Pancreatic Cancer

The pancreas is an organ located in the upper part of the abdomen, behind the stomach. It has two main functions:

• Producing enzymes that help digest food, especially fats and proteins
• Producing insulin and similar hormones that regulate blood sugar

Pancreatic cancer develops when cells in the pancreas multiply uncontrollably. The most common type is pancreatic ductal adenocarcinoma, which develops from the cells lining the ducts of the pancreas. The information on this page relates mainly to this type of cancer.

Neuroendocrine tumours that develop in the pancreas, on the other hand, have different characteristics, and their diagnosis and treatment are planned separately.

Because the pancreas lies deep within the body, small tumours cannot be felt by hand and may cause no symptoms in the early stages. For this reason, in some people the disease may only be noticed at an advanced stage. Nevertheless, advances in imaging, surgery, chemotherapy and personalised treatments are increasing the treatment options [1–3].

Treatment of pancreatic cancer must be planned by an experienced, multidisciplinary team. This team may include:

• A surgeon experienced in pancreatic surgery
• A medical oncologist
• A radiation oncologist
• A gastroenterologist and an interventional endoscopy specialist
• A radiologist
• A pathologist
• A genetic counsellor
• A dietitian
• Pain and supportive care teams.

What symptoms can pancreatic cancer cause?

There may be no symptoms at all in the early stages. Symptoms vary according to the tumour’s location in the pancreas, its size and its relationship with neighbouring organs.

Symptoms that may occur include:

• Yellowing of the skin and the whites of the eyes
• Dark urine
• Pale or clay-coloured stools
• Generalised itching
• Pain in the upper abdomen or the back
• Unexplained weight loss
• Loss of appetite and feeling full early
• Nausea or vomiting
• Bloating and indigestion
• Fatty, shiny, foul-smelling stools that float on water
• Newly developed diabetes, or diabetes whose control suddenly worsens
• Weakness and fatigue
• Swelling in a leg or formation of a blood clot

Tumours in the head of the pancreas can block the bile duct earlier and may therefore present with jaundice. In tumours of the body and tail, pain and weight loss may be more prominent.

None of these symptoms on its own means pancreatic cancer. Gallstones, inflammation of the pancreas, liver diseases, stomach and bowel problems and many other conditions can cause similar complaints. However, unexplained and persistent symptoms should be assessed.

What causes pancreatic cancer?

In most patients no definite cause can be identified. Cancer usually develops through the combined effect of age, environmental influences, lifestyle and genetic changes that build up in cells over time.

The main factors that can increase the risk are:

• Smoking
• Older age
• Pancreatic cancer in the family
• Certain inherited gene changes
• Chronic pancreatitis
• Excess weight and obesity
• Long-standing diabetes
• Certain pancreatic cysts
• Certain previous cancers and inherited cancer syndromes

New-onset diabetes can sometimes be a sign of pancreatic disease. However, the great majority of people newly diagnosed with diabetes do not have pancreatic cancer. Age, weight loss, family history and imaging findings should be assessed together.

Can pancreatic cancer be inherited?

In about 10% of pancreatic cancers, inherited gene changes or a strong family history may play a role [1].

Genes that may be associated with inherited risk include:

• BRCA1 and BRCA2
• PALB2
• ATM
• CDKN2A
• STK11
• TP53
• MLH1, MSH2, MSH6 and PMS2, which are associated with Lynch syndrome.

According to current NCCN recommendations, testing for inherited gene changes should be offered to all patients diagnosed with pancreatic cancer, even if there is no family history of cancer [1].

The result of a genetic test may be useful:

• In choosing certain medicines,
• In determining the patient’s other cancer risks,
• In assessing the risk of family members.

The diagnosis of pancreatic cancer does not rest on a single blood test. The diagnosis and treatment plan are established by assessing imaging, biopsy, blood tests and the patient’s general condition together.

What is pancreatic protocol CT?

