Pancreatic Ductal Adenocarcinoma (PDAC) Care

Pancreatic ductal adenocarcinoma is the most common pancreatic cancer. It starts in the cells lining the ducts. Those ducts carry digestive enzymes. It often causes few symptoms early. Many people are diagnosed only after other signs bring them in. Those include jaundice (yellow skin or eyes), back or abdominal pain, weight loss with no clear cause, or new diabetes.

This is a serious diagnosis. There is no useful way to soften that. But your own specifics matter more than the general statistics. Several things are worth doing early. They are easy to miss.

Stage number matters less here than one question. Can surgery remove it? NCI describes four groups.

Resectable means the tumor "has not grown into major blood vessels near the tumor" and can be removed surgically.

Borderline resectable means it "has grown into a major blood vessel or nearby tissues." Surgery might not remove it all.

Locally advanced means surgery cannot remove it, because it has grown into major blood vessels or lymph nodes nearby.

Metastatic means it has spread to other organs.

A pancreatic-protocol CT scan sets the category. Ideally a tumor board reviews it. That board should include a surgeon who does many pancreatic operations. Categories can change. Chemotherapy sometimes shrinks a borderline or locally advanced tumor. Surgery can then become possible.

The Whipple procedure (pancreaticoduodenectomy) removes the head of the pancreas. It also takes the gallbladder, the bile duct, part of the stomach, and part of the small intestine. Distal pancreatectomy removes the body and tail. Total pancreatectomy removes the whole gland. These are major operations. Results are better at hospitals that do many of them. Ask how many this hospital does.

Two multi-drug regimens dominate. FOLFIRINOX combines fluorouracil, leucovorin, irinotecan, and oxaliplatin. A modified version (mFOLFIRINOX) is often used. The other is gemcitabine with nab-paclitaxel.

FOLFIRINOX is the harder of the two on the body. It is usually offered to people in good physical shape. Gemcitabine with nab-paclitaxel is often the better fit otherwise. A regimen with liposomal irinotecan is another approved option.

NCI says genetic testing (testing for gene changes you were born with) is recommended for all people with pancreatic cancer. That holds even with no family history. About one in ten people carry an inherited variant. Genes include BRCA1, BRCA2, PALB2 and ATM. This matters twice. Olaparib is approved as maintenance therapy for germline BRCA-mutated metastatic pancreatic cancer after platinum chemotherapy. And the result guides screening for your relatives.

Somatic (tumor) testing looks at the cancer itself. It can find mismatch repair deficiency or microsatellite instability. It can also find NTRK fusions, RET changes, KRAS G12C, and other changes. These open up specific drugs or trials. Tumor tissue is sometimes limited. Then ask whether a blood test would work.

NCI notes that palliative care "may be provided at any point during cancer care, from diagnosis to the end of life." Starting it early alongside cancer treatment "can improve their quality of life and mood, and may even prolong survival." ASCO recommends palliative care for everyone with advanced cancer.

Several problems here are very treatable. Poor fat absorption causes greasy, floating, urgent stools. It also causes weight loss. Pancreatic enzyme replacement therapy treats that directly. A biliary stent opens a blocked bile duct. A celiac plexus block can ease pain that runs into the back. New or worsening diabetes needs its own plan. Ask for a dietitian early.

• Which of the four groups am I in, and who decided?
• Have germline and tumor testing been ordered?
• Would enzyme replacement help me?
• Can I have a palliative care referral now, not later?

• Call 911 or go to an emergency department if you get shaking chills with pain high in the belly, and your eyes or skin look yellow. An infected or blocked bile duct can turn serious within hours. This is a known risk after a biliary stent. Do not drive yourself.
• Call your oncology team without delay, whatever the hour, if your temperature reaches 100.4°F (38°C) or higher while you are having chemotherapy. CDC says a fever during chemotherapy is a medical emergency, and an infection during chemotherapy can be life-threatening. If you cannot reach them soon, go to an emergency department and say at the door that you are on chemotherapy.
• Call your care team the same day if yellowing comes back, your urine turns dark, or your stools go pale.
• Call your care team right away if you cannot keep fluids down. Call within a day or two if your stools stay greasy and hard to flush, or the weight keeps falling off. Enzyme doses, sugar levels and pain plans can all be adjusted.

• MedlinePlus: Cholangitis
• CDC: Fever during cancer treatment
• NCI: Drugs approved for pancreatic cancer
• NCI: Palliative care in cancer fact sheet
• NCI: Genetic testing for inherited cancer risk
• NCI: Pancreatic Cancer Treatment (PDQ), Health Professional Version
• NCI: Pancreatic Cancer Diagnosis
• NCI: Pancreatic Cancer Stages