Pancreatic cancer
Pancreatic cancer starts in the cells of the pancreas, an important part of the digestive system. The most common type by far is adenocarcinoma of the pancreas, an exocrine pancreatic cancer in the cells that line the ducts of the pancreas.
Overview
The pancreas sits behind the stomach and is shaped like a fish with a wide head, a tapering body and a narrow tail. The pancreas is made mostly of exocrine cells. Within the pancreas, exocrine glands make pancreatic enzymes that get released into the intestines via ducts to help you digest food, especially fats.
The most common type of pancreatic cancer is adenocarcinoma of the pancreas. It develops when exocrine cells grow out of control.
Endocrine cells make up a smaller percentage of the cells in the pancreas. These cells make important hormones like insulin and glucagon and release them directly into the blood. Pancreatic neuroendocrine tumors start in the endocrine cells.
Pancreatic cancer is often not detected in its early stages, and it can spread rapidly to other organs. We still don’t know the exact cause of pancreatic cancer, but we do know that some factors increase the risk of developing it.
Signs and symptoms
If you experience any of these symptoms, see your provider right away as symptoms of pancreatic cancer often don’t occur until the disease is advanced:
- Pain in the upper abdomen that radiates to your back.
- Loss of appetite or unintended weight loss.
- Depression.
- New-onset diabetes.
- Blood clots.
- Fatigue.
- Jaundice, which is yellowing of your skin and the whites of your eyes.
Risk factors
Factors that may increase your risk of pancreatic cancer include:
- Pancreatitis, which is chronic inflammation of the pancreas.
- Diabetes.
- Family history of genetic syndromes that can increase cancer risk, including a BRCA2 gene mutation, Lynch syndrome and familial atypical mole-malignant melanoma (FAMMM) syndrome.
- Family history of pancreatic cancer.
- Smoking.
- Obesity.
- Older age, as most people are diagnosed after age 65.
A large study demonstrated that the combination of smoking, long-standing diabetes and a poor diet increases the risk of pancreatic cancer beyond the risk of any one of these factors alone.
Questions and answers (FAQs)
What is pancreatitis? Is it linked to pancreatic cancer?
Pancreatitis is inflammation of the pancreas, which can be acute or chronic. Pancreatitis is typically not related to pancreatic cancer, but in some cases, there is a link.
What are pancreatic cysts? Do they lead to cancer?
Pancreatic cysts are fairly common, and most do not lead to cancer. There are different types of cysts—most are benign, but some are malignant and may be pre-cancerous so proper diagnosis and treatment is essential.
Can I live without a pancreas?
Yes, but you’ll be diabetic. If your pancreas is removed as part of your cancer treatment plan, you’ll need to take insulin and digestive enzymes for the rest of your life.
Can pancreatic cancer be prevented?
No, there is no definitive prevention. However, you can reduce your risk by maintaining a healthy weight and diet, not smoking and limiting alcohol.
Pancreatic cancer diagnosis
To properly diagnose pancreatic cancer, your provider will first take your medical history and perform a physical exam. This includes an assessment of symptoms, checking your overall health and feeling your abdomen for any abnormal changes. Then, if necessary, your doctor will refer you to a gastroenterologist, who specializes in diseases of the digestive tract.
Further diagnostic testing may include:
Blood tests. Used to help diagnose pancreatic cancer or to help determine treatment options if it is found.
- Liver function tests. Jaundice is often one of the first signs of pancreatic cancer.
- Tumor markers. Tumor markers can sometimes be found in the blood when a person has cancer. For pancreatic cancer, we look for tumor markers CA 19-9 and Carcinoembryonic antigen (CEA).
- Other blood tests, like a CBC or chemistry panel, can help evaluate a person’s general health.
Endoscopic ultrasound (EUS). Uses sound waves to produce images of the pancreas.
Biopsy. The only way to tell for sure if it is definitively cancer is by doing a biopsy.
- Percutaneous biopsy or fine needle aspiration (FNA). A doctor inserts a thin, hollow needle through the skin over the abdomen and into the pancreas to remove a small piece of a tumor.
- Endoscopic biopsy. Your doctor passes an endoscope down the throat and into the small intestine near the pancreas. At this point, the doctor can either use EUS to pass a needle into the tumor, or endoscopic retrograde cholangiopancreatography (ERCP) to place a brush to remove cells from the bile or pancreatic ducts.