One of the main imaging methods when pancreatic cancer is suspected is pancreatic protocol computed tomography, performed with contrast medium using special timing.

This examination helps to assess:

• The tumour’s location and size in the pancreas,
• Its relationship with nearby arteries and veins,
• The lymph nodes,
• Spread to the liver and other organs,
• Whether it can be removed by surgery [1,2].

A standard abdominal CT scan may not always show the pancreatic tumour and its relationship with blood vessels adequately. For this reason, it is important that the imaging follows the pancreatic protocol.

When are MRI and MRCP used?

Pancreatic protocol MRI may be used particularly:

• For small lesions not clearly seen on CT,
• For suspicious areas in the liver,
• In patients who cannot be given iodinated contrast medium,
• For detailed examination of the pancreatic and bile ducts.

MRCP is a special MRI examination that shows the bile and pancreatic ducts in detail.

How are endoscopic ultrasound and biopsy performed?

In endoscopic ultrasound, a thin endoscope with an ultrasound device at its tip is passed through the mouth into the stomach and duodenum. The pancreas is imaged at close range and, when necessary, a tissue sample is taken with a fine needle.

This procedure may be used:

• To assess small tumours,
• To confirm the diagnosis by biopsy,
• To obtain tissue for molecular tests.

If chemotherapy, radiotherapy or drug treatment alone is planned before surgery, the diagnosis must be confirmed by biopsy.

In some patients who clearly appear operable on imaging and for whom immediate surgery is planned, a biopsy before the operation may not always be mandatory. This decision should be made by the multidisciplinary tumour board [1,2].

What is ERCP?

ERCP is an interventional procedure in which the bile duct is reached with an endoscope passed through the mouth. It is not a routine imaging method in the initial diagnosis of pancreatic cancer.

If the tumour has blocked the bile duct, the duct can be opened with ERCP and a small tube called a stent can be placed.

A stent may be needed particularly:

• If there is a bile duct infection,
• If the jaundice is very marked,
• If there are complaints such as severe itching,
• If there has to be a wait before surgery,
• If chemotherapy is planned before surgery.

It is not necessary to routinely place a stent in every patient with jaundice who can be operated on straight away. An unnecessary stent procedure can lead to infection and other complications.

What is the CA 19-9 test?

CA 19-9 is a blood value that can be raised in pancreatic cancer. However:

• It may be normal in early pancreatic cancer.
• It can be raised without cancer when the bile duct is blocked.
• Some people are genetically unable to produce CA 19-9.
• It cannot establish a diagnosis of cancer on its own.
• It is not used as a screening test in healthy people.

After diagnosis, CA 19-9 can provide supporting information on the course of the disease, the response to treatment and follow-up. If jaundice is present, the value can be interpreted more accurately once the bile duct has been opened [1,2].

How is staging carried out?

Pancreatic cancer can be classified in the conventional way as stage I–IV. However, when planning treatment, the following surgical groups are more useful:

• Resectable: It appears possible to remove the tumour with safe surgical margins.
• Borderline resectable: The tumour is in limited contact with certain major blood vessels; treatment may need to be given first.
• Locally advanced: The tumour has not spread to distant organs but cannot be removed at the outset because of its relationship with major blood vessels.
• Metastatic: The disease has spread to distant sites such as the liver, lungs or the lining of the abdomen (peritoneum).

The decision on resectability should not be based on a single phrase in the radiology report. The images should be assessed by a multidisciplinary tumour board that includes a pancreatic surgeon and an experienced radiologist [1,2].

Is laparoscopic staging necessary?

Even if no distant spread is seen on imaging, small deposits of spread may be present inside the abdomen in some high-risk patients. In selected patients, the inside of the abdomen can be examined and sampled by laparoscopy before a major operation is started.

In pancreatic cancer, treatment is determined according to the extent of the disease, the tumour’s relationship with blood vessels, the patient’s general state of health and genetic characteristics.

