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Pancreatic Cancer - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Pancreatic Cancer. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

Pancreatic cancer is a disease in which healthy cells in the pancreas stop working correctly and grow uncontrollably. These cancerous cells can build up and form a mass called a tumor. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. As it grows, a pancreatic tumor can affect the function of the pancreas, grow into nearby blood vessels and organs, and eventually spread through a process called metastasis to other parts of the body.

About the pancreas

The pancreas is a pear-shaped gland located in the abdomen between the stomach and the spine. It is made up of two major components:

  • The exocrine component is made up of ducts and small sacs called acini on the end of the ducts. This part of the pancreas makes specialized proteins called enzymes that are released into the small intestine to help the body digest and break down food, particularly fats.

  • The endocrine component of the pancreas is made up of cells lumped together in different locations within this part of the pancreas, called islets of Langerhans. These cells make specific hormones, most importantly insulin. Insulin is the substance that helps control the amount of sugar in the blood. This portion of the pancreas also makes other hormones, such as glucagon, somatostatin, pancreatic polypeptide (PP), and vasoactive intestinal peptide (VIP). Each of these hormones play important roles in regulating various aspects of metabolism in the body.

Types of pancreatic cancer

There are several types of pancreatic cancer, depending on whether the cancer began in the exocrine or endocrine component. In addition, some pancreatic cancers are lymphomas or cannot be classified as a specific type.

  • Exocrine tumors. These are the most common type of pancreatic cancer, and adenocarcinoma is the most common type of exocrine tumor. These tumors usually start in the ducts of the pancreas, called ductal adenocarcinoma. Much less commonly, if the tumor begins in the acini, it is called acinar adenocarcinoma.

    An increasingly common diagnosis is called intraductal papillary mucinous neoplasm (IPMN). An IPMN is a tumor that grows within the ducts of the pancreas and makes a thick fluid called mucin. IPMN is not cancerous when it begins, but could become cancerous if not treated. Sometimes, an IPMN has already worsened and become a cancer by the time it is diagnosed.

    Much rarer types of exocrine pancreatic tumors include: acinar cell carcinoma, adenosquamous carcinoma, colloid carcinoma, giant cell tumor, hepatoid carcinoma, mucinous cystic neoplasms, pancreatoblastoma, serous cystadenoma, signet ring cell carcinoma, solid and pseudopapillary tumors, squamous cell carcinoma, and undifferentiated carcinoma.

  • Endocrine tumors. These are also called islet cell tumors or pancreatic neuroendocrine tumors (PNETs). They are much less common than exocrine tumors, making up about 1% of pancreatic cancers. A pancreatic neuroendocrine tumor can be functioning, meaning it makes hormones, or nonfunctioning, meaning it doesn’t make hormones. A functioning neuroendocrine tumor is named based on the hormone the cells normally make. These include:

    • Insulinoma

    • Glucagonoma

    • Gastrinoma

    • Somatostatinoma

    • VIPomas

    • PPomas

To learn more about tumors that start in the endocrine component of the pancreas, read about islet cell tumors and neuroendocrine tumors.

Looking for More of an Overview?

If you would like additional introductory information, explore these related items. Please note these links will take you to other sections on Cancer.Net:

  • ASCO Answers Fact Sheet: Read a 1-page fact sheet (available as a PDF) that offers an easy-to-print introduction to this type of cancer.

The next section in this guide is Statistics and it helps explain how many people are diagnosed with this disease and general survival rates. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Pancreatic Cancer - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find information about how many people are diagnosed with this type of cancer each year. You will also learn some general information on surviving the disease. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

This year, an estimated 53,070 adults (27,670 men and 25,400 women) in the United States will be diagnosed with pancreatic cancer.

It is estimated that 41,780 deaths (21,450 men and 20,330 women) from this disease will occur this year. Pancreatic cancer is the ninth most common cancer in women and the fourth leading cause of cancer death in men and women. As explained in the Overview, most pancreatic cancers are exocrine adenocarcinoma, and these statistics are for that type of pancreatic cancer.

The 1-year survival rate is tells you what percent of people live at least 1 year after the cancer is found. Percent means how many out of 100. The 1-year survival rate of people with pancreatic cancer is 29%, and the 5-year survival rate is 7%. However, survival rates are based on many factors, including the specific stage of disease.

Pancreatic cancer is often difficult to diagnose. This is because there are no specific, cost-effective screening tests that can easily and reliably find early-stage pancreatic cancer in people who have no symptoms. This means it is often not found until later stages when the cancer can no longer be removed with surgery and has spread from the pancreas to other parts of the body.

If the cancer is detected at an early stage when surgical removal of the tumor is possible, the 5-year survival rate is 27%. If the cancer has spread to surrounding tissues or organs and/or the regional lymph nodes, the 5-year survival rate is 11%. If the cancer has spread to a distant part of the body, the 1-year survival rate is 15% and the five-year survival rate is 2%.

It is important to remember that statistics on how many people survive this type of cancer are an estimate. The estimate comes from data based on thousands of people with this cancer in the United States each year. So, your own risk may be different. Doctors cannot say for sure how long anyone will live with pancreatic cancer. Also, experts measure the survival statistics yearly. This means that the estimate may not show the results of better diagnosis or treatment available over the past year. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2016.

The next section in this guide is Medical Illustrations. It offers drawings of body parts often affected by this disease. Or, use the menu on the left side of your screen to choose another section to continue reading this guide.

Pancreatic Cancer - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find a basic drawing of the main body parts affected by this disease. To see other pages, use the menu on the side of your screen.

Pancreatic Cancer Anatomy

Larger image

The pancreas is made up of the head, body, and tail. Pancreatic cancers most commonly arise from the head of the pancreas.

The next section in this guide is Risk Factors and it explains what factors may increase the chance of developing this disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Pancreatic Cancer - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

A person with an average risk of pancreatic cancer has about a 1% chance of developing the disease. Generally, most pancreatic cancers (about 90%) are considered sporadic. Also called somatic mutations, this means the genetic changes develop by chance after a person is born, so there is no risk of passing these genetic changes on to one’s children. Inherited pancreatic cancers are less common (about 10%) and occur when gene mutations or changes are passed within a family from one generation to the next (see below). These are also called germ-line mutations. Often, the cause of pancreatic cancer is not known. However, the following factors may raise a person’s risk of developing pancreatic cancer:

  • Age. The risk of developing pancreatic cancer increases with age. Most people who develop pancreatic cancer are older than 45. In fact, 90% are older than 55 and 70% are older than 65. However, adults of any age can be diagnosed with pancreatic cancer.

