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Pancreatic cancer is the 4th leading cause of cancer death in the United States. It’s estimated that over 50,000 new cases are diagnosed each year and over 40,000 people die because of this disease annually. The lifetime risk of developing the disease is 1.6%. The risk is about the same for men and women and the typical range of age at the time of diagnosis is between 65-74 years old.
About the pancreas
The pancreas is an oblong organ located behind the lower part of the stomach, between the stomach and the spine. It produces juices that aid in digestion and makes insulin and other hormones that help the body absorb sugar and control blood sugar.
The pancreas mainly contains two kinds of cells:
- Exocrine cells, which make and release enzymes that aid in food digestion.
- Endocrine cells, which produce and release important hormones directly into the bloodstream.
The majority of pancreatic cancers start in the exocrine cells that line the ducts of the pancreas. These are called pancreatic adenocarcinomas.
When cancer begins in pancreatic endocrine cells, it’s called a pancreatic neuroendocrine tumor (NET). There are many subtypes of this type of tumor.
This summary is about exocrine pancreatic cancer. Further mention of pancreatic cancer refers only to pancreatic adenocarcinoma, and not pancreatic NETs.
Pancreatic cancer risk factors
Anything that increases your chance of developing pancreatic cancer is a risk factor. Some risk factors can be changed, while others cannot.
Risk factors that can be changed include:
- Smoking and tobacco use: People who smoke are about twice as likely to develop pancreatic cancer.
- Obesity: Being very overweight (having an elevated body mass index, or BMI) increases your chance of developing pancreatic cancer by 20%.
Other pancreatic cancer risk factors can’t be changed, including:
- Age: The risk of pancreatic cancer increases sharply after 55 years old.
- Race: African-Americans are more likely to have pancreatic cancer than other ethnic groups.
- Family history: Hereditary genetic changes may account for about 10% of pancreatic cancers. Examples of genetic syndromes that can cause exocrine pancreatic cancer include: Hereditary breast and ovarian cancer syndrome caused by mutations in the BRCA1 or BRCA2 genes, Lynch syndrome (usually defects in MLH1 or MSH 2 genes), and hereditary pancreatitis due to mutations in PRSSI gene.
- Diabetes: People with long-standing history of type 2 diabetes have an increased likelihood of developing pancreatic cancer.
- Chronic pancreatitis: Long-term inflammation of the pancreas is linked with increased pancreatic cancer risk, especially in smokers.
Not everyone with the above risk factors gets pancreatic cancer. However, if you have risk factors, you should discuss them with your doctor.
Pancreatic cancer often does not cause symptoms in the early stages. When pancreatic cancer symptoms do occur, they usually result from the relationship of the pancreas to other organs of the digestive system.
Pancreatic cancer symptoms can include:
- Jaundice or yellowing of the skin or eyes
- Dark urine or light-colored stools
- Pain in the abdomen or middle of the back
- Bloating or the feeling of fullness
- Nausea, vomiting or indigestion
- Lack of appetite
- Unexplained weight loss
- Sudden-onset diabetes
These symptoms do not always mean you have pancreatic cancer. However, it is important to discuss any of these symptoms with your doctor, since they may signal other health problems.
Pancreatic cancer symptoms usually do not appear in the early stages. If they do they may be mistaken for signs of another condition. Additionally, the pancreas is deep inside the body, behind several other organs. This makes it difficult to feel or see without proper equipment. These factors mean pancreatic cancer is hard to diagnose.
Several diagnostic tests are usually required to find and stage (determine extent of) pancreatic cancer. Accurate diagnosis and staging are important because they help your doctors choose the best type of treatment.
Diagnostic tests for pancreatic cancer
One or more of the following tests may be used to test for pancreatic cancer. These tests also may be used to find out if the cancer has spread and if treatment is working.
One way to diagnose pancreatic cancer is by imaging the pancreas and surrounding areas. These tests can be used to uncover potential tumors, see if a tumor has spread and determine whether treatment is working. During some types of imaging tests, tissue samples for biopsy can be obtained if cancer is detected. Common imaging tests for pancreatic cancer include:
- CT scan: A painless, outpatient procedure that uses a series of X-rays taken from different angles to provide an image of the pancreas. Unless other factors make its use unsuitable, a CT scan optimized for imaging the pancreas is the primary option for diagnosis and staging of pancreatic cancer.
- MRI scan: A painless, outpatient procedure that uses magnets, rather than x-rays, to provide an image of the pancreas. While CT scans are more commonly used, an MRI can sometimes help visualize tumors that are hard to see.
- Endoscopic ultrasound: A special endoscope with an ultrasound probe is inserted into the mouth and directed to the first part of the small intestine to show the pancreas on a video screen. If cancer is suspected, a small piece of tissue can be taken for biopsy.
