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About Pancreatic Cancer
NewYork-Presbyterian is world-renowned for its expertise in diagnosing and treating pancreatic cancer, and in providing patients with a significantly improved length and quality of life. Much of this is made possible by our ongoing research in the field of pancreatic cancer, and in our pioneering prevention program which identifies, counsels and treats individuals with a high risk of pancreatic cancer.
Our interdisciplinary team of gastrointestinal specialists in endoscopy, radiology, oncology, and surgery work together as a team to provide each patient with the best-coordinated, advanced and individualized care. We have led the way to develop a number of new procedures for pancreatic cancer, and continue to lead the way in developing new treatments for this disease, as well as ways to detect it earlier.
Over 42,000 Americans are diagnosed each year with pancreatic cancer, most often in late-stage disease. The incidence in the US and Europe is rising for as-yet undetermined reasons, but may be linked to obesity and rising levels of environmental toxins.
The pancreas is a gland located behind the stomach and in front of the spine which produces digestive juices and hormones, including insulin and glucagon, which help control blood sugar levels. The pancreas is also crucial with helping the body store and use energy from food after it aids with digestion.
About 95% of all cases of pancreatic cancer begin in the cells that produce digestive juices, called exocrine pancreas cells. These cells are located in the head of the pancreas. Other pancreatic tumors begin in the islet or endocrine cells.
Symptoms of Pancreatic Cancer
Pancreatic cancer is often difficult to detect in the early stages because distinct symptoms usually do not occur until the cancer is advanced. The early symptoms of pancreatic cancer can resemble those of other diseases. With the pancreas located behind other organs including the stomach, liver, small intestine, gallbladder, bile ducts and spleen, symptoms usually occur only when the cancer has grown large enough to impact these surrounding organs' function.
Initial symptoms may include pain in the upper abdomen moving into the back, and unexplained weight loss. As most pancreatic tumors start in the head of the pancreas where digestive juices are produced, these tumors frequently block a bile duct, producing jaundice, and itchiness of the skin. (However, these symptoms more commonly reflect viral hepatitis or gallstones). Other signs of pancreatic cancer may include loss of appetite, nausea, fatigue, fat malabsorption, and depression. Any of these symptoms should be examined by a physician.
Risk Factors for Pancreatic Cancer
- Long-standing diabetes.
- Family history of pancreatic cancer, or familial pancreatitis.
- Pancreatitis – an inflammation of the pancreas which may be either acute or chronic, and may be hereditary.
- Rare genetic conditions, including von Hippel-Lindau syndrome, Peutz-Jehgers syndrome, hereditary non-polyposis colon cancer, ataxia-telangiectasia, early-onset familial breast cancer syndrome due to BRCA1 and BRCA2 genetic mutations, and familial atypical multiple mole melanoma (FAMM) syndrome.
- Race: African Americans are more likely to get this disease worldwide.
- Diet high in meat and fat.
- Age – most patients are diagnosed between the ages of 60 and 80, except those with a family history of pancreatic cancer, who are generally diagnosed earlier.
- Occupational or environmental exposure to carcinogens, such as pesticides, dyes or gasoline-related chemicals.
- Certain types of pancreatic cysts.
Diagnosis of Pancreatic Cancer
NewYork-Presbyterian's gastrointestinal team uses numerous state-of-the art imaging systems to detect and stage pancreatic cancer.
CT is usually considered the first radiological diagnostic study performed when someone is suspected of having pancreatic cancer. In a CT scan, an X-ray machine linked to a computer takes a series of detailed cross-sectional pictures. These "slices" are then linked together to create a detailed 3-dimensional reconstruction of the body. Unlike regular X-ray images which can only show bone, CT images show soft tissue, blood vessels, and bone.
MRI is another common diagnostic imaging study used in pancreatic cancer. MRI scans use radio waves and powerful magnets to produce images of the body. Like a CT scan, an MRI can produce detailed 3-dimensional cross-sectional images of the body. The MRI can also produce image slices running the length of the body, providing an alternate view of the affected area.
PET Scan is not the standard of care diagnostic test.
