Pancreatic Cancer Overview

Pancreatic Cancer Overview

Pancreatic cancer begins in the tissues of the pancreas—an organ in your abdomen that lies horizontally behind the lower part of your stomach. The pancreas releases enzymes that aid digestion and hormones that help manage blood sugar levels.

Pancreatic cancer often spreads rapidly to nearby organs and is rarely detected in its early stages. However, for individuals with pancreatic cysts or a family history of pancreatic cancer, certain tests may help in early detection. One sign of pancreatic cancer is the onset of diabetes, especially when it occurs with weight loss, jaundice (yellowing of the skin and eyes), or upper abdominal pain that radiates to the back.

Treatment may involve surgery, chemotherapy, radiation therapy, or a combination of these methods.

Symptoms

Signs and symptoms of pancreatic cancer often do not appear until the disease is advanced. They can include:

• Upper abdominal pain that radiates to the back
• Loss of appetite or weight loss
• Depression
• Newly diagnosed diabetes
• Blood clots
• Fatigue
• Yellowing of the skin and the whites of the eyes (jaundice)

When to See a Doctor

See your doctor if you experience unexplained weight loss, persistent fatigue, abdominal pain, jaundice, or other concerning signs and symptoms. Many conditions can cause these symptoms, so your doctor may check for these conditions as well as pancreatic cancer.

Causes

The exact causes of pancreatic cancer are unclear in most cases. However, doctors have identified several factors that increase the risk of developing the disease, including smoking.

Understanding the Pancreas

Your pancreas is about 6 inches long and resembles a pear positioned horizontally. It secretes hormones, including insulin, to help your body process sugar from the foods you eat and produces enzymes to assist in food digestion.

How Pancreatic Cancer Forms

Pancreatic cancer occurs when cells in the pancreas develop mutations in their DNA. These mutations cause the cells to grow uncontrollably and continue living when normal cells would die. The accumulated cells can form a tumor. Untreated pancreatic cancer spreads to nearby organs and blood vessels.

Pancreatic cancer usually starts in the cells lining the pancreatic ducts. This type of cancer is called pancreatic adenocarcinoma or pancreatic exocrine cancer. Rarely, cancer may form in hormone-producing cells or in the neuroendocrine cells of the pancreas. These types of cancer are known as islet cell tumors, pancreatic endocrine cancer, and pancreatic neuroendocrine tumors.

Risk Factors

Factors that may increase the risk of pancreatic cancer include:

• Chronic inflammation of the pancreas (pancreatitis)
• Diabetes
• Family history of genetic syndromes that can increase cancer risk, including 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 has shown that a combination of smoking, long-term diabetes, and poor diet increases the risk of pancreatic cancer beyond the risk of any of these factors alone.

Complications

As pancreatic cancer progresses, it can cause complications such as:

Weight Loss

Several factors can lead to weight loss in individuals with pancreatic cancer. The cancer itself can cause weight loss. Nausea and vomiting caused by cancer treatments or pressure from the tumor on your stomach can make eating difficult. Alternatively, your body may struggle to process nutrients from food because the pancreas does not produce enough enzymes.

Your doctor may recommend pancreatic enzyme supplements to aid digestion. Try to maintain your weight by adding extra calories where you can and making mealtime as enjoyable and relaxed as possible.

Jaundice

Pancreatic cancer that blocks the bile duct can cause jaundice. Signs include yellowing of the skin and eyes, dark urine, and pale stools. Jaundice usually appears without abdominal pain.

Your doctor may recommend placing a plastic or metal tube (stent) inside the bile duct to keep it open. This is done through a procedure called endoscopic retrograde cholangiopancreatography (ERCP). During ERCP, an endoscope passes through your throat, down your stomach, and into the upper part of your small intestine. A contrast dye is then injected into the pancreatic and bile ducts through a small hollow tube (catheter) that goes through the endoscope. Finally, images of the bile ducts are taken.

Pain

An increasing tumor can press on the nerves in your abdomen, causing pain that can become severe. Pain medications can help you feel more comfortable. Radiation therapy may temporarily halt tumor growth to provide some relief.

