Pancreatic cancer (pancreatic carcinoma):
late signs, enzyme replacement & diabetes

1. What is pancreatic cancer?

The pancreas lies across the upper abdomen behind the stomach. It has two jobs: its exocrine part produces digestive enzymes for fat, protein and carbohydrates, and its endocrine part produces the hormones insulin and glucagon, which control blood sugar. In the vast majority of cases, pancreatic cancer arises from the duct cells of the exocrine part; specialists call it ductal adenocarcinoma.^¹ Neuroendocrine tumours of the pancreas are a separate, often slower-growing disease with different treatment.

In Germany, around 19,900 people are newly diagnosed each year, women and men about equally often. Almost as many die of it each year — pancreatic cancer is the fourth most common cause of cancer death in both men and women. The relative five-year survival rate is around 11 per cent, one of the lowest of all cancers.^²

These figures are sobering, but they are averages. If the tumour is found while it can still be operated on, the outlook is considerably better, and even at advanced stages treatment can gain time and quality of life. The cancer should not be confused with inflammation of the pancreas (pancreatitis) — even though chronic inflammation increases the risk of cancer and both can cause similar symptoms.

2. Types and stages: what does “operable” mean?

Where the tumour sits determines the first symptoms; how far it has grown into the surrounding blood vessels determines the treatment.^¹,³

• Head of the pancreas: the most common site. The bile duct runs through here — a tumour can compress it and cause jaundice, sometimes comparatively early.
• Body and tail of the pancreas: tumours here often go unnoticed for a long time and only show up through pain or metastases.

By the time of diagnosis, the tumour can no longer be operated on in the majority of people affected — the main reason for the poor overall prognosis.^³

3. Symptoms: why they often appear late

The pancreas lies deep in the abdomen, and a small tumour does not disrupt any function for a long time. The first signs are often inconspicuous and easily attributed to other causes:^¹,³

• Painless jaundice: yellow eyes and skin, dark urine, pale stools and often severe itching. Jaundice without pain and without fever should always be investigated promptly.
• Upper abdominal and back pain: dull, belt-like, often worse at night or when lying down, better when leaning forward.
• Unintentional weight loss and loss of appetite — sometimes with an aversion to certain foods and nausea.
• Digestive problems: fatty stools (shiny, foul-smelling, hard to flush away), bloating and diarrhoea, because enzymes are missing.
• Newly developed diabetes: especially over the age of 50, without excess weight or together with weight loss. Known diabetes that suddenly becomes hard to control can also be a sign.
• Thromboses: a deep vein thrombosis in the leg or a pulmonary embolism with no apparent cause can be the first sign of a tumour.

4. Causes and risk factors

In most people affected, no single cause can be identified. Known risk factors are:^²

• Smoking: the most important avoidable risk factor — both active and passive.
• Severe obesity and type 2 diabetes: both increase the risk; conversely, new diabetes can also be a consequence of the tumour.
• Chronic pancreatitis: inflammation lasting years, often due to very heavy alcohol consumption, increases the risk considerably.
• Family and genes: pancreatic cancer in first-degree relatives, hereditary changes in genes such as BRCA1, BRCA2 or PALB2 — which are also linked to breast cancer and ovarian cancer — and hereditary pancreatitis.^¹
• Infections: Helicobacter pylori, hepatitis B and HIV are being discussed as risk factors.
• Diet: very frequent consumption of processed meat and smoked or grilled food is suspected of increasing the risk.

5. Diagnosis: from suspicion to tumour board

The aim of the tests is to clarify whether there is a tumour, how far it has spread and whether it can be operated on.^¹

• Ultrasound: often the first step, showing for example blocked bile ducts; however, a normal ultrasound does not rule out a tumour.
• CT with contrast agent: the most important test for assessing the tumour, contact with blood vessels and metastases; MRI in addition, especially for the liver.
• Endoscopic ultrasound: ultrasound from the inside via the stomach, very precise for small tumours; tissue can be taken at the same time. A tissue sample is not always necessary before planned surgery.
• Laparoscopy: for certain findings before surgery, to detect small metastases on the peritoneum.
• Relieving the bile duct: in jaundice, often via a small plastic or metal stent inserted endoscopically.
• Blood tests: CA 19-9 is used to monitor progress during treatment, not for diagnosis. In addition, liver, blood sugar and nutritional values.
• Molecular and hereditary testing: at an advanced stage, tumour tissue can be tested for rare changes that can be treated in a targeted way; many people are also asked about hereditary changes such as BRCA.
• Tumour board: a team from gastroenterology, surgery, oncology, radiology, radiotherapy and pathology agrees on the recommendation — ideally at a certified pancreatic cancer centre.

Many terms, many appointments: a list of questions and your current medicines helps — see Preparing for a doctor's appointment.