  • Gender. More men are diagnosed with pancreatic cancer than women (see Statistics).

  • Race/ethnicity. Black people are more likely than Asian, Hispanic, or white people to develop pancreatic cancer. People of Ashkenazi Jewish heritage are also more likely to develop pancreatic cancer (see Family history, below).

  • Smoking. Smokers are 2 to 3 times more likely to develop pancreatic cancer than nonsmokers.

  • Obesity and diet. Regularly eating foods high in fat is a risk factor for pancreatic cancer. Research has shown that obese and even overweight men and women have a higher risk of dying from pancreatic cancer. Chronic, heavy alcohol use can also increase the risk of pancreatic cancer, most likely through causing recurrent pancreatitis.

  • Diabetes. Many studies have indicated that diabetes, especially when a person has had it for many years, increases the risk of developing pancreatic cancer. In addition, suddenly developing diabetes later in adulthood can be an early symptom of pancreatic cancer. However, it is important to remember that not all people who have diabetes or who develop diabetes as adults develop pancreatic cancer.

  • Family history. Pancreatic cancer may run in the family, called familial pancreatic cancer, if at least 2 members of the family who are first-degree relatives, such as a parent, child, or siblings, or at least 3 members of the family have pancreatic cancer.

  • Rare inherited conditions. Members of families with certain uncommon inherited conditions also have a significantly increased risk of pancreatic cancer, as well as other types of cancer. These include the following:

    People with the following inherited conditions may also have a higher risk of pancreatic cancer:

  • Chronic pancreatitis. Pancreatitis is the inflammation of the pancreas, a painful pancreatic disease. Some research suggests that having chronic pancreatitis may increase the risk of developing pancreatic cancer.

  • Chemicals. Exposure to certain chemicals such as pesticides, benzene, certain dyes, and petrochemicals may increase the risk of developing pancreatic cancer.

  • Bacteria. A common bacterium called Helicobacter pylori, also called H. pylori, causes inflammation and ulcers in the stomach and increases the risk of stomach cancer. H. pylori also increases the risk of pancreatic cancer, although the risk is not as high as the risk of developing stomach cancer.

  • Hepatitis B infection. Hepatitis viruses are viruses that infect the liver. One study has shown that a previous hepatitis B infection was twice as common in people with pancreatic cancer than in people without the cancer. More research is needed to learn more about this link.  

  • Cirrhosis. Cirrhosis develops when liver cells are damaged and are replaced by scar tissue. Most cirrhosis in the United State is caused by alcohol abuse. Other causes are viral hepatitis (see above), too much iron in the liver from a disease called hemochromatosis, and some other rare types of chronic liver disease.

The next section in this guide is Symptoms and Signs and it explains what body changes or medical problems this disease can cause. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Pancreatic Cancer - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

People with pancreatic cancer may experience the following symptoms or signs. Sometimes, people with pancreatic cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer.

Doctors often say that pancreatic cancer is a silent disease because there are not many noticeable symptoms early on. And, there are currently no tests that can reliably find the cancer for people who do not have symptoms. When there are symptoms, they are similar to the symptoms of other medical conditions, such as ulcers or pancreatitis (see Risk Factors). As the cancer grows, symptoms may include:

  • Yellow skin and eyes, darkening of the urine, itching, and clay-colored stool, which are signs of jaundice caused by a blockage of the bile ducts

  • Pain in upper abdomen or upper back

  • Painful swelling of an arm or leg due to a blood clot

  • Burning feeling in stomach or other gastrointestinal discomforts

  • Stomach bloating

  • Floating stools with a particularly bad odor and an unusual color due to the body not digesting fats well

  • Weakness

  • Loss of appetite

  • Nausea and vomiting

  • Chills

  • Fever

  • Unexplained weight loss

If you are concerned about one or more of the symptoms or signs on this list, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section in this guide is Diagnosis and it explains what tests may be needed to learn more about the cause of the symptoms. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Pancreatic Cancer - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if it has spread to another part of the body, called metastasis. Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has spread.

This list describes options for diagnosing this type of cancer, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition

  • Type of cancer suspected

  • Signs and symptoms

  • Previous test results

If a doctor suspects that a person has pancreatic cancer, he or she will first ask about the person's medical history, family history, and examine the person to look for signs of the disease. An appropriate and timely diagnosis is very important. If possible, tests should be done at a center that has experience with the disease. The tests listed below may be used to diagnose pancreatic cancer.

General tests

  • Physical examination. The doctor will examine the skin and eyes to see if they are yellow, which is a sign of jaundice. Jaundice can be from a tumor in the head of the pancreas blocking the normal flow of a substance called bile that is produced in the liver. However, many patients with pancreatic cancer do not have jaundice when the cancer is diagnosed. The doctor will also feel the abdomen for changes caused by the cancer, although the pancreas itself, located in the back of the upper abdomen, can rarely be felt. An abnormal buildup of fluid in the abdomen, called ascites, may be another sign of cancer.

  • Blood tests. The doctor may take samples of blood to check for abnormal levels of bilirubin and other substances. Bilirubin is a chemical that may reach high levels in patients with pancreatic cancer due to blockage of the common bile duct by a tumor. There are many other non-cancerous causes of an elevated bilirubin level, such as hepatitis, gallstones, or mononucleosis.

    Carbohydrate antigen 19-9 (CA19-9) is a tumor marker. A tumor marker is a substance produced by a tumor that may be found at higher levels if cancer is present and can be measured in the blood. CA19-9 is often higher in people with pancreatic cancer. High levels of CA 19-9 should not be used as the only test to make the diagnosis of pancreatic cancer, because high levels of CA 19-9 also can be a sign other conditions. This can be a sign of other types of cancer, such as colorectal, liver, and esophageal cancers. It can also occur in noncancerous conditions, such as pancreatitis, cirrhosis of the liver, and a non-cancerous blockage of the common bile duct.

