Pancreatic Cancer

There are several types of pancreatic cancer, with pancreatic adenocarcinoma being the most common. However, the two main types of pancreatic cancer are:

Pancreatic exocrine tumours

Most pancreatic cancers are exocrine tumours originating from enzyme-producing cells. The subtypes of pancreatic exocrine tumours are:

• Pancreatic adenocarcinoma: pancreatic adenocarcinoma accounts for roughly 90% of all pancreatic cancer cases. It starts in the lining of the pancreatic ducts. The disease often spreads rapidly due to the pancreas' location and lack of early symptoms, making it challenging to treat.
• Acinar cell carcinoma: acinar cell carcinoma originates in the pancreatic acinar cells, with the tumours usually located at the ends of the ducts. It has a slow growth rate and a better outlook than adenocarcinomas.
• Cystic tumours: cystic tumours are fluid-like sacs that form in the pancreas. Although most pancreatic cysts are benign (non-cancerous), some can turn malignant (cancerous). 

Pancreatic neuroendocrine tumours (PNETs)

PNET cases account for 10% of all pancreatic cancer cases. These tumours develop from the hormone-producing cells of the pancreas, known as islet cells, thus impacting the ability of the pancreas to regulate blood sugar levels. Compared to exocrine tumours, PNETs have a slower growth rate and are classified based on the hormones that they produce. 

What causes pancreatic cancer?

Pancreatic cancer originates in the pancreas, a vital organ located behind the stomach. Pancreatic cancer occurs when genetic mutations occur in the DNA of pancreatic cells. Usually, the DNA in our cells contains instructions about when to multiply, when to stop, and when to die. However, the genetic mutations cause cells to multiply and grow out of hand, accumulating abnormal cells that become tumours.

Genetic mutations can occur due to various factors, such as carcinogens (UV rays, smoking, human papillomavirus), random mutations that occur during cell multiplication, and hereditary. However, the exact cause of pancreatic cancer remains unknown.

What are the symptoms of pancreatic cancer?

Pancreatic cancer typically does not show symptoms until it progresses to advanced stages, such as stage 3 or 4 pancreatic cancer. At this stage, the common symptoms of pancreatic cancer are:

• Abdominal pain that radiates to the back or sides
• Dark-coloured urine
• Diabetes that gradually becomes difficult to control 
• Gallbladder or liver enlargement
• Itchy skin
• Jaundice
• Light-coloured or floating stools
• Loss of appetite
• Nausea or vomiting
• Pain or swelling in the arm or leg (which can lead to blood clots)
• Tiredness or weakness
• Unintended weight loss

Who is at risk of pancreatic cancer in Singapore?

Like other types of cancer, certain individuals are more at risk of developing pancreatic cancer. Some of the risk factors for pancreatic cancer in Singapore include the following:

• Age: the risk of pancreatic cancer increases as people age, with most of the patients being older than 45 years old. 
• Gender: men are more at risk of developing pancreatic cancer than women.
• Diabetes: individuals with diabetes are at an increased risk of developing pancreatic cancer. While the reason is unknown, pancreatic cancer is often found among patients with type 2 diabetes.
• Smoking: the risk of pancreatic cancer doubles among smokers. In fact, approximately 25% of pancreatic cancers are assumed to be caused by tobacco use.
• Overweight: obese or overweight individuals with a body mass index of over 30 are 20% more likely to be diagnosed with pancreatic cancer. Additionally, people who carry extra weight around their waistlines, even though they are not overweight, are similarly at risk.
• Family history: individuals with a family history of pancreatic cancer have a higher risk of developing the disease, too.

How is pancreatic cancer diagnosed in Singapore?

