Pancreatic cancer develops when malignant (cancerous) cells form and multiply within the pancreas. These tumours are often challenging to detect in their early stages because the signs and symptoms are frequently subtle or non-specific. Consequently, the majority of cases are diagnosed when the disease has already reached an advanced stage, limiting the range of treatment options available.
Pancreatic cancer is a significant health concern, being one of the leading causes of cancer-related death globally. In India, it is estimated that approximately 60,000 new cases are diagnosed annually, leading to over 47,000 deaths each year. The lifetime risk of developing this condition is about 1.6%, with a slightly increased risk observed in men compared to women. The typical age at diagnosis is generally between 65 and 74 years.
The pancreas is an elongated organ situated deep within the abdomen, behind the lower portion of the stomach and in front of the spine. Its primary roles include:
Producing and releasing juices containing enzymes that aid in the digestion of food.
Producing insulin and other crucial hormones that help the body regulate sugar absorption and control blood sugar levels.
The pancreas is mainly composed of two types of cells:
Responsible for producing and releasing enzymes that facilitate food digestion.
Responsible for producing and releasing vital hormones directly into the bloodstream.
The vast majority of pancreatic cancers originate in the exocrine cells that line the ducts of the pancreas, and these are known as pancreatic adenocarcinomas. This health information focuses specifically on exocrine pancreatic cancer, and further mentions of pancreatic cancer refer to pancreatic adenocarcinoma, excluding pancreatic neuroendocrine tumours (NETs).
A risk factor is anything that increases an individual's probability of developing pancreatic cancer. These factors can be broadly categorised as modifiable (changeable) or non-modifiable (unchangeable).
Individuals who smoke are approximately twice as likely to develop pancreatic cancer.
Being significantly overweight (having an elevated Body Mass Index, or BMI) increases the chance of developing pancreatic cancer by around 20%.
The risk of pancreatic cancer increases sharply after the age of 55 years.
Inherited genetic changes may account for about 10% of pancreatic cancers. Examples of genetic syndromes linked to exocrine pancreatic cancer include:
People with a prolonged history of Type 2 diabetes face an increased risk of developing pancreatic cancer.
Long-term inflammation of the pancreas is associated with an increased risk, especially among those who smoke.
It is important to remember that not everyone with these risk factors will develop pancreatic cancer. However, if you have any risk factors, it is advisable to discuss them with your doctor.
Pancreatic cancer often does not present with any noticeable symptoms in its earliest stages. When symptoms do emerge, they are usually a result of the pancreas's close proximity and relationship to other digestive organs.
These symptoms can be indicative of various other health problems and do not automatically confirm pancreatic cancer. Nonetheless, it is essential to consult your doctor immediately if you experience any of these symptoms for a proper evaluation.
The diagnosis of pancreatic cancer is challenging. The lack of early symptoms, combined with the pancreas's deep location within the body behind several other organs, makes it difficult to detect without specialised equipment.
To accurately find and stage (determine the extent of) pancreatic cancer, several diagnostic tests are typically necessary. Precise diagnosis and staging are vital for your care team to determine the most suitable course of treatment.
One or more of the following tests may be used for initial testing, to determine if the cancer has spread, and to monitor the effectiveness of treatment.
Imaging procedures are used to take pictures of the pancreas and surrounding areas to look for potential tumours, assess their spread, and check treatment response. In some cases, these tests can also be used to guide the collection of tissue samples for a biopsy. Common imaging tests include:
A biopsy involves removing a small piece of tissue to be examined under a microscope to confirm the presence of cancer. While imaging tests can suggest pancreatic cancer, a biopsy is nearly always required for a definitive diagnosis.
For localised pancreatic cancer, biopsies are most commonly obtained during an Endoscopic Ultrasound (EUS) or Endoscopic Retrograde Cholangiopancreatography (ERCP).
For patients with metastatic disease (cancer that has spread), a biopsy of the most accessible distant site is often preferred, such as a liver biopsy performed via CT-guided fine-needle aspiration.
Blood samples can be analysed to check for the function of organs like the liver (e.g., bilirubin levels) or other organs that may be impacted by a pancreatic tumour. Blood tests can also measure the levels of tumour markers, such as CA-19-9. High levels of these markers may indicate pancreatic cancer and can also be used to monitor the effectiveness of treatment.
The stage of cancer describes the size of the primary tumour and how far the cancer has spread within the patient's body. Knowing the stage is crucial for the care team to understand the disease, develop an appropriate treatment plan, and estimate the patient's prognosis (chance of successful treatment).
Most cancers use the TNM staging system, which describes the cancer based on three key factors:
The size of the primary tumour and whether it has invaded nearby tissues. (Scored 1–4)
The spread of the cancer to nearby lymph nodes. (Scored 1–3)
Whether the cancer has spread (metastasised) to distant parts of the body. (Scored 0–1)
After all diagnostic and staging procedures are complete, your doctor will be able to determine the TNM stage of your cancer and explain how this impacts your treatment and outlook.
The TNM staging is often simplified into four main stages (I–IV), with some cancers also including a Stage 0. Higher numbers generally indicate a more advanced disease that is typically more challenging to treat.
Abnormal cells are found in the lining of the pancreas. This is also called carcinoma in situ ("in its original place") and is considered a pre-cancerous stage that could potentially develop into cancer. Not all cancers have a Stage 0.
