Pancreatic Cancer

What is pancreatic cancer?

Pancreatic cancer is a disease that affects the pancreas, a gland in the upper part of the abdomen which helps the body digest food and regulate blood sugar levels. The pancreas is divided into four parts – the head, neck, body and tail. Pancreatic cancer forms when cells in the tissue of the pancreas mutate and multiply uncontrollably.

Pancreatic Cancer – How it forms

How does Pancreatic cancer form?

Pancreatic cancer begins in the tissues of the pancreas, of which there are two kinds.

The first is a type of gland tissue that lines the organs in the abdomen that aids with food digestion and drains into ducts. The cells of these ducts can multiply and become cancerous. These are known as pancreatic exocrine cancers.

The second is a gland tissue that produces several important hormones, including insulin. Pancreatic cancers that begin in these tissues are known as neuroendocrine pancreatic cancers and are less common.
 

Types of Pancreatic Cancer

What are the types of pancreatic cancer?

In Singapore, pancreatic cancer is the 10th most common cancer in males and the 8th most common cancer in females. It is generally aggressive and is the 4th most common cause of cancer death in males and females.

There are two main types of pancreatic cancer:

1. Exocrine pancreatic cancer accounts for around 90% of pancreatic cancer cases. The most common subtype of this cancer is adenocarcinoma.
2. Endocrine pancreatic cancer, which is also known as pancreatic neuroendocrine tumours (PNETs), accounts for less than 10% of pancreatic cancer cases. Subtypes include insulinomas and gastrinomas.

What are the symptoms of pancreatic cancer?

There are often no or mild symptoms in the early stages of pancreatic cancer. When the cancer progresses, some of the symptoms that may present may include:

• Jaundice – a yellow or green discolouration of the skin and whites of the eyes that is indicative of underlying disease
• Diarrhoea – loose and watery stools
• Pain or discomfort in the upper part of the abdomen – a sharp and shooting or dull and tingling sensation in the upper part of the stomach
• Nausea or vomiting – an uneasy feeling in the throat or stomach with an urge to vomit, which is the throwing up of contents in the throat and stomach through the mouth
• Indigestion or bloating – a feeling of fullness or belly pain
• Loss of appetite – not feeling hunger nor the desire to eat
• Fatigue and weakness – extreme tiredness or frailty due to illness
• Unexplained and unintentional weight loss – losing 5% of one’s body weight without trying to within a period of 6 to 12 months
• Newly diagnosed diabetes mellitus

If you notice any worrying symptoms, even if they come and go, please go to the doctor so the cause can be investigated.

Pancreatic Cancer - Complications

What are some complications that arise from pancreatic cancer?

There are some complications that may arise as pancreatic cancer progresses. These include:

• Weight loss can arise from pancreatic cancer as the disease affects the body’s ability to absorb nutrients and because nausea and vomiting are some of the symptoms.
• Jaundice or the yellowing of the skin and whites of the eyes, can result when pancreatic cancer affects the liver’s bile duct.
• Bowel obstruction can happen when pancreatic cancer grows and compresses the small intestine.
• Cancer spread or metastasis to nearby blood vessels and lymph nodes, and also to organs next to the pancreas – the liver, peritoneum and lungs. 

How can you prevent pancreatic cancer?

There are several ways to lower the risk of pancreatic cancer or to diagnose it early:

• Avoid smoking or inhaling second-hand smoke from cigarettes or cigars
• Limiting alcohol consumption
• Adopting a balanced diet with high intake of fruits, vegetables and whole grains, while reducing fat intake
• Exercising regularly and maintaining a healthy weight
• Getting screened for pancreatic cancer if you have a history of chronic pancreatitis, a strong family history of pancreatic cancer or have any hereditary syndromes that put you at higher risk. Screening involves imaging tests, such as MRI or ultrasound, or endoscopic procedures.

What are the causes and risk factors of pancreatic cancer?

While the exact cause of pancreatic cancer is unknown, several factors have been found to play a role in its development. Some risk factors include:

• Smoking cigarettes, cigars and using tobacco
• Age, as pancreatic cancer is more common in people over the age of 70
• Obesity or excessive fat accumulation especially around the waist
• Pancreatitis, a condition in which the pancreas has chronic inflammation
• A family history of pancreatic cancer
• Hereditary syndromes such as BRCA2 gene mutation, Lynch syndrome and familial atypical mole-malignant melanoma (FAMMM) syndrome
  

How is pancreatic cancer diagnosed?

Tests and procedures used to diagnose pancreatic cancer include:

• Imaging tests
  Imaging tests such as CT (computed tomography) scan, MRI (magnetic resonance imaging) scan, PET (positron emission tomography) scan are used to show the inside of the body and examine the pancreas and nearby organs for signs of cancer.
• Endoscopic ultrasound (EUS)
  An endoscope, which is a long, thin tube with a camera, is passed down the oesophagus and into the stomach to take images of the pancreas using high-frequency sound waves.
• Laparoscopy
  Also known as keyhole surgery or minimally invasive surgery, this surgical procedure allows a surgeon to examine the inside of the abdomen by inserting a small tube with a light source and a camera, called a laparoscope, into small incisions in the abdomen.
• Endoscopic retrograde cholangiopancreatography (ERCP)
  An endoscope is passed down the oesophagus, through the stomach, and into the small intestine where the ducts of the pancreas drain. X-ray dye is injected through the endoscope to obtain clear X-ray scans of the pancreas.