In severe cases, your doctor may recommend a procedure to inject alcohol into the nerves that control pain in your abdomen (abdominal plexus block). This procedure prevents the nerves from sending pain signals to your brain.

Bowel Obstruction

Pancreatic cancer that grows or presses on the first part of the small intestine (duodenum) can obstruct the flow of digested food from your stomach to your intestines.

Your doctor may recommend placing a tube (stent) in the small intestine to keep it open. Alternatively, surgery may be necessary to attach your stomach to a lower part of your intestines that is not blocked by cancer.

Prevention

You can reduce your risk of developing pancreatic cancer by:

• Quitting Smoking: If you smoke, try to quit. Discuss strategies with your doctor that can help you stop, including support groups, medications, and nicotine replacement therapy. If you don’t smoke, don’t start.
• Maintaining a Healthy Weight: If you are at a healthy weight, try to maintain it. If you need to lose weight, aim for a slow, steady weight loss of 0.5 to 1 pound per week. Combine daily exercise with a diet rich in vegetables, fruits, and whole grains in smaller portions to help you lose weight.
• Choosing a Healthy Diet: A diet rich in colorful fruits, vegetables, and whole grains can help reduce your risk of cancer.
• Considering Genetic Counseling: If you have a family history of pancreatic cancer, consider meeting with a genetic counselor. They can review your family health history and determine whether you might benefit from genetic testing to understand your risk for pancreatic cancer or other cancers.

Diagnosis

If your doctor suspects pancreatic cancer, he or she may perform one or more of the following tests:

Radiological Examination

These tests help your doctors visualize your internal organs, including the pancreas. The techniques used to diagnose pancreatic cancer include ultrasound, computed tomography (CT) imaging, magnetic resonance imaging (MRI), and sometimes positron emission tomography (PET) scans.

Endoscopic Ultrasound (EUS)

An endoscopic ultrasound (EUS) uses a specialized ultrasound device to create images of your pancreas from inside your abdomen. The device is passed through a thin, flexible tube (endoscope) from your esophagus into your stomach to obtain the images.

Tissue Sample Removal for Examination (Biopsy)

A biopsy is a procedure to remove a small tissue sample for examination under a microscope. Your doctor may take a tissue sample from the pancreas by inserting a needle through your skin into your pancreas (fine needle aspiration). The doctor can also remove a sample during the EUS by guiding special tools into the pancreas.

Blood Test

Your doctor may check your blood for specific proteins (tumor markers) produced by pancreatic cancer cells. One tumor marker test used in pancreatic cancer is called CA19-9. However, this test is not always reliable, and it is unclear how best to use the CA19-9 results. Some doctors measure the levels before, during, and after treatment.

If your doctor confirms a diagnosis of pancreatic cancer, he or she will attempt to determine the extent (stage) of the cancer. Using information from staging tests, your doctor assigns a stage to the pancreatic cancer, which helps determine which treatments are most likely to benefit you.

The stages of pancreatic cancer are indicated with Roman numerals ranging from 0 to IV. Lower stages indicate that the cancer is confined to the pancreas. By stage IV, the cancer has spread to other parts of the body.

The cancer staging system continues to evolve and becomes increasingly complex as doctors improve cancer diagnosis and treatment. Your doctor uses the stage of the cancer to choose appropriate treatments for you.

Feel free to ask your doctor about his or her experience with diagnosing pancreatic cancer. If you have any doubts, seek a second opinion.

Treatment

Treatment for pancreatic cancer depends on the stage and location of the cancer, as well as your overall health preferences and personal choices. For most people, the primary goal of pancreatic cancer treatment is to eliminate the cancer when possible. When that is not an option, the focus may be on improving your quality of life and preventing the cancer from growing or causing further harm.

Treatment may include surgery, radiation therapy, chemotherapy, or a combination of these. When pancreatic cancer is advanced and these treatments are unlikely to provide a benefit, your doctor will offer symptom relief (palliative care) to make you as comfortable as possible.

Surgical Intervention

Surgical procedures used for individuals with pancreatic cancer include:

Surgery for Tumors in the Head of the Pancreas

If your cancer is located in the head of the pancreas, you may be a candidate for a surgery called the Whipple procedure (pancreaticoduodenectomy).