- Endoscopic retrograde cholangiopancreatography (ERCP): A special endoscope is inserted through the mouth and directed to the first part of the small intestine. A smaller tube is then inserted through the endoscope into the bile ducts. A dye is injected through the tube, and an X-ray is taken. If cancer is suspected, a small piece of tissue can be taken for biopsy. If the ducts are blocked by a tumor, a stent may be inserted to relieve blockage. This may help alleviate stomach pain and digestive problems.
This is the removal of a small piece of tissue to view under a microscope to determine if there’s cancer. While imaging tests can indicate the presence of pancreatic cancer, a biopsy is almost always needed to confirm a diagnosis.
In most cases, biopsies are obtained during either an endoscopic ultrasound or endoscopic retrograde cholangiopancreatography (ERCP) for localized pancreas cancer.
For patients with metastatic disease, a biopsy of the most accessible site is often preferred, such as a liver biopsy through CT-guided fine-needle aspiration.
Blood samples can be taken and examined for levels of substances that indicate the function of the liver, such as bilirubin, or other organs that may be affected by a pancreatic tumor. Blood samples may also be used to check the levels of tumor markers, such as CA-19-9. High levels of these markers may indicate the presence of pancreatic cancer. Levels can also be used to monitor treatment.
Pancreatic cancer staging
If you are diagnosed with pancreatic cancer, your doctor will determine the stage of the disease. Staging is a way of classifying cancer by how much disease is in the body and where it has spread. This helps the doctor plan the best way to treat the cancer. Once the staging classification is determined, it stays the same even if treatment is successful or the cancer spreads.
Pancreatic cancer stages
(Source: 8th Edition of the American Joint Committee on Cancer (AJCC) Staging Manual)
Stage 0: Abnormal pancreatic cells are found only in the lining of the pancreas. These cells have the potential to become cancer. Stage 0 also is called carcinoma in situ.
Stage I: Cancer has formed and is in the pancreas only. This stage is divided into IA and IB, based on tumor size.
- Stage IA: The tumor is 2 centimeters or smaller
- Stage IB: The tumor is larger than 2 centimeters
Stage II: Cancer is large or has spread to lymph nodes. This stage is divided into IIA and IIB.
- IIA: The tumor is larger than 4 centimeters
- IIB: Cancer has spread to the nearby lymph nodes
Stage III: Cancer has spread to nearby major blood vessels or to four or more lymph nodes near the pancreas.
Stage IV: Cancer has spread to distant organs beyond the pancreas, such as the liver, lung and peritoneal cavity.
While the staging guidelines above are an important part of every pancreatic cancer diagnosis and treatment plan, MD Anderson doctors more commonly rely on a “functional” staging system that is based on the likelihood that the cancer can be removed by surgery.
At MD Anderson, pancreatic cancer treatment plans are based on whether or not a tumor can be surgically removed or resected. Most pancreatic cancers are diagnosed after they’ve already spread beyond the pancreas, but about 20% of pancreatic tumors are localized to the pancreas and are resectable. Whether or not a tumor is resectable, patients’ treatment plans usually vary. Typically, patients require more than one type of therapy provided by a multidisciplinary team of doctors.
Some therapies are the current standard-of-care, while others are being tested in clinical trials. Clinical trials are critical for advancing pancreatic cancer care and improving survival outcomes. They are supported by our pancreatic cancer research.
One or more of the following therapies may be recommended to treat the cancer or help relieve symptoms.
Pancreatic cancer surgery
The main surgical approaches used to treat pancreatic cancer are:
- Potentially curative: Attempt to treat pancreatic cancer by removing it.
- Palliative: Attempt to relieve symptoms, like a blocked bile duct or bowel.
Potentially curative surgical techniques
When pancreatic cancer is confined to the pancreas, and sometimes when it has spread only to nearby areas, the tumor can be removed with surgery. Complete removal of the tumor with surgery is often the best chance at curing pancreatic cancer. Partial removal of tumors doesn’t help patients live longer, so surgery is only done if the cancer can be removed entirely.
The most common technique used to remove a pancreatic tumor is called a pancreatoduodenectomy, or, more commonly, the Whipple procedure. This operation removes parts of the pancreas, intestine, nearby lymph nodes, gallbladder, bile duct and sometimes parts of the stomach.
The pancreas is located next to important blood vessels that supply blood to the liver and drain blood from the intestine. Often, cancer in the pancreas spreads into these vessels. If the pancreatic tumor cannot be completely separated from these blood vessels, many surgeons considered it unresectable. However, at MD Anderson the surgeon will often remove the tumor and reroute the affected vessels. This is called vascular resection and reconstruction and is performed during the Whipple procedure. These complex operations are potentially curative and are performed in about half of patients with localized pancreatic cancer who undergo surgery at MD Anderson.
