Pancreatic cancer is a disease of the cells that make up the ducts that carry pancreatic juice. It develops from an initially healthy cell which transforms and multiplies in an anarchic fashion to form a mass called a malignant tumor.

Pancreatic cancer cells can break off and migrate to other tissues or organs. They then form new tumors, called metastases. Pancreatic cancer occurs mostly in people aged 40 or over and especially in men. It can affect the head of the pancreas in 80% of cases, or the body and tail of the pancreas.

According to American Cancer Society, pancreatic cancer accounts for about 3% of all cancer cases in the United States. About 57,600 Americans will be diagnosed with the disease in 2020 and 47,050 will die from it.

Role of the pancreas

The pancreas has two essential functions. On the one hand, it forms digestive enzymes that serve to break down the nutrients absorbed with food (exocrine function). On the other hand, it produces hormones (endocrine function) with certain cell groups, the so-called islands of Langerhans. The most well-known representative of these hormones is insulin, which is important for blood glucose regulation. In the pancreas, therefore, tumors of the exocrine system are distinguished from those of the endocrine system, the former being much more common.

Symptoms of pancreatic cancer

Initially, a cancer such as pancreatic cancer causes hardly any discomfort. The symptoms that occur are often uncharacteristic.

For example, pain in the upper abdomen can occur. These are usually persistent and dull and are usually described as a deeply felt pain. Back pain can also occur, which can be explained by the deep position of the pancreas directly above the spine. In addition, nausea, vomiting and subsequently loss of appetite, weight loss, decreased performance and fatigue can be possible warning signs. Diabetes can also arise if the pancreas produces too little or no insulin.

If the tumor is located in the area of the pancreas facing the duodenum (pancreatic head), a yellowing of the skin (jaundice or icterus) may also occur. Also steatorrhea, i.e. bright, greasy, shiny and unpleasant foul-smelling stool, as well as night sweats and fever can indicate a possible disease of the pancreas.

Risk factors of pancreatic cancer

• People with relatives with pancreatic cancer
• Those who have a parent who has suffered from hereditary chronic pancreatitis (inflammation of the pancreas), hereditary colorectal cancer or hereditary breast cancer, Peutz-Jeghers syndrome or dysplastic nevus syndrome;
• People with diabetes, but it is not known whether in this case cancer is a cause or a consequence of diabetes.
• Smoking. Smokers run a 2-3 times higher risk than non-smokers;
• Obesity, high calorie diet, low in fiber and antioxidants
• Alcohol consumption promotes the occurrence of chronic pancreatitis, itself increasing the risk of developing pancreatic cancer
• Exposure to aromatic hydrocarbons, organophosphate insecticides, petrochemical industry, metallurgy, sawmills

Diagnosis of pancreatic cancer

After a detailed discussion with your doctor, the first tests will be initiated. As a first step in the case of suspected pancreatic cancer, a laboratory examination is usually carried out to check the function of the pancreas and to determine the so-called tumor markers. These are substances produced by the tumor and found in the blood. In pancreatic cancer, the tumor marker cancer antigen 19-9 (CA 19-9) plays a role, but may not appear in a substantial amount in people with the disease.

Therefore, the next step is an ultrasound examination of the abdomen. The pancreas and adjacent organs can be looked at more closely and searched for pathological changes. The examination is carried out in a back position, whereby the doctor with the head of the ultrasound probe takes a look at your abdomen. This examination is usually completely painless and risk-free.

In the event that suspicious changes in the pancreas are found during the ultrasound, an endoscopic ultrasound examination (echo-endoscopy) is carried out as the next step. This is one of the most meaningful examination methods for diseases of the pancreas. A thin tube is pushed through the mouth to the stomach and further into the duodenum. At the end of the hose there is a small ultrasound head, which is used to take pictures of the pancreas and its surroundings. In addition, the doctor can also take a tissue sample (biopsy) as part of this examination, which is then examined under the microscope. This can ultimately result in a diagnosis. The examination can be carried out with mild anesthesia or under the administration of sedatives.

If the diagnosis of pancreatic cancer is made, further examinations are usually necessary to determine at what stage of the disease you are at. It is important to know how large the tumor is, how far it has spread in the abdominal cavity and whether other organs are also affected. These steps are summarized in medicine under the term staging. They are important so that your doctor can determine the best possible therapy for you individually.

For this purpose, a computed tomography (CT), a magnetic resonance imaging (MRI) and an endoscopic retrograde cholangiopancreatography or ERCP can be performed. In these examinations, sectional images of the body are taken, which can depict pathological changes of the individual organs. These individual examinations are completely painless and last between 20 and 40 minutes.

Recent investigation methods include positron emission tomography (PET), which takes advantage of the fact that certain pathological changes have a higher sugar metabolism. By administering a special substance into the vein and using modern computer techniques, these regions can be visualized. In this way, any existing daughter tumors (metastases) can be made visible. The examination is generally not invasive and takes about an hour.

Once all these examinations have been completed, your doctor will tell you which stage of the disease you are at and what therapeutic steps can now be taken.

Stages of pancreatic cancer

The division of the disease into stages depends on the size or extent of the tumor as well as whether lymph nodes and other organs are also affected.

• Stage I: The tumor is limited to the pancreas, other organs are not affected.
• Stage II:  the pancreas and adjacent tissue are affected.
• Stage III: The pancreas, adjacent tissue and regional lymph nodes are affected.
• Stage IV: The tumor has spread further and there are metastases in other organs.

