Pancreatic Cancer

Finding out you have pancreatic cancer — or that someone you love has it — is a shock. This page explains the basics in plain language, so the words your team uses start to make sense.

What pancreatic cancer is

The pancreas is a gland about 15 cm long that sits behind your stomach. It does two jobs: it makes juices that help digest food, and it makes hormones (including insulin) that control blood sugar. About 95 out of 100 pancreatic cancers start in the cells that make the digestive juices — these are called exocrine cancers, and the most common type is pancreatic ductal adenocarcinoma. A much rarer group starts in the hormone-making cells (neuroendocrine tumours); those behave quite differently and are not what this page is about.

Why it is often found late

Early pancreatic cancer usually causes no symptoms, and the pancreas sits deep in the abdomen where a small tumour can't be felt. Symptoms — yellowing of the skin or eyes (jaundice), dark urine, pale stools, pain in the upper tummy or back, weight loss without trying, loss of appetite, new diabetes — tend to appear only once the cancer is growing or blocking the bile duct. None of these automatically mean cancer, but they always deserve a prompt check.

What "stage" means

Staging describes how far the cancer has spread, and it drives every treatment decision. Your team will use two ways of describing it.

The number system (TNM staging):

• Stage 1 — the cancer is only in the pancreas and is 4 cm or smaller.
• Stage 2 — the tumour is larger than 4 cm, or cancer has reached 1–3 nearby lymph nodes.
• Stage 3 — cancer has reached 4 or more lymph nodes, or grown into the major blood vessels near the pancreas.
• Stage 4 — cancer has spread to distant organs such as the liver or lungs (also called metastatic).

The words used to plan treatment:

• Resectable — surgery can remove it; it hasn't grown into major blood vessels.
• Borderline resectable — it touches or involves a major vessel; surgery may be possible, often after chemotherapy first.
• Locally advanced — it has grown into nearby vessels so surgery can't safely remove it.
• Metastatic — it has spread to other organs.

Hearing "stage 3" or "unresectable" is frightening, but it is a planning category, not a verdict — chemotherapy can sometimes shrink a borderline or locally advanced tumour enough for surgery to become possible, and treatments for metastatic disease have improved meaningfully in the last decade.

What usually happens next

• Scans — a pancreatic-protocol CT (and sometimes MRI or PET) maps the tumour and its relationship to blood vessels.
• A biopsy — often via an endoscopic ultrasound (EUS), a thin scope passed through the stomach, to confirm the diagnosis under the microscope.
• Blood tests — including CA 19-9, a tumour marker used alongside scans to track how treatment is working (it is not used alone to make decisions).
• A multidisciplinary team (MDT) meeting — surgeons, oncologists, radiologists and others review your case together and recommend a plan. You can ask whether your case has been discussed at an MDT.
• Genetic testing — increasingly offered, because inherited changes (such as BRCA1/BRCA2) can open up specific treatment options like olaparib, and can matter for your family.

What you can do right now

• Bring someone with you to appointments — two sets of ears are better than one.
• Write questions down before you go (see the guide “Questions to ask at your next appointment” below).
• Ask for a dietitian early — pancreatic enzymes and nutrition support make a real difference to strength during treatment.
• Consider a second opinion at a centre that does a high volume of pancreatic surgery — it is a normal, reasonable request.

You do not have to take all of this in today. Your team expects questions, and asking them is part of good care, not a burden.

Pancreatic ductal adenocarcinoma (PDAC) starts in the cells lining the pancreatic ducts — the tiny tubes that carry digestive enzymes. It accounts for about 90–95% of pancreatic cancers. When people say "pancreatic cancer" without qualification, this is the type they mean.

How it behaves

PDAC tends to grow silently and spread early along nerves and blood vessels, which is why many are found after they have already moved beyond the pancreas. It often blocks the bile duct (causing jaundice) when in the head of the pancreas, and can trigger new-onset diabetes or digestive enzyme failure.

How it's usually treated

• If caught early and removable: surgery (Whipple, distal or total pancreatectomy) plus chemotherapy — the only combination offering a chance of cure.
• Chemotherapy: combinations like FOLFIRINOX, NALIRIFOX or gemcitabine/nab-paclitaxel, before and/or after surgery.
• Markers and tests: CA 19-9 blood test, CT pancreas-protocol scans, sometimes EUS biopsy; genetic testing is increasingly part of care.