The main treatments are:

• Surgery
• Chemotherapy
• Radiotherapy in selected patients
• Targeted therapy
• Immunotherapy
• Supportive treatments that relieve symptoms.

How is resectable pancreatic cancer treated?

In tumours without distant spread that appear safely removable, surgery is the main treatment offering the possibility of a lasting cure.

However, because pancreatic cancer can send microscopic cells into the body at an early stage, surgery is usually not enough on its own. Most patients need chemotherapy before or after the operation [1,2].

The sequence of treatment may be as follows:

• Surgery first, followed by chemotherapy
• Chemotherapy first, followed by surgery in suitable patients
• In some cases, radiotherapy in addition to chemotherapy

Which sequence is appropriate is determined by the characteristics of the tumour and the patient’s condition.

How is borderline resectable disease treated?

If the tumour is in limited contact with major blood vessels, going straight to surgery may increase the risk of tumour tissue being left behind.

For this reason, in borderline resectable disease, chemotherapy is usually given first. In selected patients, radiotherapy may also be added.

The aims of treatment before surgery are:

• To treat cancer cells in the body that cannot be seen on imaging at an early stage,
• To see how the tumour behaves,
• To shrink the tumour and reduce its contact with blood vessels,
• To increase the likelihood of complete and safe removal,
• To avoid a major operation that would bring no benefit in rapidly progressing disease.

After treatment, imaging, CA 19-9 and general condition are reassessed and the decision on surgery is made [1,2].

What is the Whipple operation?

The operation most often performed for tumours in the head of the pancreas is pancreaticoduodenectomy, also known as the Whipple operation.

In this operation, the following are usually removed:

• The head of the pancreas
• The duodenum
• Part of the bile duct
• The gallbladder
• The surrounding lymph nodes. In some techniques, a small part of the stomach may also be removed.

New connections are then made between the pancreas, the bile duct and the stomach or small intestine to restore the continuity of the digestive system.

The Whipple operation is major surgery. It is recommended that it be performed in centres where pancreatic surgery is carried out regularly, with an experienced team and intensive care support [1,2].

What is distal pancreatectomy?

For tumours in the body or tail of the pancreas, the left side of the pancreas is removed. This procedure is called distal pancreatectomy.

In cancer surgery, the spleen is usually removed together with the pancreas. If the spleen is to be removed, protective vaccinations against certain infections need to be given at the appropriate time.

In appropriately selected patients, distal pancreatectomy can be performed laparoscopically, that is, through small incisions. In choosing the method, removing the cancer with safe margins takes priority.

What is total pancreatectomy?

In very carefully selected patients in whom the tumour affects a large part of the pancreas, the whole pancreas may be removed.

When the whole pancreas is removed:

• The body can no longer produce its own insulin.
• Insulin must be used for life.
• Digestive enzymes cannot be produced.
• Pancreatic enzymes must be taken with every meal and snack.

Total pancreatectomy is not necessary or suitable for every patient.

Might a blood vessel need to be removed during the operation?

If the tumour is in limited contact with certain veins, part of the vein can be removed and repaired in experienced centres.

Extensive involvement of the main arteries, however, makes the decision to operate more difficult. Except in very selected situations, systemic treatment is given first. The decision should be made by a highly experienced multidisciplinary team.

Is chemotherapy needed after the operation?

In most patients whose general condition allows it, about six months of chemotherapy is recommended after the operation.

If chemotherapy was given before the operation, the type and duration of treatment after the operation are adjusted according to the treatment already given and the pathology result.

In patients in good general condition who can tolerate intensive treatment, modified FOLFIRINOX is one of the effective options after surgery. In people for whom this treatment is not suitable because of age, coexisting conditions or the risk of side effects, other chemotherapy regimens can be used [2,4].

How is locally advanced pancreatic cancer treated?

Disease that has not spread to distant organs but cannot be operated on at the outset because of significant contact with blood vessels is defined as “locally advanced”.