Endoscopic Ultrasound (EUS)
Our team will perform an endoscopic ultrasound (EUS) for suspected pancreatic tumors, inflammatory diseases of the pancreas – acute and chronic pancreatitis – and cysts, small, fluid-filled sacs that can be found on the pancreas. The EUS procedure consists of sound waves which are sent through an endoscope placed in the esophagus, stomach and small intestine which helps visualize the pancreas.
Fine Needle Aspiration
If a cyst is detected, the endoscopist will perform a fine needle aspiration. With ultrasound guidance, the physician places a very fine, hollow needle into the cyst and removes a small sample of fluid from the cyst, which is analyzed to determine the nature of the cyst, and whether surgery is necessary to remove it. In the case of some cysts, we can also use EUS to inject the cyst to cause them to regress, and in other cases, use EUS to place stents into the pancreatic duct or from the duodenum into the bile duct for drainage. In the case of individuals at high risk for cancer, EUS can help screen them for abnormalities, and help determine whether additional tests are needed. If a patient is diagnosed with pancreatic cancer, EUS can help the team determine whether the cancer is operable or not; if it is not, it helps patients avoid unnecessary surgery.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
For patients in whom pancreatic cancer is suspected, our specialists will also do an endoscopic retrograde cholangiopancreatography (ERCP) to x-ray the bile ducts leading from the pancreas to the gallbladder. Pancreatic cancer may cause these ducts to narrow or become blocked.
Patients fast for 12 hours, and are given a sedative and a local anesthetic, either in a spray or gargle, before undergoing an ERCP procedure. The procedure itself requires about an hour.
In an ERCP, a physician guides an endoscope into a patient's mouth, esophagus, stomach, and then into the duodenum, the top or first part of the small intestine. The doctor will then insert a catheter (a smaller tube) through the endoscope and into the pancreatic ducts. A drug is injected into the duodenum to relax it, and then a dye (contrast medium) is injected through the catheter and an X-ray is taken to visualize the ducts. If a duct is blocked, the physician can open it up by inserting a tiny stent into the duct through the endoscope, which can remain in place to keep the duct open. The physician may also take a small biopsy of tissue.
SpyGlass Direct Visualization System for Single-Operator Duodenoscopic-Assisted Cholangiopancreatoscopy (SODAC)
Our gastrointestinal endoscopists also may use the SpyGlass Direct Visualization System for single-operator duodenoscopic-assisted cholangiopancreatoscopy, or SODAC – the latest technology to visualize and evaluate the bile and pancreatic ducts. This device, like ERCP but with better mobility and image clarity, enables physicians to view hard-to-access ducts in patients with biliary strictures, or narrowing, in those with pre-malignant lesions, and difficult-to-manage stones. The SpyGlass System enables physicians to see the gastrointestinal tract in color and in real time.
Other tests may include an intraductal ultrasound, an endoscopic procedure which provides a very fine and detailed view of the pancreas itself by entering the pancreatic ducts with very small probes – less than 2 mm in size. This enables our physicians to better visualize tumors and cysts within the pancreas and increases the diagnostic efficacy of ERCP.
Doctors may also perform a laparoscopy, or "keyhole surgery" to determine if a tumor has spread to other organs or tissues. A minimally-invasive surgical procedure, laparoscopy is performed using general anesthesia with a fiber optic scope – a tiny camera, which is guided into the abdomen through a small incision. The images are viewed on a screen and enable physicians to examine the surrounding organs without having to make a full abdominal incision.
Treatment for Pancreatic Cancer
Surgery for Pancreatic Cancer
Surgery is the standard treatment for pancreatic cancer, often offering the best chance for cure when the cancer has not spread beyond the pancreas. At NewYork-Presbyterian, our experts customize pancreatic surgery for each patient to remove the tumor when possible while preserving healthy tissue. We specialize in surgery to remove all cancerous tissue, with a surgical mortality rate of less than 1% as compared to the nationwide rate of 4-15%. In addition, about 35% of our surgery patients were considered ineligible elsewhere because their cancer was near a major blood vessel.
At NewYork-Presbyterian, we often give patients who have inoperable tumors neoadjuvant chemotherapy (sometimes used with radiation therapy) to shrink tumors and make surgery possible. As a result, about 35% of patients traditionally considered inoperable at other institutions become candidates for surgery at our medical center.
Physicians at NewYork-Presbyterian developed the surgical paradigm for pancreatic cancer, known as the Whipple procedure (pancreaticoduodenectomy), which is now performed throughout the world to treat pancreatic (and other non-pancreatic) tumors which had been considered inoperable in the past.