- Surgical biopsy. Useful if your surgeon is concerned the cancer has spread beyond the pancreas.
Imaging tests. X-rays, magnetic fields, sound waves or radioactive substances to create pictures of the inside of your body.
- Cholangiopancreatography. Looks at the pancreatic ducts and bile ducts to see if they are blocked, narrowed or dilated.
- Computed tomography (CT or CAT) scan. Uses X-rays to make highly detailed and accurate cross-sectional images of your body. Unlike a regular x-ray, a CT scan creates detailed images of the soft tissues in the body. CT scans can also be used to guide a biopsy needle into a suspected area of cancer spread, called a CT-guided needle biopsy.
- Magnetic resonance imaging (MRI) scan. Like CT scans, MRI scans show detailed images of soft tissues in the body.
- Positron emission tomography (PET) scan. A PET scan can look for possible areas of cancer spread in all areas of the body at once.
- PET/CT scan. We can do both a PET and CT scan at the same time.
Pancreatic cancer staging
UCHealth follows the American Joint Committee on Cancer (AJCC) TNM system, which is based on three key pieces of information:
- The extent of the tumor (T). How large is the tumor and has it grown outside the pancreas into nearby blood vessels?
- The spread to nearby lymph nodes (N): Has the cancer spread to nearby lymph nodes? If so, how many of the lymph nodes have cancer?
- The spread (metastasized) to distant sites (M): Has the cancer spread to distant lymph nodes or distant organs such as the liver, peritoneum (the lining of the abdominal cavity), lungs or bones?
Cancer staging can be complex. If you have any questions about your stage, please ask your doctor to explain it to you in a way you understand.
| AJCC Stage | Stage grouping | Stage description* |
|---|---|---|
| 0 | Tis N0 M0 | The cancer is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues. It has not spread outside of the pancreas. These tumors are sometimes referred to as carcinoma in situ (Tis). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). |
| IA | T1 N0 M0 | The cancer is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues. It has not spread outside of the pancreas. These tumors are sometimes referred to as carcinoma in situ (Tis). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). |
| IB | T2 N0 M0 | The cancer is confined to the pancreas and is no bigger than 2 cm (0.8 inch) across (T1). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). |
| IIA | T3 N0 M0 | The cancer is confined to the pancreas and is larger than 2 cm (0.8 inch) but no more than 4cm (1.6 inches) across (T2). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). |
| IIB | T1 N1 M0 | The cancer is confined to the pancreas and is bigger than 4 cm (1.6 inches) across (T3). It has not spread to nearby lymph nodes (N0) or to distant sites (M0). |
| T2 N1 M0 | The cancer is confined to the pancreas and is no bigger than 2 cm (0.8 inch) across (T1) AND it has spread to no more than 3 nearby lymph nodes (N1). It has not spread to distant sites (M0). | |
| T3 N1 M0 | The cancer is confined to the pancreas and is larger than 2 cm (0.8 inch) but no more than 4cm (1.6 inches) across (T2) AND it has spread to no more than 3 nearby lymph nodes (N1). It has not spread to distant sites (M0). | |
| III | T1 N2 M0 | The cancer is confined to the pancreas and is no bigger than 2 cm (0.8 inch) across (T1) AND it has spread to 4 or more nearby lymph nodes (N2). It has not spread to distant sites (M0). |
| OR | ||
| T2 N2 M0 | The cancer is confined to the pancreas and is larger than 2 cm (0.8 inch) but no more than 4cm (1.6 inches) across (T2) AND it has spread to 4 or more nearby lymph nodes (N2). It has not spread to distant sites (M0). | |
| OR | ||
| T3 N2 M0 | The cancer is confined to the pancreas and is bigger than 4 cm (1.6 inches) across (T3) AND it has spread to 4 or more nearby lymph nodes (N2). It has not spread to distant sites (M0). | |
| OR | ||
| T4 Any N M0 | The cancer is growing outside the pancreas and into nearby major blood vessels (T4). The cancer may or may not have spread to nearby lymph nodes (Any N). It has not spread to distant sites (M0). | |
| IV | Any T Any N M1 | The cancer has spread to distant sites such as the liver, peritoneum (the lining of the abdominal cavity), lungs or bones (M1). It can be any size (Any T) and might or might not have spread to nearby lymph nodes (Any N). |
Treatment and recovery
Curative surgery treatments
Surgery is the main curative treatment for pancreatic cancer, but it is not always successful in doing so.
