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Pancreatic Cancer Treatment in SIngapore

Dr Thng Yongxian

Hepatopancreatobiliary & General Surgeon
MBBS • MMed • MRCS (IRE) • FRCSED • FAMS

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What is Pancreatic Cancer?

Pancreatic cancer arises from the tissues of the pancreas, an essential organ involved in digestion and glucose regulation. It is characterized by its late diagnosis and poor prognosis, making it a significant challenge in oncology. The disease often progresses silently, with symptoms appearing in more advanced stages.

Types of Pancreatic Cancer

Pancreatic cancer represents a group of diseases arising from different types of cells within the pancreas, each with its own unique pathology, clinical presentation, and prognosis.

By Cell Type

The main types depend on whether the cancer originates in the exocrine cells (which make digestive juices) or the endocrine cells (which make hormones). 

Exocrine Tumours

These are the most common types, accounting for over 95% of pancreatic cancers.

  • Adenocarcinoma: Adenocarcinoma, the most common type of pancreatic cancer, originates in the exocrine cells responsible for producing digestive enzymes. It accounts for about 95% of cases and typically arises in the ducts of the pancreas.

  • Acinar Cell Carcinomas: Acinar cell carcinomas arise from the pancreatic acinar cells that secrete digestive enzymes. This type is rare and tends to have a slightly better prognosis than adenocarcinoma.

Endocrine Tumours: Pancreatic Neuroendocrine Tumors (PNETs)

PNETs are less common, forming in the hormone-producing endocrine cells of the pancreas. These tumours may be benign or malignant and can produce hormones, leading to various symptoms.

By Stage (Resectability)

From a treatment perspective, especially concerning surgery, pancreatic cancers are often categorised by how ‘resectable’ (removable) they are:

  • Resectable: These are tumours that a surgeon determines can likely be removed entirely through surgery. This typically offers the best outlook for long-term control.

  • Borderline Resectable: These tumours are very close to, or just touching, major blood vessels. A cancer specialist might recommend initial treatment (like chemotherapy or radiation) to shrink the tumour before considering surgery in Singapore.
  • Locally Advanced: In these cases, the tumour has grown significantly into nearby major blood vessels or tissues, meaning surgery to remove it completely is not usually possible. Other treatments become the primary focus.

  • Metastatic: This means the cancer has spread to distant organs, such as the liver or lungs. Curative surgery is not an option, and treatment aims to control the cancer's growth and manage symptoms.

Causes and Risk Factors

The exact cause of pancreatic cancer remains unclear, but several risk factors have been identified that increase the likelihood of developing this disease.

  • Age: The risk of pancreatic cancer increases with age, most commonly affecting individuals over 55.
  • Smoking: Tobacco use significantly increases the risk, with smokers being about twice as likely to develop pancreatic cancer compared to non-smokers.
  • Obesity and Diet: Obesity and a diet high in red and processed meats can elevate the risk, while a diet rich in fruits and vegetables may lower it.
  • Chronic Pancreatitis: Long-standing inflammation of the pancreas, known as chronic pancreatitis, is linked to a higher risk of developing pancreatic cancer.
  • Diabetes: Both long-standing type 2 diabetes and new-onset diabetes may be associated with pancreatic cancer.
  • Family History and Genetic Factors: A family history of pancreatic cancer or inherited genetic syndromes can increase risk. Specific genes, such as BRCA2, may also elevate the risk when mutated.
  • Environmental Exposure: Exposure to certain chemicals, such as those used in the dry cleaning and metal industries, may increase the risk of pancreatic cancer.

Symptoms of Pancreatic Cancer

Symptoms of pancreatic cancer often do not appear until the disease is in its advanced stages, contributing to its low survival rate. The following are common symptoms associated with pancreatic cancer.

