Pancreatic Cancer

Identify the Pancreas

The pancreas is part of the digestive system. It has two main roles. It makes pancreatic juices – to help digest food for the body to use and it makes insulin – to help keep sugar levels in the blood stable. The pancreas is in the upper part of the tummy (abdomen) just behind the stomach and in front of the spine. It is level with the V-shape where the ribs meet at the front of the body. It is about 15cm (6in) long.

The three main parts are:

Pancreatic juices travel through small tubes (ducts) in the pancreas into a larger duct called the pancreatic duct. This joins with the common bile duct, which carries bile from the liver and gall bladder. They join up at the opening into the small bowel (duodenum). This is called the ampulla of Vater. The pancreatic juices and bile then  flow into the duodenum where they help to digest food.

What is pancreatic cancer?

Types of pancreatic cancer can be described by where they are found in the pancreas and by the type of cell that they start from. Cancer can occur in any part of the pancreas, but around 6 or 7 in every 10 pancreatic cancers (60–70%) start in the head of the pancreas. There are several different types of pancreatic cancer. The most common type is ductal adenocarcinoma, which starts from cells in the lining of the pancreatic ducts. More than 9 out of 10 pancreatic cancers (95%) are ductal adenocarcinomas.

Cancer may develop at the ampulla of Vater (see page 6), where the bile and pancreatic ducts join up and enter the small bowel (duodenum). This is called peri-ampullary cancer.

Other, less common, types of pancreatic cancer include:

The treatments for cancerous cystic tumours, acinar cell carcinomas and ampullary cancer are similar to those described in this article. But the tests and treatments for neuroendocrine tumours and lymphoma of the pancreas may be very different.

What are the symptoms?

Pancreatic cancer may not cause symptoms for a long time and some people may have only one symptom. The most common symptoms are:

Pain or discomfort

This often begins in the upper part of the tummy. Sometimes, it spreads to the back. The pain may come and go, or be there all the time. It may feel worse when you are lying down and better when you are sitting up or bending forward.

Jaundice

If you have peri-ampullary cancer (see page 10) or if the cancer is in the head of the pancreas and blocks the bile duct, you may develop jaundice. Cancer in the tail or body of the pancreas is less likely to cause jaundice. If bile can’t drain away, it builds up in the body. This can cause symptoms such as yellowing of the skin and the whites of the eyes, itchy skin, dark yellow urine and pale bowel motions. Jaundice can be caused by illnesses other than pancreatic cancer.

Weight loss

This may happen even if there have been no changes in what you eat.

Other symptoms

Pancreatic cancer can cause other symptoms, such as:

Remember: most pain in the abdomen is not caused by cancer of the pancreas. But see your doctor if you are worried.

Risk factors and causes

Doctors don’t know what causes this cancer, but there is ongoing research into this. Things that can increase your risk of developing a disease are called risk factors. Risk factors for pancreatic cancer include:

Age

The risk of developing pancreatic cancer increases with age. It mainly affects people in middle and older age and is rarer in younger people. Most people who develop pancreatic cancer are 65 or older.

Smoking and tobacco

About 3 in 10 pancreatic cancers (30%) may be due to smoking. People who chew tobacco are also at an increased risk.

Diet

Eating large amounts of red or processed meat over time may increase the risk of pancreatic cancer. Processed meats include ham, sausages, bacon and burgers. Regularly eating a diet that is high in fat and sugar and low in fresh fruit and vegetables may also increase the risk.

Alcohol

Drinking large amounts of alcohol regularly may increase the risk of developing pancreatic cancer, especially in people who smoke.

Body weight and physical activity

Some studies have found that being very overweight (obese) and being physically inactive may increase the risk of pancreatic cancer.

Medical conditions - Chronic pancreatitis

People who have a condition called chronic pancreatitis are more likely to develop pancreatic cancer. Chronic pancreatitis means the pancreas is inflamed, tender and swollen over a long period of time. The risk is highest for people who have chronic pancreatitis due to a rare inherited condition called hereditary pancreatitis.

Diabetes

Diabetes is linked to cancer of the pancreas. But it is not clear if diabetes causes the cancer to develop or if it’s an early symptom of the cancer. Diabetes is common and most people with diabetes will not develop pancreatic cancer.