If pancreatic cancer is suspected, the following tests will be conducted for diagnosis:

• Medical history and physical examination: your specialist will inquire about your symptoms and risk factors. A physical exam will be conducted to check for any signs of pancreatic cancer, such as jaundice (yellowing of the skin and eyes), abdominal pain, or a palpable mass.
• Imaging tests: imaging tests such as computed tomography (CT) scans, magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP), and positron emission tomography (PET) scans may be conducted to visualise the pancreas and surrounding structures to detect any abnormalities.
• Pancreas biopsy: if imaging tests suggest the presence of a pancreatic tumour, a biopsy may be performed to confirm the diagnosis. A pancreas biopsy can be done through various methods, such as:
  • Core biopsy, where a large needle is used to obtain a core tissue sample.
  • Fine-needle aspiration (FNA), where a thin needle is inserted into the pancreas to collect a small sample.
  • Surgical biopsy may be considered if other less invasive alternatives are not possible or inadequate. 
• Laboratory tests: a blood test may be performed to measure the levels of certain substances (CA 19-9) that may suggest pancreatic cancer or its complications.

What are the treatment options for Pancreatic Cancer in Singapore?

The treatment options for pancreatic cancer depend on several factors, like age, location of the tumour, the patient’s health condition and whether the cancer has metastasised. Generally, pancreatic cancer is treated with:

• Surgical interventions: the most effective treatment for pancreatic cancer is to remove the pancreas completely. However, this is only possible if the tumour is confined to the pancreas. The surgeon may opt to perform one of the following procedures:
  • Distal pancreatectomy: a distal pancreatectomy removes the tail of the pancreas and some of its body. 
  • Whipple procedure (pancreaticoduodenectomy): a Whipple procedure removes the head of the pancreas, the duodenum (the front portion of the small intestine), the gallbladder, a portion of the bile duct, and nearby lymph nodes. The surgeon will then attach the remaining stomach, bile duct and pancreas to the small intestine to reestablish the digestive tract.
  • Total pancreatectomy: in a total pancreatectomy, the entire pancreas and the spleen are removed. 
• Chemotherapy: doctors may opt for chemotherapy as a solo treatment, especially for patients with stage 4 pancreatic cancer. They may also recommend chemotherapy to shrink the size of the tumour before proceeding with surgery (neoadjuvant treatment).
• Radiation therapy: radiation therapy involves high-energy X-rays that are used to kill cancer cells. Doctors may recommend radiation therapy to help ease pancreatic cancer symptoms for patients with advanced pancreatic cancer who are unfit for surgery or as part of a combination treatment with chemotherapy.
• Targeted therapy: therapy drugs “target” certain proteins that control how cancer cells grow and spread.

Frequently asked questions

What is the life expectancy for pancreatic cancer?

The life expectancy for pancreatic cancer varies significantly depending on several factors, including the stage at which the cancer is diagnosed, the specific characteristics of the tumour, the overall health of the patient, and the effectiveness of treatment. Pancreatic cancer is often diagnosed at an advanced stage, which can affect prognosis.

Unfortunately, pancreatic cancer has a relatively poor prognosis compared to many other types of cancer. The overall survival rates are low, with the five-year survival rate for pancreatic cancer being around 10% to 15%.

Can pancreatic cancer spread to other parts of the body?

Yes, pancreatic cancer often first spreads within the abdomen and to the liver. They can also spread to the bone, brain, lungs and other organs.

Can pancreatic cancer be prevented?

Unfortunately, most pancreatic cancer cannot be prevented. However, there are steps and lifestyle changes that you can make to reduce the risk, such as maintaining a healthy weight, quitting smoking and limiting your alcohol consumption. It is also advisable to undergo a routine check-up, especially if you have a history of pancreatic cancer or chronic pancreatitis.

Is pancreatic cancer hereditary?

Experts estimate that only 5 - 10% of pancreatic cancer cases are hereditary.

Is pancreatic cancer painful?

Yes, pancreatic cancer can cause pain and discomfort. Patients have described the sensation as a dull pain that bores into you, which typically begins in the tummy area and spreads around the back.