Symptoms and treatment of Pancreatic Cancer

Diseases

What Is the Pancreas?

The pancreas is an organ located behind the stomach. It releases enzymes that help with digestion, as well as hormones that help regulate blood sugar levels.

If you have pancreatic cancer, you won’t be able to feel a lump or mass when you press on the outside of your abdomen. You may not have any symptoms until the cancer has already spread. Unlike breast, colon, and prostate cancers, pancreatic cancer isn’t routinely found with screening tests. People aren’t generally tested because no screening test for pancreatic cancer has been proven to save lives.

Pancreatic cancer is sometimes called a silent disease because it’s hard to spot early, when it’s most treatable. Besides knowing the symptoms, knowing the risk factors for pancreatic cancer is your best protection against this disease. For example, your chances of developing pancreatic cancer are significantly higher if:

  • you have a family history of the cancer
  • you’re a smoker
  • you’re obese
  • you’re exposed to certain pesticides and chemicals on a regular basis

What Are the Symptoms?

symptoms-of-pancreatic-cancerPancreatic cancer can be found in the exocrine glands, which produce enzymes that help you digest food. Or, it can be found in the endocrine glands, which produce the hormones insulin and glucagon that regulate blood sugar levels.

Although there are often no symptoms in the early phase of this cancer, there are some potential symptoms that may occur as the tumor enlarges.

Pain

As cancer spreads, it can press down on nerves or other organs, causing pain. A blockage in the digestive tract can also lead to pain. Most people experience pain in their abdomen or back regions.

Weight Loss

Pancreatic cancer can lower your appetite, leading to eventual weight loss. Some pancreatic cancers produce hormones that make it harder for your body to get nutrients from foods. So even if you eat a normal diet, you may lose weight or become malnourished.

Nausea and Vomiting

If the tumor affects hormones and enzymes involved in digestion, you may feel sick to your stomach. Some pancreatic cancers increase the amount of acid in your stomach. Others partially or completely block the stomach and intestine, preventing food from getting through.

Diarrhea

Diarrhea can occur with many types of pancreatic cancers. It also can be a sign of a tumor called a VIPoma. This uncommon pancreatic tumor releases a substance called vasoactive intestinal peptide (VIP), which sends more water into your digestive system. Excess water in your intestines can lead to severe, watery diarrhea. Pancreatic cancer can also prevent you from properly absorbing nutrients from the foods you eat, which can also trigger diarrhea.

Excessive Hunger or Thirst

These symptoms are signs of diabetes, a condition where your body doesn’t produce enough insulin to control your blood sugar. Diabetes occurs when the cancer destroys insulin-making cells in your pancreas.

Jaundice

When you have jaundice, your skin and the whites of your eyes turn yellow. People with pancreatic cancer can get jaundiced when the tumor is in the head of the pancreas and blocks the common bile duct.

Bile is a yellowish-brown fluid released by your liver to help your body digest food. Bile is normally stored in the gallbladder. From there, it travels through the common bile duct to the intestines to be removed from your body via stool. But when the common bile duct is blocked, bilirubin can’t be removed and too much of it builds up in your body, causing jaundice.

Dark Urine

When you have too much bilirubin in your body, the excess can get into your urine and stain it brown.

Light-Colored or Greasy Stools

Stools that contain little or no bilirubin turn a lighter color. Cancer can also prevent the pancreas from releasing its digestive enzymes, making it harder for your body to break down fat. That undigested fat can end up in your stool, making it float or look greasy.

Enlarged Gallbladder

If the common bile duct is blocked, bile can get trapped in your gallbladder. The gallbladder then grows larger than normal. Your doctor may be able to feel the enlarged gallbladder during an exam, and you may have upper abdominal tenderness.

Swelling, Redness, and Leg Pain

These are signs of a blood clot in a deep vein of the leg. It’s called deep vein thrombosis (DVT). A clot is sometimes the first sign of pancreatic cancer. If the clot breaks off and travels to the lung (called pulmonary embolism), you will likely have a sudden onset of difficulty breathing.

Itching

When excess bilirubin builds up in the skin, it tends to cause itchiness and irritation.

Rash

People with a glucagonoma, a type of pancreatic tumor, can get a red, blistering rash in various parts of their body.

Weakness, Confusion, Sweating, and Fast Heartbeat

These are symptoms of insulinomas, or tumors that produce insulin. Too much insulin lowers the level of sugar in your blood. You can faint or even go into a coma if your blood sugar dips too low.