Infections

Some infections have been linked to a higher risk of developing pancreatic cancer. Studies have shown there may be a link to an infection of the liver called hepatitis B.

Previous cancer

Pancreatic cancer is slightly more common in people who have had cancer before. Studies are looking at whether this is because of previous cancer treatment, a genetic link or lifestyle factors such as diet or smoking.

Family history

Most people with pancreatic cancer have no history of pancreatic cancer in their family. But about 5–10 out of every 100 pancreatic cancers (5–10%) may be linked to faulty genes that can run in families. You may have a higher risk if:

If your family history means you may be at a higher risk, you can be referred to a specialist clinic for advice and assessment. You may be offered regular screening tests to try to detect cancer of the pancreas early if it does develop. Like all cancers, pancreatic cancer isn’t infectious and can’t be passed on to other people.

How cancer of the pancreas is diagnosed?

Your surgeon will normally ask if you have noticed any changes in your bowel habits, recent onset diabetes or change in your weight look at your eyes and the colour of your skin to check for jaundice, examine your tummy (abdomen) to feel for any swelling in the area of the liver, test your urine for bile and take some blood samples.

Your surgeon may arrange an urgent CT scan or ultrasound.

To make a diagnosis, doctors often use information from several tests, along with your symptoms and medical history. Occasionally, other medical conditions can cause similar results, making it difficult to decide what is and isn’t cancer.

If you are diagnosed with pancreatic cancer, you may need more tests. These are to find out the size and position of the cancer, and whether it has spread to other parts of the body.

Other tests, such as blood tests (CA 19-9) and chest x-rays, will look at your general health and  fitness. All these results will help when your doctor looks at the best treatment for you.

The following tests are often used to test for suspected cancer of the pancreas:

Ultrasound scan

Ultrasound scans use sound waves to show internal organs such as the pancreas and the liver. You will usually be asked not to eat or drink anything for a few hours before the test.

Once you are lying comfortably on your back, a gel is spread on the skin over the area to be scanned. A small device that produces sound waves is passed over the area. The sound waves are then converted into a picture by a computer. This test only takes a few minutes.

An ultrasound can also be used to guide a biopsy where a small sample of tissue is taken to be examined under a microscope.

Endoscopic ultrasound (EUS)

If there is a tumour, your surgeon may do an endoscopic ultrasound (EUS) to measure its size and to see whether it has spread. They may also take samples of tissue (biopsies) from the tumour during the EUS.

You will be asked not to eat or drink anything for about six hours before the test, so that your stomach and duodenum are empty. Your doctor or nurse will give you an injection to help you to relax (a sedative). They will also spray some local anaesthetic on to the back of your throat.

The surgeon passes a thin  flexible tube called an endoscope down your throat, into your stomach and then into your duodenum.

An ultrasound probe is put down the endoscope to produce a picture of the pancreas and other organs on a screen.

Most people are ready to go home a couple of hours after this test. It is a good idea to arrange for someone to collect you from the hospital as you shouldn’t drive for 24 hours after a sedative.

CT (computerised tomography) scan

A CT scan takes a series of x-rays, which build up a three-dimensional picture of the inside of the body. The scan takes 10–30 minutes and is painless. It uses a small amount of radiation, which is very unlikely to harm you and will not harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan. There is a photograph of a man having a CT scan on the opposite page.

You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. This may make you feel hot all over for a few minutes. It is important to let your doctor know if you are allergic to iodine or have asthma, because you could have a more serious reaction to the injection.

You will probably be able to go home as soon as the scan is over. CT scans can also be used to guide a biopsy. A biopsy usually involves an overnight stay in hospital, but you’ll be told if this is planned.

MRI (magnetic resonance imaging) scan

This test uses magnetism to build up a detailed picture of areas of your body. The scanner is a powerful magnet so you may be asked to complete and sign a checklist to make sure it’s safe for you. The checklist asks about any metal implants you may have, such as a pacemaker, surgical clips or bone pins, etc. You should also tell your doctor if you’ve ever worked with metal or in the metal industry as very tiny fragments of metal can sometimes lodge in the body. If you do have any metal in your body, it’s likely that you won’t be able to have an MRI scan. In this situation, another type of scan can be used. Before the scan, you’ll be asked to remove any metal belongings including jewellery.

