How is pancreatic cancer diagnosed?
Diagnosing pancreatic cancer
Reaching a diagnosis of pancreatic cancer can be a lengthy and complex process with a range of tests and scans that may be required. When the cancer first develops, it often doesn’t cause any symptoms. This means that you may have had cancer for some time without knowing.
When symptoms of pancreatic cancer occur, they can vary between people in different ways and at different times.
The symptoms of pancreatic cancer can be very general – such as fatigue and tiredness – and may be similar to symptoms of more common and less serious illness. Some symptoms – such as jaundice, persistent abdominal pain or unexplained weight loss – require urgent review by your GP and may need a referral to a specialist for further tests and investigation. In other cases, symptoms of pancreatic cancer can be severe enough, and may begin rapidly enough, to require admission to hospital or a visit to the emergency department.
Because of the range of symptoms experienced with pancreatic cancer, it is common for people to have had numerous tests before pancreatic cancer is considered and a diagnosis confirmed.
Pancreatic cancer tests and investigations
Several tests and scans are used to confirm a pancreatic cancer diagnosis. Your doctors will use the test results to work out the best treatment for you. Although you will have had some of these tests, you may need others to find out exactly what type of pancreatic cancer you have and what stage it is. Your doctor may not require all the tests mentioned below to make a diagnosis of pancreatic cancer. Your specialist will give you more detailed information about what tests are most appropriate for your condition.
If you have symptoms of pancreatic cancer, your doctor may carry out a general clinical examination to feel your abdomen to check for lumps or swelling. The doctor will ask about your medical history to learn about your symptoms and possible risk factors.
Various blood tests are used to check your blood count, liver and kidney function and your general health. Blood tests can also check for tumour markers. These are chemical substances produced by cancers that may be present in the bloodstream. For example, pancreatic cancer is often linked to a tumour marker called CA19-9. Not all pancreatic cancers produce this marker, and it may also occur with some other illnesses that are not cancer.
Blood samples are usually examined in a laboratory within a day or two. Sometimes samples must be sent away for analysis, and it can take several days to get the results.
Blood tests are used together with other test results to make a diagnosis.
Ultrasound scans use sound waves to create a picture of what your body looks like inside. A probe is passed over the outside of your abdomen, and the images are collected on a screen – usually an outline of the liver, pancreas, gall bladder and bile ducts.
A CT scan uses X-rays to build up a three-dimensional picture of the pancreas and the other organs around it. It is common practice to scan your chest and pelvic area to check for any signs of cancer outside the pancreas. A CT scan can also be used to guide the needle during a biopsy that is performed in some cases. The biopsy procedure involves a tissue sample being taken for examination under a microscope.
An MRI scan uses radio waves and magnets to take pictures of organs and structures inside the body by measuring their energy. Like a CT scan, an MRI photographs the organs several times, while a patient lies on a table. A computer creates a 3D image that doctors can use to help diagnose and monitor pancreatic cancer.
A PET scan is a test where a small amount of radioactive substance is injected into a vein. On the scans, the injected substance shows areas where the cells are more active in the body. The scan works by highlighting where growing cells, such as cancer cells, use glucose for energy and growth faster than other non-cancerous cells. A PET scan may indicate whether a mass is cancerous and has spread. It can also help your healthcare team develop the right treatment plan, including whether surgery is possible.
This scan combines a CT scan with a PET scan. As mentioned above, a PET uses a small amount of radioactive material to scan for cancerous cells, and a CT is a type of X-ray. Combining the two scans into one has been shown to be extremely sensitive in detecting small tumours that are undetectable by other imaging procedures or CT alone. The images and information gained from a PET-CT scan can be used to determine what kind of surgery, radiation therapy and/or chemotherapy is most likely to be successful in treating the cancer.
Like the EUS, the ERCP is a procedure that involves the use of an endoscope. Additionally, the ERCP takes X-rays during the procedure. During an ERCP scan, dye is injected through the tube directly into the opening of the pancreatic duct (the ampulla of Vater) so that any blockages will be seen on the X-ray. While the endoscope is in place, the doctor may also take tissue samples for biopsy. If there is a blockage in your bile duct, the doctor may insert a small tube (called a stent) into the duct.
Another type of ultrasound – called an endoscopic ultrasound (EUS) – is a procedure that uses sound waves to take pictures of the pancreas, bile duct and digestive tract from within the body. This type of ultrasound is usually performed by a specialist gastroenterologist and involves an endoscope, which is a thin tube, entering a patient’s mouth and being guided down through the stomach and into the first part of the small intestine (duodenum). An EUS can help a doctor see a pancreatic tumour’s location and size, check whether the cancer has spread to other nearby areas of the body, or take a biopsy/tumour sample for examination. The images provided by this internal ultrasound have been shown to be helpful in diagnosing and staging pancreatic cancer.
