Pancreatic cancer

The pancreas is a gland of the digestive system. It is about 13–15 cm long and has three main parts: the large, rounded end called the head; the middle part, known as the body; and the narrow end, called the tail, which sits next to your spleen.

Pancreatic cancer is cancer that starts in any part of the pancreas. About 3 in 4 pancreatic cancers are found in the head. It can spread to nearby lymph nodes and to the lining of the abdomen (peritoneum), and cancer cells may also travel through the bloodstream to other parts of the body, such as the liver. Pancreatic cancer is more common in people over 60.

Role of the pancreas#

The pancreas has two major roles in digestion:

• It produces enzymes that help break down food (its exocrine function).
• It produces hormones that control blood sugar levels, the amount of acid the stomach makes, and how quickly food is absorbed (its endocrine function).

Risks and causes#

The causes of pancreatic cancer are not known, but some factors make it more likely. The risk is about twice as great for smokers. Other risk factors include:

• Obesity
• Older age (more common over 60)
• Inheriting a damaged gene
• Long-term diabetes (though diabetes can also be caused by pancreatic cancer)
• Chronic inflammation of the pancreas (pancreatitis)
• Stomach infection caused by Helicobacter pylori bacteria
• Certain cysts in the pancreatic duct, known as intraductal papillary mucinous neoplasms (IPMNs)
• Workplace exposure to certain pesticides, dyes or chemicals

Symptoms#

Early-stage pancreatic cancer rarely causes obvious symptoms. They may not appear until the cancer is large enough to affect nearby organs or has spread.

The first symptom is often jaundice, caused by a build-up of bilirubin — a dark yellow-brown substance in bile — when the cancer blocks the common bile duct. Signs of jaundice may include:

• Yellowish skin and eyes
• Dark urine
• Pale bowel motions
• Itchy skin

Other common symptoms include:

• Loss of appetite
• Nausea, with or without vomiting
• Unexplained weight loss
• Pain in the upper abdomen, side or back, which may wake you at night
• Bloating, passing wind and burping more than usual
• Changed bowel motions — including diarrhea, severe constipation, or pale, foul-smelling stools that are difficult to flush away
• Fatigue
• Newly diagnosed type 2 diabetes

Remember that pancreatic cancer is uncommon, so any one of these symptoms is more likely to be due to something else. Even so, see your doctor if you are worried or have ongoing symptoms.

Diagnosis#

If pancreatic cancer is suspected, your doctor will refer you for tests. These may include:

• Blood tests — to check how well your liver and kidneys are working, and to measure a protein called CA19.9. Pancreatic cancer often raises CA19.9 in the blood. It is not used to diagnose the cancer on its own, but it gives your doctor useful information.
• Computed tomography (CT) scan — a special x-ray taken from many angles to build a three-dimensional picture of the body. A dye may be injected to highlight internal organs.
• Magnetic resonance imaging (MRI) — similar to a CT scan, but it uses magnetism instead of x-rays.
• Ultrasound — sound waves create a picture of your pancreas.
• Endoscopy — a thin telescope is passed down your throat so the doctor can see inside your digestive system. It can also inject dye into the pancreas and bile duct so these organs show up on x-ray images (a procedure also called endoscopic retrograde cholangiopancreatography, or ERCP).
• Laparoscopy — a keyhole procedure to look inside the abdomen.
• Tissue biopsy — a sample of tissue is taken and examined.
• Positron emission tomography (PET) scan — cancerous cells take up glucose and show up as ‘hot spots’ that the scanner can detect.

These tests can also show whether the cancer has spread — into blood vessels or lymph nodes near the pancreas, or into more distant organs such as the liver or lungs. Spread to other parts of the body is called secondary cancer or metastasis.

Test results can take a few days to come back, and it is natural to feel anxious while you wait. It can help to talk to a close friend or relative about how you are feeling, or to speak with a cancer nurse through a cancer support service.

Treatment#

Treatment depends on your age, general health, the size and location of the cancer, and whether it has spread. You may have one type of treatment or a combination.

• Surgery — used when the cancer has not spread beyond the pancreas. The cancer, part of the pancreas and part of the small bowel are removed; some of the bile ducts, gall bladder and stomach may also be removed. This is major surgery, and you need to be fit enough to have it.
• Chemotherapy — anti-cancer medicines, as tablets or injections into the veins, that stop cancer cells growing and reproducing. They may be given before or after surgery, or alone to help control symptoms of advanced cancer.
• Radiotherapy — the use of x-rays to target cancer cells. It can destroy cells that may remain after surgery, be combined with chemotherapy before or after surgery, or be the main treatment when surgery is not possible.
• Complementary and alternative therapies — when used alongside conventional treatment, some can help you feel better and improve quality of life. Others may be unhelpful or even harmful, so discuss any you are considering with your doctor.

All treatments have side effects, which vary with the type of treatment. Many are temporary, but some may be permanent. Your doctor will explain the possible side effects before treatment begins.

Treatment to manage cancer and symptoms#

If the cancer involves nearby organs or blood vessels (locally advanced disease) or has spread to other parts of the body (metastatic disease), surgery to remove it may not be possible. Treatment then focuses on shrinking or slowing the cancer and relieving symptoms rather than trying to cure it. This is called palliative treatment, and it can help you feel better and may allow you to live longer. Options to relieve symptoms include:

• Stenting — if the cancer blocks the bile duct and causes jaundice, a metal or plastic tube is inserted to keep the duct open. A similar approach can relieve a blocked section of small bowel.
• Surgery — a blockage in the small bowel can be bypassed by attaching a loop of bowel directly to the stomach, or by creating an opening in the abdomen so waste can be collected in a small bag.
• Enzyme tablets — a lack of pancreatic enzymes can cause digestive problems; tablets containing these enzymes can control this.
• Pain-relieving medication — usually given by mouth, but for severe pain, medication can be injected into the nerves of the back.

Research and clinical trials#

Early detection and better treatment have improved survival for people with pancreatic cancer, and research is ongoing. Clinical trials test promising new treatments or new ways of combining existing ones. Always discuss your treatment options, including any trials, with your doctor.

Living with pancreatic cancer#

Pancreatic cancer and its treatment can affect how you feel about your body, who you are, your relationships and your sexuality. These changes can be very upsetting. Your medical team should discuss these issues with you before and during treatment, and you can ask for a referral to a counsellor or speak with a cancer nurse if you would like to talk things through.

Caring for someone with cancer can also be difficult and emotional. If you or someone you know is caring for a person with pancreatic cancer, support is available.

Key points#

• The pancreas is about 13–15 cm long and has three parts: the head, body and tail.
• Pancreatic cancer is more common in people over 60, and the risk is about twice as great for smokers.
• Early-stage pancreatic cancer rarely causes obvious symptoms, which may not appear until the cancer is large or has spread.
• Diagnosis uses blood tests and imaging such as CT, MRI, ultrasound, endoscopy and PET scans.
• Treatment may include surgery, chemotherapy and radiotherapy, with palliative options to relieve symptoms when a cure is not possible.

Where to get help#