Overview of Pancreatic Cancer

Cancer Connect

Medically reviewed by Dr. C.H. Weaver M.D. Medical Editor 7/2020

The pancreas is a glandular organ located in the posterior aspect of the abdomen. It lies between the liver and the spleen, and just below and behind the stomach. The pancreas produces digestive enzymes (exocrine function), which are emptied into the small bowel, as well as the hormone insulin (endocrine function), which enters the blood stream.

Adenocarcinoma is a type of cancer that begins in the cells that line the glands and ducts within the pancreas. It accounts for 90% of cancers originating in the pancreas. This treatment overview deals only with adenocarcinoma of the exocrine pancreas, which will be referred to as pancreatic cancer.

Other Exocrine Cancers of the Pancreas

  • Acinar cell carcinoma: a rare cancer of the pancreas that makes too much of the enzyme lipase which is necessary for the digestion of fat. Lipase can be measured in the blood.
  • Papillary mucinous neoplasm (IPMN): grows in the pancreatic ducts.
  • Mucinous cystadenocarcinoma: a rare cancer that is essentially a cyst filled with thick fluid and usually grows in the tail of the pancreas.

Information About Pancreatic Neuroendocrine Tumors

There are approximately 53,000 individuals diagnosed with cancer of the pancreas in the United States each year, and approximately 43,000 individuals succumb to the disease annually. The incidence of carcinoma of the pancreas has markedly increased over the past several decades and ranks as the fourth leading cause of cancer death in the United States. Despite the high mortality rate associated with pancreatic cancer, its cause is poorly understood.(1-5)

The treatment of pancreatic cancer may consist of surgery, precision cancer medicines, chemotherapy, and radiation therapy, and is likely to involve several different types of physicians. As newer precision cancer medicines are developed it's extremely important that all patients undergo genomic biomarker testing. Treating physicians may include a gastroenterologist, a surgeon, a medical oncologist, a radiation oncologist, or other specialists. Care must be carefully coordinated between the various treating physicians.

Symptoms & Signs of Pancreatic Cancer

The initial growth of pancreatic cancer occurs within the pancreas and may cause blockage of the pancreatic or biliary ducts and produce jaundice, a condition where the skin turns yellow. In the early stages of pancreatic cancer there are not many noticeable symptoms. Pancreatic cancer symptoms depend on the site of the cancer within the pancreas and it location. As the cancer grows, symptoms may include the following:

  • Jaundice.
  • Light-colored stools or dark urine.
  • Pain in the upper or middle abdomen and back.
  • Weight loss for no known reason.
  • Loss of appetite.
  • Fatigue

Having these symptoms does not necessarily mean a person has pancreatic cancer. Anyone with these symptoms however should see a doctor so that the problem can be caught early.(1-3)

Cause of Pancreatic Cancer

Pancreatic cancer begins when healthy cells acquire a genetic change (mutation) that causes them to turn into abnormal cells. The exact cause of most pancreatic cancers is unknown and about 5-10 percent are thought to be hereditary. (2)

Risk factors for Pancreatic Cancer

A risk factor is anything that increases a person’s chance of developing cancer. Risk factors can influence the development of cancer but most do not directly cause cancer. Many individuals with risk factors will never develop cancer and others with no known risk factors will. Most pancreatic cancers develop sporadically, which means for no known reason. Some pancreatic cancers however are more likely to develop in individuals with certain risk factors that increase an individual’s chance of developing pancreatic cancer.

The following factors may raise a person’s risk for developing pancreatic cancer.(2,3,4,5)

  • A family history of pancreatic cancer.
    • Lynch Syndrome
  • Cigarette smoking.
  • Obesity.
  • Chronic pancreatitis.
  • Advanced age

Diagnosis & Tests for Pancreatic Cancer

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. A biopsy is the only certain way to confirm a diagnosis of cancer. When performing a biopsy, the doctor takes a sample of tissue for testing in a laboratory.(2)

In order to understand the best treatment options available for treatment of pancreatic cancer, it is important to first determine where the cancer has spread in the body. More advanced cancers may invade adjacent organs, such as the liver, bile ducts, and intestine or spread to lymph nodes, the lining of the abdominal cavity, or other organs in the body via the blood system. Pancreatic cancer cells have a propensity to spread via the blood to the liver and, less commonly, to the lungs.

Determining the extent of the spread or the stage of the cancer is of initial importance to determine whether the cancer can be removed surgically. Upon completion of the clinical “staging evaluation,” your physicians will determine whether the cancer can be removed by surgery.(1) The most common surgical procedure is a “Whipple” procedure. During this procedure the surgeon removes a portion of the pancreas, duodenum, stomach, and the entire gallbladder. Recent clinical studies have suggested that surgery is underutilized in patients with early-stage cancer of the pancreas, and that there is an opportunity to improve care of pancreatic cancer patients in the United States by offering surgery to all appropriate patients with early-stage operable disease.(3)

Following surgical removal of pancreatic cancer, a final “pathologic” stage will be determined. If the cancer cannot be removed by surgery, then the results of the clinical staging evaluation will be used to assign a stage. The following diagnostic procedures may be used in the evaluation of pancreatic cancer.

Imaging tests: Tests such as X-rays, CT scans, magnetic resonance imaging (MRI) and positron emission tomography (PET) are used to help determine the stage and whether the cancer has spread.

