Pancreatic cancer

What is pancreatic cancer?

Around 8,000 people are diagnosed with pancreatic cancer (also known as cancer of the pancreas) each year.

It is the ninth most common cancer in the UK, more common in people over 60 and not usually found in people under 40 years of age.

The pancreas

The pancreas is a gland – an organ that produces and releases substances to other parts of the body.

It is approximately 15cm (six inches) in length and situated high in your abdomen (tummy) behind the stomach, where the ribs meet at the bottom of your breastbone.

The pancreas produces digestive enzymes (proteins) and a hormone known as insulin.

• digestive enzymes help break down food into fragments so they can be absorbed by your body
• insulin helps keep sugar levels in your blood at a stable level

Pancreatic cancer

Pancreatic cancer is when a tumour starts to develop in the pancreas. It rarely causes any symptoms when it first develops, which can make it hard to diagnose.

The first symptoms can include pain, unexpected weight loss and jaundice. These symptoms can be caused by a wide variety of conditions and are not usually the result of cancer. If you are concerned or these symptoms start suddenly, contact your doctor.

Learn more in

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If your doctor suspects you have pancreatic cancer, they may examine you for signs of jaundice and carry out a blood test, as well as physically examine your abdomen. They may also send you to hospital for further investigation, including an

.

Learn more in

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Who is affected?

Pancreatic cancer can occur at any age, but tends to affect people aged between 50 and 80 and is rare among younger people.

Approximately 63% of people diagnosed with cancer of the pancreas are over 70. Men tend to be more affected than women.

People who smoke and people with diabetes or chronic pancreatitis are at higher risk of pancreatic cancer.

Learn more in

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Outlook

Cancer of the pancreas is a very serious form of cancer which is both difficult to detect and treat. Because pancreatic cancer causes few symptoms in its early stages, the condition is often not diagnosed until the cancer is relatively advanced.

Surgery to remove the tumour is usually the only way to completely cure pancreatic cancer. But this is a suitable treatment for only around 15 to 20% of patients.

If your pancreatic cancer cannot be cured, then treatments can help slow the growth of the tumour and ease any symptoms you may be experiencing.

See

for more.

Pancreatic cancer symptoms

When cancer of the pancreas first develops, it rarely causes any symptoms.

This means you may not notice anything unusual until the cancer has become relatively advanced.

The symptoms of pancreatic cancer can be caused by a variety of other conditions, so it can be difficult to diagnose.

It is important to remember that many of these symptoms are not usually caused by cancer. For example, nausea and fever are common symptoms of a number of other illnesses.

If you are concerned, your symptoms develop suddenly or an area is causing you particular pain or discomfort, contact your doctor.

Some of the most common early symptoms are outlined below.

Pain

Pancreatic cancer can cause pain and discomfort in your upper abdomen (tummy), which sometimes spreads to your back.

At first the pain may come and go, but as the cancer becomes larger and more advanced you may find pain is more constant and lasts for longer.

The pain is often worse when you are lying down or eating. This tends to affect people whose tumour has formed in either the body or tail of the pancreas.

Weight loss

Many types of cancer can cause you to lose weight or lose your appetite, 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 is normally responsible for helping the digestive system digest food by releasing enzymes into your intestines (bowel).

If your pancreas is unable to release these enzymes because of the tumour, then your body will find it harder to digest food, particularly high-fat foods. This can cause you to lose weight and you may also become

, which happens when your body does not get enough nutrients from food to keep it working properly.

Jaundice

Jaundice is a condition with these symptoms:

• yellowed skin and whites of your eyes
• dark yellow or orange urine
• pale stools
• itchy skin

Jaundice can be caused by a number of other conditions such as gallstones or hepatitis, and is rarely caused by cancer. But it may develop if cancer forms in the head of your pancreas.

This is because a tumour in the head of the pancreas can block the bile duct, which is responsible for carrying bile (a fluid that helps the body digest food) from the liver to the intestine.

Bile contains a yellow chemical called bilibrubin, which needs to be removed from the body by the liver.

If the bile duct is blocked, the bilibrubin will build up, causing the symptoms of jaundice.

Diabetes

The pancreas is responsible for helping produce insulin.