Some people are given an injection of dye into a vein in the arm, which doesn’t usually cause discomfort. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test, you’ll lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It is painless but can be slightly uncomfortable, and some people feel a bit claustrophobic. It is also noisy, but you’ll be given earplugs or headphones. You can hear, and speak to, the person operating the scanner.

MRCP (magnetic resonance cholangiopancreatography)

This test uses magnetic and radio waves to get a detailed picture of your pancreas, bile ducts and liver. It is a type of MRI scan but isn’t available in every hospital. You will have to lie very still inside the MRI scanner for around 30 minutes. The scan shows any narrowing or blockages in the pancreatic ducts or bile ducts but can’t be used to take biopsies.

ERCP (endoscopic retrograde cholangiopancreatography)

Your surgeon may carry out an ERCP to put in a stent to drain a bile duct. This is a treatment for jaundice. They may also use an ERCP to take a biopsy from a tumour. You will be asked not to eat or drink anything for six hours before the procedure, so that your stomach and duodenum are empty.

The doctor or nurse will give you an injection to make you feel relaxed and sleepy. After this, the doctor passes a thin  flexible tube called an endoscope into your mouth, down into your stomach and then into the duodenum. They then put a small brush down the endoscope and take biopsies from the tumour. The brush with the cells on it is sent to a laboratory to be tested for cancer.

Biopsy

A biopsy is a small piece of tissue or a sample of cells that is taken from a tumour to be looked at under a microscope.

A biopsy may be taken during an EUS or an ERCP. Sometimes, the doctor inserts a needle through the skin into the tumour to get a sample of cells. This is called a percutaneous biopsy or  fine needle aspirate (FNA). The doctor injects a local anaesthetic into the skin to numb the area  first. They then use images from an ultrasound or CT scan to guide the needle through the skin and into the tumour to take (aspirate) a sample of cells. The sample is then sent to a laboratory to be tested for cancer.

Laparoscopy

This may be done if other tests haven’t confirmed a diagnosis of pancreatic cancer or if surgery to remove the cancer is planned. It is a small operation that allows the doctors to look at the pancreas and other organs in the tummy. They can see whether an operation to remove the cancer is possible. A laparoscopy is done under a general anaesthetic. It will mean a short stay in hospital.

The surgeon makes a small cut near the belly button. They then insert a thin tube with a tiny camera and light on the end, called a laparoscope, into your tummy. The doctor uses the laparoscope to look at the pancreas and surrounding tissues. They may also take a biopsy to be looked at under a microscope. Gas is pumped into the abdomen to make it easier to see the pancreas. The gas can cause uncomfortable wind and/or shoulder pains for several days afterwards. The pain is often eased by walking about. After the laparoscopy, you will have one or two stitches in your abdomen.

Laparotomy

If a laparoscopy isn’t suitable, your surgeon may carry out a laparotomy. This may be done if other tests don’t give a definite diagnosis, but it’s rarely needed as most people can have a laparoscopy. A laparotomy is an operation to look inside the tummy and is done under a general anaesthetic. The surgeon makes a larger cut (incision) in your tummy so that they can see the pancreas.

Blood tests

Many pancreatic cancers produce a substance called CA 19-9. This is called a tumour marker and can be measured in the blood. But some people who have pancreatic cancer don’t have raised levels of CA 19-9. And a normal level of CA 19-9 does not mean that someone definitely doesn’t have pancreatic cancer. Also, a high level may be caused by other conditions such as jaundice. Doctors will consider these things when they are looking at the test results. Doctors may measure the level of CA 19-9 to see how a pancreatic cancer responds to treatment and during follow-up if it was elevated before commencing the treatment. You may also have other blood samples taken to check your general health and how well your liver and kidneys are working.

Staging

The stage of a cancer is a term used to describe its size and whether it has spread from the place in the body where it started. Knowing the stage of the cancer helps the doctors when they are looking at the best treatment for you.

TNM staging

T describes the size of the tumour.

N describes whether the cancer has spread to the nearby lymph nodes. For example, N0 is no lymph nodes affected while N1 means there are cancer cells in the lymph nodes.

M describes if the cancer has spread to another part of the body. For example, M0 means the cancer has not spread (metastasised) to other parts of the body. M1 means the cancer has spread to other parts of the body.

TNM staging is then converted to the number staging system as described below.