  • Computed Tomography (CT) Scan: A CT scan is a technique for imaging body tissues and organs, during which X-ray transmissions are converted to detailed images, using a computer to synthesize X-ray data. A CT scan is conducted with a large machine positioned outside the body that can rotate to capture detailed images of the organs and tissues inside the body.
  • Magnetic Resonance Imaging (MRI): MRI uses a magnetic field rather than X-rays, and can often distinguish more accurately between healthy and diseased tissue than a CT. An MRI gives a better picture of cancer located near bone than does CT, does not use radiation, and provides pictures from various angles that enable doctors to construct a three-dimensional image of the cancer.
  • Positron emission tomography (PET): Positron emission tomography scanning is an advanced technique for imaging body tissues and organs. One characteristic of living tissue is the metabolism of sugar. Prior to a PET scan, a substance containing a type of sugar attached to a radioactive isotope (a molecule that emits radiation) is injected into the patient’s vein. The cancer cells “take up” the sugar and attached isotope, which emits positively charged, low energy radiation (positrons) that create the production of gamma rays that can be detected by the PET machine to produce a picture. If no gamma rays are detected in the scanned area, it is unlikely that the mass in question contains living cancer cells.

Endoscopic Retrograde Cholangiopancreatography (ERCP):

ERCP is a procedure that enables your physician to examine the pancreatic and bile ducts. A bendable, lighted tube (endoscope) about the thickness of your index finger is inserted into your mouth and passed into your stomach and first part of the small intestine. In the small intestine a small opening is identified (ampulla) and a small plastic tube (cannula) is passed through the endoscope and into this opening. Dye (contrast material) is injected and X-rays are taken to study the ducts of the pancreas and liver. ERCP can be used to obtain a sample (biopsy) of any suspicious lesions in the area or place a stent to relieve blockage of the ducts.

Endosonography: Endosonography refers to an ultrasound test performed through an endoscope. Ultrasound tests utilize sound waves to detect different densities of tissue, including cancer. Endoscopic ultrasound may be used to determine the size of the cancer and whether surrounding lymph nodes may be enlarged.

Gastroscopy: A gastroscopy is an examination performed through an endoscope, which is a flexible tube inserted through the esophagus that allows the physician to visualize, photograph and biopsy (sample) the cancer. All patients have a gastroscopy with a biopsy to determine the histology or appearance of the cancer under the microscope.

Laparoscopy: Laparoscopy is a procedure that involves the insertion of an endoscope through a small incision in the abdomen. Laparoscopy is an important tool for staging and has proven to be more reliable than CT scanning in detecting spread of cancer to the liver and the lining of the abdomen (peritoneum).

Stages of Pancreatic Cancer

In order to learn more about the most recent information available concerning the treatment of pancreatic cancer, click on the appropriate stage.

Stage I: Cancer is confined to the pancreas.

Stage II: Cancer may extend to the duodenum, bile ducts, or fat surrounding the pancreas, but does not invade any local lymph nodes.

Stage III: Cancer invades one or more of the local lymph nodes and has extended to major blood vessels.

Stage IV: Cancer has spread to the stomach, bowel, or distant locations in the body, which may include the liver, lungs, bones, or other sites.

Recurrent/Relapsed: The pancreatic cancer has been detected or returned (recurred/relapsed) following an initial treatment.

Genomic or Biomarker Testing-Precision Cancer Medicine

The purpose of precision cancer medicine is to define the genomic alterations in the cancers DNA that are driving that specific cancers growth. Once a genetic abnormality is identified, a specific targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of the cancer cells. Precision cancer medicine uses targeted drugs and immunotherapies engineered to directly attack the cancer cells with specific abnormalities, leaving normal cells largely unharmed.

  • Germline BRCA - mutated pancreatic cancer accounts for ~7% of all pancreatic cancers and can be treated with a precision cancer medicine known as a PARP inhibitor. BRCA1 and BRCA2 are human genes that produce proteins responsible for repairing damaged DNA. When either of these genes is mutated, or altered DNA damage may not be repaired properly, and the cells are more likely to develop additional genetic alterations that can lead to cancer.(6,7)

References:

  1. American Cancer Society: Cancer Facts and Figures 2017. Atlanta, Ga: American Cancer Society, 2017.
  2. NCCN Guidelines for Patients Pancreatic Cancer
  3. Silverman DT, Schiffman M, Everhart J, et al.: Diabetes mellitus, other medical conditions and familial history of cancer as risk factors for pancreatic cancer. Br J Cancer 80 (11): 1830-7, 1999.**]**National failure to operate on early stage pancreatic cancer. Annals of Surgery. 2007;246:173-180.
  4. Tersmette AC, Petersen GM, Offerhaus GJ, et al.: Increased risk of incident pancreatic cancer among first-degree relatives of patients with familial pancreatic cancer. Clin Cancer Res 7 (3): 738-44, 2001.
  5. Nöthlings U, Wilkens LR, Murphy SP, et al.: Meat and fat intake as risk factors for pancreatic cancer: the multiethnic cohort study. J Natl Cancer Inst 97 (19): 1458-65, 2005.
  6. World Cancer Research Fund International. Pancreatic cancer statistics. Accessed February 2019 from
  7. Lynparza First Promising New Drug to Treat Pancreatic Cancer in Years
  8. Kastrinos F, Mukherjee B, Tayob N et al. Risk of pancreatic cancer in families with Lynch Syndrome. Journal of the American Medical Association. 2009;302:1790-1795.
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