If your body does not have insulin, it cannot move sugar (glucose) out of the blood and into your cells.

The symptoms of diabetes include:

• excessive thirst
• passing more urine than usual
• weakness
• weight loss

You may develop

as a result of your pancreatic cancer, as it can produce chemicals that interfere with the normal effect of insulin.

Nausea and vomiting

You will normally only experience nausea (feeling sick) and vomiting when cancer of the pancreas is advanced.

This is because a larger tumour can sometimes block part of the digestive tract, which is very close to the pancreas.

Fever and shivering

You may become feverish and shivery if your pancreas becomes inflamed (swollen) as a result of the tumour.

Pancreatic cancer causes

The causes of pancreatic cancer are not fully understood, but risk factors which can raise your risk of developing it have been identified.

How does cancer begin?

Cancer begins with a change in the structure of DNA, which is found in all human cells. DNA provides cells with a basic set of instructions, such as when to grow and when to reproduce.

Cancer occurs when a change in the DNA structure alters these instructions, so cells carry on growing and reproducing uncontrollably. This produces a lump of tissue called a tumour.

How does cancer spread?

Left untreated, cancer can grow and spread to other parts of the body through the lymphatic system, blood and body cavities.

The lymphatic system is a series of glands (or nodes) located throughout your body. It is similar to the blood circulatory system. Lymph glands produce many specialised cells needed by your immune system to fight infection.

If cancer spreads via the blood, it can reach the liver and sometimes other parts of the body.

Risk factors

Although pancreatic cancer is not yet fully understood, several risk factors have been identified that may increase your chance of developing it:

• older age
• smoking
• diabetes
• chronic
  pancreatitis
  (long-term inflammation of the pancreas)
• as part of a family cancer syndrome

These risk factors are outlined below.

Older age

Pancreatic cancer can affect people of any age, but it mainly affects people aged 50 to 80. Around 63% of people diagnosed with cancer of the pancreas are over 70.

Smoking

Smoking is associated with almost a third of all pancreatic cancer cases.

Smoking cigarettes, cigars or chewing tobacco can all increase your risk of developing cancer of the pancreas. This is because tobacco smoke contains harmful toxins and chemicals that can cause irritation and inflammation (swelling) in the tissues and organs within your body.

Chronic pancreatitis

Chronic

(long-term inflammation of the pancreas) will increase your risk of pancreatic cancer.

Although very uncommon, patients with hereditary (inherited) pancreatitis have a particularly high risk of pancreatic cancer, especially from the age of 40.

Pancreatic cancer diagnosis

When pancreatic cancer first develops it often causes no symptoms, which means it can be hard for your doctor to diagnose it, particularly in its early stages.

If your doctor suspects you have pancreatic cancer, they will examine your eyes and skin for any signs of jaundice. They may also test your urine for bile or carry out a blood test. This is because in some cases jaundice can be a sign of pancreatic cancer. Learn more in

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

Your doctor may send you for further testing at a hospital. Some of the tests you may need are outlined below.

Ultrasound

An

uses high-frequency sound waves to produce an image of the inside of your body.

If your doctor suspects you may have pancreatic cancer, you will be referred for an ultrasound scan of your abdomen.

During an ultrasound scan, your doctor will be able to look at your pancreas to see if there are any signs of abnormality.

An ultrasound is painless. However, it can often miss pancreatic cancer as ultrasound waves are not good at penetrating deep into body tissues. Therefore, a normal ultrasound scan does not necessarily mean you do not have pancreatic cancer.

If you are still concerned, you should insist on a CT scan or MRI scan (see below).

Computerised tomography (CT) scan

A

is able to produce a detailed image of the inside of your body using a series of X-ray images. Your doctor can use the results of this scan to check for any abnormalities and assess the size of the tumour.

Magnetic resonance imaging (MRI) scan

A

also produces an image of the inside of your body, but uses strong magnetic and radio waves instead of X-ray images.

An MRI scan takes longer than other scans to perform. It takes place in a small, enclosed space and can be noisy. As with a CT scan, an MRI scan allows your doctor to check for signs of cancer in other parts of the body.

