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Overview
Pancreatic cancer has continued to have poor outcomes, with people who are diagnosed after the cancer has spread across the body having a 3% chance of a 5-year survival rate (American Society of Clinical Oncology, 2023).
Pathophysiology
Pancreatic cancer is broadly divided into two main groups:
- Exocrine tumours: start in the exocrine cells where digestive enzymes are made. The majority of exocrine pancreatic cancers are adenocarcinomas, which originate in the epithelial cells lining the pancreatic duct. These form gland-like structures, and account for around 90% of all pancreatic cancers (Cowgill and Muscarella, 2003)
- Endocrine tumours: originate within the endocrine cells, where insulin is produced
There are also some rare pancreatic tumours (Table 1). Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas, 15–20% occur in the body of the pancreas and 5–10% occur in the tail (Dragovich, 2022) (Figure 1).
| Table 1. Rare |
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Risk factors
The risk of developing pancreatic cancer, like may other cancer types, increases with age - with a median age of diagnosis of 72 years in England (Zhang et al, 2016). Family history has been shown to play a role in some cases of pancreatic cancer, as a result of inherited genetic mutations usually in the PRSS1 gene (American Cancer Society, 2020). In some families, the gene causing this increased risk is not known. Despite the fact that family history has been cited as a risk factor, most people (90–95%) who develop pancreatic cancer do not have a family history of the disease (American Cancer Society, 2020).
Some preventable risk factors for pancreatic cancer include:
Smoking
Smoking is reported consistently as an environmental risk factor for pancreatic cancer, and accounts for approximately 25% of all diagnosed cases (Lowenfels and Maisonneuve, 2004). People who smoke have at least a
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Symptoms
Signs and symptoms are influenced by the site of the cancer within the pancreas. Unfortunately, diagnosis at an early stage is extremely difficult, because symptoms are vague and non-specific and can be easily misinterpreted as symptoms of a number of more common diseases.
Nurses who assess patients in minor illnesses must have a high index of suspicion if the diagnosis is to be caught at an early stage. Urgent referral should occur on a 2–week wait for patients aged over 60 years with weight loss and any of the following symptoms:
- diarrhoea
- back pain
- abdominal pain
- constipation
- vomiting
- nausea
- new-onset diabetes (National Institute for Health and Care Excellence, 2023)
Significant weight loss is a characteristic feature of pancreatic cancer, along with mid-epigastric pain, sometimes with radiation of the pain to the mid- or lower-back region, night-time pain and painless obstructive jaundice (often seen in cancer of the head of the
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Diagnosis
Once the clinician suspects pancreatic cancer as a possible cause for the patient's symptoms, they will be referred for further investigations. A chest X-ray will be carried out to exclude spread to the lungs. Blood tests will also be conducted to check liver and kidney function. Although many pancreatic cancers produce a substance called CA 19-9 (a tumour marker), a normal level of CA 19-9 does not exclude a pancreatic cancer diagnosis, and a high level may be caused by several other conditions (Thaker, 2021). Further investigations that may be performed include:
- Ultrasound scan: useful to look at other internal organs, such as the liver, as well as the pancreas
- Endoscopic ultrasound: in the event of a tumour being found, endoscopic ultrasound will be useful for measuring the size and degree of spread if any, and biopsies can be taken during this procedure
- Computed tomography: this provides a more detailed
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Treatment
Treatment for the patient will depend on a number of factors, taking into account the type of cancer, its stage and degree of spread, if any, as well as the patient's age and health status. Options include surgery, chemotherapy, radiotherapy and irreversible electroporation.
Adjuvant therapy may be offered after a suitable recovery time and may be gemcitabine plus capecitabine or gemcitabine alone for those not able to tolerate combination therapy.
Surgery
Surgery may be either potentially curative, if it is possible to remove all of the cancer, or palliative, to relieve symptoms when the cancer is too widely spread for a cure.
Chemotherapy
If chemotherapy is indicated, it will often involve a combination of agents and may be used alone or in combination with other options, such as surgery or radiotherapy. Some examples of common chemotherapy drugs for pancreatic cancer are 5-fluorouracil (5-FU), gemcitabine, and
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NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
10. Use evidence-based, best practice approaches for meeting
needs for care and support at the end of life, accurately
assessing the person’s capacity for independence and selfcare and initiating appropriate interventions
11. Procedural competencies required for best practice,
evidence-based medicines administration and optimisation
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Resources
American Cancer Society. Pancreatic cancer risk factors. 2020.
https://www.cancer.org/cancer/pancreatic-cancer/causes-risks-prevention/risk-factors.html (accessed 1 December 2023)
American Society of Clinical Oncology. Pancreatic cancer: statistics. 2023. https://www.cancer.net/cancer-types/pancreatic-cancer/statistics (accessed 1 December 2023)
Basturk O, Tang L, Hruban RH et al. Poorly differentiated neuroendocrine carcinomas of the pancreas: a clinicopathologic analysis of 44 cases. Am J Surg Pathol. 2014;38(4):437-47. https://doi.org/10.1097/pas.0000000000000169
Cancer Research UK. TNM staging for pancreatic cancer.
2023. https://www.cancerresearchuk.org/about-cancer/pancreatic-cancer/stages-types-grades/tnm-staging (accessed 1 December 2023)
City of Hope. Pancreatic cancer. 2022. https://www.cancercenter.com/cancer-types/pancreatic-cancer (accessed 22 December 2022)
Cowgill SM, Muscarella P. The genetics of pancreatic cancer.
Am J Surg. 2003;186(3):279–86. https://doi.org/10.1016/s0002-9610(03)00226-5
Dragovich T. Pancreatic cancer. 2022. https://emedicine.medscape.com/article/280605-overview#a1 (accessed 1 December 2023)
Fesinmeyer MD, Austin MA, Li CI, De Roos AJ, Bowen DJ.
Differences in survival by histologic type of pancreatic cancer.
Cancer Epidemiol Biomarkers Prev. 2005;14(7):1766–1773. https://doi.org/10.1158/1055-9965.epi-05-0120
Lowenfels AB, Maisonneuve P. Epidemiology and Prevention
of Pancreatic Cancer. Jpn J Clin Oncol. 2004;34(5):238–244. https://doi.org/10.1093/jjco/hyh045
Maisonneuve P, Lowenfels AB. Risk factors for pancreatic
cancer: a summary review of meta-analytical studies. Int J
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