Pancreatic Cancer: Diagnosis

Approved by the Cancer.Net Editorial Board, 05/2020

ON THIS PAGE: You will find a list of common tests, procedures, and scans that doctors use to find the cause of a medical problem. Use the menu to see other pages.

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. If this happens, it is called metastasis. For example, imaging tests can show if the cancer has spread. Imaging tests show pictures of the inside of the body. Doctors may also do tests to learn which treatments could work best.

For most types of cancer, a biopsy is the only sure way for the doctor to know if an area of the body has cancer. However, a cancer diagnosis is also possible without a fully confirmed biopsy. In a biopsy, the doctor takes a small sample of tissue from the suspected area of the cancer for testing in a laboratory. Biopsies for pancreatic cancer are known to often be difficult to do because of the location of the pancreas and because pancreatic tumors are often initially smaller and more spread out than other cancer tumors. Sometimes the doctor can get a tissue sample, but the sample might contain a very small amount of tumor cells. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis.

This section describes options for diagnosing pancreatic cancer. Not all tests listed below will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • The type of cancer suspected

  • Your signs and symptoms

  • Your age, general health, and family history

  • The results of earlier medical tests

If a doctor suspects that a person has pancreatic cancer, they will first ask about the person's medical history and family history. Then, they will 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 medical center that has experience with the disease. The tests listed below may be used when pancreatic cancer is suspected. However, the diagnosis should be confirmed with a sample of tissue from the tumor taken during a biopsy, fine needle aspiration, or surgery.

General tests

  • Physical examination. The doctor will examine your skin, tongue, 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 people with pancreatic cancer do not have jaundice when the cancer is diagnosed. Your doctor will also feel your 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 people 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 levels are often increased in people with pancreatic cancer, although some patients have normal CA19-9 levels. CA19-9 levels often become higher as the cancer grows or spreads. CA 19-9 should not be used as the only test to diagnose pancreatic cancer because high levels of CA 19-9 can also be a sign of other conditions. For example, other types of cancer, such as colorectal, liver, and esophageal cancers, can increase CA 19-9. And noncancerous conditions, such as pancreatitis, cirrhosis of the liver, and a non-cancerous blockage of the common bile duct, may also increase CA 19-9.

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. Imaging tests may also be used to monitor whether the cancer is growing. 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 tumor. A radiologist is a doctor who specializes in interpreting imaging tests.

  • Computed tomography (CT or CAT) scan. A CT scan takes pictures of the inside of the body using x-rays taken from different angles. A computer combines these pictures into a detailed, typically 3-dimensional image that shows any abnormalities or tumors. A CT scan can be used to determine the size and location of the primary tumor and evaluate the possibility of spread to lymph nodes or other parts of the body. Typically, 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 liquid to swallow. Many cancer centers use a special CT scan method called a pancreatic protocol CT scan. This method focuses on taking pictures 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 blood vessels. The results of this test can help decide if the tumor could be removed with surgery. ASCO recommends that people with metastatic pancreatic cancer should get a CT scan done of their chest, abdomen, and pelvis to evaluate the extent of the cancer. A CT scan or other imaging may also be used 2 to 3 months after standard treatment begins to evaluate treatment effectiveness.

  • Positron emission tomography (PET) scan or PET-CT scan. A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a PET scan. 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. A PET scan alone should never be used instead of a high-quality, high-speed CT scan. PET scans differ from CT scans in that CT scans are looking at the tumor in relation to your anatomy, while PET scans are attempting to measure metabolic activity.

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

    • A transabdominal ultrasound device is placed against 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. It is slowly moved around the area 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 the 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 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 only a biopsy can make a definite diagnosis for most cancers. 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 couple of different ways to collect a tissue sample:

    • 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.

    • Core needle biopsy. This is used to collect a larger piece of tissue, which may be helpful for molecular or genetic testing of the tumor. However, a core biopsy has higher risks than an FNA, including pancreatitis and bleeding. It should be performed by a gastroenterologist who has been specifically trained and has significant experience in performing EUS.

    If the cancer has spread to other organs, a biopsy may also be needed from 1 of these other areas, such as the liver. Again, this can be through the skin, as explained above, or by surgery, which is less common. 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 show that there are no cancer cells in the area tested even if there are. This result is called a “false negative.” This can happen because the area contains inflammation and/or fibrosis (scar-like tissue), which can make the cancer cells harder to find. In general, before a patient starts treatment, every effort is made to confirm that cancer is present, even if this means that multiple biopsies are needed. An exception is for patients with a mass located in a single 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 additional molecular testing on the tumor sample to look for changes in specific genes and proteins. You may also request that this testing be done. Some molecular tests can be done in your local hospital laboratory. For other tests, the sample may need to be sent to an independent laboratory for analysis. For such tests as drug assays, talk with your doctor about the potential information they could provide that would help plan your treatment and whether such tests are covered by your insurance. You may also request in all academic centers that your tumor biopsy specimens be fresh frozen, as this expands the types of molecular testing which can be done on the biopsy sample.

    For patients with pancreatic cancer who are candidates for treatment, testing should be done to look for evidence of high microsatellite instability (MSI-high) or defective mismatch repair (dMMR); for mutations in the BRCA gene, as well as other genes involved in DNA damage repair; and for a specific genetic alteration called an NTRK fusion. These tests may help doctors determine your treatment options, including targeted therapy. However, these genetic changes are not common in pancreatic tumors. Talk with your health care team about whether genetic testing is right for you and whether you should speak with a genetic counselor.

    This “personalized” approach is an area of increasing interest and scientific focus. It is helpful to find out the type and amount of tumor sample needed for these tests and if they are covered by your health insurance. You may need to have another biopsy to get a large enough tissue sample for more extensive testing. Sometimes, however, a blood test can provide information on the molecular or genetic features of your cancer.

    Talk with your doctor for more information. People who have surgery may also choose to donate parts of the tumor that are not needed for your cancer care so the samples can be used to further pancreatic cancer research.

  • Germline testing. It is now recommended that all people with a diagnosis of pancreatic cancer be considered for germline testing (see Risk Factors). This means testing a blood or saliva sample to look for mutations in a person's DNA that may indicate a hereditary predisposition to cancer. This is typically performed in addition to a visit with a genetic counselor. If a person is found to be a carrier for particular genetic mutations, this may help guide the treatment decisions if pancreatic cancer is diagnosed. It would also signal that their family members may want to consider genetic testing.

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. It explains the system doctors use to describe the extent of the disease. Use the menu to choose a different section to read in this guide.