Pancreatic Cancer

Pancreatic cancer begins in the pancreas, an organ that sits behind the stomach. The pancreas has two main jobs: it releases enzymes that help with digestion (its exocrine function), and it produces hormones, including insulin and glucagon, that help control blood sugar (its endocrine function).

In the United States, pancreatic cancer accounts for about 7% of cancer deaths. The American Cancer Society estimated that in 2020 about 57,600 people would be diagnosed with the disease and about 47,050 would die from it.

Types of pancreatic cancer

Pancreatic cancers are grouped according to the type of cell they start in.

Exocrine pancreatic cancer is the most common form. It arises from the exocrine cells, which secrete pancreatic enzymes into the ducts of the pancreas. The most common type overall is pancreatic adenocarcinoma, which begins in the cells that line these ducts. Less common exocrine types include:

• adenosquamous carcinomas
• squamous cell carcinomas
• signet ring cell carcinomas
• undifferentiated carcinomas
• giant cell tumour

Endocrine pancreatic cancer is less common. It develops from the endocrine cells, which release hormones into the bloodstream. These tumours are also known as pancreatic neuroendocrine tumours (PNETs), islet cell tumours or pancreatic endocrine cancers. Types include insulinoma, glucagonoma, gastrinoma, somatostatinoma, VIPomas and PPomas.

Risk factors

Several factors can increase the risk of developing pancreatic cancer:

• Age: the risk of pancreatic cancer rises with age.
• Race/ethnicity: African Americans have a slightly higher risk than Caucasians.
• Family history of pancreatic cancer.
• Inherited genetic syndromes: such as BRCA1 or BRCA2 gene mutations, Lynch syndrome, FAMMM syndrome and Peutz-Jeghers syndrome.
• Chronic pancreatitis: long-term inflammation of the pancreas, often linked to heavy alcohol use and smoking.
• Smoking: the risk is twice as high in smokers as in non-smokers.
• Obesity: being overweight raises the risk.
• Diabetes: people with diabetes are at higher risk.
• Chemicals: heavy exposure to certain chemicals, such as those used in the dry-cleaning and metalworking industries, can increase the risk.

Signs and symptoms

Pancreatic cancer often causes no symptoms in its early stages. As the disease becomes more advanced, signs and symptoms may include:

• yellowing of the skin and eyes (jaundice)
• dark, brown-coloured urine
• pale or oily stools (steatorrhoea)
• itchy skin
• abdominal or back pain
• unintentional weight loss and loss of appetite
• nausea and vomiting
• an enlarged liver (hepatomegaly) or gallbladder
• blood clots, often in the legs (deep vein thrombosis, or DVT)
• diabetes
• fatigue

How pancreatic cancer is diagnosed

If pancreatic cancer is suspected, several tests may be used to confirm the diagnosis and find out whether it has spread:

• Imaging tests: ultrasound, endoscopic ultrasound (EUS), CT and MRI scans. A PET/CT scan may also be used to find out whether the cancer has spread (metastasised) to other parts of the body.
• Biopsy: taking a sample of tissue, which may be done percutaneously (through the skin), endoscopically or surgically.
• Blood tests: including liver function tests (LFTs) and tumour markers such as CA 19-9 and CEA.

Treatment options

After diagnosis, your doctor will establish the stage of the disease. Taking into account your current health, medical history and the results of staging, they will discuss the most suitable treatment options with you. Regular follow-up and periodic monitoring with tests and investigations are strongly recommended.

Treatment options include:

• Surgery to remove the tumour. The main procedures are:
• Whipple procedure (pancreaticoduodenectomy): removes the head of the pancreas and is the most common operation for pancreatic cancer.
• distal pancreatectomy: removes the tail of the pancreas.
• total pancreatectomy: removes the entire pancreas, along with the gallbladder, common bile duct, spleen and portions of the small intestine and stomach.
• palliative surgery: relieves symptoms or complications caused by a blocked bile duct, usually through stent placement or bypass surgery.
• Ablation destroys cancer cells without removing the tumour. Methods include:
• radiofrequency ablation (RFA): high-energy radio waves heat the tumour and destroy the cancer cells.
• microwave ablation (MWA): energy from electromagnetic waves heats the tumour and destroys the cancer cells.
• cryosurgery (also called cryotherapy or cryoablation): cold gases freeze the tumour and kill the cancer cells.
• ethanol (alcohol) ablation: concentrated alcohol is injected into the tumour to damage the cancer cells.
• Embolization therapy reduces the tumour's blood supply by injecting substances directly into an artery. It includes arterial embolization, chemoembolization and radioembolization.
• Radiotherapy uses high-powered energy beams to kill cancer cells; the most common form for pancreatic cancer is external beam radiation therapy (EBRT).
• Chemotherapy uses drugs, given intravenously or orally, to kill cancer cells throughout the body. It may be given before surgery (neoadjuvant), after surgery (adjuvant) or on its own.
• Targeted therapy uses drugs that act on specific abnormalities within cancer cells.
• Immunotherapy uses immune cells, or drugs that prompt the immune system, to kill cancer cells.
• Alternative treatments use other science-based approaches to attack cancer cells.

Reducing your risk

You can reduce your risk of pancreatic cancer by:

• stopping smoking
• limiting alcohol
• eating a healthy diet
• exercising regularly
• maintaining a healthy weight
• limiting exposure to chemicals known to increase the risk of pancreatic cancer