Pancreatic cancer
- Dr Sherif Raouf, Consultant in Clinical Oncology
Pancreatic cancer is a type of cancer that starts in your pancreas. Your pancreas is found in the top part of your tummy, behind your stomach. It’s part of your digestive system. Pancreatic cancer is the tenth most common cancer in the UK.
About pancreatic cancer
Your pancreas is a J-shaped organ that sits behind your stomach at the back of your tummy (abdomen). It has two different roles in your body.
- Exocrine role – it makes enzymes, which help you break down (digest) food so your body can absorb essential nutrients.
- Endocrine role – it makes hormones such as insulin, which helps to control your blood sugar levels.
Pancreatic cancer happens when cells in your pancreas grow abnormally and out of control, creating a lump (tumour). This can affect how well your pancreas works. The cancer cells can spread out of your pancreas. They may grow into surrounding blood vessels and lymph nodes. They can also affect other organs – for example, your duodenum (part of your small bowel) and liver.
Types of pancreatic cancer
There are several types of pancreatic cancer. These start in different parts of your pancreas and may be treated in different ways.
Exocrine cancers
Most pancreatic cancers are exocrine cancers. More than 9 out of 10 exocrine cancers are pancreatic ductal adenocarcinomas. This pancreatic cancer type starts in cells that line the ducts (tubes) of the pancreas. These cells make enzymes that help with digestion.
Other, rarer types of pancreatic exocrine cancers may be treated differently from pancreatic ductal adenocarcinomas. These include:
- cancer of the acinar cells (at the ends of the ducts)
- cystic tumours
Endocrine cancers
Endocrine cancers make up fewer than 1 in 10 cases of pancreatic cancer. They form in the neuroendocrine cells of the pancreas. These cells make hormones such as insulin. Endocrine cancers are sometimes called pancreatic neuroendocrine tumours (PNETS). Pancreatic endocrine cancers are treated differently from pancreatic exocrine cancers.
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Causes of pancreatic cancer
Pancreatic cancer can affect people of any age, but it tends to be more common in older people. It’s not always clear what causes it, but you’re more likely to get this type of cancer if you:
- are over 65 – it’s not common in people under 40
- smoke – the more you smoke, the higher your risk
Other possible pancreatic cancer risk factors include:
- having chronic pancreatitis – long-term inflammation of your pancreas that’s often caused by drinking a lot of alcohol for many years
- having a family history of pancreatic cancer or certain genetic conditions (including the BRCA1 and BRCA2 genes)
- being overweight or obese
- your diet – for example, eating a lot of red or processed meat and not many fruits and vegetables
- having other medical conditions such as inflammatory bowel disease and diabetes
Symptoms of pancreatic cancer
Pancreatic cancer doesn’t always cause symptoms in the early stages. Or, if it does cause symptoms, these can be hard to spot.
Tummy pain is the most common pancreatic cancer symptom. The pain is usually in the top part of your tummy and sometimes spreads to your upper back. It may be worse when you’re lying down flat and better when you sit forward.
Jaundice may be a sign of pancreatic cancer. Jaundice doesn’t cause any pain but you may notice you have darker pee and paler poo than usual. You may also feel very itchy. Your skin or the whites of your eyes may turn yellow.
Other possible pancreatic cancer symptoms include:
- not feeling hungry
- losing weight for no known reason
- feeling very tired (fatigue)
- feeling bloated
- changes to your bowel habits – for example, diarrhoea or smelly poo
- depression
- feeling or being sick
Many of these symptoms are very common and may be due to other conditions – for example, gallstones. It’s important to get symptoms checked out by your GP as soon as possible.
Some people with pancreatic cancer may be diagnosed with diabetes. This is because pancreatic cancer can affect how their body controls their blood sugar. Common symptoms of diabetes include:
- feeling very thirsty
- needing to pee a lot
- waking in the night to pee
Pancreatic cancer can spread to other parts of your body – for example, your lungs, liver, skin, and brain. It may also cause other symptoms as the cancer gets bigger. These symptoms include severe pain, especially in your back.
The tumour may block your duodenum, causing tummy pain, sickness, constipation, and bloating – you’ll need surgery to unblock it. You may also be prone to blood clots in your legs (deep vein thrombosis) and lungs (pulmonary embolism). You may be given medicines to stop the blood clotting.