Imaging tests

Imaging tests help doctors find out where the cancer is located and whether it has spread from the pancreas to other parts of the body. Pancreatic cancer often does not develop as a single large tumor, which means it can sometimes be difficult to see on imaging tests. However, newer computed tomography scanners (see below) produce better, clearer images that can make it easier to find. A radiologist is a doctor who specializes in interpreting imaging tests.

  • Computed tomography (CT or CAT) scan. A CT scan creates a multi-dimensional picture of the inside of the body with a machine similar to an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can also be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a pill to swallow. Many cancer centers use a special CT scan method called a pancreatic protocol CT scan. This method focuses specifically on taking images of the pancreas at specific times after the intravenous (IV) injection of contrast medium to find out exactly where the tumor is in relation to nearby organs and vessels. The results of this test can help decide if the tumor could be removed with surgery.

  • Positron emission tomography (PET) scan. A PET scan is usually done in combination with a CT scan, with the images placed over each. A PET scan is a way to create multi-colored pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance called a tracer is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. The combination provides a more complete picture of the area being evaluated. PET scans are done regularly at some but not all cancer centers for the diagnosis and staging of pancreatic cancer. However, they are not yet considered a standard test to diagnose pancreatic cancer. A PET scan alone should never be used instead of a high-quality CT scan.

  • Ultrasound.  An ultrasound uses sound waves to create a picture of the internal organs. There are 2 types of ultrasound devices: transabdominal and endoscopic.

    • A transabdominal ultrasound device is placed on the outside of the abdomen and is slowly moved around by the doctor to produce an image of the pancreas and surrounding structures.

    • The endoscopic ultrasound (EUS) device is a thin, lighted tube that is passed through the patient's mouth and stomach and down into the small intestine to take a picture of the pancreas. This procedure is very specialized and requires a gastroenterologist who has special training in this area. A gastroenterologist is a doctor who specializes in the gastrointestinal tract, including stomach, intestines, and similar organs. EUS is generally done under sedation, so the patient sleeps through the procedure. A biopsy (see below) may also be done at the same time as this procedure.

  • Endoscopic retrograde cholangiopancreatography (ERCP). This procedure is performed by a gastroenterologist. The doctor will put a thin, lighted tube called an endoscope through the mouth and stomach into the small intestine. Then, a smaller tube called a catheter is passed through the endoscope and into the bile ducts and pancreatic ducts. Dye is injected into the ducts, and the doctor then takes x-rays that can show whether a duct is compressed or narrowed. Often, a plastic or metal stent can be placed across the obstructed bile duct during ERCP to help relieve any jaundice. Samples of the tissue can be taken during this procedure and can sometimes help confirm the diagnosis of cancer. The patient is lightly sedated during this procedure. ERCP is generally used to place bile duct stents and not commonly used for diagnosis.

  • Percutaneous transhepatic cholangiography (PTC). In this x-ray procedure, a thin needle is inserted through the skin and into the liver. A dye is injected through the needle, so the bile ducts show up on x-rays. By looking at the x-rays, the doctor can tell whether there is a blockage of the bile ducts.

Biopsy and tissue tests

  • Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but for most cancers only a biopsy can make a definite diagnosis. A pathologist then analyzes the sample(s). A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. For pancreatic cancer, the pathologist may often have specific experience in looking at pancreatic cancer biopsy samples. There are a few different ways to collect a tissue sample:

    • One technique is called fine needle aspiration (FNA). An FNA uses a thin needle that is inserted into the pancreas to suction out cells. This is typically done by EUS (see above) or through the skin, called percutaneously, guided by a CT scan.

    • Another method uses a core or Tru-Cut needle biopsy to collects a larger piece of tissue. A larger piece of tissue may be helpful for molecular or genetic testing of the tumor. However, a core biopsy has higher risks than an FNA. It should be performed by a well-trained specialist.

    If the cancer has spread to other organs, a biopsy may also be needed from one of these other sites, such as the liver. Again, this can be through the skin, as explained above, or less commonly, by surgery. This type of surgery can be done through a larger incision in the abdomen, called a laparotomy. Or, it can be done using  much smaller incisions that provide openings for a tiny camera and surgical instruments, called a laparoscopic approach.

    Rarely, a biopsy may not show that cancer cells are present because the area sampled may be made up of areas of inflammation and/or fibrosis (scar-like tissue), in addition to cancer cells. In general, before a patient starts treatment, every effort is made to confirm that cancer it present, even if this means that multiple biopsies are needed. One exception is for patients with a mass located in one area of the pancreas that can be removed with surgery even if a biopsy is not performed or the biopsy does not show cancer cells.

  • Molecular testing of the tumor. Your doctor may recommend running laboratory tests on a tumor sample or a blood sample to identify specific genes, proteins, and other factors unique to the tumor. These are called biomarkers. Examples of biomarkers for pancreatic cancer include RAS, SPARChENT1, and DPC4. Some patients, when having surgery or certain types of biopsies (see above), choose to have some of the tissue sent to independent laboratories that look at some or all of these biomarkers. Results of these tests may help to guide treatment decisions, although more research is needed for this to become a standard way of making treatment decisions. However, it is an area of increasing interest and scientific focus. It is important to note that many insurance companies do not provide coverage for these types of tests yet. Talk with your doctor for more information. Also, patients who have surgery may choose to donate parts of the tumor that are not needed for diagnostic tests so the samples can be used to further pancreatic cancer research.

After diagnostic tests are done, your doctor will review all of the results with you, including the exact type of cancer you have, how much the cancer has grown and spread (called the stage), and the options for treatment.

The next section in this guide is Stages, and it explains the system doctors use to describe the extent of the disease. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Pancreatic Cancer - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer. For pancreatic cancer, it is important for the staging to be done at a medical center with experience in staging pancreatic cancer.

Doctors use several systems to stage pancreatic cancer. The method used to stage other cancers, called the TNM classification, is not often used for pancreatic cancer; however, for completeness, it is discussed below.

The more common way to classify pancreatic cancer is to divide it into 4 categories based on whether it can be removed with surgery and where it has spread:

Resectable

This type of pancreatic cancer can be surgically removed. The tumor may be located only in the pancreas or extends beyond it, but it has not grown into important arteries or veins in the area. There is no evidence that the tumor has spread to areas outside of the pancreas. Approximately 10% to 15% of patients are diagnosed with this stage.