It’s important to remember that a lot of conditions can cause these or similar symptoms. Having one or more of these symptoms doesn’t mean you have pancreatic cancer. However, it is a good reason to see your doctor.

Pancreatic cancer is difficult to detect  and diagnose early

CDR636528-750Pancreatic cancer is difficult to detect and diagnose for the following reasons:

  • There aren’t any noticeable signs or symptoms in the early stages of pancreatic cancer.
  • The signs and symptoms of pancreatic cancer, when present, are like the signs and symptoms of many other illnesses.
  • The pancreas is hidden behind other organs such as the stomach, small intestine, liver, gallbladder, spleen, and bile ducts.

Tests that examine the pancreas are used to detect, diagnose, and stage pancreatic cancer.

Pancreatic cancer is usually diagnosed with tests and procedures that make pictures of the pancreas and the area around it. The process used to find out if cancer cells have spread within and around the pancreas is called staging. Tests and procedures to detect, diagnose, and stage pancreatic cancer are usually done at the same time. In order to plan treatment, it is important to know the stage of the disease and whether or not the pancreatic cancer can be removed by surgery.

The following tests and procedures may be used:

  • Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
  • Blood chemistry studies: A procedure in which a blood sample is checked to measure the amounts of certain substances, such as bilirubin, released into the blood by organs and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
  • Tumor marker test: A procedure in which a sample of blood, urine, or tissue is checked to measure the amounts of certain substances, such as CA 19-9, and carcino embryonic antigen (CEA), made by organs, tissues, or tumor cells in the body. Certain substances are linked to specific types of cancer when found in increased levels in the body. These are called tumor markers.
  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray  A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. A spiralor helical CT scan makes a series of very detailed pictures of areas inside the body using an x-ray machine that scans the body in a spiral path.
  • PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. A PET scan and CT scan may be done at the same time. This is called a PET-CT.
  • Abdominal ultrasound : An ultrasound exam used to make pictures of the inside of the abdomen. The ultrasound transducer is pressed against the skin of the abdomen and directs high-energy sound waves (ultrasound) into the abdomen. The sound waves bounce off the internal tissues and organs and make echoes. The transducer receives the echoes and sends them to a computer, which uses the echoes to make pictures called sonograms. The picture can be printed to be looked at later.
  • Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
  • Endoscopic retrograde cholangio pancreatography (ERCP): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes pancreatic cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope (a thin, lighted tube) is passed through the mouth, esophagus, and stomach into the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumor, a fine tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. Tissue samples may also be taken.
  • Per cutaneous trans hepatic cholangiography (PTC): A procedure used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is sometimes left in the liver to drain bile into the small intestine or a collection bag outside the body. This test is done only if ERCP cannot be done.
  • Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and alaparoscope (a thin, lighted tube) is inserted into one of the incisions. The laparoscope may have an ultrasound probe at the end in order to bounce high-energy sound waves off internal organs, such as the pancreas. This is called laparoscopic ultrasound. Other instruments may be inserted through the same or other incisions to perform procedures such as taking tissue samples from the pancreas or a sample of fluid from the abdomen to check for cancer.
  • Biopsy: The removal of cells or tissues so they can be viewed under amicroscope by apathologist to check for signs of cancer. There are several ways to do a biopsy for pancreatic cancer. A fine needle or a core needle may be inserted into the pancreas during an x-ray or ultrasound to remove cells. Tissue may also be removed during a laparoscopy.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • Whether or not the tumor can be removed by surgery.
  • The stage of the cancer (the size of the tumor and whether the cancer has spread outside the pancreas to nearby tissues orlymph nodes or to other places in the body).
  • The patient’s general health.
  • Whether the cancer has just been diagnosed or has recurred (come back).

Pancreatic cancer can be controlled only if it is found before it has spread, when it can be completely removed by surgery. If the cancer has spread, palliative treatment can improve the patient’s quality of life by controlling the symptoms and complications of this disease.

KEY POINTS

  • Tests and procedures to stage pancreatic cancer are usually done at the same time as diagnosis.
  • There are three ways that cancer spreads in the body.
  • Cancer may spread from where it began to other parts of the body.
  • The following stages are used for pancreatic cancer:
    • Stage 0 (Carcinoma in Situ)
    • Stage I
    • Stage II
    • Stage III
    • Stage IV

Tests and procedures to stage pancreatic cancer are usually done at the same time as diagnosis.

