Pancreatic cancer

The pancreas is a gland of the digestive system that lies between your stomach and spine. It is about 13–15 cm long and is divided into 3 main parts:

• the large, rounded end, called the head of the pancreas
• the middle part, known as the body
• the narrow end, called the tail, that sits up next to your spleen.

Pancreatic cancer is cancer that starts in any part of the pancreas. About 3 in 4 pancreatic cancers are found in the head of the pancreas.

Pancreatic cancer can spread to nearby lymph nodes and to the lining of the abdomen (peritoneum). Cancer cells may also travel through the bloodstream to other parts of the body, such as the liver.

The causes of pancreatic cancer are unknown, but smokers are at greater risk. It is more common in people over 60. About 4500 Australians develop pancreatic cancer each year.

Role of the pancreas

The pancreas has two major roles in the digestive system being that:

• It produces enzymes to help break down food (exocrine function).
• It produces hormones that control blood sugar levels, the amount of acid produced by the stomach, and how quickly food is absorbed (endocrine function).

Risks and causes of pancreatic cancer

The causes of pancreatic cancer are not known, but research has shown that people with certain risk factors are more likely to develop pancreatic cancer. The risk of pancreatic cancer is about two times greater for smokers.

Other risk factors include:

• obesity
• age – more common in people over the age of 60 years
• genes – inheriting a damaged gene
• long-term diabetes (but diabetes can also be caused by the pancreatic cancer)
• inflammation – chronic inflammation of the pancreas (pancreatitis)
• certain types of cysts in the pancreatic duct known as intraductal papillary mucinous neoplasms (IPMNs)
• stomach infections caused by the Helicobacter pylori bacteria
• workplace exposure to certain pesticides, dyes or chemicals.

Symptoms of pancreatic cancer

Early-stage pancreatic cancer rarely causes obvious symptoms. Symptoms may not appear until the cancer is large enough to affect nearby organs or has spread. The first symptom of pancreatic cancer is often jaundice. Signs of jaundice may include:

• yellowish skin and eyes
• dark urine
• pale bowel motions, and
• itchy skin.

Jaundice is caused by the build-up of bilirubin, a dark yellow-brown substance found in bile. Bilirubin can build up if pancreatic cancer blocks the common bile duct.

Other common symptoms of pancreatic cancer include:

• appetite loss
• nausea (with or without vomiting)
• unexplained weight loss
• pain in the upper abdomen, side or back, which may cause you to wake up at night
• changed bowel motions – including diarrhoea, severe constipation, or pale, oily, foul-smelling stools (poo) that are difficult to flush away in the toilet
• bloating and passing wind and burping more than usual
• newly diagnosed type 2 diabetes
• fatigue (feeling very tired).

Remember that pancreatic cancer is rare. If you have one of these symptoms, it is likely to be due to something else. However, see your GP (doctor) if you are worried or have ongoing symptoms.

Diagnosis of pancreatic cancer

If pancreatic cancer is suspected, your doctor will refer you for tests. These may include:

• Blood tests – these check how well your liver and kidney are working and measure for a protein known as CA19.9. Pancreatic cancer often sends CA19.9 into the blood. It is not used to diagnose pancreatic cancer, but it gives your doctor important information.
• Computed tomography (CT) scan – a special x-ray is taken from many different angles to build a three-dimensional picture of your body. A dye may be injected to further highlight internal organs.
• Magnetic resonance imaging (MRI) – this is similar to a CT scan, but uses magnetism instead of x-rays to build three-dimensional pictures of your body.
• Ultrasound – sound waves create a picture of your pancreas.
• Endoscopy (also called endoscopic retrograde cholangiopancreatography, ERCP) – a thin telescope is inserted down your throat to allow the doctor to see inside your digestive system. This device may also be used to inject dye into the pancreas and bile duct to allow images of these organs to appear on x-ray pictures.
• Laparoscopy – the internal organs are examined with an instrument inserted into the abdomen through a small cut.
• Tissue biopsy – a small sample of the pancreas is removed with a needle and examined in a laboratory.
• Positron emission tomography (PET) scan – an injection with a glucose solution containing a very small amount of radioactive material is given. The scanner can ‘see’ the radioactive substance. Cancerous cells show up as ‘hot spots’ – areas where the glucose is being taken up.

These tests can also help your doctor find out if your cancer has spread. The cancer may have spread into blood vessels or lymph nodes near the pancreas, or into organs further away, like the liver or the lungs. This is called ‘secondary cancer’ or metastasis. The tests you have will help your doctors decide the best treatment for you.

