Pancreatic cancer


Diagnosing pancreatic cancer

If your doctor suspects you have pancreatic cancer, you will need a number of tests to confirm the diagnosis. Together, the tests will show what type of pancreatic cancer it is, where in the pancreas it is, and whether it has spread to nearby organs or other parts of the body. This is called staging.

Tests may include blood tests, a CT scan and other imaging tests, endoscopic tests and tissue sampling (biopsy). The tests you have will depend on the symptoms, type and stage of the cancer. You will not have all the tests described below. Some are used only to detect pancreatic NETs.

Blood tests

Blood tests are used together with other test results to diagnose pancreatic cancer. You are likely to have blood tests to check your general health and how well your liver and kidneys are working.

Some blood tests look for particular markers of pancreatic cancer. Many people with pancreatic cancer have higher levels of the markers CA19-9 (carbohydrate associated antigen) and CEA (carcinoembryonic antigen). Other conditions can also raise the level of these markers, and some people with pancreatic cancer have normal levels, so these markers can't be used to diagnose pancreatic cancer on their own. However, they may tell your doctor more about the cancer and how it is responding to treatment.

It is normal for the levels of these markers to go up and down a bit, but your doctor will look for sharp increases and overall patterns.

Pancreatic NETs may produce high levels of certain hormones, which can be detected in the blood. In addition, pancreatic NETs may make a tumour marker called CgA (chromogranin-A).

Scans (imaging tests)

Tests that create images of the inside of the body are known as scans. Different scans can provide different details about the cancer. Depending on your individual situation, you may need only one or several types of scans. You are likely to have scans during the process of diagnosis, as well as throughout and after treatment.

Ultrasound

An ultrasound uses soundwaves to create a picture of the inside of your body. An ultrasound of your abdomen will show the pancreas and the surrounding area, including your liver. It can show if a tumour is present and its size.

You will lie on your back for the procedure. A gel will be spread onto your abdomen and a small device called a transducer will be moved across the area. The transducer creates soundwaves that echo when they meet something solid, such as an organ or tumour. A computer turns these echoes into pictures. The ultrasound is painless and takes about 15–20 minutes.

CT scan

A CT (computerised tomography) scan uses x-rays to take many pictures of the inside of your body and then compiles them into one detailed, cross-sectional picture.

The dye used in a CT or MRI scan can cause allergies. If you have had an allergic reaction to iodine or dyes during a previous scan, let your medical team know beforehand. You should also tell them if you are diabetic, have kidney function problems or are pregnant.

CT scans are usually done at a hospital or a radiology clinic. Before the scan, dye is injected into a vein to help make the pictures clearer. This may cause you to feel hot throughout your body and may give you a strange taste in your mouth. These sensations are temporary and usually go away in a few minutes.

The CT scanner is large and round like a doughnut. You will lie on a table that moves in and out of the scanner. It takes about 30 minutes to set up the machine, but the CT scan itself takes only 5–10 minutes.

MRI and MRCP scans

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

Before an MRI scan, you may be asked not to eat or drink for a few hours. You may also be given an injection of dye to highlight the organs in your body.

You may not be able to have an MRI if you have a pacemaker or another iron-based metallic object in your body, because the scan may damage these devices. However, some newer pacemakers are MRI-compatible.

An MRI takes about an hour and you will be able to go home when it is over. The test is painless, but some people feel anxious lying in such a confined space. If you think this will be a problem, let the doctor or nurse know beforehand, as there are medicines that can help you relax. During the test, the machine makes a series of bangs and clicks and can be quite noisy, but you will usually be given earplugs or headphones.

MRIs for pancreatic cancer are not always covered by Medicare, so check with your treatment team about whether you will need to pay for these tests.

Endoscopic scans

Endoscopic scans can show blockages or inflammation in the common bile duct, stomach and duodenum. They are done using an endoscope, which is a thin, flexible tube with a light and a camera that is passed down your throat into your digestive system. This is also called an endoscopy. It will usually be performed by a specialist called a gastroenterologist.