  • Jaundice
    Yellowing of the skin and eyes is often one of the first and most noticeable signs, caused by the buildup of bilirubin.
  • Abdominal and Back Pain
    Pain in the abdomen or back, resulting from the tumour pressing against surrounding organs or nerves.
  • Weight Loss and Loss of Appetite
    Unintended weight loss and a decrease in appetite are common as the cancer progresses.
  • Nausea and Vomiting
    Digestive issues, including nausea and vomiting, may occur if the tumour blocks part of the digestive tract.
  • New-onset Diabetes
    Sudden development of diabetes in individuals without a history of the condition can be a sign of pancreatic cancer.
  • Changes in Stool
    Pale, oily, or smelly stools that float in the toilet can indicate a problem with digestive enzyme production.
  • Fatigue
    A general feeling of being unwell and fatigued is common among those with pancreatic cancer.

Diagnosis of Pancreatic Cancer

The diagnosis of pancreatic cancer typically involves a combination of steps ordered and interpreted by your doctor or cancer specialist. These steps help confirm the presence of cancer, determine its type, and understand its extent.

Blood Tests

Blood tests assist the diagnostic process; liver function tests can indicate blockages caused by a tumour, and tumour markers like CA 19-9 may be elevated, although they are not definitive for diagnosis alone. A doctor uses these results alongside other tests.

Imaging Tests

Your doctor will likely recommend imaging tests such as Computed Tomography (CT) scans or Magnetic Resonance Imaging (MRI). These scans create detailed pictures, allowing the specialist to visualise the pancreas, identify potential tumours, and determine their size, location, and involvement with nearby structures.

Biopsy

A definitive diagnosis is made by examining a small tissue sample under a microscope, usually obtained via fine-needle aspiration during an Endoscopic Ultrasound (EUS).

Endoscopic Procedures

Procedures like Endoscopic Ultrasound (EUS) allow a doctor close views and the ability to perform biopsies. Endoscopic Retrograde Cholangiopancreatography (ERCP) helps visualise bile and pancreatic ducts, often used to see or relieve blockages before treatment like surgery.

Get an Accurate Diagnosis & Specialised Treatment For Pancreatic Cancer

Consult our dual fellowship-trained Pancreatic Cancer surgeon for an accurate diagnosis and discuss a suitable treatment plan in Singapore today.

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Staging of Pancreatic Cancer

Staging determines the extent of pancreatic cancer and guides treatment decisions. Staging not only influences the treatment approach but also helps in predicting the prognosis of the disease.

 

The TNM system, developed by the American Joint Committee on Cancer (AJCC), is commonly used.

Tumor (T)

Indicates the size of the primary tumour and whether it has invaded nearby tissues. T1 to T4 categories exist, with higher numbers indicating larger or more invasive tumours.

Prognostically, a smaller tumour confined to the pancreas offers a better outlook. As the T stage increases, indicating larger size or invasion into nearby tissues or major blood vessels, the prognosis tends to worsen, and it significantly impacts whether a cancer surgeon can consider curative surgery.

Node (N)

Describes whether cancer has spread to nearby lymph nodes. N0 indicates no lymph node involvement, while N1 and N2 show increasing involvement of lymph nodes.

 

Lymph node involvement (N1/N2) is a key prognostic factor. It signifies that the cancer cells have begun to spread regionally, increasing the likelihood of recurrence after treatment and generally indicating a more challenging prognosis than when nodes are clear (N0).

Metastasis (M)

Reflects whether the cancer has spread to distant parts of the body. M0 means no distant spread, and M1 indicates metastasis to distant organs.

 

The presence of distant metastases (M1) is the strongest indicator of an advanced stage and a guarded prognosis. When pancreatic cancer spreads to distant organs, treatment usually focuses on controlling growth and managing symptoms, often limiting the role of surgery.

