Pancreatic Cancer Symptoms and Signs

It is very difficult to diagnose pancreatic cancer as the pancreas is so deep within the body and symptoms vary depending on the exact location of the tumour in the pancreas and which cells or function of the pancreas is affected by the tumour or cancer.

It is principally a disease affecting middle-aged and older patients but this is not always the case and the diagnosis can be missed in younger patients.

Although the commonest form of pancreatic cancer - pancreatic ductal adenocarcinoma - is so deadly, there are other much rarer forms - eg. endocrine tumours - which can affect younger patients and have a much better outlook with surgery and chemotherapy or immunotherapy.

Unfortunately there are frequently no symptoms at all at the very early stages. The tumour may have grown significantly before it causes any obvious recognised symptoms.

Unfortunately the symptoms of pancreatic cancer can also be quite vague and non specific ie may be caused by many other more common and less serious conditions. Diagnosis can be delayed as the GP or specialist tries to rule out other causes such as hepatitis, gall stones, irritable bowel syndrome and stress.

Not everyone has every symptom, it depends very much on the location of the tumour in the pancreas. For example jaundice can be an early sign of a tumour in the head of the pancreas affecting the bile duct and back pain can be a late sign of a tumour in the body or tail of the pancreas possibly affecting the nerves and spine.

Jaundice may also be a late sign of a tumour that has developed initially further away from the bile duct and then grown or spread until it causes obstruction of the bile duct.

• General discomfort or pain around the stomach area
• Sickness
• Bowel disturbances
• Diabetes
• Jaundice
• Skin itching

• Loss of appetite
• Unexplained weight loss
• Back pain
• Low mood and depression

The pancreas helps to digest your food and also produces insulin which balances the sugar level in the blood. It is behind the stomach and shaped like a tadpole.

As mentioned above the symptoms of pancreatic cancer can be quite vague and common to many other less serious conditions. However if cancer is affecting the function of the pancreas it can potentially cause 2 problems:

• Poor absorption of food, especially fat leading to weight loss and rather fatty, pale, smelly stools and diarrhoea
• Diabetes if too little insulin is produced

About 70% of patients have obstructive jaundice at the time of diagnosis, due to a tumour in the head of the pancreas obstructing the bile duct, and hence the associated symptoms (yellowing eyes and skin, dark urine, pale stools, itchy skin). The jaundice is often painless and accompanied by no other symptoms so that the patient first notices something is wrong when their skin starts itching, their urine becomes very dark and they start to turn yellow (it is noticeable first in the whites of the eyes).

Most tumours occur in the head of the pancreas and typical early symptoms can include

• Jaundice and associated symptoms
• Feeling of sickness (nausea)
• Slight weight loss
• Unexpected development of diabetes

Tumours in the body and tail of the pancreas are more difficult to pick up early as they do not cause obstructive jaundice at an early stage. Typical symptoms can include:

• Vague abdominal pain
• Dyspepsia (indigestion)
• Stomach ulcer-like pain
• Intermittent diarrhoea
• Feeling of sickness (nausea)
• Unexplained weight loss
• Unexpected development of diabetes
• Back pain that does not go away
• Unexplained blood clots (venous thrombosis)

Although there is a link between diabetes and pancreatic cancer, diabetes is more commonly not associated with pancreatic cancer. However the liklihood of it being associated with pancreatic cancer increases if the onset is sudden and unexpected (eg no family history) and occurs in someone over 50 years old who is not obese. There is still scientific debate about whether diabetes causes pancreatic cancer or whether it is just a symptom of something going wrong with the pancreas ie cancer affecting the production of insulin.

A variety of bowel disturbances can be experienced with pancreatic cancer including both diarrhoea and constipation. One aspect that doesn't seem to get emphasised is the effect due to poor fat absorption. The lack of digestion of fat causes steatorrhoea which is pale, greasy stools that can be foul smelling and float and be difficult to flush away.

Pancreatic cancer may have few obvious or specific symptoms at the early stages.

The most obvious symptom is jaundice (a yellow discolouration of the eyes and skin) which is often associated with dark urine and pale motions (stools) and itching of the skin. If the head of the pancreas is enlarged or abnormal then the bile duct may become blocked as it enters the pancreas, this blockage causes a build up of bile which causes the jaundice, dark urine, pale motions and itching. The symptoms should rapidly disappear once the blockage is cleared or bypassed by surgery or insertion of a stent.

