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Pancreatic cancer

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Pancreatic cancer






Cancer of the pancreas is more common in older people, with about half of all new cases diagnosed in people who are aged 75 or over. It's uncommon in people under 40 years of age. Pancreatic cancer affects men and women equally.


 

The pancreas

The pancreas is a large gland that's part of the digestive system. It's about 15cm (six inches) long, and is located high in the abdomen, behind the stomach, where the ribs meet at the bottom of the breastbone.


The pancreas produces:



digestive enzymes – which break down food so it can be absorbed into the body



hormones – including insulin, which helps keep your blood sugar levels stable



 

Pancreatic cancer

In the early stages, a tumour in the pancreas doesn't usually cause any symptoms, which can make it difficult to diagnose.

 

The first noticeable symptoms of pancreatic cancer are often:



pain in the back or stomach area



unexpected weight loss



jaundice (yellowing of the skin and whites of the eyes)



 

It's important to remember that these symptoms can be caused by many different conditions, and aren't usually the result of cancer. However, you should contact your GP if you're concerned, or if these symptoms start suddenly.

 

Causes of pancreatic cancer

It's not fully understood what causes pancreatic cancer, but risk factors for developing the condition have been identified.

Risk factors for pancreatic cancer include:



age – it mainly affects people who are 50-80 years of age 



smoking



having a history of other health conditions – such as diabetes, chronic pancreatitis (long-term inflammation of the pancreas), stomach ulcer and Helicobacter pylori infection (a stomach infection) 



 

Diagnosing pancreatic cancer

Your GP will ask about your general health and carry out a physical examination.

They will check your skin and eyes for signs of jaundice, and you may also have a urine and blood test.

Your GP may also examine your tummy (abdomen) for a lump and to see whether your liver is enlarged.

If your GP suspects pancreatic cancer, you may be referred to a specialist at a hospital for further investigation. You may have an ultrasound scan, computerised tomography (CT) scan, or a magnetic resonance imaging (MRI) scan.

 

Treating pancreatic cancer

Cancer of the pancreas is difficult to treat. It rarely causes any symptoms in the early stages, so it's often not detected until the cancer is fairly advanced. If the tumour is large, treating the cancer will be more difficult.

If you've been diagnosed with pancreatic cancer, your treatment will depend on the type and location of your cancer, and how far it's advanced. Your age, general health and personal preferences will also be taken into consideration.

The first aim will be to completely remove the tumour and any other cancerous cells. If this isn't possible, treatment will focus on preventing the tumour growing and causing further harm to your body.

 

The three main treatments for pancreatic cancer are:



surgery



chemotherapy



radiotherapy



 

Some types of pancreatic cancer will only require one form of treatment, whereas others may require two types of treatment or a combination of all three.

Recovering from surgery. The recovery process after surgery to remove a cancerous tumour can take a long time.

 

Following surgery, you will probably have a six-month course of chemotherapy, which will greatly increase your chance of being cured.

              Anatomy of the abdomen 





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Symptoms of pancreatic cancer

In its early stages, pancreatic cancer rarely causes symptoms.

The pancreas is actually two glands in one, and symptoms depend on which part is affected. This is because:



the exocrine pancreas produces digestive enzymes, which break down food so they can be absorbed by your body



the endocrine pancreas produces hormones – including insulin, which keeps your blood sugar levels stable



 

Most cases of pancreatic cancer are in the exocrine pancreas, and the three most common symptoms are:



pain in the stomach or back



jaundice



weight loss



 

It's important to remember that these symptoms can be caused by many different health conditions and aren't usually the result of cancer. However, you should contact your GP if you're concerned, or if you suddenly develop these symptoms.

 

Pain in the stomach or back

Pancreatic cancer can cause a dull pain in your upper tummy (abdomen), which may spread to your back.

To begin with, the pain may come and go, but as the tumour becomes larger and more advanced, the pain may be more constant and last longer.

The pain is often worse when you lie down or after you've eaten. You may also have pain or tenderness in your abdomen if your liver, pancreas or gallbladder are enlarged.

