Pancreatic cancer

Pancreatic cancer or pancreatic carcinoma are terms doctors usually use to refer to tumors that start in the gland cells in the ducts of the pancreas. These ducts pass digestive juices from the exocrine (pertaining to the secretion of a substance out through a duct) part of the pancreas to the intestines. Doctors refer to this as pancreatic (exocrine) ductal adenocarcinoma. 

Pancreatic cancer also develops from hormone-producing pancreatic cells, i.e. the endocrine tissue, but this is rarer. They are known as pancreatic neuroendocrine tumors (NETs). Pancreatic NETs will not be discussed in this article. 

People who develop pancreatic cancer do not often get their diagnosis until a very late stage. This is because in the early stages of pancreatic cancer most patients do not develop any symptoms.  

If they do, they are usually not specific to pancreatic cancer. This means that these signs of illness can also indicate other diseases in the digestive tract.  

Symptoms of pancreatic cancer can include: 

• pain in the upper abdomen or back 
• weight loss 
• jaundice (especially in the case of tumors of the head of the pancreas) 
• fatty stools (as a result of a lack of digestive juices) 
• blood sugar dysregulation, potentially culminating in diabetes mellitus 
• loss of appetite 
• digestive problems such as nausea, vomiting or diarrhea 

It is strongly recommended that you consult your doctor if symptoms persist or if there is a new onset of symptoms of unknown cause. General Practitioners can already narrow down what is causing the symptoms and, if necessary, initiate further diagnostic steps with specialists. 

It is still unknown precisely what causes pancreatic cancer, but it is believed there must be a combination of different factors.

The risk of developing pancreatic cancer increases with age. As people get older, genetic changes (mutations) build up in the healthy cells of the pancreas. The more mutations there are, the higher the risk of cancer.

There are a few factors that statistically increase the risk of pancreatic cancer. Some concern lifestyle, others are caused by pre-existing conditions:

• tobacco consumption (active and passive smoking)
• being very overweight (obesity)
• certain pre-existing conditions such as diabetes (type 2 diabetes mellitus) or a chronic inflammation of the pancreas (pancreatitis)
• high levels of alcohol consumption
• family history: the first degree relatives of a patient with pancreatic cancer, i.e. parents, children or siblings have a greater risk of also developing it. The risk increases with the number of relatives affected.
• genetic conditions: a small proportion of pancreatic carcinomas are attributed to inherited mutations. These mutations mainly occur in conjunction with genetic disorders (syndromes) such as Peutz-Jeghers syndrome or FAMMM syndrome, or inherited (hereditary) pancreatitis.

There are different and complementary diagnostic procedures available to doctors if they suspect pancreatic cancer.

First, the doctor asks the patient if they have any pre-existing conditions and symptoms (medical history). This is then followed by a thorough physical examination.

If doctors suspect pancreatic cancer they can further confirm the diagnosis with various imaging procedures. Possible investigations include:

• an abdominal ultrasound through the abdominal wall,
• an internal ultrasound (endoscopic ultrasound),
• a CT scan and/or
• various forms of magnetic resonance imaging (MRI).

An examination of the stomach and duodenum combined with X-ray contrast images of the pancreatic duct and bile duct can verify the diagnosis. This investigation is called endoscopic retrograde cholangiopancreatography, in short: ERCP. This procedure involves taking tissue samples for microscopic examination.

Further tests may be possible in addition to the imaging procedures mentioned:

• determining if endogenous substances that point to cancer are present in the blood (tumor markers)
• a chest X-ray (preferably as a CT scan) or a combination of positron emission tomography (PET) and CT to clarify how far the tumor has already spread

A surgical procedure known as laparoscopy can also confirm the diagnosis of “pancreatic cancer”. This involves taking tissue samples for examining under the microscope. The laparoscopy can also establish whether the tumor has spread to the neighboring organs or the peritoneum.

Detailed information about the processes and techniques used in imaging and surgical procedures in diagnosing cancer can be found on the German Cancer Research Center’s Cancer Information Service website (in German).

There are various ways of treating pancreatic cancer: surgical removal, radiation therapy or chemotherapy. Doctors usually try out new treatment approaches in clinical trials.

The type of treatment suitable in each case depends above all on:

• the stage of illness: is the tumor confined to the pancreas, advanced locally or are there already metastases?
• the patient’s health: are there other conditions that should be considered when choosing treatment?

When is recovery possible?

A cure is possible in the early stages of the disease if the surgeon is able to completely remove the tumor with enough of a safety margin. The operation should be carried out at centers with sufficient experience of pancreatic surgery (more than 20 such operations per year). Surgery may be contraindicated if

• the tumor is too advanced locally (and, for example, has grown too close to vessels or has spread to the lymph nodes),
• it has already spread to other organs
• or the patient’s general condition is too poor.

Depending on the method of surgery used, parts of the pancreas are preserved or else the surgeon removes the entire organ. It is usually also necessary to remove neighboring organs such as the gallbladder and bile duct, duodenum or spleen or parts of these organs. Experts also recommend removing at least 12 adjacent lymph nodes.

