Diagnosing pancreatic cancer

Many people with pancreatic cancer have higher levels of particular tumour markers in their bloodstream. The markers that doctors will look for are CA 19-9 (carbohydrate antigen) and CEA (carcinoembryonic antigen).

On their own, however, these tumour markers can’t be used to diagnose pancreatic cancer.

This is because some people with pancreatic cancer have normal levels of these markers, and other conditions can also raise the levels of these markers in the bloodstream.

It is normal for the levels of these tumour markers to go up and down a little. Your doctor will look for sharp increases and overall patterns.

Raised levels can tell your doctor more about the cancer and, after diagnosis, can also show how well the treatment is working.

Most people suspected of having pancreatic cancer will have a CT (computerised tomography) scan.

This scan uses x-ray beams to take many pictures of the inside of your body and then compiles them into one detailed, cross-sectional picture. A CT scan is usually done at a hospital or a radiology clinic.

Before the scan, a liquid dye (called contrast) will be injected into a vein to help make the pictures clearer. The dye travels through your bloodstream to the pancreas and nearby organs and helps show up any abnormal areas.

This may cause you to feel hot all over, may give you a strange taste in your mouth and you could feel as if you need to pass urine (pee).

These reactions are temporary and usually go away in a few minutes, but tell your treatment team if you feel unwell. The CT scanner is large and round like a doughnut.

You will need to lie still on an examination table while the scanner moves around you. The scan itself is painless and takes only a few minutes, but getting it set up can take 10–30 minutes.

Endoscopic tests can show blockages or inflammation in the common bile duct, stomach and duodenum.

For these tests, you will have an endoscopy, a procedure that is usually done as day surgery by a specialist doctor called a gastroenterologist.

The doctor passes a long, flexible tube with a light and small camera on the end (endoscope) down your throat into your digestive tract. There are two main types of endoscopic tests:

• Endoscopic ultrasound (EUS) – An EUS uses an endoscope with an ultrasound probe (transducer) attached. The endoscope is passed through your mouth into the small bowel. The transducer makes soundwaves that create detailed pictures of the pancreas and ducts. This helps to locate small tumours and shows if the cancer has spread into nearby tissue. A biopsy of the cancer can be taken at the same time (see below).
• Endoscopic retrograde cholangiopancreatography (ERCP) – An ERCP is used to take an x-ray of the common bile duct and pancreatic duct. The doctor uses the endoscope to guide a tube into the bile duct and insert a small amount of dye. The x-ray images show blockages or narrowing that might be caused by cancer. ERCP may also be used to put a thin plastic or metal tube ( stent) into the bile duct to keep it open.

During an endoscopic procedure, the doctor can also take a tissue or fluid sample (biopsy) to help with the diagnosis (see below). You will be asked not to eat or drink (fast) for six hours before an endoscopic test.

The doctor will give you medicine to help you relax and feel as comfortable as possible. Because of this medicine, you shouldn’t drive or operate machinery until the next day.

Having an endoscopic test has some risks, including infection, bleeding and inflammation of the pancreas (pancreatitis). These complications are not common.

Your doctor will explain the risks before asking you to agree (consent) to the procedure.

In some cases, you may also have another type of scan such as an MRI or MRCP scan.

• An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed cross-sectional pictures of the pancreas and nearby organs.
• An MRCP (magnetic resonance cholangiopancreatography) scan is a different type of MRI scan that produces more detailed images and can be used to check the common bile duct for a blockage (obstruction).

An MRI or MRCP takes about an hour and you will be able to go home when it is over. Before the scan, you may be asked not to eat or drink (fast) for a few hours.

You may also be given an injection of dye (contrast) to highlight the organs in your body. During the scan, you will lie on a treatment table that slides into a large metal tube that is open at both ends.

The noisy, narrow machine makes some people feel anxious or claustrophobic. If you think you might be distressed, mention this beforehand to your doctor or nurse.

You may be given medicine to help you relax, and you will usually be offered headphones or earplugs.

Also let the doctor or nurse know if you have a pacemaker or any other metallic object in your body, as this can interfere with the scan.