Everything in the treatment sections of this site — the guides, the trial numbers, the surgery pages — applies to PDAC unless stated otherwise. The other tumour types below follow different rules.

Pancreatic neuroendocrine tumours (PanNETs, also called islet cell tumours or pNETs) arise from the hormone-producing islet cells, not the ducts. They make up only a few percent of pancreatic tumours and behave very differently from typical pancreatic cancer — most grow slowly, and many are very treatable.

Two broad kinds

• Functioning NETs make hormones: insulinomas (too much insulin → low sugar), gastrinomas (too much gastrin → ulcers), and rarer types. Symptoms come from the hormone, often while the tumour is still small.
• Non-functioning NETs make no hormones, so they grow quietly and are often found later or by accident on a scan.

Different tests, different treatments

• Scans: a special PET scan (Gallium-68 DOTATATE) lights up most NETs; blood tests include chromogranin A and specific hormone levels.
• Treatment is NOT the usual pancreatic-cancer playbook: surgery (sometimes just shelling the tumour out) cures many. For advanced disease there are more options than for PDAC: hormone-blocking injections (octreotide/lanreotide), targeted tablets (everolimus, sunitinib), PRRT (radioactive Lutetium therapy), and specific chemo combinations (like CAPTEM).
• Standard FOLFIRINOX-style regimens are generally not the first choice here.

If your pathology report says "neuroendocrine", make sure you're reading NET-specific information — the survival figures and treatments for PDAC do not apply to you.

Several cancers arise in the small area where the bile duct and pancreatic duct empty into the duodenum (the ampulla of Vater). They are separate diseases from pancreatic cancer, even though the operation to remove them is usually the same Whipple procedure:

• Ampullary cancer — arises at the ampulla itself.
• Distal cholangiocarcinoma — cancer of the lower bile duct as it passes through the pancreas.
• Duodenal cancer — from the first part of the small bowel.

Why they tend to be found earlier

These tumours sit directly on the bile duct, so even a small one blocks bile flow — causing jaundice (yellow eyes/skin, dark urine, pale stools) while the tumour is still small. That early alarm bell means a higher proportion are removable at diagnosis, and overall survival is generally considerably better than for PDAC.

Treatment

• Surgery: usually a Whipple operation; smaller ampullary tumours can occasionally be removed endoscopically in highly selected cases.
• After surgery: chemotherapy may be recommended depending on the type and stage — the regimens differ by tumour origin (bile-duct-type cancers follow different protocols than intestinal-type ones).
• Markers: CA 19-9 and CEA are commonly tracked; your pathology report's exact type matters more here than anywhere else.

If your diagnosis is one of these, ask which specific type it is — the follow-up plan and chemotherapy choices genuinely differ between them.

Treatment for pancreatic cancer depends mainly on one question: can the cancer be removed with surgery? Your stage, your general health, and your own preferences shape the plan. Most people receive more than one type of treatment.

Surgery — the only treatment that can cure pancreatic cancer

• Whipple procedure (pancreaticoduodenectomy) — removes the head of the pancreas, the gallbladder, part of the stomach, part of the small intestine and the bile duct. It is a major operation, best done at high-volume centres.
• Distal pancreatectomy — removes the body and tail of the pancreas (the spleen is often removed too).
• Total pancreatectomy — removes the whole pancreas; you would take insulin and digestive enzymes for life.

If surgery isn't possible, smaller procedures can relieve symptoms: a stent to drain a blocked bile duct, or a bypass if the tumour blocks the stomach outlet.

Chemotherapy — medicines that travel through the whole body

Chemotherapy is used in three situations:

• Neoadjuvant (before surgery) — to shrink the tumour and treat microscopic spread early; standard for borderline resectable disease.
• Adjuvant (after surgery) — to mop up remaining cancer cells. The PRODIGE-24 trial showed modified FOLFIRINOX roughly doubled average survival compared with the older single drug after surgery, and it is now standard for fit patients.
• For advanced disease — to control the cancer and help people live longer and feel better.

The main regimens you will hear about:

• FOLFIRINOX — a four-drug combination (5-FU, oxaliplatin, irinotecan, leucovorin); effective but demanding, usually offered to people who are otherwise fit.
• Gemcitabine + nab-paclitaxel — the MPACT trial showed this pair beats gemcitabine alone; a mainstay for over a decade.
• NALIRIFOX — 5-FU, oxaliplatin and liposomal irinotecan; the NAPOLI-3 trial (2023) showed it beats gemcitabine/nab-paclitaxel as first treatment for metastatic disease.