Endoluminal ultrasonography (EUS)

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

During an EUS, a thin flexible instrument called an

is passed through your mouth and towards your stomach. An ultrasound probe attached to the tip of the endoscope is then able to take very accurate pictures of the pancreas, as it is very close to it.

You will usually be given a sedative to help you relax. EUS can also be used to take a biopsy (tissue sample).

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

.

During an ERCP, an endoscope is passed through your mouth and towards your stomach. The endoscope is then able 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 should be able to outline any tumour that is blocking the bile and pancreatic ducts. An ERCP can take 30 to 60 minutes. You will usually be given a sedative to help you relax.

During the procedure, a small brush is pushed into the bile duct and the cells there are examined to see if they are cancerous.

Laparoscopy

A

is a surgical procedure that allows the surgeon to access the inside of the abdomen (tummy) and the pelvis.

During a laparoscopy, a small cut is made in your abdomen and a laparoscope (a thin, bendy microscope) is passed through. This will allow your doctor to see the inside of your body and make sure that the tumour has not spread before recommending the removal of the cancer. This procedure is done under a

(where you are put to sleep).

Biopsy

A

involves taking a small sample of cancerous cells from a suspected tumour. These cells can then be tested in a laboratory to see if they are cancerous (malignant) or non-cancerous (benign).

A biopsy can be taken during an EUS, ERCP or laparoscopy, where a small instrument attached to the endoscope collects a number of cells.

A biopsy may also be taken using a long, thin needle that is passed through your abdomen. The needle can be guided towards the tumour using an ultrasound scan or CT scan.

Treatment for pancreatic cancer

Treatment for pancreatic cancer will depend on the type, location and stage of your cancer.

It will also depend on your age, general health and personal preferences.

The first aim is to completely remove the tumour and any other cancerous cells in your body. If this is not possible, your doctors will focus on preventing your tumour getting any bigger and causing further harm to your body.

In some cases, it is not possible to get rid of the cancer or to slow down its progress. In this case, your treatment will aim to relieve your symptoms and make you as comfortable as possible.

Cancer of the pancreas is currently very difficult to treat. Because early-stage pancreatic cancer rarely causes any symptoms, the condition is often not detected until the cancer is relatively advanced. When the tumour has grown larger, curing or treating the cancer is much harder.

Discussing your treatment

Deciding on what treatment is best for you can be a difficult process. There is a lot to take in, so it is important you talk through your thoughts and decisions with a member of your family or a friend.

You should also make sure you have a thorough discussion with your doctor and consultant. They will be able to inform you of the pros, cons and side effects of all the different treatments available to you.

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

Cancer of the pancreas can be treated in three main ways:

• surgery
• chemotherapy
• radiotherapy

Some forms of pancreatic cancer will only require one form of treatment, whereas others may require a combination, sometimes of all three.

Surgery

Surgery is usually the only way pancreatic cancer can be completely cured. Because pancreatic cancer is usually advanced by the time it is diagnosed, surgery is only suitable for around 15 to 20% of patients.

If your tumour has wrapped itself around important blood vessels, surgery will not be a suitable option. If your cancer has spread to other areas of the body, then you will also not be recommended for surgery. This is because the risks of surgery often outweigh the potential benefits.

Surgery for pancreatic cancer can usually only be carried out on patients who have good general health. This is because surgery on the pancreas is often long and complex, and the recovery process can be slow.

This type of surgery is not always successful. It is usually very difficult to completely remove all the cancerous cells. This is because sometimes abnormal, cancerous cells break off and begin to form in other parts of the body.

Sometimes these collections of cells are so small that they cannot be detected by scans or X-rays, so your doctor is unable to remove them.

Your doctor will discuss whether surgery is a suitable option with you.

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. It involves removing the head of the pancreas.

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

The end of the bile duct and the remaining part of your pancreas is then connected to your small intestine. This means that bile and pancreatic enzymes (chemicals that speed up chemical reactions in the body) can still be released into the digestive system.

After this operation, around one in three patients need to take enzymes to help them digest food. The Whipple procedure involves long and intense surgery, but is easier to recover from than a total pancreatectomy.