Borderline resectable

This category describes a tumor that may be difficult, or not possible, to remove surgically when it is first diagnosed, but if chemotherapy and/or radiation therapy is able to shrink the tumor first, it may be able to be removed later with negative margins, which means that no visible cancer cells are left behind.

Locally advanced

This type is still located only in the area around the pancreas, but it cannot be surgically removed because it has grown into nearby arteries or veins or to nearby organs. However, there are no signs that it has spread to any distant parts of the body. Approximately 35% to 40% of patients are diagnosed with this stage.

Metastatic

The tumor has spread beyond the area of the pancreas and to other organs, such as the liver or distant areas of the abdomen. Approximately 45% to 55% of patients are diagnosed with this stage.

By classifying each cancer into one of these categories, the health care team can plan the best treatment strategy.

TNM Staging System

Doctors frequently use a tool called the TNM system to stage other types of cancer. Because doctors generally classify a tumor during surgery, and because many patients with pancreatic cancer do not receive surgery, the TNM system is not used as much for pancreatic cancer as it is for other cancers.

Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?

  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many? 

  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are 5 stages: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments. Here are more details on each part of the TNM system for pancreatic cancer:

Tumor (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. This helps the doctor develop the best treatment plan for each patient. Specific tumor stage information listed below.

TX: The primary tumor cannot be evaluated.

T0: No evidence of cancer was found in the pancreas.

Tis: Refers to carcinoma in situ, which is very early cancer that has not spread.

T1: The tumor is in the pancreas only, and it is 2 centimeters (cm) or smaller in size.

T2: The tumor is in the pancreas only, and it is larger than 2 cm.

T3: The tumor extends beyond the pancreas, but the tumor does not involve the major arteries or veins near the pancreas.

T4: The tumor extends beyond the pancreas into major arteries or veins near the pancreas. A T4 tumor cannot be completely removed with surgery.

Node (N)

The "N" in the TNM staging system is for lymph nodes. Lymph nodes are tiny, bean-shaped organs located throughout the body that help fight infection and disease as part of the body's immune system. In pancreatic cancer, regional lymph nodes are those lymph nodes near the pancreas and distant lymph nodes are those lymph nodes in other parts of the body.

NX: The regional lymph nodes cannot be evaluated.

N0: Cancer was not found in the regional lymph nodes.

N1: Cancer has spread to regional lymph nodes.

Metastasis (M) 

The "M" in the TNM system indicates whether the cancer has spread to other parts of the body, called distant metastasis.

MX: Distant metastasis cannot be evaluated.

M0: The disease has not spread to other parts of the body. 

M1: Cancer has spread to another part of the body, including distant lymph nodes. Pancreatic cancer most commonly spreads to the liver, the lining of the abdominal cavity called the peritoneum, and lungs.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage 0: Refers to cancer in situ, in which the cancer has not yet invaded outside the duct in which it started (Tis, N0, M0).

Stage IA: The tumor is 2 cm or smaller in the pancreas. It has not spread to lymph nodes or other parts of the body (T1, N0, M0).

Stage IB: A tumor larger than 2 cm is in the pancreas. It has not spread to lymph nodes or other parts of the body (T2, N0, M0).

Stage IIA: A tumor extends beyond the pancreas, but the tumor has not spread to nearby arteries or veins. It has not spread to any lymph nodes or other parts of the body (T3, N0, M0).

Stage IIB: A tumor of any size has not spread to nearby arteries or veins. It has spread to lymph nodes but not to other parts of the body (T1, T2, or T3; N1; M0).

Stage III: A tumor has spread to nearby arteries, veins, and/or lymph nodes but has not spread to other parts of the body (T4, N1, M0).

Stage IV: Any tumor that has spread to other parts of the body (any T, any N, M1).

Recurrent: Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition published by Springer-Verlag New York, www.cancerstaging.net.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Pancreatic Cancer - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will learn about the different ways doctors use to treat people with this type of cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best known treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, see the About Clinical Trials and Latest Research sections.

Treatment overview 

In cancer care, different types of doctors and other health care professionals often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the most common treatment options for pancreatic cancer are listed below. The current treatment options for pancreatic cancer are surgery, radiation therapy, chemotherapy, and targeted therapy. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

When detected at an early stage, pancreatic cancer has a much higher chance of being successfully treated. However, there are also treatments that can help control the disease for patients with later stage pancreatic cancer to help them live longer.

Surgery

Surgery for pancreatic cancer includes removing all or part of the pancreas, depending on the location and size of the tumor in the pancreas. A surgical oncologist is a doctor who specializes in treating cancer using surgery. Learn more about the basics of cancer surgery.

Only about 20% of patients with pancreatic cancer are able to have surgery because most pancreatic cancers are first diagnosed when the disease has already spread. If surgery is not an option, you and your doctor will talk about other treatment options.

Surgery for pancreatic cancer may be combined with radiation therapy and/or chemotherapy (see below). Typically, radiation therapy and chemotherapy are given after surgery, called adjuvant therapy. If a tumor is borderline resectable, meaning it is unclear if it can be removed with surgery, radiation therapy and/or chemotherapy may be given first to try to shrink the tumor so it can be removed with surgery. This is called neoadjuvant therapy.

Different types of surgery are performed depending on the purpose of the surgery:

  • Laparoscopy. Sometimes, the surgeon may choose to start with a laparoscopy. During a laparoscopy, several small holes are made in the abdomen and a tiny camera is passed into the body while a patient receives anesthesia, which is medication to help block the awareness of pain. This helps the surgeon find out if the cancer has spread to other parts of the abdomen. If it has, surgery to remove the primary tumor is generally not recommended.

  • Surgery to remove the tumor. Different types of surgery are used depending on where the tumor is located in the pancreas. In all of the surgeries discussed below, nearby lymph nodes are removed as part of the operation. More than one type of surgeon, as well as other specialists, will usually be involved in your surgery.

    • If the cancer is located only in the head of the pancreas, the surgeon may do a Whipple procedure. This is an extensive surgery in which the surgeon removes the head of the pancreas and part of the small intestine, bile duct, and stomach, and then reconnects the digestive tract and biliary system. An experienced pancreatic cancer surgeon should perform this procedure.

