Pancreatic cancer

The pancreas sits deep in the upper abdomen, behind the stomach. It produces the enzymes that digest food and hormones including insulin. A tumour inside it grows quietly for a long time, and when symptoms do appear they are easily put down to gastritis, gallstones or an irritable bowel. That silence is why the disease is usually found late — and why it is worth knowing which combinations of signs mean the investigation should not wait.

Why it is rarely caught early

A small tumour inside the pancreas gives nothing away. Symptoms start when it begins to interfere with its neighbours: pressing on the bile duct, growing into the nerve networks behind the gland, narrowing the duodenum.

What a person notices depends on where in the gland the tumour grows. A tumour in the head blocks the bile duct, and the first sign is jaundice — which is why these are sometimes found earlier and still operable. Tumours of the body and tail cause no jaundice and show themselves through back pain and weight loss, by which time they have already grown.

There is no general screening for healthy people: no test is accurate and safe enough to apply to everyone. Planned surveillance is offered only to people with a strong inherited predisposition.

Symptoms not to blame on the stomach

Each of these signs on its own turns up in dozens of harmless conditions. What is worrying is that they combine and that they do not settle.

• yellowing of the whites of the eyes and the skin, dark urine, pale clay-coloured stools, itchy skin;
• pain in the upper abdomen going through to the back; it is worse after eating and when lying down, and eases if you lean forward or draw your knees up;
• weight loss without trying, over months rather than years;
• loss of appetite and feeling full after a few mouthfuls;
• pale, greasy, strong-smelling stools that are hard to flush away — a sign the gland has stopped supplying enzymes;
• nausea, vomiting, bloating and a feeling of fullness;
• tiredness and weakness that everyday activity does not explain.

Jaundice deserves a separate note. Painless jaundice without fever in an adult is always a reason to find the cause quickly. Jaundice from a gallstone is usually preceded by an attack of severe pain under the right ribs, often with shivering. When jaundice builds up gradually and painlessly while the person is losing weight, the explanation may be a tumour blocking the duct.

Clues that often get missed

A few situations do not mean cancer in themselves, but they do mean a doctor should rule it out deliberately.

Diabetes appearing for the first time after fifty. A pancreatic tumour can disturb insulin production months before anything else shows. Diabetes starting in someone who is not overweight, particularly alongside weight loss and abdominal pain, is a reason to investigate the gland rather than simply to start glucose-lowering treatment. The same applies to long-standing diabetes that suddenly stops behaving on the usual doses.

Pancreatitis with no explanation. Acute inflammation of the gland in an adult who does not drink heavily and has no gallstones calls for the cause to be found — including a tumour obstructing the duct.

Unexplained blood clots. A clot in the deep veins of the leg with no injury, operation or long period of immobility, especially a recurring one, is occasionally the first sign of an internal tumour.

What it gets mistaken for

Telling these apart matters a great deal here, because there are many similar and far commoner conditions.

• Gallstones in the gallbladder or bile duct. They cause attacks of pain under the right ribs, often after fatty food, and jaundice with pain and shivering. A tumour of the head of the pancreas more often gives jaundice without pain.
• Chronic pancreatitis. It also causes back pain, greasy stools and weight loss, and on scans it can be hard to separate from a tumour. It also raises the risk of cancer in its own right, so "but I already have pancreatitis" does not account for a fresh deterioration.
• Ulcers and gastritis. The pain is linked to meals but does not usually go through to the back or come with jaundice and steady weight loss.
• Irritable bowel syndrome. It does not produce weight loss, jaundice, night-time pain or bleeding. If someone with a long-standing diagnosis develops any of these, the diagnosis needs revisiting.
• Hepatitis and other liver disease. These also cause jaundice, but with a different blood test pattern: the liver tissue is affected rather than the drainage of bile.

Hence a practical rule: the familiar diagnosis stops explaining things once the symptoms change character, weight loss or jaundice is added, and treatment that used to work no longer does.

What raises the risk

• smoking, the biggest cause you can do something about; the risk falls after stopping but only matches a non-smoker's after some years;
• age: most cases appear after sixty-five and it is uncommon below forty;
• long-standing chronic pancreatitis;
• diabetes of many years' duration;
• excess weight and inactivity;
• heavy drinking, largely through pancreatitis;
• a diet with a lot of red and processed meat;
• pancreatic cancer in close relatives;
• inherited syndromes: changes in the BRCA2 gene and others, Lynch syndrome, hereditary pancreatitis, familial atypical mole and melanoma syndrome.