Treatment usually begins with chemotherapy. Depending on the patient’s condition, radiotherapy or stereotactic radiotherapy may be considered.

The aims of treatment are:

• To keep the disease under control,
• To slow the growth of the tumour,
• To relieve symptoms such as pain,
• To make surgery possible in selected patients.

Some patients who respond well to treatment may become operable after reassessment in experienced centres. Having been told “inoperable” at the outset does not mean that the situation can never be reassessed after treatment.

How is metastatic pancreatic cancer treated?

If the disease has spread to distant organs, the basis of treatment is systemic medicines that act on the whole body. At this stage, removing the tumour in the pancreas generally does not cure the disease and is not the standard approach.

Some of the combinations that can be used in patients in good general condition are:

• FOLFIRINOX or modified FOLFIRINOX
• NALIRIFOX
• Gemcitabine with nab-paclitaxel.

Which treatment is chosen depends on:

• The patient’s general performance status,
• Age and coexisting conditions,
• Liver and kidney function,
• Whether or not jaundice is present,
• Previous treatments,
• The genetic characteristics of the tumour,
• The patient’s preference.

The 2025 ESMO update revised the current first-line and second-line options in metastatic pancreatic cancer, including NALIRIFOX [3].

In patients who need lower-intensity treatment, a single medicine or milder combinations can be used. In some patients the side effects of treatment may outweigh the expected benefit; in this case, supportive care focused on quality of life comes to the fore.

Do genetic and molecular tests change treatment?

Yes. Inherited gene testing is recommended for all patients with pancreatic cancer. In advanced or metastatic disease, testing the molecular characteristics of the tumour tissue can also change the choice of treatment [1].

Characteristics that may be tested for include:

• BRCA1, BRCA2 and PALB2 changes
• MSI-H or dMMR
• NTRK fusion
• BRAF changes
• HER2 amplification
• Certain subtypes of KRAS
• Rare changes such as NRG1 and RET.

Each of these changes is rare. However, when one is found, options such as platinum-containing chemotherapy, a PARP inhibitor, immunotherapy or targeted medicines may become available for some patients.

Not every targeted medicine may be licensed for the same indication or reimbursed in every country. Taking part in clinical trials should also be considered in suitable patients.

What is the role of radiotherapy?

Radiotherapy is not necessary for every patient with pancreatic cancer. It may be considered in the following situations:

• After chemotherapy in borderline resectable disease
• For local control in locally advanced disease
• To relieve symptoms such as pain or bleeding
• In selected patients because of the surgical margin and the risk of recurrence

The decision should be made jointly by the medical oncologist, the radiation oncologist and the surgeon.

Supportive Care

Supportive care is not an approach used only in the final stage of the disease. It can be used from diagnosis onwards, alongside chemotherapy and surgery.

The aim is:

• To relieve pain,
• To maintain nutrition,
• To relieve jaundice,
• To control nausea and vomiting,
• To improve digestion,
• To support problems with sleep, anxiety and daily life.

How is jaundice treated?

If the bile duct is blocked by the tumour, a metal or plastic stent can be placed with ERCP. If ERCP is not possible, other endoscopic, radiological (PTC) or surgical methods can be used.

How is pain controlled?

Pain treatment may include:

• Appropriate painkillers
• Coeliac plexus block or neurolysis
• Chemotherapy
• Radiotherapy
• Psychological and supportive therapies.

An increasing need for painkillers is nothing to be ashamed of or to hide. Early pain control improves nutrition, mobility and quality of life.

Why are pancreatic enzymes used?

With pancreatic cancer or after surgery, the production of digestive enzymes may decrease. This is called exocrine pancreatic insufficiency.

Its signs may include:

• Fatty and foul-smelling stools
• Stools that float on water
• Bloating and wind
• Diarrhoea
• Weight loss
• Deficiency of fat-soluble vitamins.

