Pancreatic cancer is not one of the most common cancers, but it is one of the deadliest, largely because it is usually found late. The pancreas sits deep in the abdomen, so small tumors cannot be felt, and early symptoms are vague. Knowing the subtle warning signs and the higher-risk groups is important, because finding it early is the best chance of successful treatment.
What the pancreas does
The pancreas is a gland behind the stomach. It makes digestive enzymes that help break down food and hormones, including insulin, that control blood sugar. Most pancreatic cancers (pancreatic ductal adenocarcinomas) start in the cells lining the ducts that carry digestive enzymes. A smaller group, pancreatic neuroendocrine tumors, start in hormone-producing cells and often grow more slowly.
Early warning signs
Symptoms are often vague and easy to blame on other problems. Talk to a doctor if you notice:
- Yellowing of the skin or whites of the eyes (jaundice), often with itchy skin, dark urine and pale or greasy stools. Painless jaundice is an important warning sign, especially in older adults.
- Pain in the upper abdomen that may spread to the back, often worse after eating or when lying down
- Unexplained weight loss and loss of appetite
- New-onset diabetes after age 50, especially with weight loss, or diabetes that suddenly becomes hard to control
- Pale, oily, foul-smelling stools that float (steatorrhea), a sign of poor fat digestion
- Indigestion, nausea or bloating that does not go away
- New blood clots in the legs or lungs without an obvious cause
- Fatigue
These symptoms usually have other causes, but a combination of them, or symptoms that persist for several weeks, deserves evaluation.
Risk factors
- Smoking, one of the most important modifiable risk factors
- Age, with most cases diagnosed after 65
- Obesity
- Long-standing diabetes
- Chronic pancreatitis
- Heavy alcohol use (through its link to pancreatitis)
- Family history: two or more close relatives with pancreatic cancer
- Inherited gene changes, including BRCA1, BRCA2, PALB2, ATM, Lynch syndrome and others
- Certain pancreatic cysts (such as intraductal papillary mucinous neoplasms, or IPMNs)
Who should be screened
There is no screening test for people at average risk. However, surveillance with MRI or endoscopic ultrasound is recommended for certain high-risk people, usually in specialized programs. This typically includes people with:
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- Two or more close relatives with pancreatic cancer on the same side of the family
- Certain inherited gene changes combined with a family history of pancreatic cancer
- Some rare inherited syndromes, such as Peutz-Jeghers syndrome or familial pancreatitis
Professional guidelines also recommend genetic testing for everyone diagnosed with pancreatic cancer, because results can guide treatment and help relatives understand their own risk.
How it is diagnosed
- CT scan with contrast, using a special pancreas protocol, is usually the first test
- MRI and MRCP for further detail
- Endoscopic ultrasound (EUS), in which a camera on a thin tube passed through the mouth gives close-up images and allows a needle biopsy
- Blood tests, including liver tests and the tumor marker CA 19-9, which helps monitor treatment but is not reliable enough to diagnose cancer on its own
Staging determines whether the tumor can be removed surgically:
- Resectable: can be removed with surgery
- Borderline resectable: may be removable after initial chemotherapy
- Locally advanced: involves major blood vessels
- Metastatic: has spread to other organs, most often the liver
Treatment
Surgery offers the best chance of long-term survival. The Whipple procedure (pancreaticoduodenectomy) is used for tumors in the head of the pancreas, and distal pancreatectomy for tumors in the body or tail. These are complex operations, and outcomes are better at high-volume centers with experienced surgical teams.
Chemotherapy is used before and/or after surgery and is the main treatment for advanced disease. Common regimens include FOLFIRINOX and gemcitabine with nab-paclitaxel.
Radiation therapy may be used in some cases.
Targeted therapy is available for tumors with specific gene changes, such as PARP inhibitors for some people with BRCA mutations.
Supportive care is a vital part of treatment. Stents relieve jaundice, enzyme supplements improve digestion and weight, and palliative care teams help with pain and quality of life from the time of diagnosis.
Clinical trials are especially important in pancreatic cancer, and patients are encouraged to ask about them early.
Lowering your risk
- Do not smoke, or quit if you do
- Maintain a healthy weight and stay active
- Limit alcohol
- Manage diabetes
- If pancreatic cancer runs in your family, ask about genetic counseling and whether you qualify for a surveillance program
The bottom line
Pancreatic cancer is often silent until it is advanced. Painless jaundice, unexplained weight loss, persistent upper abdominal or back pain, greasy stools and new diabetes after 50 are warning signs worth discussing with a doctor. If you have a strong family history or a known gene change, ask about genetic counseling and surveillance.
This article is for general information and does not replace medical advice.