The Whipple procedure is a technically challenging operation that involves removing the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, and part of the bile duct. In some cases, part of the stomach and nearby lymph nodes may also be removed. Your surgeon will reconnect the remaining parts of the pancreas, stomach, and intestines to allow for proper digestion of food.

Surgery for Tumors in the Body and Tail of the Pancreas

Surgery to remove the left side (body and tail) of the pancreas is called a distal pancreatectomy. Your surgeon may also remove your spleen during this procedure.

Surgery to Remove the Entire Pancreas

In some cases, it may be necessary to remove the entire pancreas, known as a total pancreatectomy. You can live a relatively normal life without a pancreas, but you will require lifelong insulin therapy and enzyme replacement.

Surgery for Tumors Involving Nearby Blood Vessels

Many people with advanced pancreatic cancer are not considered eligible for the Whipple procedure or other pancreatic surgeries if their tumors involve nearby blood vessels. In very few medical centers in the United States, highly specialized and experienced surgeons can safely perform these procedures by removing and reconstructing portions of blood vessels in selected patients.

Each of these surgeries carries risks of bleeding and infection. After surgery, some individuals may experience nausea and vomiting if the stomach has difficulty emptying (delayed gastric emptying). Expect a lengthy recovery period after any of these procedures. You will spend several days in the hospital and then recover at home for several weeks.

Extensive research shows that surgery for pancreatic cancer tends to result in fewer complications when performed by experienced surgeons at centers that conduct many of these procedures. Don’t hesitate to inquire about your surgeon’s and hospital’s experience with pancreatic cancer surgery. If you have doubts, seek a second opinion.

Chemotherapy

Chemotherapy uses medications to help kill cancer cells. These drugs can be administered intravenously or taken orally. You may receive a single chemotherapy drug or a combination of them.

Chemotherapy can also be combined with radiation therapy. This combination is commonly used for treating cancer that has spread beyond the pancreas, but only to nearby organs and not to distant areas of the body. In specialized medical centers, this combination may be used before surgery to help shrink the tumor. Sometimes, it is used after surgery to reduce the risk of pancreatic cancer recurrence.

In individuals with advanced pancreatic cancer, chemotherapy is often used to control the growth of cancer and extend survival.

Radiation Therapy

Radiation therapy uses high-energy beams, such as X-rays and protons, to destroy cancer cells. You may receive radiation treatments before or after cancer surgery, often in combination with chemotherapy. Alternatively, your doctor may recommend a combination of radiation and chemotherapy when your cancer cannot be treated surgically.

Radiation therapy typically comes from a machine that moves around you, directing the radiation to specific points in your body (external beam radiation). In specialized medical centers, radiation therapy may be delivered during surgery.

Traditionally, radiation therapy uses X-rays to treat cancer. Some medical centers offer proton radiation therapy, which may be a treatment option for certain individuals with advanced pancreatic cancer.

Clinical Trials

Clinical trials are studies designed to test new treatments, such as systemic therapy, and new approaches to surgery or radiation therapy. If the studied treatment proves to be safer and more effective than current therapies, it may become the new standard of care.

Clinical trials for pancreatic cancer will give you the opportunity to try new targeted therapies, chemotherapy drugs, immunotherapy treatments, or vaccines.

Clinical trials cannot guarantee a cure and may have serious or unexpected side effects. On the other hand, clinical trials for cancer are closely monitored to ensure they are conducted in the safest possible way. They also provide access to treatments that would otherwise not be available to you.

Discuss with your doctor which clinical trials may be appropriate for you.

Palliative Care

Palliative care is specialized medical care focused on providing relief from pain and other symptoms of serious illness. Palliative care specialists work with you, your family, and your other doctors to provide an extra layer of support that complements your ongoing care. Palliative care can be used while undergoing aggressive treatments, such as surgery, chemotherapy, and radiation therapy.

When palliative care is used alongside other appropriate treatments—even shortly after diagnosis—individuals with cancer may feel better and live longer.

