24th July 2023

Pancreatic cancer

Pancreatic cancer is a relatively common malignancy, being in the top 10 for both women and men. It is associated with a poor prognosis – with the 5-year survival rate being as low as 10%. Pancreatic cancers can be highly aggressive and debilitating, meaning prompt diagnosis is essential to improving survival – as it generally presents late, with advanced disease. Approximately 90% are adenocarcinomas arising from the digestive acinar cells, with the rest being non-adenocarcinomas of this cell origin, and a small minority being neuroendocrine tumours, which are associated with a better prognosis.

Causes and risk factors

Demographic risk factors include age (with the 60s being the most common decade of onset), male gender, and Afro-Caribbean ethnicity. The biggest modifiable risk factor for pancreatic cancer is smoking, with obesity and alcohol excess further lifestyle factors.

Pancreatic cancer is also associated with a positive family history, and conditions such as diabetes also increase risk. Pancreatitis is an important risk factor, especially chronic pancreatitis and hereditary pancreatitis.

Clinical features

The most common presenting feature is unexplained weight loss. Tumours at the head of the pancreas are associated with obstructive features – such as jaundice, pale stools, and dark urine – as well as pain and anorexia. Tumours of the body and tail are also associated with pain.

Pain is not necessarily a symptom, however, and hence an important maxim in medicine is that painless jaundice should be treated as suspected cancer until proven otherwise.

Assessment and diagnosis

The diagnostic investigation of choice is a CT scan. If the diagnosis is unclear, PET and endoscopic-guided ultrasound (EUS) scans can be used as further modalities. EUS is also used to obtain histological samples.

If there are features of obstruction, then an ERCP should be done to drain the bile duct.

CT of the chest, abdomen and pelvis, and PET scans, are also used for staging. If there is a suspicion of liver metastases, then an MRI should be performed.

Management

The 2 focuses of management are anti-cancer treatment and supportive care.

Analgesia and nutritional support are key. Although not necessarily a presenting feature for most patients, many will progress to experience severe and debilitating pain, which may require specialist palliative care and pain team input. Strong opioids are often indicated, and a coeliac plexus block is amongst the NICE recommendations for uncontrolled pain. Many individuals will suffer exocrine insufficiency and subsequent malnutrition – artificial feeding may be required, and pancreatic enzyme replacement.

Surgery is the first line treatment for those with resectable disease, with subsequent adjuvant chemotherapy or radiotherapy. Only around 20% of tumours are resectable. For non-resectable disease, there is also a role for palliative chemotherapy, which is the first line treatment for those able to tolerate it.

Obstruction should be relieved with either surgery or ERCP, and biliary stenting may also be indicated.

As mentioned, prognosis is poor, and many cancers are often very advanced at the time of presentation. Therefore, palliative care input is often early on and may lead the patient’s care.