- Whipple procedure or pancreaticoduodenectomy. An operation to remove the head of the pancreas, the first part of the small intestine duodenum, the gallbladder and part of the bile duct. In some situations, part of the stomach and nearby lymph nodes may be removed as well. Your surgeon reconnects the remaining parts of your pancreas, stomach and intestines to allow you to digest food.
- Distal pancreatectomy. Surgery to remove the body and tail of the pancreas, and possibly the spleen.
- Total pancreatectomy. The entire pancreas is removed. Afterward, patients will need lifelong insulin and enzyme replacement.
Palliative surgery treatments
If the cancer has spread too far to be removed completely, any surgery being considered would be done to relieve symptoms from a blocked bile duct:
- Stent placement. Done with an endoscope to place a stent inside the duct to keep it open. Often this is part of an endoscopic retrograde cholangiopancreatography (ERCP).
- Bypass surgery. Your surgeon reroutes the passage of food from the stomach directly to the small intestine, bypassing the pancreas.
Radiofrequency ablation. A special probe with tiny electrodes that attack cancer cells.
Cryosurgery. An instrument that freezes and destroys abnormal tissue.
Chemotherapy. Drugs that destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. We often use more than one drug at a time for maximum results.
Targeted therapy or novel therapy. Drugs that target the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. In recent years, targeted therapy has proven to be increasingly successful at controlling cancer and improving prognosis.
Immunotherapy. The treatment of cancer with medications to increase immune system function against the cancer.
Radiation therapy. High-energy X-rays or other particles that destroy cancer cells.
Types of pancreatic cancer
Exocrine cancers are by far the most common type of pancreatic cancer, but there are a few other types as well:
Pancreatic adenocarcinoma. About 95% of cancers of the exocrine pancreas, usually starting in the ducts of the pancreas. Less often, they develop from the cells that make the pancreatic enzymes, in which case they are called acinar cell carcinomas.
Other, less common exocrine cancers include:
- Adenosquamous carcinomas
- Squamous cell carcinomas
- Signet ring cell carcinomas
- Undifferentiated carcinomas
- Undifferentiated carcinomas with giant cells
Ampullary cancer (carcinoma of the ampulla of Vater). This cancer starts in the ampulla of Vater, which is where the bile duct and pancreatic duct come together and empty into the small intestine.
Pancreatic neuroendocrine tumors. These rare tumors start in the endocrine cells.
Benign and precancerous growths.
Some growths in the pancreas are not cancer, while others might become cancer over time if left untreated. These are known as precancers.
- Serous cystic neoplasms (SCNs). Tumors that have cysts filled with fluid. SCNs are almost always benign, and most don’t need to be treated unless they grow large or cause symptoms.
- Mucinous cystic neoplasms (MCNs). Slow-growing tumors that have cysts filled with a jelly-like substance called mucin. These tumors almost always occur in women. While they are not cancer, some of them can progress to cancer over time if not treated, so these tumors are typically removed with surgery.
- Intraductal papillary mucinous neoplasms (IPMNs). Benign tumors that grow in the pancreatic ducts. Like MCNs, these tumors make mucin, and over time they sometimes become cancer if not treated.
- Solid pseudopapillary neoplasms (SPNs) are rare, slow-growing tumors that almost always develop in young women. Even though these tumors tend to grow slowly, they can sometimes spread to other parts of the body, so they are best treated with surgery.
Five-year pancreatic cancer survival rates
Data source: Surveillance, Epidemiology, and End Results (SEER) 17 registries, National Cancer Institute, 2022. AJCC All Stages, 5 Year Relative Survival. Date of diagnosis from 2012 – 2018.
References
National Cancer Institute (NCI). Pancreatic Cancer (https://www.cancer.gov/types/pancreatic)
MedlinePlus: National Library of Medicine. Pancreatic Cancer (https://medlineplus.gov/pancreaticcancer.html)
National Center for Biotechnology Information (NCBI): National Library of Medicine. Pancreatic Cancer (https://www.ncbi.nlm.nih.gov/books/NBK518996/)