MRIs for pancreatic cancer are not always covered by Medicare. If this test is recommended, check with your treatment team what you may have to pay.

Doctors sometimes use a PET (positron emission tomography) scan combined with a CT scan to help work out if the pancreatic cancer has spread or how it is responding to treatment.

It may take several hours to prepare for and complete a PET–CT scan. Before the scan you will be injected with a small amount of radioactive material, usually a glucose solution called fluorodeoxyglucose (FDG).

Some cancer cells will show up brighter on the scan because they take up more of this solution than normal cells do. PET–CT scans are specialised tests.

They are not available in every hospital and may not be covered by Medicare, so talk to your medical team for more information.

A sample of cells may be collected with a fine needle (fine needle biopsy), or a tissue sample may be collected with a larger needle (core biopsy).

A fine needle or core biopsy can be done during an endoscopic procedure (see above). Another method is to insert the needle through the skin of the abdomen, using an ultrasound or CT scan for guidance.

You will be awake during the procedure, but you will be given a local anaesthetic so you do not feel any pain.

Also called a laparoscopy or minimally invasive surgery, keyhole surgery is sometimes used to look inside the abdomen to see if the cancer has spread to other parts of the body.

It can also be done to take tissue samples before any further surgery. Keyhole surgery is done under general anaesthetic, so you will be asked not to eat or drink (fast) for six hours beforehand.

If you take blood-thinning medicines or have diabetes, let your doctor or nurse know before the surgery as they may need to adjust your medicines in the days leading up to the procedure.

The procedure uses an instrument called a laparoscope (a long tube with a light and camera on the end). The camera projects images onto a screen so the doctor can see inside your body.

The doctor will guide the laparoscope through a small cut near your bellybutton. The doctor can then insert other instruments through other small cuts to take the biopsy.

You will have stitches where the cuts were made. You may feel sore while you heal, so you will be given pain medicine during and after the operation, and to take at home.

There is a small risk of infection or damage to an organ with a laparoscopy. Your doctor will explain the risks before asking you to agree to the procedure.

If you are having a larger operation to remove the tumour, your surgeon may take the tissue sample at that time.

Pancreatic cancer is commonly staged using the TNM system, with each letter given a number that shows how advanced the cancer is:

• T stands for Tumour and refers to the size of the tumour or how close it is to major blood vessels. It will be given a score of T0–4. The higher the number, the more advanced the cancer is.
• N stands for Nodes and refers to whether the cancer has spread to lymph nodes. N0 means the cancer has not spread to nearby lymph nodes; N1 means the cancer has spread to 1–3 nodes, N2 means the cancer has spread to 4 or more lymph nodes.
• M stands for Metastasis. M0 means the cancer has not spread to other parts of the body; M1 means it has.

The TNM scores are combined to work out the overall stage of the cancer, from stage 1 to stage 4 (see below).

If you need help to understand staging, ask someone in your treatment team to explain it in a way that makes sense to you. You can also call Cancer Council 13 11 20.

• Stage 1 – Cancer is small and found only in the pancreas.
• Stage 2  – Cancer is large but has not spread outside the pancreas; or it is small and has spread to a few nearby lymph nodes. 

Stage 1–2 cancers are considered early pancreatic cancer. They may also be called resectable, which means surgery to remove the cancer may be an option if you are well enough.

About 1 in 5 pancreatic cancers are stage 1–2 when first diagnosed.

• Stage 3 – Cancer has grown into nearby major blood vessels or into a lot of nearby lymph nodes.

Some stage 3 cancers are borderline resectable cancers, which means surgery to remove the cancer may be an option if other treatment can shrink the cancer first.

Other stage 3 cancers are called locally advanced, which means that surgery cannot remove the cancer, but treatments can relieve symptoms. About 30% of pancreatic cancers are stage 3 when first diagnosed.

• Stage 4 – The cancer has spread to more distant parts of the body, such as the liver, lungs or lining of the abdomen. There may or may not be cancer in the lymph nodes.

This is called metastatic cancer. Surgery cannot remove the cancer, but treatments can relieve symptoms. About half of all pancreatic cancers are stage 4 when first diagnosed.