The process used to find out if cancer has spread within the pancreas or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage of the disease in order to plan treatment. The results of some of the tests used to diagnose pancreatic cancer are often also used to stage the disease. See the General Information section for more information.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

  • The cancer spreads from where it began by growing into nearby areas.
  • Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
  • The cancer spreads from where it began by getting into the blood. The cancer travels through theblood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

  • Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms atumor (metastatic tumor) in another part of the body.
  • The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if pancreatic cancer spreads to the liver, the cancer cells in the liver are actually pancreatic cancer cells. The disease is metastatic pancreatic cancer, not liver cancer.

The following stages are used for pancreatic cancer:

Stage 0 (Carcinoma in Situ)

Stage-0In stage 0, abnormal cells are found in the lining of the pancreas. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

 Stage I

Stage I pancreatic cancer. In stage IA, the tumor is 2 centimeters or smaller. In stage IB, the tumor is larger than 2 centimeters.
Stage I pancreatic cancer. In stage IA, the tumor is 2 centimeters or smaller. In stage IB, the tumor is larger than 2 centimeters.

In stage I, cancer has formed and is found in the pancreas only. Stage I is divided into stage IA and stage IB, based on the size of the tumor.

  • Stage IA: The tumor is 2 centimeters or smaller.
  • Stage IB: The tumor is larger than 2 centimeters.

Stage II

Stage IIA pancreatic cancer. Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.
Stage IIA pancreatic cancer. Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.

In stage II, cancer may have spread to nearby tissue and organs, and may have spread tolymph nodes near the pancreas. Stage II is divided into stage IIA and stage IIB, based on where the cancer has spread.

  • Stage IIA: Cancer has spread to nearby tissue and organs but has not spread to nearby lymph nodes.

Stage IIB

Stage IIB pancreatic cancer. Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.
Stage IIB pancreatic cancer. Cancer has spread to nearby lymph nodes and may have spread to nearby tissue and organs.

Cancer has spread to nearby lymph nodes and may have spread to nearb ytissue and organs.

Stage III

Stage III pancreatic cancer. Cancer has spread to the major blood vessels near the pancreas. These include the superior mesenteric artery, celiac axis, common hepatic artery, and portal vein. Cancer may have spread to nearby lymph nodes.
Stage III pancreatic cancer. Cancer has spread to the major blood vessels near the pancreas. These include the superior mesenteric artery, celiac axis, common hepatic artery, and portal vein. Cancer may have spread to nearby lymph nodes.

In stage III, cancer has spread to the major blood vessels near the pancreas and may have spread to nearby lymph nodes.

Stage IVStage IV

Stage IV pancreatic cancer. Cancer may be any size and has spread to distant organs, such as the lung, liver, and peritoneal cavity (the space in the abdomen that contains the intestines, stomach, and liver). Cancer may also have spread to tissue and organs near the pancreas or to lymph nodes.
In stage IV, cancer may be of any size and has spread to distant organs, such as the liver,lung, and peritoneal cavity. It may have also spread to organs and tissues near the pancreas or to lymph nodes.

Recurrent pancreatic cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the pancreas or in other parts of the body.

Treatment Option Overview

KEY POINTS

  • There are different types of treatment for patients with pancreatic cancer.
  • Five types of standard treatment are used:
    • Surgery
    • Radiation therapy
    • Chemotherapy
    • Chemoradiation therapy
    • Targeted therapy
  • There are treatments for pain caused by pancreatic cancer.
  • Patients with pancreatic cancer have special nutritional needs.
  • New types of treatment are being tested in clinical trials.
    • Biologic therapy
  • Patients may want to think about taking part in a clinical trial.
  • Patients can enter clinical trials before, during, or after starting their cancer treatment.
  • Follow-up tests may be needed

There are different types of treatment for patients with pancreatic cancer.

Different types of treatment are available for patients with pancreatic cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Five types of standard treatment are used:

Surgery

One of the following types of surgery may be used to take out the tumor:

  • Whipple procedure: A surgical procedure in which the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine, and the bile duct are removed. Enough of the pancreas is left to produce digestive juices and insulin.
  • Total pancreatectomy: This operation removes the whole pancreas, part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen, and nearby lymph nodes.
  • Distal pancreatectomy: The body and the tail of the pancreas and usually the spleen are removed.