Types of Surgery for Pancreatic Cancer
With the Whipple procedure, surgeons remove the head and sometimes the body of the pancreas, the lower portion of the stomach, the duodenum, and lymph nodes near the pancreas. Surgeons also remove the gallbladder and part of the common bile duct, and connect the remaining bile duct to the small intestine so that bile can enter the small intestine from the liver.
For patients in whom the cancer has spread beyond the pancreas, other laparoscopic techniques are employed. Laparoscopic distal pancreatectomy is performed on patients with neuroendocrine pancreatic tumors and cysts. In this procedure, we remove the body and tail of the pancreas while preserving the spleen.
Removing the tail was once considered too challenging due to its proximity to the splenic artery and vein. However, our surgeons have perfected the technique involved and now commonly perform spleen-preserving distal pancreatectomy with less blood loss, shorter hospital stays, and lower leak rates than patients operated on in open procedures.
Central pancreatectomy may be performed to eliminate a cancer in the pancreas' body or neck without removing the healthy tail of the organ, enabling the patient to retain a functioning pancreatic head and tail and their respective functions.
Total pancreatectomy surgery involves removing all or part of the pancreas, part of the stomach and small intestine, the common bile duct, gallbladder, spleen, and neighboring lymph nodes.
Chemotherapy for Pancreatic Cancer
Our medical oncology team may offer patients chemotherapy before or after surgery, or for primary treatment if surgery is not possible. Pancreatic cancer is known to be resistant to chemotherapy, but in their roles as researchers at either Columbia University College of Physicians and Surgeons or Weill Cornell Medical College, the two medical schools affiliated with NewYork-Presbyterian, our physicians have developed a number of multi-drug regimens that have produced excellent results.
A three drug combination, called GTX (gemcitabine, docetaxel, and capecitabine) has been shown to decrease pancreatic cancer's traditional resistance to chemotherapy, and has demonstrated substantial anti-tumor effects with low toxicity even in late-stage metastatic pancreatic cancer. Coupled with radiation therapy, this drug may also show promise in shrinking earlier-stage, inoperable tumors. This efficacy is currently being investigated.
For patients with pancreatic cancer that has spread throughout the abdomen, called carcinomatosis, our physicians have developed a protocol to surgically remove as much of the tumor as possible, followed by continuous heated chemotherapy administered directly into the abdomen to treat any residual disease.
We are also testing a number of new drug combinations for metastatic neuroendocrine tumors and other pancreatic tumors, including gene therapy and a peptide drug that kill only cells with pre-malignant or cancerous genetic (K-ras and p-53) mutations.
Radiation for Pancreatic Cancer
Our radiation oncologists employ state-of-the art, computer-controlled linear accelerators with three-dimensional conformal radiation, or intensity-modulated radiation therapy (IMRT). This is a type of 3-dimensional radiation therapy that uses computer-generated images to show the size and shape of the tumor. Once the tumor is "mapped," thin beams of radiation of different intensities are aimed at it from many angles, destroying the tumor while reducing damage to the surrounding healthy tissue.
We also offer brachytherapy for patients with tumors of the bile ducts, in which very small catheters are threaded to the site of the tumor to deliver a high dose of liquid radiation directly upon it. The therapy reduces the tumor's size and opens up the bile duct.
Research for Pancreatic Cancer
NewYork-Presbyterian has a vigorous basic research program in which we are studying the molecular genetics of pancreatic cancer, and pancreatic cysts in order to better understand how this disease develops.
We are conducting a unique prevention program dedicated to helping those with a family history of pancreatic cancer determine their own risk of getting this disease. With the goal of preventing pancreatic cancer, we analyze personal and family history, provide genetic counseling, and recommend regular imaging of the pancreas to determine whether precancerous abnormalities or small cancers are present, and if so, whether they should be addressed with surgery.
As part of this program, we maintain a pancreatic cancer registry that includes tissue and blood samples, clinical and family histories, and epidemiological information of patients with pancreatic cancer, and those at high risk of disease.
NewYork-Presbyterian is a member of the Pancreatic Cancer Research Team (PCRT), a national consortium which sponsors both basic research and clinical trials.