Pancreatic enzyme capsules are taken with meals and snacks. It is important to take the enzymes at the right dose at the start of the meal and throughout it. The dose can be adjusted according to the fat content of the meal and the symptoms.

Enzyme supplementation can reduce weight loss and improve nutrient absorption and quality of life.

Can diabetes develop?

Pancreatic cancer and pancreatic surgery can reduce insulin production. In some patients new diabetes may develop, or existing diabetes may become harder to control.

Blood sugar is monitored regularly. If necessary, oral medicines or insulin treatment are started. If the whole pancreas has been removed, insulin is needed for life.

How long is the hospital stay after the operation?

The length of the hospital stay varies according to the type of operation, the patient’s general condition and whether complications develop. After a Whipple operation, a hospital stay of more than a week is often needed. In some patients this period may be shorter or longer.

After the operation, early walking, appropriate pain control and gradual reintroduction of food are used.

What are the possible problems after the operation?

The main problems that can occur after pancreatic surgery are:

• Leakage of fluid from the pancreatic connection
• Delayed emptying of the stomach
• Bleeding
• Infection
• Bile leakage
• Difficulty eating
• Pancreatic enzyme insufficiency
• Disturbed blood sugar
• Formation of blood clots in the veins.

The risk of these complications varies according to the type of operation and the patient’s state of health. It is important to be assessed and treated in centres where pancreatic surgery is performed regularly.

How is nutrition managed?

Unintended loss of weight and muscle is common in pancreatic cancer. Nutritional support is important from before treatment begins.

General recommendations are:

• Eating small, frequent meals
• Including protein-containing foods at every meal
• Avoiding unnecessary dietary restrictions if there is weight loss
• Taking pancreatic enzymes as recommended
• Reporting problems such as nausea, diarrhoea and mouth ulcers early
• Getting support from a dietitian
• Keeping physically active as far as tolerated.

Not everyone with pancreatic cancer needs a fat-free diet. If pancreatic enzymes are taken at the right dose, healthy fats can be part of the diet to meet energy needs. A personal nutrition plan should be drawn up by the dietitian and the treatment team.

How is follow-up carried out?

The follow-up plan after treatment is individualised according to the stage of the disease and the treatment given.

Follow-up may include:

• Examination and assessment of complaints
• Monitoring of weight and nutritional status
• Blood tests
• CA 19-9 in suitable patients
• Pancreatic protocol CT or MRI
• Assessment of treatment side effects
• Adjustment of pancreatic enzyme and diabetes treatment.

Follow-up is not carried out only to look for recurrence of the disease; it is also done to identify problems with nutrition, pain, blood sugar and quality of life early.

1. National Comprehensive Cancer Network. NCCN Guidelines for Patients: Pancreatic Cancer. 2025. Access the patient guide
2. Conroy T, Pfeiffer P, Vilgrain V, et al. Pancreatic Cancer: ESMO Clinical Practice Guideline for Diagnosis, Treatment and Follow-up. Annals of Oncology. 2023;34(11):987–1002. doi:10.1016/j.annonc.2023.08.009. PubMed record
3. Conroy T, Ducreux M; ESMO Guidelines Committee. ESMO Clinical Practice Guideline Express Update on the Management of Metastatic Pancreatic Cancer. ESMO Open. 2025;10:104528. doi:10.1016/j.esmoop.2025.104528. Access the publication
4. Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. New England Journal of Medicine. 2018;379(25):2395–2406. doi:10.1056/NEJMoa1809775. Access the publication
5. Wainberg ZA, Melisi D, Macarulla T, et al. NALIRIFOX Versus nab-Paclitaxel and Gemcitabine in Treatment-Naive Patients With Metastatic Pancreatic Ductal Adenocarcinoma: The NAPOLI 3 Trial. The Lancet. 2023;402(10409):1272–1281. doi:10.1016/S0140-6736(23)01366-1. PubMed record