If the cancer has spread and cannot be removed, the following types of palliative surgery may be done to relieve symptoms and improve quality of life:

  • Surgical biliary bypass: If cancer is blocking the small intestine and bile is building up in the gallbladder, a biliary bypass may be done. During this operation, the doctor will cut the gallbladder or bile duct and sew it to the small intestine to create a new pathway around the blocked area.
  • Endoscopic stent placement: If the tumor is blocking the bile duct, surgery may be done to put in a stent (a thin tube) to drain bile that has built up in the area. The doctor may place the stent through a catheter that drains to the outside of the body or the stent may go around the blocked area and drain the bile into the small intestine.
  • Gastric bypass: If the tumor is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.

Radiation therapy

Radiation therapy  is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Combination chemotherapy is treatment using more than one anticancer drug. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Chemoradiation therapy

Chemoradiation therapy combines chemotherapy and radiation therapy to increase the effects of both.

Targeted therapy

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Tyrosine kinase inhibitors (TKIs) are targeted therapy drugs that block signals needed for tumors to grow. Erlotinib is a type of TKI used to treat pancreatic cancer.

There are treatments for pain caused by pancreatic cancer.

Pain can occur when the tumor presses on nerves or other organs near the pancreas. When pain medicine is not enough, there are treatments that act on nerves in the abdomen to relieve the pain. The doctor may inject medicine into the area around affected nerves or may cut the nerves to block the feeling of pain. Radiation therapy with or without chemotherapy can also help relieve pain by shrinking the tumor. See the PDQ summary on Pain for more information.

Patients with pancreatic cancer have special nutritional needs.

Surgery to remove the pancreas may affect its ability to make pancreatic enzymes that help to digest food. As a result, patients may have problems digesting food and absorbing nutrients into the body. To prevent malnutrition, the doctor may prescribe medicines that replace these enzymes. See the PDQ summary on Nutrition in Cancer Care for more information.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site.

Biologic therapy

Biologic therapy is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.

Many of today’s standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.

Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI’s listing of clinical trials.

Follow-up tests may be needed

Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.

Treatment Options by Stage

  • Stages I and II Pancreatic Cancer
  • Stage III Pancreatic Cancer
  • Stage IV Pancreatic Cancer

Stages I and II Pancreatic Cancer

Treatment of stage I and stage II pancreatic cancer may include the following:

  • Surgery.
  • Surgery followed bychemotherapy.
  • Surgery followed bychemoradiation.
  • Aclinical trial of combination chemotherapy.
  • A clinical trial of chemotherapy and targeted therapy, with or without chemoradiation.
  • A clinical trial of chemotherapy and/orradiation therapy before surgery.

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage I pancreatic cancer and stage II pancreatic cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

Stage III Pancreatic Cancer

Treatment of stage III pancreatic cancer may include the following:

  • Palliative surgery or stent placement to bypass blocked areas in ducts or the small intestine.
  • Chemotherapy followed by chemoradiation.
  • Chemoradiation followed by chemotherapy.
  • Chemotherapy with or withouttargeted therapy.
  • Aclinical trial of new anticancer therapies together with chemotherapy or chemoradiation.
  • A clinical trial ofradiation therapy given during surgery or internal radiation

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage III pancreatic cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

Stage IV Pancreatic Cancer

Treatment of stage IV pancreatic cancer may include the following:

  • Palliative treatments to relieve pain, such as nerve blocks, and other supportive care.
  • Palliative surgery or stent placement to bypass blocked areas in ducts or the small intestine.
  • Chemotherapy with or without targeted therapy.
  • Clinical trials of new anticancer agents with or without chemotherapy.

Check the list of NCI-supported cancer clinical trials that are now accepting patients with stage IV pancreatic cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

Treatment Options for Recurrent Pancreatic Cancer

Treatment of recurrent pancreatic cancer may include the following:

  • Palliative surgery or stent placement to bypass blocked areas inducts or the small intestine.
  • Palliativeradiation therapy to shrink the tumor.
  • Other palliative medical care to reduce symptoms, such as nerve blocks to relieve pain.
  • Chemotherapy.
  • Clinical trials of chemotherapy, new anticancer therapies, or biologic therapy.

Check the list of NCI-supported cancer clinical trials that are now accepting patients with recurrent pancreatic cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI website.

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