Palliative care is provided by teams of doctors, nurses, and other trained professionals. These teams aim to improve the quality of life for people with cancer and their families. Palliative care is not the same as hospital care or end-of-life care.

Alternative Medicine

Some approaches to integrative and alternative medicine may help you manage the signs and symptoms you experience due to your cancer or its treatments.

Treatments That Can Help Manage Discomfort

People with cancer often experience discomfort. Some research suggests that discomfort is more common in people with pancreatic cancer than in those with other types of cancer.

If you are suffering, you may have trouble sleeping and find yourself constantly thinking about your cancer. You may feel angry or sad.

Discuss your feelings with your doctor. Specialists can help you sort out your emotions and assist you in developing coping strategies. In some cases, medications may help.

Integrative medicine and alternative therapies may also help you cope with distress. Examples include:

• Art therapy
• Exercise
• Meditation
• Music therapy
• Relaxation exercises
• Spirituality

Talk to your doctor if you are interested in these treatment options.

Coping and Support

Learning that you have a life-threatening illness can be devastating. Some of the following suggestions may help:

• Learn What You Need to Know About Your Cancer: Gather enough information about your cancer to help you make decisions regarding your care. Ask your doctor about the details of your cancer and your treatment options. Inquire about reliable sources for further information. If you do your own research, good places to start are support groups specializing in pancreatic cancer.
• Create a Support System: Ask your friends and family to form a support network for you. You may feel helpless and uncertain after your diagnosis. Helping you with simple tasks can provide comfort. You may find relief in not having to worry about certain chores. Think about the things you would like help with, such as meal preparation or getting to appointments.
• Find Someone to Talk To: While friends and family can be your best allies, in some cases, they may struggle to cope with the shock of your diagnosis. In these instances, talking to a counselor, a medical social worker, or a pastoral or religious counselor may be helpful. Ask your doctor for a referral.
• Connect with Other Cancer Survivors: You may find comfort in talking with other cancer survivors. Reach out to your doctor or other support groups that may connect you with a pancreatic cancer survivor who can provide support through phone calls or emails.
• Reach Out to the Hospital: Nursing care provides comfort and support to terminally ill patients and their loved ones. It allows family and friends—with the help of nurses, social workers, and trained volunteers—to care for and facilitate a loved one at home or in a home residence. Palliative care also offers emotional, social, and spiritual support for the ill and those closest to them.

Preparing for Your Appointment

Start by making an appointment with your doctor if you have any signs or symptoms that concern you. They may recommend tests to investigate your signs and symptoms. If your doctor determines that you have pancreatic cancer, they may refer you to:

• A doctor who treats cancer (oncologist)
• A doctor who uses radiation to treat cancer (radiation oncologist)
• A surgeon who specializes in surgeries involving the digestive system
• A doctor who diagnoses and treats digestive diseases (gastroenterologist)

What You Can Do

• Keep in mind any pre-appointment restrictions, such as dietary limitations.
• Write down your symptoms, including those that do not seem related to the reason for your appointment.
• Record key personal information, including any recent changes or stressors.
• List all your medications, vitamins, and supplements, including their dosages.
• Ask a family member or friend to accompany you to help remember what the doctor says.

Questions to Ask Your Doctor

• Do I have pancreatic cancer?
• What is the stage of my cancer?
• Will I need additional tests?
• Can my cancer be cured?
• What are my treatment options?
• Could any treatment help me live longer?
• What are the potential risks of each treatment?
• Is there a treatment you think is best for me?
• What advice would you give to a friend or family member in my situation?
• What is your experience with diagnosing and treating pancreatic cancer?
• How many surgeries for this type of cancer are performed each year at this medical center?
• I am experiencing these symptoms. What can be done to help me feel more comfortable?
• What clinical trials are available for pancreatic cancer?
• Am I eligible for any?
• Am I eligible for molecular testing of my cancer?
• Do you have brochures or other printed materials that I can take with me?

What to Expect from Your Doctor

Your doctor may ask you a series of questions, such as:

• When did you first start experiencing symptoms?
• How severe are your symptoms?
• Are they occasional or continuous?
• Does anything improve or worsen your symptoms?