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Pancreatic Cancer

Pancreatic cancer is among the hardest cancers to diagnose, because the organ lies deep and the disease gives no early symptoms. Even so, establishing correctly whether the disease is operable, and setting the right order of treatment, markedly affects the outcome.

  • CA 19-9 blood marker used in follow-up
  • 3 groups assessment of fitness for surgery
  • BRCA inherited gene that changes the choice of treatment

What is pancreatic cancer?

The pancreas lies behind the stomach and produces both digestive enzymes and insulin. Most of its cancers are of the adenocarcinoma type, arising from the ducts that carry those enzymes. The rarer neuroendocrine tumours follow a different course and are treated differently.

If the tumour is in the head of the pancreas it can press on the bile duct and cause jaundice, and so be noticed relatively early. Tumours in the body and tail can stay silent for a long time; complaints often begin as vague back pain and weight loss.

Diagnosis and fitness for surgery

In this cancer the most critical decision is whether the disease can be removed by an operation.

  1. Imaging

    Pancreas protocol CT

    Diagnosis and the decision about surgery require a CT performed with a protocol specific to the pancreas; a standard abdominal CT may not be sufficient for that assessment. MRI and endoscopic ultrasound are added where needed.

  2. Biopsy

    Tissue diagnosis

    The tissue sample is usually taken under the guidance of endoscopic ultrasound. A pathological diagnosis must be in hand for every patient who is to start drug treatment, and it is important that a sample is kept for molecular and inherited gene tests.

  3. Decision

    Three groups

    Patients are assessed in three groups: operable, borderline operable, and not operable. In borderline patients drug treatment is given first and surgery is then reconsidered. Having this distinction made in an experienced centre changes the course of treatment.

Treatment approaches

In operable patients surgery is performed and followed by chemotherapy; in some, chemotherapy is given before the operation. Pancreatic operations call for experience and are best carried out in centres that perform this surgery often.

In disease that is not operable and in advanced disease, treatment is carried out with chemotherapy, and the patient's general condition is decisive in choosing the regimen. In patients carrying a BRCA1/2 or PALB2 change, platinum based treatments and PARP inhibitors come into question, and in the rare MSI-high patients, immunotherapy.

Supportive treatment and inherited risk

In pancreatic cancer supportive treatment is as decisive as the treatment directed at the disease itself.

  1. Support

    Nutrition, pain and enzymes

    Pancreatic enzyme supplements reduce digestive complaints and weight loss. Placing a stent in the bile duct in jaundice, and planning early, effective treatment for pain, are what make it possible to continue treatment. These are not a side issue but a part of it.

  2. Inherited

    Who needs a genetic test?

    Current advice is that patients diagnosed with pancreatic cancer be assessed for inherited gene testing. Changes such as BRCA1/2, PALB2 or ATM can alter both the patient's treatment and the follow-up of their relatives.

Frequently Asked Questions

I have back pain and weight loss. Could it be pancreatic cancer?

There are far more common causes of these complaints. But pain in the abdomen striking through to the back, together with unexplained weight loss, loss of appetite or new onset diabetes, does call for the pancreas to be assessed with imaging. That assessment should be made with a pancreas specific protocol.

Is there screening for pancreatic cancer?

There is no screening programme aimed at the general population. However, surveillance programmes with MRI and endoscopic ultrasound are used for people with more than one case of pancreatic cancer in the family, or who carry an inherited gene change such as BRCA1/2 or PALB2. This group needs genetic counselling.

If I cannot have surgery, is treatment pointless?

No. In patients who are not fit for surgery, chemotherapy still slows the progression of the disease, reduces complaints and extends survival. In borderline patients surgery can become possible after drug treatment, which is why reassessment is made during treatment.

My diabetes has just started. Could it be related?

Diabetes that starts after the age of fifty, or that becomes hard to control for no clear reason, calls for assessment of the pancreas, particularly when it comes with weight loss. On its own this does not mean cancer, but it is a finding that should be looked into.

Does a raised CA 19-9 mean cancer?

No. CA 19-9 also rises when the bile duct is blocked and in some benign conditions, and in some people it does not rise at all even when a cancer is present. It is not used to make a diagnosis; it is a test that helps follow the response to treatment once a diagnosis has been made.