Diagnosis of pancreatic cancer
Your GP will ask about your symptoms. They may ask about your medical history and family history too, and your general health. They may also feel your tummy. Your GP may arrange for you to have a blood test to check:
- how well your liver and kidneys are working
- your blood sugar levels
- if you have any specific tumour markers in your blood
If you’re over 40 and have jaundice or your GP thinks you may have pancreatic cancer, they’ll urgently refer you for more tests and scans or to see a specialist in a hospital. But being referred urgently doesn’t mean you have cancer.
Tests and scans used to diagnose pancreatic cancer may include:
If you've been told you have pancreatic cancer, your doctor will look at the results of these tests and scans to see how big the cancer is and how far it's spread. This is called staging. Staging helps your doctor decide on best treatment plan for you.
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Treatment of pancreatic cancer
Pancreatic cancer can be difficult to treat. The treatment you have will depend on:
- the size and type of pancreatic cancer you have
- where it is
- if it has spread
- your general health
- your age
You’ll be looked after by a specialist pancreatic cancer multidisciplinary team. They’ll explain your treatment options and plan your care. Your medical team may include:
- a specialist nurse (sometimes called a clinical nurse specialist)
- an oncologist (a doctor who specialises in treating cancer)
- a gastroenterologist (a doctor who specialises in treating diseases of the digestive system)
- a dietitian (who will give you advice on what to eat and drink)
Your pancreatic cancer treatment options may include:
- surgery
- chemotherapy
- radiotherapy
- pain management
- psychological support
- nutritional support
Your medical team will discuss which treatment is best for you, and why. A genetic analysis to look for certain gene changes may lead to some different treatment options.
Surgery
Surgery is the main treatment if your pancreatic cancer is found early and hasn’t spread. There are several different types of surgery for pancreatic cancer, depending on where the tumour is in the pancreas. Whipple’s procedure is the most common type of surgery used for pancreatic cancer. Your specialist medical team will discuss all of the benefits and risks of surgery with you.
If the cancer has grown close to major blood vessels near your pancreas, you may be offered chemotherapy or radiotherapy to shrink the cancer. The surgeon may then be able to remove cancer with surgery.
You may also be offered surgery to help control some of your symptoms. This includes surgery to:
- unblock the bile duct or stop it getting blocked – this may reduce any jaundice
- unblock your duodenum or stop it getting blocked – to help stop you feeling or being sick
It can take at least a few months to recovery from surgery to treat pancreatic cancer. But everyone recovers differently.
Chemotherapy
If your cancer can’t be removed with surgery, you may be offered chemotherapy. Chemotherapy uses medicines to kill cancer cells. It’s used in different ways depending on your cancer and your general health. You may be offered chemotherapy for pancreatic cancer:
- if you can’t have surgery
- to control some of your symptoms
- before surgery to make the cancer easier to remove
- after surgery to stop the cancer coming back
There are several chemotherapy medicines used to treat pancreatic cancer. These include:
- gemcitabine on its own
- FOLFIRINOX (a combination of fluorouracil, oxaliplatin, leucovorin, and irinotecan)
- gemcitabine with capecitabine
- gemcitabine with nab-paclitaxel
Chemotherapy can cause some side-effects, such as a sore mouth, feeling or being sick, hair loss and an increased risk of blood clots (deep vein thrombosis). It can also make you more prone to infections. The specific side-effects may depend on the chemotherapy medicines being used. Your medical team will explain about possible side-effects.
Radiotherapy
Radiotherapy uses radiation to destroy cancer cells. Sometimes you may be offered radiotherapy on its own to treat pancreatic cancer. Or you may have chemotherapy with radiotherapy (called chemoradiotherapy).
You may be offered stereotactic body radiotherapy (SBRT).This type of external radiotherapy gives targeted radiation from lots of positions around your body. The beams of radiation then meet at the tumour. The tumour receives a high dose of radiation, but the surrounding tissues only get a low dose. This should reduce the risk of side-effects.