    • If the cancer is located in the tail of the pancreas, the common operation is a distal pancreatectomy. In this surgery, the surgeon removes the tail and body of the pancreas, as well as the spleen.

    • If the cancer has spread throughout the pancreas, or is located in many areas in the pancreas, a total pancreatectomy may be needed. A total pancreatectomy is the removal of the entire pancreas, part of the small intestine, a portion of the stomach, the common bile duct, the gallbladder, and the spleen.

After surgery, the patient will need to stay in the hospital for several days and will probably need to rest at home for about a month. Side effects of surgery include weakness, tiredness, and pain for the first few days after the procedure. Other side effects caused by the removal of the pancreas include difficulty digesting food and diabetes from the loss of insulin produced by the pancreas. For more information on relieving these side effects, see Getting care for the symptoms and side effects, below.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. Learn more about the basics of radiation therapy.

Radiation therapy may be given for pancreatic cancer in the following situations:

  • After surgery for patients who have a high risk of their cancer coming back in the area of surgery. This includes patients with a tumor that is large or was removed with close or positive surgical margins, meaning that cancer cells are seen up to or very close to the edge of the tissue removed during surgery.

  • Before surgery to try to shrink a borderline resectable tumor

  • For patients with locally advanced, unresectable disease

  • To relieve severe pain for people with metastatic cancer

External-beam radiation therapy is the type of radiation therapy used most often for pancreatic cancer, and treatment usually takes 5 to 6 weeks with once-daily doses of radiation. Newer types of radiation therapy, such as stereotactic radiosurgery (for example, CyberknifeTM), are being used for pancreatic cancer because they can provide more localized treatment and require a fewer number of treatment sessions. However, these newer types of radiation therapy have not been compared with standard-fractionation radiation therapy and should not be considered a replacement for it.

Often, chemotherapy (see below) will be given at the same time as radiation therapy because it can enhance the effects of the radiation therapy, which is called radiosensitization. Combining chemotherapy and radiation therapy may occasionally help shrink the tumor enough so it can be removed by surgery. However, chemotherapy given at the same time as radiation therapy often has to be given at lower doses than when given alone.

It is important to note that radiation therapy may be helpful for decreasing the likelihood of a pancreatic cancer returning or re-growing at the original location, but there remains much uncertainty as to how much, if at all, it lengthens a person’s life.

Side effects from radiation therapy may include fatigue, mild skin reaction, nausea, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication.

Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or combinations of different drugs at the same time.

  • Adjuvant chemotherapy. Adjuvant chemotherapy is given after a pancreatic tumor is removed with surgery to prevent the cancer from coming back. Currently, the standard adjuvant chemotherapy uses gemcitabine (Gemzar) alone. Ongoing clinical trials are looking at combinations of different drugs for adjuvant treatment, including more intensive combinations similar to those used for advanced pancreatic cancer; see First-line chemotherapy, below. Chemotherapy given before surgery is generally used for patients with borderline resectable disease, when shrinking the tumor may increase the chance of removing it with surgery.

  • First-line chemotherapy. This is generally the first treatment used for patients with either locally advanced or metastatic pancreatic cancer (see Stages). Gemcitabine was the first drug approved for first-line chemotherapy in 1997, as it was shown to lengthen patients’ lives and improve quality of life. Since then, many large clinical trials have tested whether adding a second drug to gemcitabine is more effective when compared to treatment with gemcitabine alone. However, until 2010, only the drug erlotinib (Tarceva; see Targeted therapy, below) was shown to lengthen patients’ lives when added to gemcitabine, and the increase in survival was quite small.

    In the past few years, large clinical trials have identified 2 particular chemotherapy combinations as new standards of care, each of which has been shown to lengthen patients’ lives and delay the growth and spread of metastatic pancreatic cancer for a longer than with gemcitabine alone. The first of these is a combination of drugs called FOLFIRINOX, which uses fluorouracil (5-FU), leucovorin (Wellcovorin), irinotecan (Camptosar), and oxaliplatin (Eloxatin). Because of the side effects, this regimen is only for patients who are in good physical condition and otherwise healthy despite the cancer. The second is a combination of gemcitabine plus nanoparticle-bound nab-paclitaxel (Abraxane).

    There are generally more side effects when 2 or more drugs are used together, and combination treatments are usually best for patients who are able to carry out their usual activities of daily living without help. The choice of which combination to use varies depending on the cancer center and often depends on the oncologist’s experience with the drugs, as well as the different side effects. For patients who are older and less healthy, gemcitabine alone may still be the most appropriate option.

  • Second-line chemotherapy. When treatment does not work or stops working to control cancer growth, the cancer is called refractory. Sometimes, first-line treatment does not work at all, which is called primary resistance. Or, treatment may work well for a while and then stop being effective later, which is sometimes called secondary or acquired resistance. In these situations, patients may benefit from additional treatment with different drugs if the patient’s overall health is good. For example, 2 combinations are available: FOLFIRINOX and gemcitabine/nab-paclitaxel. It is common to try the other regimen if the first regimen given is no longer working. Therefore, a patient who started treatment with gemcitabine/nab-paclitaxel may switch to FOLFIRINOX, or some simplified version of it, as second-line therapy; and vice-versa. While this makes a great deal of sense, it is important to recognize that there is not yet a lot of evidence to support how well each of these regimens works as second-line therapy.

    In 2015, the first drug specifically indicated for use as second-line treatment for pancreatic cancer was approved by the U.S. Food and Drug Administration (FDA). This drug, called nanoliposomal irinotecan (Onivyde), when given with 5-FU and leucovorin, was shown to benefit patients who had previously received a chemotherapy regimen containing gemcitabine.

    There is significant ongoing research focused on developing other new treatments for second-line, as well as third-line treatment and beyond. Some of which have shown considerable promise (see the Latest Research section).

  • Off-label use. This is when a drug is used to treat conditions not listed on the label, which are the conditions that drug is approved for, or is given differently than the instructions on the label. Off-label drug use in pancreatic cancer treatment is common for many reasons. First, drugs are generally approved for treating only a particular type or stage of cancer. Second, many cancer treatments use a combination of drugs and one or more of the drugs is often being used off label. Drug regimens are also constantly changing as doctors study new combinations to improve patient care. However, off-label use of drugs may not be covered by your health insurance company. Exceptions are possible, but it is important for you and/or your doctor to talk with your insurance company ahead of time.