The surgery is usually followed by 6 months of supportive (adjuvant) chemotherapy, if possible within 12 weeks of the start of treatment with the aim of improving the chances of recovery and avoiding a relapse. Follow-up (additive) chemotherapy can be helpful even if the tumor could not be removed completely.

Is surgery still an option following therapy?

Chemotherapy or chemoradiotherapy with subsequent surgery is an option for patients with a borderline operable tumor. The preceding (neoadjuvant) therapy is able to shrink the tumor to an extent that the surgeon can then completely surgically remove it. Surgery after initial chemotherapy can be considered even for locally advanced tumors. This should be decided by doctors from a center with the requisite experience.

What treatment is there if there is no cure?

A cure is usually no longer possible if the disease is already advanced. The focus is then on palliative treatments

• that stop the disease from spreading further,
• relieve pain and
• alleviate tumor-related symptoms.

Experts recommend starting with chemotherapy for locally advanced pancreatic cancer. Sometimes this is followed by a combined treatment of chemotherapy and radiotherapy (chemoradiotherapy). Within clinical trials, patients can also start treatment with radiotherapy or chemoradiotherapy.

If the tumor has already formed metastases, the focus is on making sure the person affected has a good quality of life. Chemotherapy can delay tumor growth and relieve symptoms. Immunotherapy or targeted treatments are also an option for some patients. This depends on the specific characteristics of the tumor such as mutations (changes to the genetic material) or changes to the enzyme patterns in the cancer cells. However, these and other approaches are currently possible for research purposes only.

Bile drainage is often required as a supportive treatment for pancreatic cancer. This involves, for example, a doctor inserting a tube (stent) into the bile ducts to prevent a backlog of bile or to relieve discomfort caused by biliary stasis.

Diversion surgery may be required if the tumor hinders the passage of food.

Do you want to find out more about each treatment method? What are the possible side effects and what can be done about them? You can find detailed information on the German Cancer Research Center’s Cancer Information Service website (in German).

Medical rehabilitation (rehab) should be offered to pancreatic cancer patients especially after treatment with the aim of cure.  

Possible rehabilitation measures are: 

• psychological care: psycho-oncological counseling services can help many patients to cope with their cancer disease. 
• nutrition advice: patients receive a personal diet plan and are told what happens when the pancreas doesn’t work properly. Some patients need medication that supports digestion. 
• diabetes mellitus: patients often have diabetes mellitus following pancreas surgery. The rehab involves training them in how to measure their blood sugar and perform insulin injections. 
• physiotherapy and sport: individually tailored sport and exercise therapy can improve muscle strength and cardiovascular performance. 
• return to everyday work: if those affected are of working age, a medical examiner clarifies whether the patient is able to work. 

Was the aim of the treatment to effect a cure? Follow-up examinations then follow. There is no uniform aftercare regimen for pancreatic cancer patients: the doctors treating you usually determine the examinations on an individual basis. 

The aftercare aims to identify and treat the effects of the disease and treatment or a relapse in good time.  

The pancreatic cancer can’t be cured? Then regular examinations should monitor the course of the disease with the aim of maintaining the patient’s quality of life for as long as possible.  

There are various ways of supporting pancreatic cancer patients so that they can cope better with the disease and the effects of their treatment. What helps depends on the individual situation.  

• Exercise can help overcome tiredness and exhaustion. Specially trained therapists adapt it to individual performance. 
• People whose pancreas is removed in full or in part often suffer from digestive problems and develop diabetes mellitus, but appropriate medication can largely compensate for these problems.  
• Psycho-oncological counseling can help those affected when worries and fears become overwhelming. 

If the disease can no longer be cured and it advances, good medical and nursing care is very important. Many patients with pancreatic cancer suffer from severe emaciation (cachexia). It is very important for these patients’ quality of life to stabilize their weight with appropriate nutritional therapy. 

Distressing symptoms such as pain and nausea can be alleviated. And psychosocial support can help to maintain a good quality of life for as long as possible.  

Do you want to know how doctors can give you psychological support with advanced cancer? And how you can have a positive effect on your quality of life and how you can combat anxiety? You can find lots of information and reference points on aspects of disease management on the German Cancer Research Center’s Cancer Information Service website (in German). 

Doctors of various specialties work closely together in the treatment of pancreatic cancer. Hospitals that are particularly experienced in the treatment of patients with pancreatic cancer can have this confirmed with certification. The German Cancer Society (DKG) regularly checks their compliance with certain professional requirements.  

You can find the addresses of the certified centers on the OncoMAP website.

The German Society for General and Visceral Surgery (DGAV) also assesses the quality of surgical clinics and departments. The “Surgical working group for liver, gall bladder and pancreatic diseases” (Chirurgische Arbeitsgemeinschaft Leber-Galle-Pankreas) of the DGAV certifies centers that meet certain requirements.

Link to the overview of the centers for surgical diseases of the pancreas

Do you have further questions about dealing with the condition in everyday life and additional support options? You can find information about this on the website of the Cancer Information Service of the German Cancer Research Center (in German). 

If you have any questions about pancreatic cancer you can also make personal contact with the Cancer Information Service by dialing the freephone number 0800 - 420 30 40 or writing an email to krebsinformationsdienst@dkfz.de