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Symptoms of Pancreatic Cancer

Suresh T. Chari, M.D.
Mayo Clinic, Rochester

Pancreatic cancer is the second most frequent cancer of the digestive organs. It is estimated that about 32.000 patients were diagnosed with pancreatic cancer in 2004 in the United States. The incidence of pancreatic cancer is relatively low compared to many other cancers. For example. it is estimated that 230,110 prostate cancers and 55,100 melanomas (a type of skin cancer) occurred in the United States in the year 2004. Despite this, more people died of pancreatic cancer than of prostate cancer or melanoma. Pancreatic cancer has risen to become fourth leading cause of cancer death in both men and women in the United States. This is because pancreatic cancer is usually diagnosed late in the course of the disease. At the time of diagnosis less than 20% of patients with pancreatic cancer have potentially curable (i.e., surgically removable) disease.

Pancreatic cancer is most frequently diagnosed in the seventh decade of life and is rare below the age of 40. It is slightly more common in men than in women. Apart from smoking, little is known about environmental and lifestyle factors that might cause pancreatic cancer. Most patients with pancreatic cancer have symptoms at the time the diagnosis of cancer is made; in very few patients is the diagnosis made in the absence of symptoms. The initial symptoms may start just a week to months before the diagnosis is made. However, in most patients, by the time symptoms develop the cancer has already spread beyond the confines of the pancreas.

Jaundice is often the first symptom that brings the patient to medical attention or draws the physician’s attention to the possibility of pancreatic cancer as the cause of patient’s symptoms. Jaundice occurs due to obstruction of the bile duct by the cancer. Since the majority of cancers occur in the head of the pancreas, in close proximity to the bile duct, jaundice is a frequent symptom of pancreatic cancer.

Apart from yellowing of the white of the eyes (jaundice), blockage of flow of bile into the intestine due to bile duct obstruction leads to a constellation of other symptoms: dark urine (due to excretion of some of the contents of bile into the urine), pale stools (due to lack of secretion of bile, which provides color to the stool, into the intestine) and itching (due to unknown substances that remain in the blood as a result of lack of flow of bile). Some patients may experience diarrhea due to lack of bile and pancreatic juice necessary for proper digestion of food.

Other symptoms that commonly occur in patients with pancreatic cancer are abdominal pain, back pain, loss of appetite, unusual and involuntary weight loss, early satiety and fullness after meals.

Abdominal pain occurs in over half the patients with pancreatic cancer. The pain is localized to the upper mid-abdomen. It can be intermittent, occurring after meals, or constant. Its intensity can vary from mild pain, not requiring analgesics, to severe, debilitating pain requiring powerful narcotics for control. Until it is associated with severe loss of appetite, weight loss or jaundice, the abdominal pain of pancreatic cancer is often confused with pain due to ulcer disease or reflux and treated as such.

Back pain occurs in a quarter of the patients with pancreatic cancer. When it occurs in isolation, it is often misdiagnosed as mechanical back pain and treated with physiotherapy. So patients may even have back surgery or manipulation by chiropractors before investigations are performed for an abdominal cause for persisting and worsening pain despite local treatment. Patients with tumors in the pancreatic body often present with back pain. It is thought to be due to infiltration of nerves by the tumor and generally portends a poorer prognosis.

A marked lack of appetite is often preceded and accompanied by inability to eat a full meal due to a feeling of fullness and satiety. Associated with this is weight loss and in advanced stage of cancer loss of muscle mass, also called muscle wasting. Patients also feel weak and fatigued. This syndrome of anorexia, weight loss and muscle wasting, called cancer cachexia, is seen in many cancers, but is most pronounced and frequent in pancreatic cancer.

A new diagnosis of diabetes in the elderly is a less frequently recognized presentation of pancreatic cancer. While high blood glucose levels are seen in half to two-thirds of pancreatic cancer patients at diagnosis, in most patients the diabetes is undiagnosed and unrecognized. In some patients the diagnosis of diabetes is made many months before development of other characteristic symptoms of pancreatic cancer described above. However, adult-onset type 2 diabetes is far more common than diabetes due to pancreatic cancer. There is currently no simple test that can distinguish type 2 diabetes from diabetes associated with pancreatic cancer.