Distal pancreatectomy

A distal pancreatectomy involves having the tail and body of your pancreas removed. Your surgeon will normally remove your spleen at the same time. Sometimes they will also remove part of the stomach and even a part of the bowel, left adrenal gland, left kidney and left diaphragm (muscle separating the chest cavity from the abdomen).

As with the Whipple procedure, a distal pancreatectomy is a long and complex operation which will not be done unless your doctor thinks it is necessary.

Total pancreatectomy

During a total pancreatectomy, your entire pancreas is removed. This is sometimes necessary because of the position of the cancer.

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 your body's immune system)

After a total pancreatectomy, you will need to take enzymes to help your digestive system digest your food. You will also be diabetic for the rest of your life, as your pancreas is responsible for producing insulin.

Removing your spleen can increase your risk of developing infections and may also affect your blood's ability to clot. This means you will be on penicillin (or an alternative antibiotic if you are allergic to this) all your life and you will 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 small cells that make the blood clot).

Surgery to ease your symptoms

Although surgery may not be a suitable way of removing your cancer, you may be offered it to help ease your symptoms. This type of surgery will not cure your condition, but will make your cancer easier to manage and make you more comfortable.

To help ease symptoms of jaundice, a stent can be placed in your bile duct using ERCP (see

) to help keep it open. A stent is a small tube that will allow your bile to be processed by the liver, stopping the yellow chemical present in bile (bilibrubin) from building up and causing jaundice.

If a stent is not a suitable option for you, you may require an operation to bypass your blocked bile duct. During the operation, 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 forms of surgery are far less intensive than surgery carried out on the pancreas. Patients normally recover much more quickly and find that their jaundice symptoms have been significantly eased.

Chemotherapy

is a type of cancer treatment that uses anti-cancer medicines to either kill the malignant (cancerous) cells in your body or stop them from multiplying. Chemotherapy medicines can either be injected into a vein or given to you orally (by mouth).

Chemotherapy can also attack normal, healthy cells in your body, which is why this form of treatment can have many side effects. The most common ones include:

• vomiting
• nausea
• mouth sores
• fatigue

These are usually only temporary and should improve once you have completed your treatment.

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

Radiotherapy

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

Side effects of this type of treatment can include:

• fatigue
• skin rashes
• loss of appetite
• sores in your oesophagus (gullet)

These side effects are usually only temporary and should improve once you have completed your treatment.

Social support for pancreatic cancer

If you have been diagnosed with cancer, your treatment and medical care will probably be the first thing on your mind. But there are other aspects of your life to think about and it is important to know exactly what kind of assistance is available and where you can get it.

If you are finding it hard to cope with day-to-day life, talk about your needs with your doctor or nurse, who will refer you to a social worker. Your social worker will assess exactly the kind of help you need.

Support page

If you're caring for a family member, you may not consider yourself a carer: but a carer is anyone who looks after a family member, partner or friend because of their illness, disability or frailty.

Caring for someone can be a varied and demanding job. You may have been forced to leave your job, give up hobbies and stop socialising, which can be isolating. You may experience stress, and difficult feelings towards the person you're caring for.

It's important to remember that you're not alone and that there is support available. By law, you're entitled to a free health and social care assessment, which you can access through your local authority. The assessment will look at the possibility of you getting practical and financial help.

Being a carer means that you may be entitled to certain financial benefits, especially if you have to give up work.

Recovery from pancreatic surgery

It can be a long and difficult process to recover from pancreatic surgery.

You will usually be in some pain shortly after your operation. The staff at your hospital will make sure you have adequate pain relief.

After any surgery to your digestive system your bowel will temporarily stop working. This means you will not be able to eat or drink straight away. You will gradually be able to sip fluids before eventually being able to drink and eat more regularly. You will then be referred to a dietitian, who will be able to advise you on what foods you should be eating following your operation.

After the removal of the cancer it is normal practice to have a six-month course of chemotherapy, which greatly increases your chance of being cured.

Unfortunately, because cancer of the pancreas is difficult to diagnose and treat, many people do not completely recover. Treatment can be very effective in helping to ease symptoms and make you as comfortable as possible. Chemotherapy can both help to shrink your tumour and slow down its growth.