  • Side effects of chemotherapy. The side effects of chemotherapy depend on which drugs the patient receives. In addition, not all patients have the same side effects. Side effects can include poor appetite, nausea, vomiting, diarrhea, gastrointestinal problems, mouth sores, hair loss, and a lack of energy. People receiving chemotherapy also are more likely to get infections and bruise and bleed easily because chemotherapy decreases the production of white blood cells, red blood cells, and platelets. Certain drugs used in pancreatic cancer are also associated with specific side effects. For example, capecitabine (Xeloda) can cause redness and discomfort on the palms of the hands and the soles of the feet. This condition is called hand-foot syndrome. Oxaliplatin, one of the drugs used in the FOLFIRINOX regimen, can cause cold sensitivity and numbness and tingling in the fingers and toes, called peripheral neuropathy. Peripheral neuropathy is a side effect of nab-paclitaxel as well. These side effects typically go away between treatments and after the treatments have ended, but some can be longer-lasting and can worsen as treatment continues. The doctor can suggest ways to relieve these side effects.

Learn about the basics of chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

The targeted therapy erlotinib is approved by the FDA for patients with advanced pancreatic cancer in combination with gemcitabine. Erlotinib blocks the effect of the epidermal growth factor receptor (EGFR), a protein that can become abnormal and help cancer grow and spread. Side effects of erlotinib include a skin rash similar to acne. Talk with your doctor about possible side effects for a specific medication and how they can be managed.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment. Palliative care should not be confused with hospice care, which is discussed further below. 

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in the treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and palliative care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible.

Supportive care for people with pancreatic cancer includes:

  • Palliative chemotherapy. Any chemotherapy regimen discussed above may help relieve the symptoms of pancreatic cancer, such as lessening pain, improving a patient’s energy and appetite, and stopping or slowing weight loss. When making decisions about palliative chemotherapy, it is important that you and your doctor weigh the benefits with the possible side effects and consider how each treatment might affect your quality of life.

  • Relieving bile duct or small intestine blockage. If the tumor is blocking the common bile duct or small intestine, placement of a tiny tube called a stent to help keep the blocked area open can be performed to relieve the blockage using nonsurgical approaches, such as ERCP, PTC, or endoscopy (see the Diagnosis section for more information). A stent can be either plastic or metal. The type used depends on the availability, cost, a person’s expected lifespan, and whether the cancer will eventually be removed with surgery. In general, plastic stents are less expensive and are easier to insert and remove, but need to be replaced every few months, are associated with more infections, and more likely to move out of place. Stents are typically placed inside the body, but sometimes, a tube may need to be placed through a hole in the skin of the abdomen to drain fluid, such as bile, to the outside, called percutaneous drainage. Sometimes, a patient may need surgery to create a bypass, even if the tumor itself cannot be completely removed.

  • Improving digestion and appetite. A special diet, medications, and specially prescribed enzymes may help a person digest food better if their pancreas is not working well or has been partially or entirely removed. Meeting with a nutritionist is recommended for most patients, especially those who are losing weight and have a poor appetite because of the disease.

  • Controlling diabetes. Insulin will usually be recommended if a person develops diabetes due to the loss of insulin produced by the pancreas, which is more common after a total pancreatectomy.

  • Relieving pain and other side effects. Radiation therapy may be given to help relieve pain. Gemcitabine has also been shown to improve cancer-related symptoms, such as weight loss, pain, and weakness. Morphine-like drugs called opioid analgesics are often needed to help reduce pain. Special types of nerve blocks done by pain specialists may also be used. One type of nerve block is a celiac plexus block, which helps relieve abdominal pain. During a nerve block, the nerves are injected with either an anesthetic to stop pain for a short time or a medication that destroys the nerves and can relieve pain for a longer time. A nerve block can be performed either through the skin or through an endoscope that is placed through the mouth and past the stomach. Learn more about managing pain.

Recommended supportive care may also include complementary and alternative therapies.

Palliative and supportive care is not limited to managing a patient’s physical symptoms. There are also emotional and psychological issues patients experience that can be managed with professional help and support, such as anxiety, depression, help with coping skills, and the overall difficulty of dealing with cancer. Cancer also affects caregivers and loved ones, and they are encouraged to develop support networks as well.

Learn more about palliative care.

Metastatic pancreatic cancer

If cancer has spread to another location in the body, it is called metastatic cancer. Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about getting a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials.

Your health care team may recommend a treatment plan that includes a combination of the treatments discussed above. Palliative care will also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer does return after the original treatment, it is called recurrent cancer. Pancreatic cancer may come back in or near the pancreas (called a local or regional recurrence), or elsewhere in the body (distant recurrence, which is similar to metastatic disease).

When this occurs, diagnostic testing will begin again to learn as much as possible about the extent and location of the recurrence. After testing is done, you and your doctor will talk about your treatment options. The treatment of recurrent pancreatic cancer is similar to the treatments described above and usually involves chemotherapy (see first-line and second-line chemotherapy above). Radiation therapy or surgery may also be used to help relieve symptoms (see above). Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

If treatment fails 

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and advanced cancer is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced cancer and who are expected to live less than 6 months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is About Clinical Trials and it offers more information about research studies that are focused on finding better ways to care for people with cancer. Or, use the menu on the side of your screen to choose another section to continue reading this guide.  

Pancreatic Cancer - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

What are clinical trials?

Doctors and scientists are always looking for better ways to care for patients with pancreatic cancer. To make scientific advances, doctors create research studies involving volunteers called clinical trials. In fact, every drug that is now approved by the FDA was previously tested in clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Deciding to join a clinical trial

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating pancreatic cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with pancreatic cancer.

Sometimes people have concerns that, in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” However, placebos are usually combined with standard treatment in most cancer clinical trials. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

Patient safety and informed consent

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, a member of the health care team should list all of the patient’s options so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends. 

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for pancreatic cancer, learn more in the Latest Research section.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

In addition, this website offers free access to a video-based educational program about cancer clinical trials, located outside of this guide.

