Pancreatic Cancer

What pancreatic cancer is

The pancreas is about 15 cm (6 inches) long and lies across the back of the abdomen. Its head sits in the curve of the duodenum, next to the common bile duct, and its body and tail extend to the left toward the spleen.

The pancreas has two jobs:

• Exocrine: making enzymes that digest food. Cancers here, mostly pancreatic ductal adenocarcinoma, account for over 90 percent of cases. This page focuses on them.
• Endocrine: making insulin and other hormones. Cancers from these cells are neuroendocrine tumors, which behave differently and usually have a much better outlook.

Pancreatic cancer develops from precursor changes in the ducts over many years. Some cysts, such as intraductal papillary mucinous neoplasms (IPMNs), can also turn cancerous and are monitored.

Early signs and symptoms of pancreatic cancer

Symptoms depend on where the tumor is. About two-thirds start in the head of the pancreas.

Tumors in the head of the pancreas

• Jaundice: yellow skin and eyes, often without pain, caused by the tumor blocking the bile duct.
• Dark urine, pale or clay-colored stools and itchy skin, from blocked bile.
• An enlarged, non-tender gallbladder that a doctor can sometimes feel.

Tumors in the body and tail

• Few early symptoms, so they are often found later.
• Dull upper belly pain that spreads to the middle of the back, often worse lying flat and eased by leaning forward.

Symptoms at any location

• Unexplained weight loss and loss of appetite.
• Pale, greasy, foul-smelling stools that float (steatorrhea), from lack of digestive enzymes.
• Indigestion, nausea and bloating.
• New-onset diabetes, or sudden worsening of existing diabetes, especially after 50 with weight loss.
• Fatigue.
• Blood clots in the legs or lungs, sometimes recurring in different places (Trousseau syndrome).
• Depression, which may appear before diagnosis.

Most of these symptoms have common, harmless causes. The combination, persistence and age matter.

Causes and risk factors

• Smoking: roughly doubles the risk and accounts for about a quarter of cases.
• Age: most people are over 65.
• Obesity and lack of physical activity.
• Long-standing diabetes.
• Chronic pancreatitis, especially hereditary pancreatitis.
• Heavy alcohol use, mainly through chronic pancreatitis.
• Family history: having two or more first-degree relatives with pancreatic cancer raises risk significantly.
• Inherited gene changes: BRCA2 and BRCA1, PALB2, ATM, Lynch syndrome, Peutz-Jeghers syndrome (STK11) and familial atypical multiple mole melanoma (CDKN2A). About 1 in 10 cases has an inherited cause.
• Pancreatic cysts with high-risk features.

How pancreatic cancer is diagnosed

1. Blood tests: liver tests (bilirubin) and CA 19-9, a tumor marker. CA 19-9 is not reliable for screening, because it is raised in other conditions and normal in some cancers, but it helps monitor treatment.
2. CT scan with a pancreas protocol: the main imaging test. It shows the tumor, its relation to major blood vessels and any spread.
3. MRI and MRCP: detailed views of the pancreas and bile ducts.
4. Endoscopic ultrasound (EUS): an ultrasound probe on an endoscope passed into the stomach gives close-up images and allows a needle biopsy.
5. ERCP: an endoscope places a stent to relieve a blocked bile duct and can take samples.
6. Laparoscopy: sometimes used to check for small spread inside the abdomen before major surgery.
7. Genetic testing: now recommended for everyone diagnosed with pancreatic cancer, and tumor molecular testing for those with advanced disease.

Pancreatic cancer stages

Doctors use the TNM system (stage 0 to 4), but treatment decisions depend mainly on whether the tumor can be removed:

Pancreatic cancer treatment

Surgery

Surgery is the only potential cure. The operation depends on the tumor's location:

• Whipple procedure (pancreaticoduodenectomy): removes the head of the pancreas, the duodenum, the gallbladder, part of the bile duct and sometimes part of the stomach, then reconnects the digestive tract.
• Distal pancreatectomy: removes the body and tail, often with the spleen.
• Total pancreatectomy: removes the whole pancreas, causing lifelong diabetes.

