All About Pancreatic Cancer: Symptoms, Diagnosis, and Treatment
The pancreas is an organ in the body that sits just behind the stomach. It helps convert the food we eat into energy to fuel our cells. That makes the pancreas pretty important to our day-to-day functioning. Pancreatic cancer is a disease in which the cells of the pancreas grow out of control.
A healthy pancreas has two main roles, says Walter Park, MD, a gastroenterologist and pancreas specialist at Stanford Health Care. First, he explains, “It helps digest the food we eat by secreting out enzymes that break down those different components of food: fat, carbohydrates, and protein.”
Second, the pancreas also houses the cells that make insulin, the hormone that regulates the sugars that get carried in your blood cells throughout the body, Park says. If this process gets disrupted or stops working entirely, you develop diabetes.
Pancreatic cancer occurs much less frequently than some of the leading types of cancer, such as breast cancer, lung cancer, and prostate cancer. A little more than 55,000 new cases of pancreatic cancer are predicted to be diagnosed in the U.S. this year. (That’s compared to more than 260,000 new cases of breast cancer.)
But pancreatic cancer tends to be one of the more difficult types of cancer to treat, and it’s also more deadly. (About 44,000 people will die of pancreatic cancer in 2018, compared to 40,920 people who will die of breast cancer.) That’s because the more common tumors typically spread quickly, and people with these tumors won’t notice symptoms until the later stages of the disease.
Types of pancreatic cancer
Pancreatic cancers fall into two major categories, depending on what type of pancreas cell the cancer originated in: either the exocrine cells of the pancreas (which release the enzymes that help you digest food) or the endocrine cells of the pancreas (which produce the hormones that regulate blood sugar).
Pancreatic exocrine cancer
Exocrine tumors (also called pancreatic adenocarcinoma or just adenocarcinoma) are the more common type of pancreatic cancer, accounting for more than 95 percent of all pancreatic cancers. Exocrine pancreatic cancers typically start in the ducts (think tubes or pipes) that connect the pancreas cells that produce digestive enzymes to the rest of the pancreas and eventually to the bile duct, which carries those enzymes to the small intestine. Less commonly, these tumors originate in the pancreas cells that make those enzymes.
Pancreatic endocrine cancer
Pancreatic endocrine cancers (also called islet cell tumors, pancreatic neuroendocrine tumors, or NETs) start in the endocrine cells of the pancreas, which make the hormones insulin, gastrin, and glucagon. All are cancerous, but some remain small enough not to cause problems.
Statistics show that people with this type of pancreatic cancer tend to have better prognoses and outcomes than people with the more-common exocrine tumors.
“Cancerous endocrine tumors tend to be slower growing, and are often more amenable to surgical treatment,” Park explains.
Pancreatic cancer symptoms
One of the biggest challenges doctors face when it comes to diagnosing and managing pancreatic cancer is that it usually doesn’t cause symptoms until the advanced stages of the disease, when tumors have spread and are tougher to stop.
Some of the common signs of pancreatic cancer that people first notice are:
- Pain in the abdomen (typically radiating to the lower back)
- Loss of appetite or unintended weight loss
- Jaundice (which can cause yellowing of the skin and the whites of your eyes, dark urine, or changes to your stool)
- Persistent diarrhea
Other symptoms that may result from pancreatic cancer can include:
- Blood clots (which are more unusual, Park notes—but if it happens you’ll notice swelling of the affected area, and shortness of breath)
- Nausea, vomiting, and pain after eating
- Gallbladder or liver enlargement
Symptoms that tend to be more specific to pancreatic endocrine cancers include:
- Black, tarry stool
- Developing diabetes
- Irritation of the tongue and mouth as a result of nutrition problems
- Low blood sugar, which can cause dizziness, confusion, rapid heartbeat, and in severe cases, comas or seizures
- Muscle cramping
- Redness in the face or neck
See a doctor if you notice any of these symptoms—or any others that bother you. It’s worth noting, though, that there are many other conditions besides pancreatic cancer that can cause all of these symptoms (or a combination of them), according to Park.
“We’re all entitled to eat something bad and get gastroenteritis, so there’s no need to overreact to an episode of diarrhea,” he says. But do pay attention to persistent symptoms and losing weight when you’re not altering your diet and trying to, especially if you’re older, he says.
What causes pancreatic cancer
Pancreatic cancer starts to form when the DNA in the cells of your pancreas develop mutations, causing those cells start to grow out of control. These mutated cells form a tumor, which starts to spread within the pancreas and eventually to other organs outside of it.
What causes the DNA in pancreatic cells to mutate in the first place is, however, less well understood—other than that these mutations are either inherited from your parents, they are acquired throughout our life, or they happen by chance. Doctors know that certain factors can put an individual at higher risk for this happening, including:
- Having chronic inflammation of the pancreas (a condition called pancreatitis)
- Having diabetes (either type)
- Having a family history of certain genetic syndromes that raise cancer risk, including BRCA2 gene mutation, Lynch syndrome, and familial atypical mole-malignant melanoma syndrome
- Having a family history of pancreatic cancer
- Being a smoker
- Being obese
- Being 65 or older, the age when most people with this type of cancer are diagnosed
- Being African-American (though it is unclear if this increased risk is due to compounding socioeconomic factors, such as smoking rates being higher among African-Americans) or being of Ashkenazi Jewish background
- Being male
- Eating a diet high in red meat and processed meats (such as bacon and hot dogs)
Again, while these factors have been linked to a greater likelihood of an individual developing pancreatic cancer, the biological mechanisms behind these processes still require further research. And just because you have one or several of these risk factors does not necessarily mean you will develop pancreatic cancer—though if your risk is high enough, your doctor may recommend screening, Park explains.
