Key points:
The symptoms of pancreatic cancer can be vague and non-specific:
- Ask specifically about symptoms of steatorrhea and early signs of jaundice.
- Record a patient’s weight.
- Consider pancreatic cancer in patients over 60 with new onset diabetes and weight loss.
- Consider a referral on a suspected cancer pathway for pancreatic cancer in a patient with an unexplained bilirubin of >50.
- A CT abdomen is the gold standard investigation for the diagnosis of pancreatic cancer.
Pancreatic cancer
- Pancreatic cancer is the 10th most common cancer in the UK and has an estimated 5-year survival rate of 10%.
- Patients commonly present at a late stage (stage 3 or 4) and 1 in 2 patients are diagnosed through the emergency route.
- Surgery is the only potential cure, but around 80% of patients are diagnosed at a stage where curative surgery is no longer possible.
- Pancreatic cancer is more common in older patients, with almost half of all new cases being diagnosed in patients aged 75 and over
Key risk factors include (although more exist):
- Tobacco use
- Family history
- Inherited cancer predisposition syndromes – See GatewayC’s learning module on pancreatic cancer to find out more.
Potential pitfalls: Non-specific symptoms
- In the early stages of pancreatic cancer, patients often have no symptoms.
- Some of the presenting symptoms of pancreatic cancer can be non-specific and related to other conditions.
- Painless jaundice is a common presentation of pancreatic cancer but can indicate a late stage of disease.
Helpful hints: Assessment and referral
When a patient presents with vague symptoms ask specifically about:
- Steatorrhea – pale or foul-smelling stools which can be difficult to flush. As often patients do not specifically offer this information.
- Early signs of jaundice – dark urine or pale stools.
- Measure and record a patient’s weight at the initial presentation.
- Consider offering a pre-booked follow-up appointment to re-assess the patient’s weight and symptoms.
Two thirds of patients with pancreatic cancer may present with non-specific epigastric pain and can mimic the symptoms of benign conditions such as GORD or gallstones.
Back pain, particularly in the upper back, can be a symptom of pancreatic cancer, although this is often a late sign of the disease.
Investigations:
- There are no specific blood tests solely for diagnosing pancreatic cancer, so normal results should not provide reassurance.
- Patients with an unexplained bilirubin of >50 should be referred for further investigation on a suspected cancer pathway for suspected pancreatic cancer.
- Do not be reassured by a normal ultrasound scan, as an ultrasound can miss up to 30% of pancreatic cancers.
- A CT scan is the investigation of choice for the diagnosis of pancreatic cancer.
NICE guidance advises a direct access CT scan, or an urgent ultrasound if a CT is not available, to assess for pancreatic cancer in patients aged 60 and over with weight loss and new-onset diabetes:
- An unexplained new diagnosis of diabetes in this age group should be considered a potential indicator for pancreatic cancer. Consider whether this diagnosis is ‘expected’.
- Explore any additional new vague symptoms that could be associated with pancreatic cancer such as weight loss, steatorrhea, early signs of jaundice, back or abdominal pain, nausea, and constipation.
- Patients with diabetes have an increased risk of pancreatic cancer. If the patient is an existing diabetic, consider whether their diabetic control has suddenly become poorly controlled and if they have any associated symptoms.
- Check your local referral pathways for suspected pancreatic cancer as these differ across the UK.
- Utilise your non-specific symptoms pathways (if available) in cases of vague symptoms and suspected pancreatic cancer.
- Around 1 in 10 pancreatic cancers are due to an inherited germline variation: See Pancreatic Cancer UK’s resources hub, where they discuss referring high risk patients to a national study known as EUROPAC.
Practice takeaway:
Access these gateway C resources to learn more about improving the early diagnosis of pancreatic cancer.