Stenting
If the cancer is blocking your bile duct and causing jaundice, your doctor may recommend you have a biliary stent. A stent is a plastic or metal tube that’s put inside your bile duct to hold it open. It’s inserted using endoscopic retrograde cholangiopancreatography (ERCP). The stent may treat the jaundice and ease associated symptoms such as itching. Stents may need to be replaced if they get blocked. After stenting, you can also get an infection or inflammation of the pancreas (pancreatitis).
Symptom relief
Pancreatic cancer affects everyone differently. Your doctors may offer you several treatments to ease your symptoms. So it’s important to tell your doctor or nurse how you’re feeling.Pancreatic cancer can cause a lot of tummy pain. The pain can be severe and affect your daily activities. You may be offered pain relief, for example:
- opioid painkillers, sometimes as skin patches
- injections of a local anaesthetic into your upper tummy
You may also be offered medicines or other treatments to ease pancreatic cancer symptoms such as:
- itching
- feeling or being sick
- fatigue
If your pancreatic cancer has caused diabetes, you’ll be offered tablets or insulin injections to help control your blood sugar levels.
Nutritional support
You’ll usually be referred to a dietitian to discuss nutrition and problems with eating.You shouldn’t need to eat a special diet if you have pancreatic cancer. But you’ll usually be given pancreatic enzyme capsules to help you digest food. Pancreatic enzyme replacement therapy (PERT) replaces any enzymes that your pancreas usually makes. This should help to ease any diarrhoea.It may also help to slow down weight loss.
Help and support
Being diagnosed with pancreatic cancer can be distressing for you and your loved ones. Pancreatic cancer symptoms, such as fatigue and pain, can also make you feel very down. Anxiety and depression are very common in people with pancreatic cancer.
An important part of cancer treatment is getting enough support to deal with the emotional aspects as well as the physical symptoms. If you’re feeling down or worried about anything, it’s important to speak to your specialist medical team. They are experts in providing the support you need. A clinical nurse specialist will usually be assigned to you as soon as you’ve been diagnosed. This person will coordinate your care.
Talking to your family and friends will help them understand how you’re feeling and what you’re going through. You can be referred to a counsellor or clinical psychologist for talking therapies or cognitive behavioural therapy. It’s important that your family can access support too, if they need it.
Patient charities and support groups can be a great source of information and support. For more information, see our section on other helpful websites. Voluntary groups and patient organisations such as Macmillan Cancer Support and Marie Curie can provide nursing and care. If you have more advanced cancer, you can get support through hospices or at home. Your doctor will discuss this with you.
Prevention of pancreatic cancer
If you smoke, the best way to reduce your risk of pancreatic cancer is to stop smoking. Ask your local pharmacist or a GP about the best way to quit smoking.
Other lifestyle factors that may lower your risk include:
- trying to lose weight if you’re overweight
- cutting down on red and processed meats (for example, ham, bacon, and salami)
- taking regular exercise
- eating more fruit and vegetables
- cutting down on alcohol – avoid drinking more than 14 units each week
If your family history or genetic risk factors mean you’re more likely to get pancreatic cancer, you should be referred to a specialist clinic for genetic testing and counselling. You may be offered regular monitoring with a CT scan, MRI scan or endoscopic ultrasound scan (EUS).
Pancreatic cancer doesn’t usually cause any specific symptoms in the early stages. But it can cause pain in the top part of your tummy. The pain sometimes spreads to your back.
Some people may notice signs such as:
- their bowel habits have changed
- they’re losing weight for no known reason
- they have signs of jaundice such as itching, darker pee, and paler poo than usual.
For more information, see our section on symptoms of pancreatic cancer.
It’s not always clear what causes pancreatic cancer. But smoking is the biggest risk factor, especially in people over 65. Other possible causes include being overweight or obese, or having a family history of pancreatic cancer.
For more information, see our section on causes of pancreatic cancer.
Pancreatitis
Pancreatitis is when your pancreas becomes inflamed, which can stop it working properly.
What is cancer?
Find out more about what causes cancer, how it’s treated, and steps you can take to help prevent it.
How to reduce your risk of cancer
In the UK, one in two people will have cancer at some point in their life, but over a third of cancer cases could be prevented. Understand some of the steps to help reduce the risk of cancer.
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- Victoria Goldman, Freelance Health Editor