“Often times a pancreatic cyst will bring you to the attention of a gastroenterologist who will recommend a surveillance management plan, such as getting an MRI once a year to see if there are signs the cysts are changing,” he says.
How pancreatic cancer is diagnosed
If you have signs or symptoms that could be a result of pancreatic cancer, you will likely be referred to a gastroenterologist, who will run several tests to determine if you have pancreatic cancer. If those tests are positive, additional ones will be done (usually by a cancer specialist) to identify how advanced the disease is and the best treatment options.
The following tests are commonly used to help diagnose pancreatic cancer:
A medical history and physical exam. Your doctor will likely ask about family history of pancreatic cancer or other genetic syndromes to help understand your personal risk factors. They will also look for physical signs of pancreatic cancer, such as an enlarged belly (which can be a sign of a swelling gallbladder, and which a doctor can feel during an exam) or jaundice.
Imaging tests. These tests produce images of the insides of your pancreas and other organs. The images help the doctor identify suspicious growths and if there are growths, how far the cancer appears to have spread. Tests can include:
- PET scans
- Endoscopic retrograde cholangiopancreatography (which combines an X-ray and the use of an endoscope to produce an image of the liver, gallbladder, pancreas, and bile duct)
- Angiography (an X-ray that looks at the blood vessels)
- Laparoscopy (for which the doctor makes a small incision and is able to look directly into the abdomen with a small camera).
- Computed tomography (CT) scan. CT scans are a type of X-ray that give a cross-sectional image of the inside of your body. They tend to show the pancreas fairly clearly, so they are usually helpful in diagnosing pancreas cancers (as well as showing how far the disease has spread).
Blood tests. Blood tests, such as liver function tests, tumor marker tests, and kidney and bone marrow function tests can all be helpful in determining if someone has symptoms of pancreatic cancer and how far the disease has spread.
Biopsy. A biopsy is the only way to conclusively diagnose cancer, which involves taking a small sample of the tumor and examining it under a microscope. Sometimes biopsies are performed percutaneously, meaning the doctor removes the sample through a small needle inserted through the abdomen. In other cases biopsies are done endoscopically, meaning a small flexible tube with a camera is inserted down the throat and into the small intestine, and then a needle gets inserted into the pancreas. Or they may be done surgically.
From the initial scan to when you see a cancer specialist, getting a diagnosis may take several days or a few weeks, Park notes.
“Patients are going to have a lot of questions and want to figure out what their options are as soon as possible,” says Park. “But it’s important to remember that these cancers didn’t come last night or even a month ago—the process probably took months or years. So waiting a couple of weeks to confirm a diagnosis or decide on a treatment course is not necessarily going to change a patient’s outcome.”
How doctors treat pancreatic cancer
Treatment options for people with pancreatic cancer vary depending on the type of tumor it is, the stage of the cancer when it’s diagnosed, and the age and health of the patient.
Some treatment options the cancer care team might discuss with people with pancreatic cancer include:
- Surgery. If the tumor is diagnosed early enough that the entire tumor can be removed (or “resected”), a curative surgery may be an option. In other cases palliative surgeries, such as opening a blocked bile duct or intestine, may be done to help relieve symptoms that are a result of the cancer or to prevent a complication. In these cases, curing the cancer is not the goal.
- Ablative treatments. These treatments destroy tumors with extreme temperatures (via high-energy radio waves, microwaves, or gas). Typically they’re used to treat pancreatic cancer that has spread to other organs, but they won’t necessarily remove cancer that is in the pancreas. That means these treatments may slow the growth of a tumor, but they will not cure it.
- Embolization. This treatment is an injection that goes directly into an artery as an attempt to block blood flow to cancer cells to kill them.
- Radiation therapy. Radiation therapy delivers high-energy X-rays to the tumor to kill cancer cell. Radiation therapy may be given with chemotherapy; before surgery to try to shrink a tumor to increase the chances of removing it completely; after surgery to lower the chances a tumor will come back; or to relieve symptoms in people who do not have other treatment options.
- Chemotherapy. Chemotherapy drugs are anti-cancer medications that get injected into a vein or are taken orally. The drugs enter the bloodstream so they are able to reach cancer in all parts of the body, but they can have severe side effects. The more aggressive chemotherapies (with more severe side effects) tend to lead to better outcomes for pancreatic cancers, but they are not necessarily an option for all people with cancer depending on their age and overall health status, Park explains.
- Palliative care. Palliative care is medical care that focuses on patient and caregiver quality of life. It often plays an important role in treatment for people with pancreatic cancer, because these doctors help with physical symptoms like pain, fatigue, nausea, and vomiting, Park says. But they can also help meet other needs the person with cancer may have, such as talking to their employer about their illness.
There is also an extensive clinical trials network with a lot of studies looking for patients across the country to try new and emerging therapies, which for some individuals may be a very helpful option, Park says.
Another important treatment consideration for people with pancreatic cancer: if and when to stop treatment. For cancers that are not curable, the discomfort and side effects of treatment may outweigh the survival benefit they are providing. The cancer care team should help people facing these decisions understand their options and pick what’s best.