These are major operations best done at high-volume specialist centers, where complication and death rates are lower.

Chemotherapy

• After surgery (adjuvant): about 6 months of chemotherapy, usually modified FOLFIRINOX, lowers the chance of recurrence.
• Before surgery (neoadjuvant): increasingly used, especially for borderline resectable tumors.
• Advanced disease: combinations such as FOLFIRINOX, NALIRIFOX, or gemcitabine with nab-paclitaxel can extend life and ease symptoms.
• Targeted therapy: PARP inhibitors for some people with BRCA mutations, and specific drugs for rare tumors with certain gene changes.

Radiotherapy

Chemoradiation or stereotactic body radiation therapy may be used for locally advanced tumors, or to control pain.

Symptom control and supportive care

• Biliary stent to relieve jaundice and itching.
• Duodenal stent or bypass if the tumor blocks the stomach outlet.
• Pancreatic enzyme replacement with meals to improve digestion and weight.
• Pain control, including a nerve block (celiac plexus block).
• Treatment of blood clots and diabetes.
• Nutrition support.
• Palliative care, ideally early, alongside cancer treatment.

Clinical trials are encouraged for pancreatic cancer at all stages.

Survival rate and outlook

Pancreatic cancer has one of the lowest survival rates of any cancer, because it is usually found late and resists treatment. In the US, the 5-year relative survival is about 13 percent overall: around 44 percent for localized cancer, about 16 percent for regional spread and about 3 percent for distant spread. These figures are averages from people diagnosed years ago. Outcomes are improving with better chemotherapy and surgery, and individual outlook varies widely.

Can pancreatic cancer be prevented or screened for?

Screening the general population is not recommended, because no test is accurate enough and the cancer is uncommon. People at high risk because of family history or inherited gene changes may be offered yearly MRI or endoscopic ultrasound surveillance in specialist programs.

To lower risk:

• Do not smoke.
• Keep a healthy weight and stay active.
• Limit alcohol.
• Manage diabetes.

Frequently asked questions

What are the early signs of pancreatic cancer?

Early signs are often subtle: yellowing of the skin or eyes, dark urine and pale stools, upper belly pain spreading to the back, unexplained weight loss, loss of appetite, greasy floating stools, and new diabetes after 50. Many have harmless causes, but persistent or combined symptoms should be checked.

What causes pancreatic cancer?

The exact cause is not known, but smoking is the biggest avoidable risk factor. Others include older age, obesity, long-standing diabetes, chronic pancreatitis, heavy alcohol use, a family history of pancreatic cancer and inherited gene changes such as BRCA2, PALB2 and Lynch syndrome.

What is the survival rate for pancreatic cancer?

The overall 5-year relative survival in the US is about 13 percent. It is around 44 percent when the cancer is found while still confined to the pancreas, but much lower once it has spread. Surgery with chemotherapy gives the best chance of long-term survival.

Why is pancreatic cancer so hard to detect?

The pancreas lies deep in the abdomen, so small tumors cannot be felt and rarely cause early symptoms. Early symptoms such as indigestion and back pain are common and nonspecific. No reliable blood screening test exists yet, so most cancers are found after they have spread.

Can pancreatic cancer be cured?

It can be cured in some people when found early enough for surgery. Only about 15 to 20 percent are operable at diagnosis. Even after surgery, recurrence is common, which is why chemotherapy is given as well. For advanced cancer, treatment aims to extend life and control symptoms.

Is jaundice a sign of pancreatic cancer?

It can be. Painless jaundice in an older adult, especially with weight loss, dark urine and pale stools, is a classic sign of a tumor in the head of the pancreas blocking the bile duct. Gallstones and hepatitis are more common causes, but jaundice always needs prompt investigation.