Test results can take a few days to come back. It is very natural to feel anxious waiting to get your results. It can help to talk to a close friend or relative about how you are feeling. You can also contact the Cancer Council and speak with a cancer nurse on 13 11 20.

Treatment of pancreatic cancer

Treatment for pancreatic cancer depends on your age, general health, the size and location of the cancer and whether it has spread to other parts of the body. You may receive one type of treatment or a combination.

Generally, options include:

• Surgery – is used when the cancer has not spread beyond the pancreas. The cancer and part of the pancreas and part of the small bowel are removed. Some of the bile ducts, gall bladder and stomach may also be removed. This is major surgery and you need to be fit enough to have it.
• Chemotherapy – anti-cancer medications (either tablets or injections into the veins) may be used before or after surgery. The drugs work by stopping cancer cells growing and reproducing. Chemotherapy may be given with surgery or alone to help control the symptoms of an advanced cancer.
• Radiotherapy – the use of x-rays to target cancer cells may be used to destroy any cancer cells that might remain in the body. Radiotherapy can also be used as the main treatment when surgery is not possible, in combination with chemotherapy before or after surgery.
• Complementary and alternative therapies – it’s common for people with cancer to seek out complementary or alternative treatments. When used alongside your conventional cancer treatment, some of these therapies can make you feel better and improve quality of life. Others may not be so helpful and in some cases may be harmful. The Cancer Council Victoria booklet called Understanding Complementary Therapies can be a useful resource.

All treatments have side effects. These will vary depending on the type of treatment you are having. Many side effects are temporary, but some may be permanent. Your doctor will explain all the possible side effects before your treatment begins.

Treatment to manage cancer and symptoms

If the cancer involves nearby organs or blood vessels (locally advanced – some stage 3 cancers) or has spread to other parts of the body (metastasised – all stage 4 cancers), surgery to remove the cancer may not be possible. Instead, treatments will focus on shrinking or slowing the growth of the cancer and relieving symptoms without trying to cure the disease. This is called palliative treatment.

Options may to help relieve symptoms include:

• Stenting - the cancer may cause jaundice because it is blocking the bile duct. Stenting relieves the pressure by inserting a metal or plastic tube into the bile duct to keep it open. Similar treatment can relieve a section of the small bowel if the cancer is pressing on it.
• Surgery – a blockage in the small bowel can be bypassed by a surgical procedure that attaches a loop of bowel directly to the stomach. The stomach can also be connected to the middle section of the small bowel, or to an opening in the abdomen so wase can be collected in a small bag outside the body.
• Tablets – there may be a lack of pancreatic enzymes to properly digest food, which results in digestive problems. Tablets containing these enzymes can control this symptom.
• Pain-relieving medication – oral medication is usually given to control pain, but if the pain is particularly severe, medication can be injected into the nerves of the back.

Research into pancreatic cancer

Early detection and better treatment have improved survival for people with pancreatic cancer. The research is ongoing. The CancerHelp UK websitehas information about research into pancreatic cancer.

Clinical trials can test the effectiveness of promising new treatments or new ways of combining cancer treatments. Always discuss treatment options with your doctor. The Cancer Council Victoria information sheet called Clinical Trials may also be a helpful to read.

Your sexuality and pancreatic cancer

Having pancreatic cancer and its treatment can affect the way you feel about your body, who you are, your relationships, the way you express yourself sexually and your sexual feelings (your ‘sexuality’). These changes can be very upsetting.

Your medical team should discuss these issues with you before and during your treatment. If you feel you would like to discuss things further, ask your doctor for a referral to a counsellor or speak to a cancer nurse on the Cancer Council Victoria Tel. 13 11 20. The Cancer Council Victoria booklet called Sexuality, Intimacy and Cancer may also be helpful to read.

Caring for someone with cancer

Caring for someone with cancer can be a difficult and emotional time. If you or someone you know is caring for someone with pancreatic cancer, there is support available. The Cancer Council Victoria booklet called Caring for Someone with Cancer may also be helpful to read.

When a cure isn’t possible

If the cancer has spread and it is not possible to cure it with surgery, your doctor may still recommend treatment that focuses on improving quality of life by relieving the symptoms (this is called palliative treatment). This can help make you feel better and may allow you to live longer. The Cancer Council Victoria booklet called Living with advanced cancer may be helpful to read.

Where to get help

• Your GP (doctor)
• Cancer Council Victoria, Information and Support Service Tel. 13 11 20
• Multilingual Cancer Information Line, Victoria Tel. 13 14 50
• WeCan website helps people affected by cancer find the information, resources and support services they may need following a diagnosis of cancer.