The cancer has formed but is confined to the pancreas.
The cancer has spread to nearby tissue and/or lymph nodes.
The cancer has spread to distant areas of the body. While Stage IV cancer is often not curable, it can frequently be managed like a chronic disease.
Abnormal cells are found only in the lining of the pancreas (carcinoma in situ).
Cancer is in the pancreas only.
The tumour is any size and has spread to:
The tumour is any size and has spread to other distant parts of the body, such as the liver, lung, or peritoneal cavity (the abdominal body cavity).
The treatment strategy at SSCHRC combines pioneering research, advanced technology, and a multidisciplinary team approach to create a personalised care plan.
Pancreatic cancer treatment plans are largely determined by whether or not the tumour can be surgically removed (resected). As most pancreatic cancers are diagnosed after they have spread beyond the pancreas, only about 20% of tumours are localised and considered resectable. Regardless of resectability, treatment plans are often varied, and patients typically require more than one type of therapy provided by a team of specialists.
Treatment options may include current standard-of-care therapies or those being evaluated in clinical trials. The following therapies may be recommended to treat the cancer or help relieve symptoms:
Surgery is the only treatment that offers a potential cure for pancreatic cancer, but it is only an option for a minority of patients (~20%). Therefore, determining if a patient will benefit from surgery at the time of diagnosis is paramount.
SSCHRC doctors utilise a contemporary system called resectability staging to plan treatment. This classification divides pancreatic cancers into three groups based on their potential for complete surgical removal:
The cancer is confined to the pancreas or has only spread to immediately adjacent tissue, and the entire tumour can be removed surgically. This typically includes Stage I and some Stage II pancreatic cancers. Patients may proceed with:
The cancer has reached nearby blood vessels but still has the potential to be removed entirely with surgery. This generally includes some Stage II and Stage III cancers. Patients often receive chemotherapy and may subsequently receive radiation before surgery (neoadjuvant therapy). Following these initial treatments, the tumour is re-evaluated to determine if complete surgical removal is possible.
The cancer cannot be removed completely by surgery. This stage is further divided into:
Surgical approaches are classified into two main types:
Aimed at treating the pancreatic cancer by removing the tumour entirely.
Aimed at relieving symptoms, such as a blocked bile duct or bowel.
Complete surgical removal of the tumour offers the best prospect for a cure when the cancer is confined to the pancreas or has only spread to nearby areas. Partial tumour removal is not beneficial for long-term survival, so surgery is only performed if the tumour can be entirely resected.
The most common technique for removing a pancreatic tumour is called a pancreatoduodenectomy, or the Whipple procedure. This complex operation involves removing portions of the pancreas, intestine, nearby lymph nodes, gallbladder, bile duct, and sometimes parts of the stomach.
Since the pancreas is located near vital blood vessels supplying the liver and draining the intestine, cancer may spread into these vessels. Surgeons at SSCHRC may perform vascular resection and reconstruction (removing the tumour and rerouting affected vessels) during the Whipple procedure, even if the tumour is closely associated with these vessels. These complex operations are potentially curative and are frequently performed at SSCHRC for patients with localised pancreatic cancer undergoing surgery. The Whipple procedure is a major operation with a high risk of complications; studies suggest it is more successful and carries less risk when performed at a major cancer centre with surgeons who have extensive experience in the procedure.
When cancer is unresectable because it has spread too far or into major blood vessels, surgery may be used to relieve symptoms. Blockage of the bile duct is a common symptom addressed surgically, as it can cause bile to leak into surrounding organs, leading to pain and digestive issues. Two techniques are used to alleviate this:
Chemotherapy drugs are used to destroy cancer cells, control their growth, or ease disease-related symptoms. Treatment may involve a single drug or a combination of two or more drugs, depending on the cancer type and its rate of growth.
Depending on the tumour's resectability, chemotherapy can be administered in several ways:
Many chemotherapy drugs are used, including Gemcitabine, Nab-paclitaxel, 5-fluorouracil (F-5U), Irinotecan, Oxaliplatin, Capecitabine, Cisplatin, and Liposomal Irinotecan. Typically, two or more drugs are given in combination, based on the patient's ability to tolerate the treatment. Two common combinations approved for initial treatment include:
Radiation therapy employs high-energy photon beams (X-rays) to slow or shrink pancreatic tumours. Due to the high precision of certain types of radiation, higher-than-normal doses (dose-escalation) can be used while minimising damage to healthy surrounding tissues. SSCHRC employs several different types of radiation therapy:
At SSCHRC, radiation oncologists use specialised equipment to deliver higher than normal doses of radiation with extreme precision, a technique typically employed during IMRT and SBRT.
Targeted therapy is a treatment approach that focuses on isolating specific molecules to slow or halt the cancer's growth, offering a way to target cancer cells while sparing healthy cells more than traditional chemotherapy.
For some patients with advanced pancreatic cancer, SSCHRC doctors can perform genetic sequencing to determine if the patient is suitable for one of SSCHRC's targeted therapy clinical trials. These research studies are exploring novel therapies to target specific genetic mutations, such as the KRAS mutation, which were previously considered difficult to treat. These experimental therapies represent a significant area of research with the potential to improve treatment success and survival rates.