • MRI (magnetic resonance imaging)
  • Biopsy: used to confirm diagnosis of cancer, often in conjunction with CT scan

Prevention

The main risk factor for pancreatic cancer is preventable: smoking. About 30% of pancreatic cancers are thought to be a direct result of cigarette smoking. Other risks include:

  • Age (risk increases with age and the average age at diagnosis is 71 years)
  • Overweight and obesity
  • Gender (men are 30 per cent more likely to develop pancreatic cancer)
  • Chronic pancreatitis 
  • Diabetes mellitus
  • Exposure to some industrial chemicals, such as certain pesticides and petroleum products
  • Family History (an inherited tendency may be a factor in 5% to 10% of cases)

It should be noted that most people who have known risk factors do not get pancreatic cancer, and many who do get pancreatic cancer have none of these risk factors.


Treatment

Treatment of pancreatic cancer centres first around staging - determining how much of the pancreas is involved and whether the cancer has spread. This may be done using a formal staging/naming system or by categorising the cancer into resectable (within the pancreas and can be surgically removed), locally advanced (spread into nearby organs and not removable), or metastatic (spread to distant organs).

Unfortunately resection (removal) is possible less than 15% of the time. How much surgery is done depends on where the tumour is, its size, how far it has spread, and the patient's health. Pancreatic surgery is very difficult. It requires an experienced surgeon, is associated with significant complications, and requires several weeks of recovery time. Procedures include:

  • Whipple procedure: the surgeon removes the head of the pancreas and part of the small intestine, bile duct, and stomach
  • Distal pancreatectomy: the body and tail of the pancreas and the spleen are removed
  • Total pancreatectomy: the pancreas, part of the small intestine, some of the stomach, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes are removed

Radiation and chemotherapy also may be used and are often necessary as tiny, undetectable amounts of the tumour have often spread by the time surgery is done. Unfortunately, pancreatic cancer does not respond well to current treatments. However, new chemotherapy agents, such as gemcitabine, are showing promise and advances in molecular pathology are also providing a foundation for the development of new chemotherapeutic and biological agents that appear to be promising.

For those with recurring or inoperable pancreatic cancer, palliative (comfort-oriented) care is the primary priority. Radiation, chemotherapy, and surgery may be used to help relieve pain. Surgery also may be done on non-resectable cancers to remove or bypass blockages in the bile duct and to help relieve pain and jaundice. A procedure may be done with a flexible endoscope to place a stent (plastic or metal tube that can help keep the duct open). Surgery also may be performed to cut nerves to help relieve pain that is resistant to other measures.

Patients with inoperable pancreatic cancer also may want to consider enrolment in clinical trials of new treatments. There are promising areas of research that may offer patients additional options.


Related pages

On this site
Tests: Amylase, CA 19-9, CEA, E/LFT, lipase, sweat chloride, trypsin, trypsinogen
Conditions: Cystic fibrosis, diabetes, pancreatic diseases

Elsewhere on the web
Better Health Channel: Pancreatic cancer
healthdirect Australia: Pancreatic cancer
Cancer Council Victoria
Pancreas.org: Pancreatic cancer (US)
Medscape Reference – Pancreatic Cancer