 

Weight loss

Many types of cancer cause weight loss, because the cancerous cells deprive your healthy cells of the nutrients they need.

Pancreatic cancer is more likely to cause weight loss than some other cancers because the pancreas produces digestive enzymes, which help food to be absorbed into your body.

If a tumour disrupts that production, your body will find it harder to digest food, particularly high-fat foods.

This can cause you to lose weight and become malnourished.

 

Jaundice

Jaundice is caused by a build-up of a yellowish-brown substance called bilirubin in the blood and tissues of the body. The most obvious sign of jaundice is yellow skin and yellowing of the whites of the eyes. It also causes your urine to be dark yellow or orange and your stools (faeces) to be pale-coloured. Bilirubin is a waste product produced by the liver, and passed out of the body through the bile duct and into the intestine. Jaundice is more often a sign of conditions such as gallstones or hepatitis than it is of cancer. However, a tumour can sometimes develop in the head of the pancreas and block the bile duct, causing bilirubin to build up in the body.

 

Diabetes

The pancreas produces the hormone insulin. Without it, the body can't move glucose (sugar) out of the blood and into your cells.

The main symptoms of diabetes include:



excessive thirst



urinating frequently – particularly at night 



extreme tiredness 



weight loss and loss of muscle bulk



 

You may develop diabetes if you have pancreatic cancer, because it can produce chemicals that interfere with the normal effect of insulin.

Other possible symptoms

Other possible symptoms of pancreatic cancer include:



itching (if you have jaundice)



nausea and vomiting



bowel changes



fever and shivering



indigestion



blood clots



 

Endocrine pancreatic cancer

Endocrine pancreatic tumours, also known as neuroendocrine tumours, are uncommon.

There are a number of different endocrine tumours that cause different symptoms, depending on the hormone the tumour produces.

The Cancer Research UK website has more information about the symptoms of endocrine pancreatic tumours.

 

Causes of pancreatic cancer 

The exact cause of pancreatic cancer isn't fully understood.

However, there are a number of risk factors that can increase your chances of developing it.

 

Age

Pancreatic cancer can affect people of any age, but it mainly affects people who are aged 50 to 80. Almost 50% of people diagnosed with cancer of the pancreas are aged 75 or over.

 

Smoking

Research has found that about one in three cases of pancreatic cancer is associated with smoking and other tobacco use.

Smoking cigarettes, cigars or chewing tobacco can all increase your risk of developing cancer of the pancreas.

This is because tobacco smoke contains harmful chemicals and toxins that can cause irritation and inflammation within your body's organs and tissues.

 

Diabetes

If you have diabetes, your risk of developing pancreatic cancer is thought to be increased.

However, it's important to remember that diabetes is very common, affecting more than 3 million people in the UK, and most people with diabetes won't develop pancreatic cancer.

As well as diabetes being a risk factor for pancreatic cancer, it's also thought that a cancerous tumour that grows in the pancreas could be responsible for some cases of diabetes.

 

Chronic pancreatitis and hereditary pancreatitis

Chronic pancreatitis (long-term inflammation of the pancreas) increases your risk of getting pancreatic cancer, but isn't responsible for many cases. Chronic pancreatitis is often caused by long-term alcohol misuse. 

Although it's a very rare condition, if you have hereditary pancreatitis, your risk of developing pancreatic cancer is 50 times greater than the rest of the population.

 

Helicobacter pylori infection

Helicobacter pylori are bacteria that cause stomach ulcers, and is a known risk factor for stomach cancer.

Research has shown that a Helicobacter pylori infection may slightly increase your risk of getting pancreatic cancer. However, the risk is thought to be small because most people with this infection don't get cancer of the pancreas.

 

Other known risk factors

There are also a number of other factors that have been associated with an increased risk of pancreatic cancer. These are:



long-term hepatitis



tooth or gum disease



heavy alcohol use



a previous history of certain types of cancer



previously having radiotherapy



diet, weight and level of physical activity



 

The Cancer Research UK website has more information about these other possible risk factors for pancreatic cancer.