If two or more close relatives have had this cancer, or one had it young, say so: genetic counselling and surveillance on a separate schedule may be appropriate.

Which tests actually find the tumour

The order of the tests matters more than their number, and one mistake comes up particularly often.

Abdominal ultrasound. It is usually first because it is quick to arrange and shows dilated bile ducts and gallstones straight away. But a normal ultrasound does not rule out a pancreatic tumour: the gland lies deep, bowel gas obscures it, and the tail is often not seen at all. If symptoms persist, "the ultrasound was clear" is not a place to stop.

CT with intravenous contrast. This is the main test. Done with a dedicated pancreatic protocol, it shows the tumour itself, its relationship to the major blood vessels — which decides whether surgery is possible — and any deposits in the liver and abdominal lining.

Endoscopic ultrasound. The probe is brought close to the pancreas through the stomach, so even small lesions are visible. Tissue for biopsy is taken at the same time: histological confirmation is needed before chemotherapy begins. MRI with MRCP is added when the CT leaves doubt.

Blood tests. They show the degree of bile obstruction, liver function, glucose and anaemia. The marker CA 19-9 is no good for screening or for making the diagnosis: it rises with ordinary jaundice and inflammation and stays normal in some patients. It is used to follow the trend over time.

Before major surgery, a PET scan and a diagnostic laparoscopy — a look inside the abdomen through a small incision — are sometimes added so that tiny deposits are not missed.

How it is treated

The plan is put together by a team: surgeon, medical oncologist, clinical oncologist, pain specialist and dietitian. It depends on where the tumour is, its relationship to the vessels, whether it has spread, and how much treatment the person can withstand.

Surgery. Removing the tumour completely is the only route to cure, but it is possible in roughly one patient in five: in the rest the tumour already encases the vessels or has spread by the time it is found. Tumours of the head are treated with a Whipple operation; those of the body and tail by removing that part of the gland. These are major procedures with a long recovery.

Chemotherapy. It is given after surgery to reduce the chance of the disease returning, and before surgery to pull the tumour away from the vessels and make it removable. In advanced disease it holds the tumour back and extends life. Radiotherapy is used less often, usually alongside chemotherapy, to shrink local disease or ease pain.

Relieving blockages. If the bile duct is obstructed, a stent is placed through an endoscope to restore drainage; jaundice and itching settle within days. The same is done when the duodenum is compressed. It does not treat the tumour, but it transforms how a person feels.

What makes daily life easier

Supportive treatment starts at once, not "once everything else has been tried" — it is what changes day-to-day life most.

• pancreatic enzyme capsules with every meal if stools have become greasy and weight is falling: without them food simply is not absorbed;
• pain relief stepped up as needed; for persistent back pain a coeliac plexus block helps;
• blood glucose control, often moving on to insulin;
• anti-sickness medicines, small frequent meals and dietetic support;
• attention to the risk of blood clots, which is raised in this illness.

When the tumour cannot be cured, the aim becomes holding it back and protecting quality of life. Bringing in the palliative care team early, rather than in the final weeks, controls symptoms better and takes pressure off the family.

When help is needed urgently

Call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine the single number is 112 — if any of these appear:

• jaundice together with a high temperature, shivering, confusion or a drop in blood pressure: this is how infection of the bile ducts presents;
• sudden severe abdominal pain with a rigid abdomen;
• vomiting blood, or black tarry stools;
• sudden breathlessness, chest pain, or swelling and pain in one leg — a clot in the lung is possible.

The same day, though not by ambulance, see a doctor if vomiting keeps recurring and you cannot keep fluids down, if you have not passed urine for many hours, if jaundice and itching are worsening quickly, or if the pain no longer responds to your usual painkillers.

Online consultation

A remote appointment is useful at two stages. Before the diagnosis, to go through the combination of symptoms, work out which test should come first, and not stop at "the ultrasound was clear". After the diagnosis, to read the reports calmly, understand the proposed plan and get a second opinion before decisions are made.

Have ready: your symptoms with dates — when they began, how they changed, how many kilograms you have lost and over what period; ultrasound, CT, MRI and histology reports; blood results including bilirubin, liver tests and glucose; a list of your medicines; and details of cancer in your relatives.

An online appointment does not replace a scan, an endoscopy or a biopsy, and jaundice with fever or unrelenting vomiting needs face-to-face care immediately. It works well, though, where the decision rests on reviewing documents rather than examining: enzymes, pain relief, nutrition and the question of what to do next.

This material is for information only and does not replace medical advice.