The next section in this guide is Latest Research and it explains areas of scientific research currently going on for this type of cancer. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Pancreatic Cancer - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about pancreatic cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

  • Early detection. The best chance of successful treatment is when pancreatic cancer is found early. This is why ongoing research is focused on finding and using special blood tests, diagnostic imaging tools, and other approaches to find pancreatic cancer at its earliest stages before it spreads. This includes finding it at precancerous stages, known as pancreatic intraepithelial neoplasia, or PanIN lesions. These screening approaches are typically being used for people who have a high risk for pancreatic cancer, such as those with a strong family history or a known genetic condition that increases the risk of pancreatic cancer. It is not yet known if these screening tools could be used effectively for the general population.

  • Genetic/molecular studies. In cancer, damaged or abnormal genes cause uncontrolled cell growth. Many new research developments are based on identifying damaged genes and proteins, and repairing them or changing how they work.

    Pancreatic tumor samples can be analyzed using a variety of molecular techniques, such as DNA sequencing and mutational analysis, to look for genetic changes. Some of these same analyses can now even also be performed on blood samples, as newer technologies allow for collection and analysis of tumor DNA present in the blood.

    This information can then be used to develop new drugs that target these changes (see Targeted therapy below), as well as potentially to screen for pancreatic cancer in people who have a high risk of the disease. At this point, these tools are only being used in clinical trials.

  • Immunotherapy. Immunotherapy is designed to boost the body’s natural defenses to fight cancer. It uses materials either made by the body or in a laboratory to improve, target, or restore immune system function.

    • One example of immunotherapy is a cancer vaccine, which stimulates a person’s immune system to recognize and attack cancer cells. A number of clinical trials have been done or are underway to study vaccines in a variety of types of cancer, including pancreatic cancer. Depending on the circumstances, vaccines may be given either after, during, or instead of chemotherapy.

    • Another type of immunotherapy called immune checkpoint inhibitors is also being researched. This type of immunotherapy is already approved for other types of cancer, like melanoma and lung cancer, but not in pancreatic cancer.

    • In addition, researchers are studying methods to collect and genetically modify a person’s T cells, which are a type of white blood cells. This is called adoptive immunotherapy.

    Learn more about the basics of immunotherapy.

  • Targeted therapy. As discussed in the Treatment Options section, erlotinib is the only targeted therapy currently approved for pancreatic cancer, in combination with gemcitabine. Other drugs that may help block tumor growth and spread are being studied for pancreatic cancer, both as single drugs and as part of combination therapy. However, no other targeted therapies, including bevacizumab (Avastin) and cetuximab (Erbitux), have been shown to lengthen the lives of patients with pancreatic cancer. A gene called Ras is often mutated in pancreatic cancer. Drugs that target how this mutation contributes to cancer growth are being studied, either alone or in combination with other types of targeted therapy or chemotherapy. Another gene mutation linked to pancreatic cancer growth called Jak/Stat can also be blocked by certain targeted therapies, and is currently being researched in several clinical trials. Researchers are also studying drugs that can break down the stroma, which is the fibrous-like connective tissue that surrounds cancer cells and is involved in maintaining the cancer. By disrupting the tumor-associated stroma, these drugs may allow chemotherapy to reach and destroy cancer cells more effectively. Learn more about the basics of targeted therapy.

  • Gene therapy.  Gene therapy is the delivery of specific genes to cancer cells, which are often carried by specially designed viruses. These include normal genes that are delivered into the center of cancer cells; as the cancer cells divide, the working genes that were inserted in the cell replace the abnormal genes that contribute to cancer growth.

  • Chemotherapy. Newer, stronger types of standard chemotherapy continue to be researched. One example is nanoliposomal irinotecan (see Treatment Options), which is now approved as a second-line treatment for advanced pancreatic cancer.

  • Cancer stem cells. Pancreatic cancer stem cells are cells in the tumor that may be particularly resistant to standard therapies. Research is currently focused on identifying treatments that may specifically target those cancer stem cells.

  • Palliative care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current pancreatic cancer treatments in order to improve patients’ comfort and quality of life.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding pancreatic cancer, explore these related items that take you outside of this guide:

The next section in this guide is Coping with Side Effects and it offers some guidance in how to cope with the physical, emotional, and social changes that cancer and its treatment can bring. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Pancreatic Cancer - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

There are possible side effects for every cancer treatment, but patients don’t experience the same side effects when given the same treatments for many reasons. That can make it hard to predict exactly how you will feel during treatment.

Abdominal and/or back pain are common side effects of pancreatic cancer. Pain medications and a nerve block (see Treatment Options) can help relieve the pain associated with pancreatic cancer. Other common side effects from each treatment option for pancreatic cancer are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Talking with your health care team about side effects

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them.

And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with pancreatic cancer. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies, including concerns about managing the cost of your cancer care.

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more by reading the Follow-up Care section of this guide or talking with your doctor.

The next section in this guide is Follow-up Care and it explains the importance of check-ups after cancer treatment is finished. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Pancreatic Cancer - Follow-Up Care

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will read about your medical care after cancer treatment is completed, and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

Care for people diagnosed with cancer doesn’t end when active treatment has finished. Your health care team will continue to check to make sure the cancer has not returned, manage any side effects, and monitor your overall health. This is called follow-up care.

This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. For people who have had surgery, follow-up visits every 3 to 6 months with the oncologist are typically recommended. Blood tests, including monitoring liver function and the tumor marker CA 19-9, may be done during these visits. CT scans are not needed regularly, but they may be used depending on a person’s symptoms and any changes found during the physical examination or with the blood work. PET scans may be used to look for a recurrence after treatment. 

Learn more about the importance of follow-up care.

Watching for recurrence

One goal of follow-up care is to check for a recurrence. Cancer recurs because small areas of cancer cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms. During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of recurrence. Your doctor will also ask specific questions about your health. Some people may have blood tests or imaging tests as part of regular follow-up care, but testing recommendations depend on several factors including the type and stage of cancer originally diagnosed and the types of treatment given.

Managing long-term and late side effects

Most people expect to experience side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. In addition, other side effects called late effects may develop months or even years afterwards. Long-term and late effects can include both physical and emotional changes.

Talk with your doctor about your risk of developing such side effects based on the type of cancer, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may also have certain physical examinations, scans, or blood tests to help find and manage them.