Radiation therapy

High-energy x-rays target the tumour. It is sometimes used before surgery (with chemotherapy — "chemoradiation"), or to relieve pain by shrinking a tumour pressing on nerves.

Targeted therapy — drugs aimed at specific tumour features

A small but important minority of pancreatic cancers have features that specific drugs can exploit:

• Olaparib — for people with an inherited BRCA1/BRCA2 mutation whose cancer responded to platinum chemotherapy (the POLO trial).
• Rare gene fusions (NTRK, NRG1) and BRAF mutations have matched drugs — which is why molecular testing of the tumour matters. Ask whether your tumour has been tested.

KRAS mutations are found in about 9 out of 10 pancreatic cancers, and KRAS-blocking drugs are among the most active areas of research — some are already available through trials or compassionate access.

Supporting you through treatment

• Pancreatic enzyme replacement (PERT) — capsules taken with food when the pancreas can't make enough digestive enzymes; prevents weight loss and malnutrition.
• Pain control — medicines, nerve blocks, or radiation.
• Dietitian, psychologist, palliative care team — palliative care is about quality of life at any stage, and works best started early, alongside active treatment.

Every option has trade-offs. It is always reasonable to ask: "What is the goal of this treatment for me — cure, control, or comfort — and what difference is it likely to make?"

Good doctors welcome questions — they help you make decisions together. Bring this list (or your own version) to your next appointment, and don't feel you need to ask everything at once.

About your diagnosis and stage

• Is my cancer resectable, borderline resectable, locally advanced, or metastatic — and what does that mean for my options?
• Has my case been discussed at a multidisciplinary team (MDT) meeting?
• What is my CA 19-9 level, and how will we use it to follow my treatment?
• Should I have genetic testing? Changes like BRCA1/BRCA2 can open up treatments such as olaparib — and can matter for my family.
• Should my tumour have molecular testing? Rare mutations sometimes have matched targeted drugs.

About treatment choices

• What treatments are available for my stage, and what are the benefits and risks of each?
• What treatment do you recommend, and why is it the best fit for me?
• If chemotherapy: which regimen — FOLFIRINOX, gemcitabine with nab-paclitaxel, or NALIRIFOX — and why that one?
• Would chemotherapy before surgery (neoadjuvant) or after (adjuvant) be better in my case?
• What is the goal of this treatment — to cure, to control the cancer, or to help me feel better?
• How will we know if it is working, and how often will I have scans?

About surgery (if it is on the table)

• Am I a candidate for surgery — the Whipple procedure, or a distal or total pancreatectomy?
• How many of these operations does this centre do each year? (Volume matters for safety.)
• What is the likely recovery, in hospital and at home?
• Will I need pancreatic enzyme capsules (PERT) afterwards, and will a dietitian be involved?

About clinical trials

• Is there a clinical trial that would suit me — here or at another centre?
• If not now, could I become eligible later?

About day-to-day life

• How will I feel during treatment? Will I be able to work, drive, look after my family?
• What side effects should I call you about straight away — day or night?
• Who do I contact after hours if something goes wrong?
• Can I see a dietitian? Should I be taking pancreatic enzymes with food?
• Is there a psychologist or counsellor who works with cancer patients? (Asking for support is normal — this is a hard road.)

Two practical tips

• Bring someone with you, and ask if you can record the conversation on your phone — most teams are happy for you to.
• If anything is unclear, ask them to say it again in simpler words. It is their job to make it make sense.

Pancreatic surgery — especially a Whipple — is one of the biggest operations the body can go through. Checking fitness beforehand is not about passing or failing you; it is about making the operation as safe as it can be, and finding things that can be improved first.

How fitness is checked

Your team looks at the whole picture, not one test:

• What you can do day to day — walking, stairs, shopping. Teams often call this your "performance status" (ECOG score). It predicts recovery better than age alone.
• Heart and lungs — an ECG (heart tracing) is routine; some people need an echo (heart ultrasound) or breathing tests. Some centres use a CPET — a stationary-bike test that measures how your body handles exertion.
• Blood tests — looking for anaemia (low blood count), kidney and liver function, diabetes control and nutrition markers.
• Frailty and nutrition — unintentional weight loss, muscle loss and frailty matter more than the number on your birthday cake.