Whether or not vascular resection and reconstruction is necessary, the Whipple procedure is a major operation that carries a high risk of complications, even when it is performed by experienced surgeons. Studies have shown this procedure is more successful and has less risk when it’s performed at a major cancer center by doctors with extensive experience in the procedures. Learn more about what makes MD Anderson surgeons some of the most experienced and skilled in the nation.
Palliative surgical operations
In many cases, cancer cannot be completely removed because it has spread too far beyond the pancreas or into major blood vessels. For these patients, surgery is sometimes used to help relieve symptoms of pancreatic cancer. Blockage of the bile duct is the most common symptom of pancreatic cancer that is treated with surgery. Blockages can cause bile to leak into surrounding organs, leading to pain and digestive problems. There are two techniques used to relieve this symptom:
- Stent placement: An endoscope is used to insert metal tubes (called stents) that help keep the bile duct open. This is often done during endoscopic retrograde cholangiopancreatography (ECRP).
- Bypass operations: The flow of bile is re-routed from the bile duct directly to the intestine, bypassing the pancreas. Bypass operations can provide longer-lasting relief, but have longer recovery periods than stent replacements.
Chemotherapy for pancreatic cancer
Chemotherapy uses cancer drugs to slow or shrink pancreatic tumors. These drugs are either given intravenously (IV) or taken by mouth, and spread throughout the body through the bloodstream. Depending on the resectability (likelihood that the tumor can be completely removed by surgery) of the pancreatic cancer, chemotherapy can be given:
- Prior to surgery, to try to reduce the size of the pancreatic tumor that needs to be removed. This is called neoadjuvant therapy.
- After surgery, to destroy any cancer that may not have been completely removed. This can reduce the chance that the cancer returns and is called adjuvant therapy.
- Along with radiation, which is called chemoradiation. This is sometimes used for localized pancreatic cancer.
There are many chemotherapy drugs used to treat pancreatic cancer, including:
- 5-fluorouracil (F-5U)
- Liposomal Irinotecan
Based on the patient’s ability to tolerate therapy, two or more chemotherapy drugs are typically given in combination to treat patients.
Two chemotherapy combinations have been approved for the initial treatment of pancreatic cancer, including:
- Gemcitabine + nab-paclitaxel
- FOLFIRINOX (5-flurouracil, irinotecan and oxaliplatin)
Radiation for pancreatic cancer
Radiation therapy uses high-energy photon beams (x-rays) to slow or shrink pancreatic tumors. Due to the level of precision of some types of radiation therapy, higher than normal doses of radiation (dose-escalation) can be considered and used without damaging normal tissues. MD Anderson uses several different types of radiation therapy to treat pancreatic cancers.
- Intensity-modulated radiation therapy (IMRT): Delivers radiation beams from several different angles using advanced imaging and computational techniques. Because of the extreme precision associated with this therapy, higher-than-normal doses of radiation (dose-escalation) can be used. This type of therapy is usually administered between 3-6 weeks and is sometimes given in addition to chemotherapy.
- Stereotactic body radiation therapy (SBRT): Delivers radiation beams of different intensity from several angles. Because of the extreme precision associated with this therapy, large doses can be given every day, and higher-than-normal doses of radiation (dose-escalation) can be considered if needed. Treatment usually lasts less than a week.
- 3D conformal radiation therapy: The traditional method that uses three-dimensional scans to image the tumor prior to delivering radiation beams. This type of therapy is usually administered for about 2-6 weeks.
- Proton therapy: Delivers proton beams, rather than photon beams. In some situations, protons cause less radiation exposure to surrounding tissue than photons. This type of therapy may be used for pancreatic cancer patients whose disease has recurred in the same area, despite prior radiation therapy.
At MD Anderson, our radiation oncologists use a special machine called a CT on rails to deliver higher than normal doses of radiation (dose-escalation) with extreme precision. This technique is typically used during IMRT and SBRT.
Surgery is the only potentially curative treatment option for pancreatic cancer, but is an only option for about 20% of cases. This means that it’s important to define whether a patient may benefit from surgery at the time of pancreatic cancer diagnosis, and reserve surgery only for when it may provide clinical benefit.
Because of this, MD Anderson doctors use a contemporary staging system, called resectability staging, to plan a patient’s treatment. This type of staging classifies pancreatic cancers into three groups, based on whether or not they can be removed with surgery. A patient’s potential treatment plan varies depending on the resectability staging of their pancreatic cancer.