Stage 1

This is the earliest stage. The cancer is contained inside the pancreas, although it may be quite large. Stage 1A means the cancer is smaller than 2cm. Stage 1B means it is bigger than 2cm. There is no cancer in the lymph nodes close to the pancreas and no sign that it has spread anywhere else in the body.

Stage 2

The cancer has started to grow outside the pancreas into nearby tissues and/or there is cancer in lymph nodes near the pancreas. In stage 2A, the cancer is in nearby tissue but does not involve blood vessels or lymph nodes. In stage 2B, the cancer may have grown into nearby tissue and is in the lymph nodes but not in the blood vessels. Doctors often call stages 1 and 2 resectable or early-stage cancer. Resectable means a surgeon may be able to operate to remove (resect) the tumour. Fewer than 1 in 5 cancers of the pancreas (20%) are diagnosed at stages 1 and 2.

Stage 3

The cancer has spread to large blood vessels near the pancreas but hasn’t spread to other parts of the body such as the liver or lungs. Stage 3 cancer is often called locally advanced cancer. Surgery may not always be possible for this cancer. It is sometimes called unresectable cancer. Occasionally, a person with stage 3 cancer may be able to have surgery to try to remove the cancer. It will depend on what blood vessels are involved. This is called borderline resectable cancer. About 2 in 5 cancers of the pancreas (35–40%) are diagnosed at stage 3.

Stage 4

The cancer has spread to other parts of the body such as the liver or lungs. Stage 4 cancer is often called metastatic or advanced cancer. This means the cancer has spread to other parts of your body. About half of pancreatic cancers (45–55%) are diagnosed at stage 4.

Planning your treatment

The type of treatment offered will depend on the stage and size of your cancer, and your general health. The treatment will be planned by a team of specialist doctors and other healthcare professionals. This is known as a multidisciplinary team (MDT), and may include:

The MDT may also include other healthcare professionals, such as:

Surgery, chemotherapy and radiotherapy may all be used to treat pancreatic cancer. An important part of the care of people with pancreatic cancer is using treatments to control symptoms and make you feel more comfortable. This is known as supportive care (see pages 68–77). Research is going on to find more effective treatments for pancreatic cancer and you may be invited to take part in a clinical trial of a new drug or treatment.

Early-stage (resectable)

The most effective treatment for early-stage pancreatic cancer is surgery to remove part, or all, of the pancreas. This may cure the cancer for some people but it is a major operation. It is only suitable for people who are  t enough to have the surgery and who have cancers that are small and haven’t spread.

Chemotherapy may be given before surgery to shrink the tumour or to reduce the risk of the cancer cells spreading. This is called neoadjuvant treatment and may be given as part of a clinical trial.

Chemotherapy may also be used after surgery to reduce the chances of the cancer coming back. This is called adjuvant chemotherapy.

Locally-advanced (unresectable)

Chemotherapy may be used to control the cancer for some time and to relieve symptoms. Sometimes, chemotherapy and radiotherapy are given together. This is called chemoradiation. If the cancer is blocking the bile duct or the bowel, surgery or stents may be used to relieve symptoms.

Locally-advanced (borderline resectable)

Very occasionally, it’s possible to operate to try to remove locally-advanced cancers. Chemotherapy (with or without radiotherapy) may be given first to shrink the tumour. However, this is rare.

Metastatic or advanced cancer

If the cancer is advanced, you may be offered treatment to control it. The main aim of this treatment is to reduce symptoms so that you feel as well as possible. This is called supportive care. Chemotherapy may be given to shrink the cancer and to relieve symptoms. Chemotherapy may also help some people to live for longer. Stents may be used to relieve jaundice or other symptoms caused by a blocked bile duct or bowel. Radiotherapy, painkillers and nerve blocks  may be used on their own or in a combination to control any pain.

The benefits and disadvantages of treatment

Before deciding whether to go ahead with a treatment, you may want to know how well it is likely to work. If you’re offered a choice of treatments, you’ll need to think about the possible benefits and disadvantages of each to help you decide.

Some treatments have more side effects and risks than others. For some people, treatment will have no effect on the cancer and they’ll get the side effects with little benefit. Making decisions about treatment can be difficult. Your surgeon or the multidisciplinary team members can answer any questions you have.