 

What is cancer?

Cancer begins with a change (mutation) in the DNA in cells. This causes the cells to reproduce uncontrollably, producing a lump of tissue called a tumour.

Left untreated, cancer can grow and spread to other parts of the body.



 

Can I inherit pancreatic cancer?

In about 1 in 10 cases, pancreatic cancer is inherited from a person's parents.

Certain genes can increase your chances of getting pancreatitis, which in turn increases your risk of developing cancer of the pancreas.

 

Diagnosing pancreatic cancer 

In the early stages, pancreatic cancer often causes no symptoms. This can make it difficult to diagnose.

If you visit your GP with symptoms of pancreatic cancer, they will probably examine your eyes and skin for signs of jaundice.

They may also test your urine for bile, or carry out a blood test. This is because jaundice can sometimes be a sign of pancreatic cancer.

 

Your GP may also examine your tummy (abdomen) to feel for any swelling or abnormality. The pancreas is quite well-hidden within the body because it's covered by part of the bowel. This can make it difficult to feel for tumours during a physical examination.

If your GP suspects pancreatic cancer, you'll be referred for further testing at a hospital. Some of the tests you may need are outlined below.

 

Ultrasound scan

An ultrasound scan is a painless procedure that uses high-frequency sound waves to produce an image of the inside of your body.

If pancreatic cancer is suspected, you'll be referred for an ultrasound scan of your abdomen to see if your pancreas appears abnormal.

However, this type of scan can often miss pancreatic cancer, because ultrasound waves aren't very good at penetrating deep into body tissues. 

 

Computerised tomography (CT) scan

A computerised tomography (CT) scan produces a detailed image of the inside of your body using a series of X-ray images.

Your doctor can use the results of a CT scan to check for abnormalities and assess the size of the tumour.

 

Magnetic resonance imaging (MRI) scan

A magnetic resonance imaging (MRI) scan also produces an image of the inside of your body, but it uses strong magnetic and radio waves instead of X-rays.

MRI scans are carried out in a tube-shaped MRI scanner. It's a noisy procedure that can feel claustrophobic. It also takes longer than other types of scans.

Like a CT scan, an MRI scan allows your doctor to check for signs of cancer in other parts of the body.

 

Positron emission tomography (PET) scan

A positron emission tomography (PET) scan can help to show where the cancer is and whether it has spread to other parts of the body.

Before the scan, you'll be given an injection of a very small amount of a radioactive medication, known as a tracer. The amount of radiation is very small and no more than you would receive from a normal X-ray. The most common tracer used is a radioactive form of glucose (sugar). You'll then rest for about an hour to allow the tracer to travel to areas in your body where glucose is used for energy. The scan itself can take up to an hour and produces an image of the tracer in your body. The tracer shows up cancers because they use glucose in a different way to normal tissue.

 

Endoluminal ultrasonography (EUS)

If a small shadow is seen on a CT or MRI scan but it's not obvious what it is, another test called endoluminal ultrasonography (EUS) can be carried out.

During EUS, a thin, flexible instrument called an endoscope is passed through your mouth and guided towards your stomach.

An ultrasound probe attached to the tip of the endoscope will then be used to take close-up pictures of your pancreas.

Before the procedure, you may be given a sedative to help you relax. EUS can also be used to take a biopsy (see below) for further examination.

 

Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure used to insert a plastic tube or stent into the bile duct if someone has jaundice.

During ERCP, an endoscope is passed through your mouth and guided towards your stomach. The endoscope can then be used to inject a special dye into your bile and pancreatic ducts.

After the dye has been injected, an X-ray will be taken. The dye will show up on the X-ray and will highlight any tumour that's blocking the bile and pancreatic ducts.

During the procedure, tissue samples may be taken. These samples can be looked at under a microscope to see whether the cells are cancerous.

ERCP can take 30-60 minutes. As with EUS, you'll usually be given a sedative to help you relax.