Keeping personal health records

You and your doctor should work together to develop a personalized follow-up care plan. Be sure to ask about any concerns you have about your future physical or emotional health. ASCO offers forms to help create a treatment summary to keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

This is also a good time to decide who will lead your follow-up care. Some survivors continue to see their oncologist, while others transition back to the general care of their family doctor or another health care professional. This decision depends on several factors, including the type and stage of cancer, side effects, health insurance rules, and your personal preferences.

If a doctor who was not directly involved in your cancer care will lead your follow-up care, be sure to share your cancer treatment summary and survivorship care plan forms with him or her, as well as all future health care providers. Details about your cancer treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

Many people choose to keep their own record of the dates or tests, procedures, and results. You can also request copies of these from your health care team throughout your diagnosis, treatment, and recovery.

The next section in this guide is Survivorship and it describes how to cope with challenges in everyday life after a cancer diagnosis. Or, use the menu on the side of your screen to choose another section to continue reading this guide. 

Pancreatic Cancer - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

Questions to ask after getting as diagnosis

  • What type of pancreatic cancer do I have?

  • Is my cancer located only in the pancreas?

  • What is the stage of the disease? What does this mean?

  • Can you explain my pathology report (laboratory test results) to me? Could I have a copy of the results?

  • What is my prognosis (chance of recovery)?

  • Can I donate tumor or blood samples or body tissues to research for pancreatic cancer?

Questions to ask about choosing a treatment and managing side effects

  • What are my treatment options?

  • What clinical trials are open to me? Where are they located, and how do I find out more about them?

  • What treatment plan do you recommend? Why?

  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?

  • Who will be part of my health care team, and what does each member do? Do they have experience treating pancreatic cancer?

  • Who will be coordinating my overall treatment?

  • What is the goal of each treatment?

  • What are the side effects of this treatment, both in the short term and the long term?

  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

  • Could this treatment affect my sex life? If so, how and for how long?

  • Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist?

  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?

  • What support services are available to me? To my family?

  • Whom should I call for questions or problems?

  • Is there anything else I should be asking?

Questions to ask about having surgery

  • Is surgery a possibility to remove the cancer? If so, what type is recommended?

  • How experienced is my surgeon in performing this type of operation? How often are there complications after surgery?

  • How long will the operation take?

  • How long will I be in the hospital?

  • Can you describe what my recovery from surgery will be like?

  • What are the possible long-term effects of having surgery?

  • If surgery is not a possibility, what are my other treatment options?

Questions to ask about having radiation therapy

  • Should I receive radiation therapy? Why or why not?

  • What is the goal of this treatment?

  • How long will it take to give this treatment?

  • What side effects can I expect during treatment?

  • What are the possible long-term side effects of having this treatment?

  • What can be done to relieve side effects?

Questions to ask about having chemotherapy

  • Can chemotherapy control my cancer?

  • What is the goal of this treatment?

  • How long will it take to give this treatment?

  • What side effects can I expect during treatment?

  • What are the possible long-term side effects of having this treatment?

  • What can be done to relieve side effects?

Questions to ask about planning follow-up care

  • What is the risk of the cancer returning? Are there signs and symptoms I should watch for?

  • What long-term side effects or late effects are possible based on the cancer treatment I received?

  • What follow-up tests will I need, and how often will I need them?

  • How do I get a treatment summary and survivorship care plan to keep in my personal records?

  • Who will be coordinating my follow-up care?

  • What survivorship support services are available to me? To my family?

The next section in this guide is Additional Resources, and it offers some more resources on this website beyond this guide that may be helpful to you. Or, use the menu on the side of your screen to choose another section to continue reading this guide.

Pancreatic Cancer - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Pancreatic Cancer. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond.

Beyond this guide, here are a few links to help you explore other parts of Cancer.Net:

This is the end of Cancer.Net’s Guide to Pancreatic Cancer. Use the menu on the side of your screen to select another section to continue reading this guide.  

Pancreatic Cancer - Survivorship

This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/2015

ON THIS PAGE: You will read about how to cope with challenges in everyday life after a cancer diagnosis. To see other pages, use the menu on the side of your screen.

What is survivorship?

The word survivorship means different things to different people. Two common definitions include:

  • Having no signs of cancer after finishing treatment.

  • The process of living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of recurrence or to manage chronic disease.

In some ways, survivorship is one of the most complex aspects of the cancer experience because it is different for every person.

Survivors may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain of how to cope with everyday life.

Survivors may feel some stress when frequent visits to the health care team end following treatment. Often, relationships built with the cancer care team provide a sense of security during treatment, and people miss this source of support. This may be especially true as new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of recurrence, sexuality and fertility concerns, and financial and workplace issues.

Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

  • Understanding the challenge you are facing,

  • Thinking through solutions,

  • Asking for and allowing the support of others, and

  • Feeling comfortable with the course of action you choose.

Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the center where you received treatment.

Changing role of caregivers

Family members and friends may also go through periods of transition. A caregiver plays a very important role in supporting a person diagnosed with cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

However, as treatment is completed, the caregiver's role often changes. Eventually, the need for caregiving related to the cancer diagnosis will become much less or come to an end. Caregivers can learn more about adjusting to life after caregiving in this article.

A new perspective on your health

For many people, survivorship serves as a strong motivator to make positive lifestyle changes.

People recovering from pancreatic cancer are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about making healthy lifestyle choices.

In addition, it is important to have recommended medical check-ups and tests (see Follow-up Care) to take care of your health. Cancer rehabilitation may also be recommended, and this could mean any of a wide range of services such as physical therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.

Talk with your doctor to develop a survivorship care plan that is best for your needs.

Looking for More Survivorship Resources?

For more information about cancer survivorship, explore these related items. Please note these links will take you to other sections of Cancer.Net:

  • ASCO Answers Cancer Survivorship Guide: This 44-page booklet (available as a PDF) helps people transition into life after treatment. It includes blank treatment summary and survivorship care plan forms.

  • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about what comes next after finishing treatment.

  • Survivorship Resources: Cancer.Net offers an entire area of this website with resources to help survivors, including for survivors in different age groups.

The next section offers Questions to Ask the Doctor to help start conversations with your cancer care team. Or, use the menu on the side of your screen to choose another section to continue reading this guide.