6. Treatment: surgery, chemotherapy, palliative care

Treatment depends on the stage, your general condition and your own goals. It is planned at the tumour board; you make the decision together with your treatment team. A cure is only possible if the tumour can be removed completely — and even then, chemotherapy is part of it.^¹

7. Supportive medicines: pain, thrombosis, nausea

Alongside chemotherapy, many people need several supportive medicines — and often also take long-term medication for high blood pressure, diabetes or heart disease. This makes planning and checking for interactions particularly important.^⁵

Pain: enough, and on schedule

Cancer pain is treated according to a fixed schedule, not only when needed. Commonly used are metamizole and opioids such as morphine, oxycodone or a fentanyl patch. Opioids almost always cause constipation; that is why a laxative such as macrogol belongs with them from the start. For severe pain, blocking the nerve network behind the pancreas (coeliac plexus) can help reduce the need for opioids.^⁴

Thrombosis: high risk, special rules

Pancreatic cancer is one of the cancers with the highest risk of thrombosis and pulmonary embolism. It is treated with a low-molecular-weight heparin such as enoxaparin or with an anticoagulant in tablet form; which one is suitable depends, among other things, on the bleeding risk, blood values and interactions with chemotherapy.^⁵ Everyday tips in the guide Living with blood thinners.

Nausea and cortisone

Nausea caused by chemotherapy can be prevented effectively, for example with ondansetron, often combined with dexamethasone. The cortisone can make blood sugar rise sharply — if you have diabetes, measure more often on these days.^⁵

8. Enzyme replacement: taking capsules correctly

If the tumour blocks the pancreatic duct or part of the gland has been removed, digestive enzymes are missing. This exocrine pancreatic insufficiency is very common and shows itself through fatty stools, bloating, abdominal cramps and weight loss despite eating enough. The solution is enzyme capsules containing pancreatin, which replace the missing enzymes. The guideline expressly recommends enzyme replacement when these symptoms are present, because it improves nutritional status and quality of life.^¹,⁶

1. With every meal: the capsules only work if they reach the intestine together with the food — so take them with your meal, not before it or hours afterwards. With larger meals, the dose can be split between the beginning and the middle of the meal.^⁶
2. With snacks too: every snack containing fat or protein also needs enzymes, usually at a lower dose. A glass of water or tea without milk does not need any.
3. Do not chew: the capsules contain gastro-resistant pellets. If you cannot swallow them, open the capsule and take the contents, as described in the package leaflet, with a little soft, slightly acidic food such as apple sauce — without chewing.^⁶
4. Dose by effect: the amount is given in lipase units and adjusted by the practice to your meals and symptoms. If fatty stools and weight loss persist, the dose is often too low — report this rather than going hungry on a low-fat diet.
5. Keep an eye on vitamins: when fat digestion is impaired, the fat-soluble vitamins A, D, E and K can be lacking; they are checked and replaced if needed.

9. Diabetes caused by pancreatic cancer

The tumour or an operation can also destroy the cells that produce insulin. This results in a form of diabetes that differs from ordinary diabetes — specialists call it pancreatogenic diabetes or type 3c diabetes.^¹,³

• Glucagon is missing too: this hormone raises blood sugar again when it is too low. If it is missing, for example after removal of the whole pancreas, hypoglycaemia develops faster and is more severe. Always keep glucose tablets to hand.
• Insulin is often needed: always after removal of the whole gland, and frequently otherwise. How injecting works in everyday life is explained in the guide Injecting insulin correctly; information on the active ingredient under insulin.
• Measure blood sugar more closely: appetite fluctuates, meals are skipped, cortisone days push sugar up — the insulin dose often needs adjusting. Tips in the guide Measuring blood sugar correctly.
• Enzymes and insulin go together: without enzyme replacement, food is poorly absorbed and blood sugar rises less than expected — hypoglycaemia becomes a risk. If you take both, clarify how to coordinate them with your practice.
• Adjust the targets: at an advanced stage, the priority is not perfect long-term control but avoiding hypoglycaemia and very high blood sugar. Strict dietary rules are then usually not sensible.

If you already had type 2 diabetes and take tablets such as metformin, have your medication reviewed at the start of cancer treatment — weight loss, loss of appetite and chemotherapy change what you need.

10. Everyday life with pancreatic cancer

• Maintaining weight comes first — eat energy- and protein-rich food, ideally several small meals. Involve nutritional counselling early, not only once there is marked weight loss.^³
• Keep a complete medication plan — chemotherapy, enzymes, insulin, heparin, painkillers and laxatives, long-term medication and anything you buy yourself. Instructions under Creating a medication plan.
• Note stools and symptoms — fatty stools, pain, blood sugar and weight, with the date. This helps when adjusting enzymes, insulin and painkillers.
• Keep moving — suitably adapted exercise maintains strength and lowers the risk of thrombosis, even during chemotherapy.
• Discuss herbal products and supplements — some products affect chemotherapy or blood clotting, see Supplements and medications.
• Accept help — psycho-oncology services, cancer counselling centres, the hospital social services and outpatient palliative care teams. Relatives can come along to appointments and should know the centre's emergency number.

Pancreatic cancer is a serious diagnosis. That is precisely why anything that eases everyday life is worthwhile: clear plans, fewer forgotten doses, less guesswork about symptoms — and time for what matters to you.

Many medicines, one plan — with brite

Reminders for enzymes with meals, insulin and painkillers, interactions checked, progress documented. Free.

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