The cancer is confined to the pancreas, or has only spread to immediately nearby tissue, and the tumor can be removed entirely with surgery. This typically includes pancreatic cancers that are stage I and II. Patients with resectable pancreatic cancer may:
- Go straight to surgery
- Receive chemotherapy prior to surgery
- Receive radiation and chemotherapy prior to surgery
The cancer has reached nearby blood vessels, but it has the potential to be removed with surgery. This typically includes some stage II and III cancers. Patients with borderline resectable pancreatic cancer often receive chemotherapy and may subsequently receive radiation. After these initial therapies, patients are then evaluated to determine whether their tumor can be completely removed with surgery.
The cancer cannot be removed by surgery. This stage is divided into locally advanced and metastatic.
- Locally-advanced: The cancer is still largely confined to the pancreas and surrounding organs, but has grown into or is surrounding major blood vessels. This typically includes many stage III cancers. Patients with locally-advanced, unresectable pancreatic cancer always receive chemotherapy first and then are considered for radiation therapy. Depending on the size and placement of the tumor, higher than normal doses of radiation (dose-escalation) may be used during treatment.
- Metastatic: The cancer has spread to distant organs and can’t be completely removed. Patients with metastatic pancreatic cancer are treated with chemotherapy if it can be given safely based on patient’s tolerance. Radiation therapy is sometimes used to relieve symptoms associated with their cancer.
About 80% of pancreatic cancers are diagnosed after the disease has reached an advanced stage, which makes them hard to treat. Less than 20% of pancreatic cancers are caught when the cancer is still confined to the pancreas or closely surrounding areas. Though the disease has not spread, these cases are treated with complicated surgical operations that require a high level of experience to perform safely and effectively.
Whether you’re diagnosed with localized or metastatic pancreatic cancer, it’s important to find a team of physicians with the most innovative treatment options and expertise. At MD Anderson, you are the focus of a personalized pancreatic cancer treatment plan that brings together a multidisciplinary team of some of the top pancreatic cancer professionals that use the most advanced techniques.
World-class surgeons treating localized pancreatic cancer
When pancreatic cancer is confined to the pancreas, and sometimes when it has spread only to the nearby areas, it can be removed with surgery. The highest chances for successful treatment occur when the tumor is completely removed, and the surgical techniques required are extremely complex. Because our surgeons are among the most experienced and skilled in the nation, MD Anderson has:
- The highest 5-year survival rate reported in the surgical literature for patients who have undergone surgery for pancreatic cancer.
- Less than a 1% mortality rate after surgery. That is over 6% lower than the national average.
- Among the shortest average length of hospital stay after surgery.
Pioneers of pancreatic cancer treatment
Our experts provide comprehensive pancreatic cancer care, and they have pioneered several advances in the field, including:
- The use of chemotherapy and/or radiation in the preoperative setting.
- Establishment of the “borderline resectable” staging subgroup and definition of the best course of treatment. Incorporating this staging group leads to larger numbers of patients with advanced cancer that may benefit from combining several types of therapy, including surgery.
- Innovative radiation techniques, such as giving higher-than-normal doses of radiation therapy (dose escalation) and stereotactic body radiation therapy (SBRT).
Developing more effective treatment options through clinical trials
MD Anderson conducts a wide range of clinical trials to test new and innovative treatment options for both localized and metastatic pancreatic cancer. The treatment options used in these trials often cannot be found anywhere else and are critical for advancing pancreatic cancer treatment.
Current clinical trials focus on:
- Combining several types of therapy before surgery to treat resectable and borderline resectable pancreatic cancer.
- Identifying more effective ways to use chemotherapy and radiation therapy to treat pancreatic cancer tumors that can’t be removed surgically.
- Developing more effective treatment options for pancreatic cancers that have metastasized.
- Detecting pancreatic cancer earlier (especially in patients with risk factors).
- Promoting healthy habits that enhance the effectiveness of treatment.
Offering the latest radiation therapy techniques
Radiation therapy can be a powerful tool in pancreatic cancer treatment. Our radiation oncologists are experts at stereotactic body radiation therapy (SBRT) and dose-escalation, which allow high doses of radiation to be delivered to the tumor without damaging healthy tissue. Many MD Anderson faculty have led or are leading national clinical trials to improve radiation therapy for pancreatic cancer.
At MD Anderson, I feel safe; I feel comfortable; I feel loved and cared for.
Pancreatic cancer survivor
Did You Know
Pancreatic Cancer Moon Shot
MD Anderson’s Pancreatic Cancer Moon Shot™ aims to rapidly and dramatically improve the disease’s survival rates and reduce suffering through prevention, early detection, research and new treatments.Learn more about the Pancreatic Cancer Moon Shot