If the cancer blocks the pancreatic duct this will lead to poor digestion, loose motions and weight loss. This can be relieved by clearing the blockage or by giving pancreatic enzyme tablets. Steatorrhoea is the medical term for the loose, pale, fatty, floating, offensive bowel motions which occur when the pancreas is not releasing digestive juices into the intestines and there is failure to absorb fats from the gut.

Weight loss is common because of the interference with digestion (due to blocked bile and/or pancreatic ducts or interference with production of pancreatic enzymes) and sugar metabolism, loss of appetite and the action of cancer itself.

Diabetes can be caused by pancreatic failure, it is usually characterised by weight loss, lethargy, thirst, blurred vision, increased volumes of urine and drowsiness. Diabetes may already be present in a number of patients prior to developing the cancer or become apparent soon after it is diagnosed or following surgery.

Pain is also a common symptom of pancreatic cancer once the tumours are large enough to press on other organs or the spine and nerves. However only about half of all pancreatic cancer patients have any pain at the time of their diagnosis and pain is more common in cancers of the body and tail of the pancreas. Patients describe it as a dull pain that feels like a screwdriver boring into you. The pain is very typically worse when you lie down and is better if you sit or lean forward. It can start in the stomach area and spread around to the back. It can be worse after meals. Patients may also have a generally tender or painful abdomen if the liver, pancreas or gall bladder are inflamed or enlarged. In the case of enlarged liver or gall bladder this pain will be on the right hand side of the body.

When the pancreas is inflamed (e.g. acute pancreatitis) it often causes pain, this is usually felt in the central or upper part of the abdomen and is often associated with back pain. The pain may be sharp, aching or burning in nature. Some patients with pancreatic cancer may also have pancreatitis either due to disease in the pancreas or as a result of investigative procedures such as ERCP. The presence of pancreatitis can complicate diagnosis as it may mask pancreatic cancer in diagnostic imagery.

A feeling of nausea and actual sickness/vomitting may be the result of a number of things. It may be associated with a blocked bile-duct and hence jaundice or due to an inflamed pancreas. The change in chemical balance of the body caused by these conditions can make you feel sick. If the duodenum becomes blocked or restricted by cancer or inflamation this can stop food passing through and cause vomitting.

Some patients may develop high temperature (fever) and start shivering and feel cold despite the high temperature. This can be a side-effect of a blocked bile-duct (jaundice) or an inflamed pancreas.

Endocrine type cancers can also have symptoms associated with excessive production of different types of hormones and these are described on our page on pancreatic cancer types.

The link with sudden onset diabetes has been backed up by a recent study (August 2005 issue of American Gastroenterological Association (AGA) journal Gastroenterology) that has shown that middle-aged patients with sudden onset diabetes have greater risk of developing pancreatic cancer within 3 years of diagnosis with diabetes than the general population. According to the study 1 in 120 people newly diagnosed with diabetes age 50 and older have a higher risk of developing pancreatic cancer--a risk that is eight times more than expected for the general population.

While study findings show that older patients have less than a 1 percent chance of having pancreatic cancer as the cause of their diabetes, they are still considered a high-risk group for developing the cancer. According to reports on the study between 55 and 65 percent of people with pancreatic cancer have hyperglycemia and diabetes. For these factors to be useful in establishing the need for screening in relatively asymptomatic patients, researchers say it is necessary to find the difference between pancreatic cancer-induced diabetes and type 2 diabetes.

However reports of incidence of hyperglycemia and diabetes in patients with pancreatic cancer vary from 5% to 80%. This appears to be due to the fact that the hyperglycemia and diabetes has also been undiagnosed although patients may have the associated (but possibly unreported) symptoms of weight loss, lethargy, thirst, blurred vision, increased volumes of urine and drowsiness. According to Diabetes UK one in four cases of diabetes are undiagnosed or unrecorded in England.

Do Early Symptoms of Pancreatic Cancer Exist that Can Allow an Earlier Diagnosis? 2001, Gullo et al, Pancreas, Vol22, No 2, pp210-213.

Pancreatic cancer: clinical presentation, pitfalls and early clues.DiMagno EP, 1999 Ann Oncol;10 Suppl 4:140-2.

Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area. Holly EA, Chaliha I, Bracci PM, Gautam M. 2004 Clin Gastroenterol Hepatol. Jun;2(6):510-7.