You will be asked not to eat or drink for several hours before an endoscopy. The doctor will give you a sedative so you are as relaxed and comfortable as possible. Because of the sedative, you shouldn't drive or operate machinery until the next day.

An endoscopic scan to investigate pancreatic cancer has some risks, including infection, bleeding and inflammation of the pancreas (pancreatitis). Your doctor will explain these risks before asking you to consent to the procedure. During these scans, the doctor can also take a tissue or fluid sample to help with the diagnosis. This is called a biopsy (see tissue sampling).

There are two main types of endoscopic scans:

EUS

An EUS (endoscopic ultrasound) 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.

ERCP

The endoscopic scan known as an ERCP (endoscopic retrograde cholangiopancreatography) performs an x-ray of the common bile duct and/or pancreatic duct. The doctor uses the endoscope to guide a catheter 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 duct to keep it open.

PET scans

A PET (positron emission tomography) scan is a specialised imaging test. It involves the injection of a very small amount of radioactive substance to highlight tumours in the body. It may take several hours to prepare for and complete a PET scan.

FDG-PET scan

This PET scan uses a radioactive substance called fluorodeoxyglucose (FDG). It can help doctors work out whether a pancreatic cancer has spread or how it is responding to treatment.

68-Gallium PET scan

For most pancreatic NETs, the radioactive substance used in a PET scan is 68-Gallium. It may be used to help work out whether a pancreatic NET has spread. For some pancreatic NETs, an FDG-PET is used instead of or as well as this test.

Another type of scan called an SRS (somatostatin receptor scintigraphy) scan was once commonly used to stage pancreatic NETs, but it has been largely replaced by the 68-Gallium PET scan. It uses a different type of radioactive substance to highlight the tumour in the scan.

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

Tissue sampling

While imaging scans can show the presence and location of a tumour in the pancreas, the main way to confirm that it is cancer is by testing a sample of cells or tissue taken from the tumour (biopsy). This sample can also be tested to help your doctor work out exactly what type of pancreatic cancer it is. The sample may be collected with a needle (fine needle or core biopsy) or during keyhole surgery (laparoscopy).

"I went to the doctor because I was itchy and had constant diarrhoea. My GP initially thought it was gallstones and sent me for routine tests. After the CT scan I went into hospital for a laparoscopy and then had a biopsy, which confirmed I had cancer." – Jan

Fine needle or core biopsy

This method uses a needle to remove a sample from an organ for examination under a microscope. It is done during an endoscopy or endoscopic ultrasound. A fine needle biopsy removes some cells, while a core biopsy uses a thicker needle to remove a sample of tissue.

An ultrasound or CT scan can help the doctor guide the needle through the abdomen and into the pancreas. You will be awake during the procedure, but you will be given a local anaesthetic so you do not feel any pain.

Laparoscopy

A laparoscopy, also called 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.

This procedure is performed with an instrument called a laparoscope, which is a long tube with a light and camera attached. It is done under general anaesthetic, so you will be asked not to eat or drink for six hours beforehand.

The doctor will guide the laparoscope through a small cut near your belly button. The doctor can 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-relieving 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 operation.

If you take blood-thinning medicines or are a diabetic, let your doctor or nurse know before the laparoscopy.

Staging and grading

Using the test results, your doctors will assign a stage to the cancer. The stage describes how far the cancer has spread and can help your doctors work out the best treatment options for your situation. The information below shows how pancreatic cancers may be staged using the TNM (tumour–nodes–metastasis) system and/or given a number for the overall stage.

Your doctor may also talk to you about the grade of the cancer. This is based on laboratory tests of a tissue sample (biopsy) and describes how quickly the cancer might grow. The higher the number, the more likely the cancer is to grow quickly. Grade is particularly important for pancreatic NETs, which may be described as grade 1, 2 or 3 (low, intermediate or high grade).

Staging systems for pancreatic cancer

TNM system

The most common staging system for pancreatic cancer is the TNM system. In this system, each letter is given a number that shows how advanced the cancer is.