 

Laparoscopy

A laparoscopy is a surgical procedure that allows the surgeon to access the inside of your abdomen and pelvis.

During the procedure, a small incision will be made in your abdomen, and a laparoscope (a thin, flexible microscope) will be inserted.

This will allow the surgeon to see inside your body and make sure the tumour hasn't spread before recommending its removal.

This procedure will be carried out under a general anaesthetic (where you're put to sleep so you don't feel any pain or discomfort).

 

Biopsy

A biopsy involves taking a sample from a suspected tumour, which can then be tested to see if it's cancerous (malignant) or non-cancerous (benign).

A biopsy can be carried out during an EUS, ERCP or laparoscopy using a small instrument attached to the endoscope to collect a number of cells.

It's also possible for a biopsy to be carried out using a long, thin needle that's passed through your abdomen. The needle will be guided towards the tumour using an ultrasound or CT scan.

 

Treating pancreatic cancer 

Treatment for pancreatic cancer depends on the type, location and stage of your cancer (how far it's spread).

Your age, general health and personal preferences will also be taken into consideration when deciding on your treatment plan.

The first aim will be to completely remove the tumour and any other cancerous cells in your body.

If this isn't possible, the focus will be on preventing the tumour growing and causing further harm.

Sometimes it's not possible to get rid of the cancer or slow it down, so treatment will aim to relieve your symptoms and make you as comfortable as possible.

Cancer of the pancreas is very difficult to treat. In its early stages, this type of cancer rarely causes symptoms, so it's often not detected until it's quite advanced. If the tumour is large or has spread, treating or curing the cancer is much harder.

 

Discussing your treatment

Deciding what treatment is best for you can be a difficult process. There's a lot to take in, so it's important to talk about the possible alternatives with a family member or friend.

You should also have an in-depth discussion with your doctor, who can tell you the pros and cons of the treatments available to you.

If at any stage you don't understand the treatment options being explained to you, make sure you ask your doctor for more details.

 

There are three main ways that cancer of the pancreas can be treated. They are:



surgery



chemotherapy



radiotherapy



Some types of pancreatic cancer will only require one form of treatment, whereas others may require two or a combination of all three.

 

Surgery

Surgery is usually the only way pancreatic cancer can be completely cured. However, as the condition is usually advanced by the time it's diagnosed, surgery is only suitable for around 15-20% of people.

However, this isn't a suitable option if your tumour has wrapped itself around important blood vessels. If your cancer has spread to other areas of the body, surgically removing the tumour won't cure you.

Surgery for pancreatic cancer is usually only an option for people who have a good general level of health. This is because pancreas surgery is often long and complex, and the recovery process can be slow. Sometimes the risks of surgery can outweigh the potential benefits.

Your doctor will discuss with you whether surgery is a suitable option. There are several possible surgical procedures, which are outlined below.

 

Whipple procedure

The Whipple procedure is the most common operation used to treat pancreatic cancer, and involves removing the head of the pancreas.

Your surgeon must also remove the first part of your small intestine (bowel), your gall bladder (which stores bile) and part of your bile duct. Sometimes, part of the stomach also has to be removed.

The end of the bile duct and the remaining part of your pancreas is connected to your small intestine. This allows bile and the hormones and enzymes produced by the pancreas to still be released into your system. After this type of surgery, about one in three people need to take enzymes to help them digest food.

The Whipple procedure involves long and intensive surgery, but it's easier to recover from than a total pancreatectomy (see below).

 

Distal pancreatectomy

A distal pancreatectomy involves removing the tail and body of your pancreas.

Your spleen will usually also be removed at the same time. Part of your stomach, bowel, left adrenal gland, left kidney and left diaphragm (the muscle that separates the chest cavity from the abdomen) may also be removed.

Like the Whipple procedure, a distal pancreatectomy is a long and complex operation that won't be carried out unless your doctor thinks it's necessary.

 

Total pancreatectomy

During a total pancreatectomy, your entire pancreas will be removed. This is sometimes necessary due to the position of the tumour.