If pancreatic cancer is diagnosed, further tests may be required to determine if the cancer has spread and to determine the stage of the cancer. These may include:

• Blood tests
  Blood tests to detect specific proteins known as tumour markers shed by pancreatic cancer cells, such as the CA19-9 tumour marker test.
• Biopsy
  A minor procedure usually done under local anaesthetic, where you are conscious, where a tissue sample is collected. It may be performed during an endoscopic ultrasound (EUS). Alternatively, tissue samples may be collected by inserting a needle through the skin into the pancreas.

Pancreatic Cancer – Staging

What are the stages of pancreatic cancer?

Pancreatic cancer is staged using several different systems, with the number staging system being a commonly used approach.

Stage 1 pancreatic cancer: Occurs when the tumour is no larger than 4cm and remains contained within the pancreas with no spread to the lymph nodes. This stage is divided into Stage 1A, where the tumour is less than 2cm, and Stage 1B, where the tumour is larger than 2cm but smaller than 4cm.

Stage 2 pancreatic cancer: Split into two categories: Stage 2A occurs when the tumour is larger than 4cm but has not spread to the lymph nodes or other parts of the body and Stage 2B occurs when the primary tumour, regardless of size, has involved up to three surrounding lymph nodes but shows no distant spread.

Stage 3 pancreatic cancer: When a tumour of any size within the pancreas has affected the surrounding blood vessels or four or more surrounding lymph nodes, with no distant spread.

Stage 4 pancreatic cancer: The cancer has metastasised or spread to areas farther away in the body, affecting multiple sites such as the liver and lungs.

How is pancreatic cancer treated?

The type of treatment recommended for pancreatic cancer depends on the size, type and location of the tumour and stage of the cancer. The patient’s overall health is also taken into consideration.

The main treatment for localised pancreatic cancer is surgery. Some patients may also require other treatments such as chemotherapy, and radiation therapy. For patients who are not suitable for curative surgery, surgery may be performed to relieve symptoms such as jaundice or nausea caused by a blockage in the bile duct.

Each patient should be assessed by a specialist to determine which treatment is best suited for them.

Surgery
The surgical procedure depends on the location of the tumour and whether it can be removed. Additional procedures to clear any obstruction of the bile ducts might be done before surgery. This can be done with a tube inserted into the bile duct via endoscopic access, or through a tube inserted directly through the skin into the liver, known as percutaneous transhepatic biliary drainage (PTBD).

• Whipple’s operation
  If the cancer is located in the head of the pancreas, a Whipple’s operation – also known as pancreaticoduodenectomy – may be performed. This involves the removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, part of the bile duct and nearby lymph nodes. In some situations, part of the stomach and colon may also be removed.
• Distal pancreatectomy
  This is done for removal of tumours in the neck, body, or tail of pancreas. In some cases, the spleen may also be removed. This operation may be carried out via laparoscopic (keyhole) access or robotic surgery. For large tumours which extend beyond the pancreas, conventional open surgery may be required.
• Pancreatectomy
  This is done to remove the whole pancreas when the cancer is widespread. Post surgery, patients will be on life-long medication to replace hormones and enzymes produced by the pancreas.
• Blood vessel surgery
  A procedure to reconstruct blood vessels may be performed when pancreatic cancer affects nearby blood vessels.

Radiotherapy/ Radiation therapy
Radiotherapy also known as radiation therapy, uses energy beams to kill cancer cells. It can be used before and after surgery, and as part of the main approach to treat the disease. It may be used when the cancer cannot be completely removed during surgery or to reduce the risk of cancer recurrence. It can also help ease the symptoms in those with advanced cancer who do not undergo surgery.

Chemotherapy
Chemotherapy administers drugs or combination of drugs to kill the cancer cells or control their growth. For pancreatic cancer it is usually combined with radiation therapy. It may be administered before surgery to shrink the cancer, to improve chances of complete tumour removal during surgery and can be recommended after surgery if there is a risk that the cancer might return.

Supportive care
Supportive care, which is treatment that helps to improve the symptoms of pancreatic cancer, such as lack of appetite, weight loss, pain, nausea, tiredness or lethargy, may be provided.

Clinical Trials
Clinical trials provide patients a chance to try new treatments. Patients should check with their doctor to see if they are eligible to participate in a clinical trial for pancreatic cancer treatment.

1. Is pancreatic cancer curable?
   Yes. Pancreatic cancer is curable if diagnosed early. Surgery is required to remove the cancer. Chemotherapy and radiotherapy may be delivered before or after the surgery.
2. What are some signs that pancreatic cancer has spread?
   At a more advanced stage, symptoms of pancreatic cancer may include jaundice, unexplained weight loss, nausea, upper abdominal pain, indigestion, and, or, diarrhoea.
3. How long can a person live with pancreatic cancer?
   Based on people diagnosed with pancreatic cancer between 2014 and 2020 in the United States, the 5-year survival rate of pancreatic cancer with localised spread is 44%, with regional spread is 16% and with distant spread is less than 3%.
4. What are the warning signs of pancreatic cancer?
   There are often no warning signs of pancreatic cancer. However, if you are above the age of 70, have pancreatitis, a family history of pancreatic cancer or hereditary syndromes such as BRCA2 gene mutation, Lynch syndrome and familial atypical mole-malignant melanoma (FAMMM) syndrome, please check with your doctor for screening advice.
5. How aggressive is pancreatic cancer?
   Pancreatic cancer (exocrine) is an aggressive cancer. In Singapore, it is the 4th cause of cancer-related death for both male and females.
6. Why is pancreatic cancer so deadly?
   There are often no or mild symptoms in the early stages of pancreatic cancer, which results in the late diagnosis of pancreatic cancer. When cancers are diagnosed late, they are harder to treat and have poorer outcomes.

For further information or enquiries on Pancreatic Cancer and treatment, please call the Cancer Helpline at (65) 6225 5655 or email cancerhelpline@nccs.com.sg.