In some circumstances a biopsy is performed as part of the investigations to be certain about your diagnosis. Tissue samples for examination under a microscope can be taken during an EUS, ERCP or laparoscopy, or through your skin with local anaesthetic and guided by CT. A biopsy may not be performed in certain cases when surgical removal is planned upfront. In cases when surgery is not planned at the beginning, you will need to have a biopsy before starting chemotherapy or taking part in a clinical trial, to obtain a definite cancer diagnosis.
The MRCP scan is a different type of MRI scan that is sometimes used to give clearer pictures of the bile and pancreatic ducts. It can also show if there are any blockages in the bile and pancreatic ducts. An MRCP can happen at the same time as an MRI.
This is a small operation done under general anaesthetic by a surgeon. A long tube with a camera at one end is inserted through a small cut in your abdomen so that the doctor can examine your organs internally. Other small cuts may be made so instruments can be inserted to help with the examination. This test can help to clarify whether a tumour has spread to other regions and can be removed by surgery. Sometimes an ultrasound probe (laparoscopic ultrasound) is also used to help identify suspicious areas and take a biopsy. This test may or may not be performed depending on your surgeon’s practices and the results of other tests.
Waiting to have tests carried out
Even if you have been given an urgent referral for a particular scan or investigation you may have to wait several days or possibly weeks for your appointment. This can be frustrating and worrying, especially if you are already feeling unwell.
If your symptoms get worse or you start to feel more unwell while you are waiting, it’s a good idea to get in touch with your GP or specialist if you already have one. If you cannot get in contact with your doctors, you may need to present to the closest emergency department if your symptoms cannot be controlled at home.
How long will I have to wait for my test results?
Depending on which tests you have had, it may take from a few days to a few weeks for the results to come through. Waiting for test results can be an anxious time.
It is a good idea to ask how long you may have to wait when you go for tests. If you think you have been waiting too long, then contact your GP or a specialist to follow up on the progress of your results. Usually, the doctor who does the test will write a report and send it to your specialist. If your GP sent you for the test, the results will be sent to the GP clinic.
You will need an appointment with your specialist or GP to discuss the test results and how the results might affect your treatment. Your specialist will discuss your results and plan your subsequent care.
Your test results will enable your doctors to make a detailed diagnosis and indicate to them at what stage your cancer is.
Staging is how doctors refer to the size of a cancer and whether it has spread around the tumour site or to other areas of the body. It is an important part of their assessment and contributes to treatment planning. In cases of cancers localised to the pancreas that are surgically operable, the staging, which includes whether there is spread to lymph nodes, often can only be determined once the cancer has been surgically removed.
One system uses numbers to describe the stage of the cancer, the other uses the tumour-nodes-metasteses staging system. Your cancer staging may be explained to you by one or both ways.
|Stage||1||The earliest stage when the cancer is only inside the pancreas.|
|Stage||2||The cancer is usually larger and may have started to grow into the duodenum, bile duct or tissues around the pancreas or there may be cancer in the lymph nodes near the pancreas.|
|Stage||3||The cancer is growing outside the pancreas into nearby major blood vessels or nerves but has not spread to other parts of the body.|
|Stage||4||The cancer has spread to other parts of the body such as the lungs or liver (metastatic cancer).|
TNM (Tumour-Nodes-Metastases) staging
The TNM gives a number according to tumour size (T), how many lymph nodes are affected (N), and how far the cancer has spread, or metastasised, to distant parts of the body (M). This information is used to help decide the best treatment.
|T1||Tumour confined to the pancreas 2cm or less in greatest dimension.|
|T2||Tumour confined to the pancreas more than 2cm and less than 4cm in greatest dimension.|
|T3||Tumour greater than 4cm or invades duodenum or bile duct.|
|T4||Tumour invades adjacent structures.|
|N1||1-3 lymph nodes involved.|
|N2||4 or more lymph nodes involved.|
Receiving a pancreatic cancer diagnosis
Receiving the diagnosis of pancreatic cancer can be unnerving, confusing, and disorienting. You may have mixed emotions of surprise, disbelief, and anger. You may feel sad and disappointed and have fear and uncertainty for the future. But you are not alone.
The PanSupport Team is here for you – to connect you with a community of people who have a shared experience and to support you through all stages of your experience.
A Common Path: pancreatic cancer
The ‘A Common Path’ suite of cancer support and advice videos have been developed by the North Eastern Melbourne Integrated Cancer Service, with support from Pancare, for people who have been newly diagnosed with cancer. They provide people with an opportunity to learn from others who have already experienced a cancer diagnosis and treatment, highlighting how they made decisions, the things they learned along the way, the things that helped, and the things they wish they had known or done better.