The passing of some legendary figures in 2020 such as Jeopardy host, Alex Trebek, and Supreme Court Justice, Ruth Bader Ginsburg, serves as a reminder of how far we have yet to go in the fight against pancreatic cancer. This disease is estimated to be the second-leading cause of cancer deaths by 2030. This quick primer is for anyone unfamiliar with the condition to serve as a starting point for his or her research. Strength and peace!

1. Pancreatic Cancer
Zeena Nackerdien

2. Pancreas: A Mixed Glandular Organ
Pancreatic Cancer. NCCN Guidelines for Patients. 2019;
https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdf. Accessed January 2021.
Don Bliss -Illustrator: Image was released by the National Cancer Institute, an agency part of the National
Institutes of Health, with the ID 4363 (image)
Adel N. American Journal of Managed Care. 2019;25(1).
Endocrine gland portion
produces key hormones,
including insulin,
glucagon, somatostatin,
and pancreatic
polypeptide
Exocrine gland produces
a mixture of bicarbonate
and enzymes to aid in
digestion of complex
molecules
Located behind stomach,
which makes palpation
of this organ hard, and
detection not easy
Location of the tumor will dictate surgical options,
which are available to just 15-20% of patients at the
time of diagnosis.

3. Disease Trends in the USA
• 56,770 estimated new cases diagnosed in 2019
• Expected to be second-leading cause of cancer
death by 2030
• Together with liver cancer, linked to steady
increase in mortality in USA
• Incidence of pancreatic ductal adenocarcinoma
has been increasing steadily in the USA, albeit
at slower rates recently
Wilson L da Costa, Jr, Abiodun O Oluyomi, et al, JNCI Cancer Spectrum, Volume 4,
Issue 4

4. Key Triggers
Pancreatic Cancer. NCCN Guidelines for Patients. 2019;
https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdf. Accessed January 2021
Risk Factors
• Tobacco smoking
• Heavy alcohol use
• High body mass index or excess fat
• Lack of exercise
• Genetics
• Family history of pancreatitis
• Family history of pancreatic cancer
• Pre-diabetes
• Long-term diabetes
• Chronic pancreatitis
• Periodontal disease
• Contact with chemicals and heavy metals
Some cancer-related syndromes
• Peutz-Jeghers syndrome
• Melanoma-pancreatic cancer syndrome
• Lynch syndrome
• Hereditary breast-ovarian cancer syndrome

5. Symptoms
Pancreatic Cancer. NCCN Guidelines for Patients. 2019;
https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdf. Accessed January 2021.
New-onset
diabetes
Trouble
controlling
diabetes
Sometimes
pancreatitis
Pain in the
abdomen or
back
IndigestionJaundiceVomitingNausea
Floating
stools
Weight loss

6. Testing
This section covers possible tests physicians might order after obtaining
a medical history.

7. Diagnosis
Imaging
• Computed tomography
scan
• Magnetic Resonance
Imaging
• Minimally invasive
laparoscopic techniques
Blood Tests
• Liver functional tests
• Serum cancer antigen (CA
19-9) has low specificity
• There are no validated
tumor-specific markers
for pancreatic cancer

8. Subtypes
• Neuroendocrine and a
variety of other
histological subtypes
make up the remainder of
malignancies
Pancreatic Cancer. NCCN Guidelines for Patients. 2019;
https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdf. Accessed January 2021
Most
malignancies •Pancreatic ductal adenocarcinoma
3-5% of tumors
•Neuroendocrine cancer and other histological
subtypes
Precancerous/
cancerous lesions
•High-grade pancreatic intraepithelial
neoplasia
•Intraductal papillary mucinous tumor
•Mucinous cystic tumor

9. Eastern
Cooperative
Oncology Group
Performance
Status (PS) of
Patient:
• PS 0 means a fully active patient
• PS 1 means patient is still able to
perform moderate activity
• PS 2 means patient can still care for him-
or herself but not active
• PS 3 means that patient is limited to the
chair or bed more than half of the time
• PS 4 means a need for a caregiver and
patient is limited to chair or bed
Pancreatic Cancer. NCCN Guidelines for Patients. 2019; https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdf. Accessed January 2021

10. Pancreatic
Cancer
Groups Based
on Presurgery
Imaging Tests

11. Genetic Testing
• Physicians will perform germline
and tumor testing
• Germline testing is done for:
• BRCA1
• BRCA2
• PALB2
Pancreatic Cancer. NCCN Guidelines for Patients. 2019;
https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdf. Accessed January
2021.
1. Physicians may choose platinum-based chemotherapies or other
treatments known to work better in the presence of certain
germline mutations.
2. Physicians may also perform microsatellite instability or
mismatch repair testing of tumors to help plan treatment.

12. Treatment
• Some FDA-approved therapies
Adel N. American Journal of Managed Care. 2019;25(1).
Fluorinated pyrimidine
antimetabolites
Fluorouracil
Gemcitabine
Toposiomerase I inhibitors
Irinotecan (metabolized to the active
agent SN-38)
Liposomal irinotecan
DNA-crosslinking agents
Oxaliplatin
Cisplatin
Tubulin inhibitors
Paclitaxel
Nab-paclitaxel (albumin-bound
paclitaxel)

13. Advanced Disease: First/Subsequent Lines of
Treatment Examples
• Some FDA-approved therapies
Adel N. American Journal of Managed Care. 2019;25(1).
• 5-fluorouracil (5-FU), leucovorin (folinic acid; LV), irinotecan,
oxaliplatin (FOLFIRINOX)
• Nab-paclitaxel/gemcitabine
First-Line Treatment
for ECOG PS 0-1
• Whichever regimen was not administered in the first-line setting
Subsequent lines of
therapy
• Pembrolizumab may be suggested for patients with
microsatellite instability-high tumors or with deficiencies in
mismatch repair mechanisms
Immunotherapy

14. Drug Resistance
• Why pancreatic cancer is so hard to treat
Adel N. American Journal of Managed Care. 2019;25(1).
Aberrant gene expression
Mutations
Deregulation of key signaling
pathways
Presence of dense stroma Highly resistant stem cells

15. Palliative Care
• Assessment is made of benefits and burdens of
anticancer therapy
• Physical symptoms
• Psychosocial or spiritual distress
• Educational and informational needs
• Cultural factors affecting care
• American Cancer Society provides information
on Advanced Cancer Care Planning
Adel N. American Journal of Managed Care. 2019;25(1).

16. Disclaimer
“This information is provided as-is. It is not
intended to be a substitute for medical
advice, but hopefully could serve as a
starting point in the journey of any
potential caregiver or patient who wishes
to research this condition.”