Treatment of pancreatic cancer

If it is established that you have pancreatic cancer, your doctor will talk to you in detail about the individual treatment options. In principle, surgery and chemotherapy and sometimes radiotherapy are eligible for treatment. New molecular biology therapies (so-called “targeted therapies”) may also be used.

• Surgery

In order to get the best possible chance of healing, the entire tumor tissue should be removed if possible. Therefore, surgery is especially useful if the tumor is detected at an early stage. Depending on which part of the pancreas the tumor is located, different surgical procedures are used.

When the tumor sits in the head of the pancreas, a very extensive surgical procedure is usually chosen to ensure that no cancer cells are left behind – even those that are already scattered but not yet visible. The tumor is removed together with a part of the pancreas, the stomach, the duodenum and the gallbladder including the bile duct. This surgical procedure is called Whipple operation. Sometimes the entire pancreas has to be removed (Total Pancreatectomy).

After this very extensive surgical procedure, the digestive system must be partially restored. This also requires different, so-called reconstructive measures.

If the tumor is located in the tail of the pancreas, the operation is less extensive. In these cases, in addition to the tumor, only the spleen usually needs to be removed. A reconstruction is not required here.

Whether surgery is possible depends, among other things, on the patient’s general health. Depending on the scope of the procedure, the recovery takes different lengths and various consequences may occur. For example, the patient may develop diabetes after the removal of a large part of the pancreas. Often, the enzymes formed by the pancreas also need to be replaced by medication. Your doctor will inform you about which surgical method is available for you and which short- or long-term consequences you have to expect. He or she will help you balance the benefits and risks, and can also advise on how to get the right support for the post-surgery period.

• Chemotherapy

Chemotherapy is used at all stages of the disease. It can be used as a sole therapeutic measure as well as before or after surgery and often makes a significant contribution to improving the chances of healing and quality of life. The aim of chemotherapy is to kill tumor cells while sparing as much as possible healthy body cells. The drugs used (so-called cytostatics) inhibit the growth of cancer cells and also directly damage them. Cancer cells differ from healthy cells mainly in that they divide faster and thus grow faster. Cytostatic drugs specifically attack those cells that are currently in the division phase – so chemotherapy is more damaging to tumor tissue than healthy tissue. However, rapidly growing normal cells are also attacked, often causing undesirable side effects. Ask your doctor what side effects are likely to appear and discuss with him or her the ways to alleviate these ailments.

• Radiation therapy

Radiotherapy is also used in some patients and can make a significant contribution to improving the quality of life of the patient. The aim of this therapy is also to destroy cancer cells and thus prevent the spread of the tumor. Energy-rich (ionizing) rays attack the nucleus of tumor cells, preventing them from splitting. The irradiation takes place over a certain period of time in several sessions, with the individual treatments themselves lasting only a few minutes and running painlessly. Your doctor will inform you about the side effects that may occur.

• Targeted Therapies

In the newer therapies, also called targeted therapies, substances are available that target key molecular processes in the cancer cells. These new substances can also be used in pancreatic cancer. Many of the new active ingredients are directed against attack points that are preferred or increasingly present in certain tumor cells. They differ from classic cancer therapies such as chemotherapy and radiotherapy in that they attack almost only cancer cells. Discuss with your doctor whether this type of therapy is appropriate for you. He or she will also educate you about the respective benefits and possible side effects.

The best treatment for you

Which treatment options are specifically available to you depends primarily on the stage of the disease you are in and how well your general health is.

Indeed, several doctors from different medical disciplines (e.g. gastroenterologist, surgeon, oncologist and radiation therapist, but also radiologist) are involved in the planning of the exact therapy strategy. This collaboration of different experts is called a tumor board review in medicine. This ensures that all important factors are taken into account and that the optimal treatment options are found for you individually.

Prevention of pancreatic cancer

It is not known how it would be possible to prevent pancreatic cancer. However, the risk of developing it can be reduced by avoiding smoking, maintaining a healthy diet, and participating in regular physical activity. Indeed, tobacco, overweight, obesity, high fat nutrition are considered to be risk factors for pancreatic cancer on which it is possible to act.

Smoking is involved in cancers of the pancreas but also of the upper aerodigestive tract (mouth, lungs, larynx, pharynx, esophagus) and bladder cancer. It would also be involved in cancers of the urinary tract and of the kidney, stomach, cervix and in certain leukemias.

Things are less clear for alcohol, which could have a role in the development of pancreatitis, but as a rule of thumb alcohol should be avoided.

Maintaining a healthy weight can also help in preventing pancreatic cancer. If you are at a healthy weight, strive to maintain it. If you need to lose weight, aim for slow and steady weight loss — 1-2 lbs. per week. Combine daily exercise with a diet high in vegetables, fruits and whole grains in smaller portions to help you lose weight.

Choose a healthy diet. Eating a diet rich in colorful fruits and vegetables and whole grains can help lower your risk of cancer in general.

In conclusion

Getting diagnosed with cancer is never an easy news to swallow. However, scientific research is underway for early detection of pancreatic cancer, which greatly improves the chances of survival. If you have been diagnosed with pancreatic cancer, make sure you find psychological and mental health support from specialists, friends, family and other people going through the same thing. Talk to your doctor, he or she will advise you on how to proceed. Good luck!