What you can do before surgery ("prehabilitation")

The weeks before surgery are a chance to bank strength:

• Walk every day — even 20–30 minutes builds reserve.
• Eat protein with every meal; ask early about a dietitian if you've lost weight.
• Stop smoking and cut out alcohol — both measurably improve wound healing and lung function.
• Get diabetes and blood pressure as controlled as possible.
• Treat any anaemia before the operation, not after.

Questions worth asking

• Is there anything I can improve in the next few weeks?
• Should I see a dietitian or physiotherapist before surgery?
• Will I see an anaesthetist before the day?
• Would a shorter or keyhole operation suit me better?

A distal pancreatectomy removes the body and tail of the pancreas — the part stretching toward the left side of the abdomen, next to the spleen. It is used when the tumour sits in that part of the gland. The head of the pancreas (the part next to the duodenum) stays.

How it's done

Many distal pancreatectomies can be done with keyhole (laparoscopic or robotic) surgery rather than one large cut — this usually means less pain and a shorter stay. Typical time in hospital is about 3–7 days after keyhole surgery.

Why the spleen sometimes comes out too

The spleen's blood vessels run right along the back of the pancreatic tail, so when the tail is removed the spleen often has to come with it. You can live a normal life without a spleen, but it plays a role in fighting certain infections — so if yours is removed you will need:

• Vaccinations (pneumococcal, meningococcal and Hib), ideally before or shortly after surgery
• To tell any doctor treating you that you have no spleen
• Prompt antibiotics for significant fevers — your team will give you specific advice and often a card to carry

Risks worth knowing about

• Pancreatic leak (fistula) — pancreatic juice leaking from the cut edge happens in about 20–40% of cases. It sounds alarming but is usually managed with the drain that is placed during surgery and settles on its own.
• Diabetes — develops in roughly 10–20% of people, depending on how much pancreas is removed. Checked with blood tests at follow-up.

After you go home

Most people are walking the day after surgery and home within two weeks. Some need enzyme capsules (PERT) with meals — if you notice pale, floating or greasy stools or ongoing weight loss, mention it at your next visit.

A total pancreatectomy removes the entire pancreas — usually along with the duodenum, gallbladder, part of the bile duct, and sometimes the spleen and part of the stomach. It is chosen when disease runs through the whole gland (for example, main-duct IPMN or tumours in several parts of the pancreas), where leaving part behind would leave disease behind.

What always changes afterwards

With no pancreas at all, two things become lifelong:

• Insulin — everyone develops diabetes after this operation (called type 3c diabetes; see that guide). Most people use a basal-bolus insulin plan: a long-acting background dose plus quick doses with meals. An endocrinologist (diabetes specialist) becomes a regular part of your team.
• Enzyme capsules (PERT) — everyone needs them, with every meal and snack, for life. Without them, food is poorly digested and weight falls away.

Why the diabetes needs extra respect

The pancreas also makes glucagon, the hormone that rescues you from a low blood sugar. Without it, lows can sneak up with less warning. Practical habits matter: regular meals, carrying glucose (jelly beans or glucose tablets), checking sugars before driving, and wearing a MedicAlert. Many people do very well with modern insulin pens, pumps and continuous glucose monitors.

The big picture

This is a major operation, but for the right person it is done with curative intent. People do travel, work and live well without a pancreas — it takes a team (surgeon, endocrinologist, dietitian, GP) and a bit of routine. Ask early for a diabetes educator and a dietitian, not after problems appear.

Type 3c diabetes is diabetes caused by damage to — or removal of part of — the pancreas. It is different from type 2 diabetes: the pancreas makes less insulin AND less glucagon (the hormone that protects against low blood sugar), so it behaves differently and is managed more like type 1 in many ways.

Who gets it

• After total pancreatectomy: everyone.
• After distal pancreatectomy: roughly 10–20%, rising with how much gland was removed.
• After a Whipple: less common, but it happens — and pancreatic cancer itself can cause diabetes even before surgery.

What it can feel like

High sugars: thirst, passing urine often, tiredness, blurred vision, losing weight. Low sugars (if you're on insulin): shaking, sweating, hunger, confusion, palpitations. Lows need sugar immediately — carry jelly beans or glucose tablets.

How it's managed

• Insulin is usually the right treatment (tablets that squeeze the pancreas don't work when the pancreas is gone) — typically a background dose plus meal doses.
• Keep taking your enzymes (PERT) — steady food absorption makes sugars far easier to control.
• Monitoring — finger-prick checks or a continuous glucose monitor; HbA1c blood test every 3–6 months.
• Team — an endocrinologist or diabetes educator should be part of your follow-up, plus your dietitian and GP.