  • T (Tumour): Refers to the size of the tumour (T0-4). The higher the number, the larger the cancer.
  • N (Nodes): N0 means there is no spread to nearby lymph nodes; N1 means there is cancer in nearby lymph nodes.
  • M (Metastasis): M0 means the cancer has not spread to other parts of the body; M1 means it has.

Numbers

Your doctor may just use an overall number to describe the stage.

  • Stage 1: Cancer is found only in the pancreas. This is sometimes called early-stage disease.
  • Stage 2: Cancer has either spread to lymph nodes or structures near the pancreas (such as the duodenum or common bile duct), or is large but has not spread to nearby organs.
  • Stage 3: Cancer has grown into nearby major arteries. There may or may not be cancer in the lymph nodes. This is called locally advanced cancer.
  • Stage 4: The cancer has spread to other organs, such as the liver, lungs or lining of the abdomen. This is known as metastatic cancer.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis with your doctor, but it is not possible for anyone to predict the exact course of the disease.

To work out your prognosis, your doctor will consider:

  • test results
  • the type, stage and location of the cancer
  • how the cancer responds to initial treatment
  • your medical history
  • your age and general health.

As symptoms can be vague or go unnoticed, most pancreatic cancers are not found until they are advanced. Cancer that has spread to nearby organs or blood vessels (locally advanced) or other parts of the body (metastatic) is difficult to treat successfully. If the cancer is detected at an early stage and can be surgically removed, the prognosis may be better, especially in the case of pancreatic NETs.

It is important to know that although the statistics for pancreatic cancer can be frightening, they are an average and may not apply to your individual situation, so talk to your doctor about how to interpret any statistics that you come across.

When pancreatic cancer is advanced, treatment will usually aim to control the cancer for as long as possible, relieve symptoms and improve quality of life. This is known as palliative treatment.

What to expect

To help people with pancreatic cancer receive the best care possible, we have developed an optimal cancer care pathway. View the guide to make sure you get the best care and support at each stage.

Key points

  • You will have several tests to confirm the diagnosis.
  • Blood tests can check your general health and may identify tumour markers.
  • A PET scan is a specialised scan involving an injection of a small amount of radioactive substance. It may be used to see whether pancreatic cancer has spread.
  • During an ultrasound, gel is spread over your abdomen and a scanner creates pictures of your organs.
  • CT and MRI scans involve an injection of dye into your body, followed by a scan. Some people have a type of MRI called an MRCP. This produces more detailed images and can help show blockages in the common bile duct.
  • During an endoscopic ultrasound (EUS), a tube with a camera and ultrasound probe is passed into your digestive system.
  • An ERCP is an endoscopic scan that takes x-rays rather than an ultrasound.
  • A biopsy means removing cells or tissue samples from an organ for examination under a microscope. This can confirm that a tumour is cancer and what type of cancer it is.
  • The sample may be removed during an endoscopy or endoscopic ultrasound with a needle, or during a surgery called a laparoscopy.
  • Staging describes how large the cancer is and how far it has spread. Grade describes how quickly it may grow.
  • You may wish to ask your doctor about your prognosis. Keep in mind that any statistics are averages and may not apply to you.

Expert content reviewers:

Dr Lorraine Chantrill, Senior Staff Specialist Medical Oncology, The Kinghorn Cancer Centre, St Vincent's Hospital, and Honorary Research Fellow, Garvan Institute of Medical Research, NSW; Jennifer Arena, Pancreatic and Neuroendocrine Cancer Care Coordinator, Northern Sydney Cancer Centre, Royal North Shore Hospital, and Northern Cancer Institute, NSW; Dr Michael Briffa, Southern Adelaide Palliative Services, Flinders Medical Centre, SA; Rachel Corbett, 13 11 20 Consultant, Cancer Council Victoria; A/Prof Nick O'Rourke, The University of Queensland, Chairman of General Surgery, Head of Hepatobiliary Surgery, Royal Brisbane and Women's Hospital, QLD; Steve Pendry, consumer; Caley Schnaid, Accredited Practising Dietitian, Northern Cancer Institute and Wellac Lifestyle, NSW; Deane Standley, Consumer.

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