Your surgeon will also remove your:



bile duct



gall bladder



spleen



part of your small intestine



part of your stomach (sometimes)



surrounding lymph nodes (part of the immune system)



After a total pancreatectomy, you'll need to take enzymes to help your digestive system digest food. You'll also have diabetes for the rest of your life because the pancreas produces insulin – the hormone that regulates blood sugar.

Removing your spleen can increase your risk of developing infections and may also affect your blood's ability to clot. This means you'll be on penicillin (or an alternative antibiotic if you're allergic to it) for the rest of your life, and you'll need to have regular vaccinations.

Sometimes, you may need to take tablets for a short period to stop the platelets in your blood sticking to each other. Platelets are a type of blood cell that cause your blood to clot (thicken).

 

Surgery to ease your symptoms

Although surgery may not be a suitable way of removing your tumour, you may be offered it to help ease your symptoms.

This type of surgery won't cure your cancer, but will mean that your condition is easier to manage, and it will make you more comfortable.

To help control jaundice, a stent can be placed in your bile duct using endoscopic retrograde cholangiopancreatography (ERCP). This will help keep the bile duct open and prevent bilirubin – the yellow chemical in bile – from building up and causing jaundice.

If a stent isn't a suitable option for you, you may need an operation to bypass your blocked bile duct. Your surgeon will cut the bile duct just above the blockage and reconnect it to your intestine, which will allow your bile to drain away.

These types of surgery are much less intensive than surgery carried out on the pancreas. The recovery time is much quicker, and people find that their jaundice improves significantly.

 

Chemotherapy

Chemotherapy is a type of cancer treatment that uses anti-cancer medicines to either kill the cancerous (malignant) cells in your body or stop them multiplying.

Chemotherapy treatment is often used alongside surgery and radiotherapy (see below) to help ensure that as much of the cancer is treated as possible.

Chemotherapy may be given:



before surgery – to try to shrink the cancer, so that there's a greater chance of the surgeon being able to remove all of the cancer



after surgery – to help reduce the risk of the cancer coming back



when surgery isn't possible – to try to shrink the cancer, slow its growth and relieve your symptoms



Some chemotherapy medicines can be taken orally (by mouth), but some need to be given directly into a vein (intravenously).

 

Chemotherapy also attacks normal, healthy cells, which is why this type of treatment can have many side effects. The most common side effects include:



vomiting



nausea



mouth sores



fatigue



increased risk of infection 



These are usually only temporary, and should improve once you've completed your treatment.

The chemotherapy medications can also be used in combination, so your doctor may suggest using one medication or a combination of two or three.

Combining chemotherapy medications can give a better chance of shrinking or controlling the cancer, but increases the chance of side effects.  Sometimes, the risks of chemotherapy can outweigh the potential benefits. 

 

Radiotherapy

Radiotherapy is a form of cancer therapy that uses high-energy beams of radiation to help shrink your tumour and relieve pain.

 

Side effects of radiotherapy can include:



fatigue



skin rashes



loss of appetite



diarrhoea



nausea or vomiting 



 

These side effects are usually only temporary, and should improve after your treatment has been completed.

The Cancer Research UK website has more information about the types of treatment for pancreatic cancer.

 

Recovering from surgery 

Recovering from pancreatic cancer surgery can be a long and difficult process.

You'll probably experience some pain after your operation. The staff at your hospital will make sure you have adequate pain relief.

After any type of surgery to your digestive system, your bowel will temporarily stop working. This means you won't be able to eat or drink straight away.

You'll gradually be able to sip fluids, before eventually being able to drink and eat more regularly. You may be referred to a dietitian, who can advise you about what foods you should eat following your operation.

After the tumour has been removed, you will probably have a six-month course of chemotherapy, which greatly increases your chance of being cured. However, as cancer of the pancreas is difficult to diagnose and treat, many people don't recover completely.

Treatment can be very effective in helping to ease symptoms and make you as comfortable as possible. Chemotherapy can help shrink your tumour and slow down its growth.