Day-to-day safety

Check your sugar before driving. Carry glucose and ID saying you have diabetes. When unwell and not eating, don't simply stop insulin — follow the sick-day rules your team gives you. If your weight keeps falling despite good sugars, your enzyme dose probably needs adjusting — mention it.

Follow-up after surgery has two jobs: to catch any sign of the cancer returning as early as possible, and to look after your recovery — enzymes, diabetes, strength and mood. Both matter.

A typical schedule

Every team has its own pattern, but a common one is:

• First 2 years: a visit every 3–6 months, with a CA 19-9 blood test and a CT scan of the chest, abdomen and pelvis.
• Years 2–5: visits stretch to every 6–12 months.
• After 5 years: many people move to annual review or are discharged to their GP with clear instructions.

Your own schedule depends on your pathology and how you're travelling — ask your team what yours looks like and who coordinates it.

What each visit usually covers

• How you're feeling: appetite, weight, energy, pain, bowel habit
• Enzyme dose and diabetes control, if relevant
• Blood tests (CA 19-9 — if it was useful for you before surgery — plus general bloods)
• Scan results, and what happens next

Symptoms to report between visits — don't wait

• New or worsening pain, especially in the abdomen or back
• Yellowing of the eyes or skin, dark urine or pale stools (jaundice)
• Losing weight without trying, or your appetite disappearing
• Newly high blood-sugar readings
• Persistent vomiting or fevers

Getting the most from appointments

Keep a notebook or phone note of questions as they come up, bring someone with you, and ask at the end: "What is the plan until I see you next?" If your GP is sharing the care, make sure letters reach them after each visit.

Every treatment used today — including FOLFIRINOX and gemcitabine/nab-paclitaxel — exists because patients before you joined clinical trials. Trials are how better treatments are found, and joining one can give you access to promising options years before they become standard.

What a clinical trial is

A trial is a careful research study that compares a new approach against the current best standard. Trials are reviewed by independent ethics committees, and joining is always voluntary — you can leave at any time without affecting your care.

The phases, in plain words

• Phase 1 — is the treatment safe, and what dose is right? (Small groups.)
• Phase 2 — does it show signs of working against this cancer?
• Phase 3 — is it better than the current standard? Large, randomised studies; this is where practice-changing answers come from.

"Will I get a placebo instead of real treatment?"

This is the most common worry. In pancreatic cancer trials, a placebo is almost never given on its own — everyone receives at least the current standard treatment, and the trial adds the new treatment (or compares it head-to-head) on top. The POLO trial, for example, gave every patient standard chemotherapy first, then compared olaparib against placebo as extra maintenance — patients on placebo were still receiving proper care.

Who can join?

Each trial has eligibility rules — about stage, previous treatments, general health, sometimes a specific tumour mutation (which is another reason molecular testing matters). Some trials only accept people who haven't started treatment yet, so it is worth asking early, at diagnosis or when a treatment change is being considered.

How to find one

• Ask your oncologist directly: "Is there a trial that would suit me — here or anywhere?"
• Search ANZCTR (anzctr.org.au) for Australian trials and ClinicalTrials.gov worldwide — both are free public registries.
• NCI's trial search (cancer.gov) is another good starting point.

What's being tested in pancreatic cancer now

Research is unusually active in this disease:

• KRAS inhibitors — drugs aimed at the mutation found in about 90% of pancreatic cancers; early results are encouraging and several are in trials or compassionate access.
• ctDNA ("liquid biopsies") — blood tests that detect tiny traces of tumour DNA, being tested to guide when to start, stop or change treatment.
• Neoadjuvant chemotherapy — trials like PREOPANC testing whether treatment before surgery improves outcomes in borderline resectable cancer.
• Immunotherapy combinations — so far disappointing on its own in pancreatic cancer, but still being tested in smarter combinations and in the small subgroup with MSI-high tumours, where it works well.

Questions to ask about a specific trial

• What is this trial trying to find out, and why do you think it might help me?
• What treatment would I get if I'm NOT in the trial — and is the trial arm at least as good?
• What extra visits, scans or biopsies are involved?
• What are the known side effects of the study drug?
• Who pays for what — are trial drugs and extra tests covered?

A trial is not a last resort — for many people it is a first-class option worth asking about from day one.