THE PANCREAS

PANCREATIC CANCER: CAUSES, SYMPTOMS, AND DIAGNOSIS

Pancreatic cancer is a cancer that begins in the pancreas, an organ responsible for aiding digestion and controlling blood sugar levels. It's one of the most challenging cancers to detect and treat due to its location at the back of the abdomen and the subtlety of early symptoms.

There are two main types of pancreatic cancer: Pancreatic Ductal Adenocarcinoma (PDAC), which is more common, and Pancreatic Neuroendocrine Tumours (PNET), a rarer type with generally better prognosis.

What are the causes of pancreatic cancer?

The majority of pancreatic cancers are sporadic i.e., they have no identifiable cause. There are, however, associated risk factors. Modifiable risk factors include:

Obesity
Smoking
Excessive alcohol intake
Diabetes

Non-modifiable risk factors include:

Age
Hereditary syndromes e.g., hereditary pancreatitis, Peutz Jeghers syndrome, Lynch Syndrome, BRCA mutations
A family history of pancreatic cancer

What are symptoms of pancreatic cancer?

PDACs are often asymptomatic, which is why they typically present late. When symptomatic, patients may present with:

Jaundice
Vague abdominal pain
Weight loss
Lethargy

PNETs can present similarly, with the addition of symptoms related to hormonal excess:

Low blood sugar, dizziness, and sweating, usually relieved by sugar or carbohydrate consumption. This is characteristic of a type of PNET called insulinomas
Difficult to control diabetes, skin rash, diarrhoea, typical of glucagonomas

Early detection is often challenging as symptoms can be subtle and vague. This makes regular screening for high-risk individuals important. As pancreatic cancer is rare, widespread population based screening is not currently supported by evidence.

How is pancreatic cancer diagnosed?

If pancreatic cancer is suspected, routine blood tests with tumour markers (and hormone levels for PNETs), and a CT abdomen with intravenous contrast are the most helpful next steps. Some patients may need further investigation with an MRI or Magnetic Resonance Cholangiopancreatography (MRCP).

A tissue sample may be obtained via an Endoscopic Retrograde Cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) to confirm the diagnosis. However, this is not always performed prior to surgery particularly if the degree of suspicion for cancer is high.

PANCREATIC SURGERY

Treatment for pancreatic cancer is complex and evolving. As such, patients should be managed within a multidisciplinary team setting. Surgery remains the only curative option for localised pancreatic cancer. Some patients may not be a surgical candidate upfront but may respond favourably to chemotherapy, allowing reassessment for surgery.

Whipple Procedure (Pancreaticoduodenectomy)

Primarily used for tumours located in the head of the pancreas. This complex surgery involves removing part of the pancreas, small intestine, and sometimes the stomach.

Distal Pancreatectomy

This surgery removes tumours in the tail or body of the pancreas. It is less extensive compared to a Whipple procedure, and associated with less complications. A distal pancreatectomy can be spleen-preserving or spleen-sacrificing depending on the type of cancer and its relation to the splenic vessels.

Total Pancreatectomy

In cases where the tumour has spread significantly or is affecting a large portion of the pancreas, the entire pancreas, as well as nearby structures, may be removed.

What are the risks of pancreatic surgery?

Pancreatic resections are considered major surgery with a moderate to high risk of complications. Evidence show that patients have better outcomes when surgery is performed at experienced centres. In addition to anaesthetic and general risks like infection and bleeding, specific risks include:

Leakage of pancreatic secretions, bile or bowel content from the joins constructed during surgery
Delayed stomach emptying
Chronic diarrhoea and malnutrition requiring enzyme replacement
Diabetes if a significant proportion of the pancreas is removed
Less than 5% of patients who have a Whipple procedure may die within 30 days of surgery due to serious surgical complications or other medical issues

RECOVERY AFTER PANCREATIC SURGERY

A typical hospital stay after a Whipple procedure without complications is 10-14 days, and 5-7 days for distal pancreatectomy. This may be extended depending on the severity of complications.

In the initial weeks, it is not unusual to experience pain, fatigue, discomfort and reduced appetite. Patients are seen daily by myself and the surgical team, as well as receive support from a dietitian and physiotherapist to get them back on their feet. Full recovery may take 3-6 months.

After-surgery care and lifestyle adjustments

Dietary Changes: After pancreatic surgery, patients will need to adjust their diet, typically eating smaller and more frequent meals that are easier to digest.
Enzyme Replacement Therapy: Many patients, particularly those who had significant portions of their pancreas removed, may need pancreatic enzyme supplements to help with digestion.
Blood Sugar Monitoring: If a significant proportion of the pancreas was resected, blood sugar levels may be affected, and some patients may develop diabetes.

SURVIVAL RATES FOR PANCREATIC CANCER

Long-term outcomes depend on the type, stage and biological behaviour of the disease, as well as an individual's general fitness. PNETs generally have a better prognosis than PDAC due to their slower growth and better response to treatment. However, a subset of PDAC patients do well with carefully planned treatment, even with fairly advanced disease.

Questions on survival rates are natural but due to its complexity and sensitivity, it would be more appropriate to discuss this in person with a pancreatic surgeon or oncologist.

With ongoing research into refining treatment, evidence is constantly evolving and patients benefit from care provided by a team of experts from different specialties.

RESOURCES FOR PATIENTS AND CAREGIVERS

It can be overwhelming to receive a diagnosis or possible diagnosis of pancreatic cancer. These resources can be helpful for patients, their family and their friends through the process.

Pancreatic Cancer Australia. https://pancare.org.au/cancer-information/resources-cancer/
Pankind’s Patient & Carer Hub. https://pankind.org.au/patient-carer-hub/

***The content on this website or linked web pages are intended for educational purposes only and should not be relied on to make healthcare decisions in the absence of a consultation with a healthcare professional