 

Based on the TNM classification, pancreatic cancer is then staged:

  • Stage 0: Also known as carcinoma in situ, indicates abnormal cells are present but have not spread to nearby tissues.
  • Stage I: The cancer is limited to the pancreas and is relatively small.
  • Stage II: Cancer may be larger and might have spread to nearby lymph nodes but not to distant sites.
  • Stage III: Cancer has spread to major blood vessels or nearby lymph nodes but not to distant sites.
  • Stage IV: Indicates cancer has metastasized to distant organs, such as the liver, lungs, or peritoneum.

Treatment Options for Pancreatic Cancer

Treatment for pancreatic cancer depends on the stage of the disease, the patient’s overall health, and personal preferences.

Surgery

Surgery may be an option for those with localized cancer and involves removing the tumour and some surrounding tissue. Types of surgery include:

  • Whipple Procedure: Removes the head of the pancreas, part of the small intestine, the gallbladder, and a portion of the bile duct.
  • Distal Pancreatectomy: Involves removing the tail and possibly a portion of the body of the pancreas.
  • Total Pancreatectomy: The entire pancreas, part of the stomach, small intestine, spleen, gallbladder, and lymph nodes are removed.

Radiation Therapy

Uses high-energy rays to target and kill cancer cells. It may be used before surgery to shrink tumours or after surgery to eliminate remaining cancer cells.

Chemotherapy

Involves the use of drugs to kill cancer cells, often used in advanced pancreatic cancer or as an adjuvant therapy to surgery.

Targeted Therapy

Targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This approach is typically used for tumours that have specific genetic mutations.

Immunotherapy

A treatment that uses the body’s immune system to fight cancer, though its effectiveness in pancreatic cancer is still under investigation.

Palliative Care

Aims to improve the quality of life by managing symptoms and side effects of the disease and treatment. It is an essential component of care for all stages of pancreatic cancer

Challenges in Treating Pancreatic Cancer

Treating pancreatic cancer presents several challenges that significantly impact the effectiveness of treatments and the overall prognosis for patients. These challenges include:

  • Late Diagnosis
    Pancreatic cancer is often diagnosed at an advanced stage when the tumour has already grown large or metastasized, limiting treatment options.
  • Resistance to Treatment
    Pancreatic tumours tend to be resistant to chemotherapy and radiation therapy, making them difficult to treat effectively.
  • Location of the PancreasThe pancreas’ location deep within the abdomen complicates surgical approaches and increases the risk of complications.
  • Genetic Diversity of TumorsThe genetic makeup of pancreatic cancer can vary significantly between patients, requiring personalised treatment approaches that are still under development.
  • Limited Early Detection MethodsThere are currently no widely recommended screening tests for early detection of pancreatic cancer in people at average risk, making it harder to catch the disease in its early, more treatable stages. However CT or MRI imaging might pick up early disease.

Dr Thng Yongxian

Senior Consultant

HEPATOPANCREATOBILIARY & GENERAL SURGEON

MBBS (SG) • MMed (Surg) • MRCS (Ire) • FRCSEd (Gen) • FAMS (Surg)

Dr Thng Yongxian is a dual fellowship-trained Hepatopancreatobiliary & General Surgeon who has performed over 6000 surgical procedures.

  • Bachelor of Medicine & Bachelor of Surgery
  • National University of Singapore
  • Membership of the Royal College of Surgeons, Ireland
  • Master of Medicine, General Surgery, Singapore
  • Fellow of the Royal College of Surgeons, Edinburgh
  • Fellow of the Academy of Medicine, Singapore

He pursued his subspecialty training in Hepatopancreatobiliary surgery first in the Department of Hepatopancreatobiliary Surgery, Singapore General Hospital. Following this, he completed a clinical fellowship in Minimally Invasive Hepatopancreatobiliary Surgery at Seoul National University Hospital in Bundang, South Korea.


Dr Thng set up and pioneered the Minimally invasive surgery program for his hospital in complex liver and pancreas cases. His surgeries were featured on live national television. His surgical videos have also been presented at international surgical conferences. He also pioneered the use of capsule colonoscopy for colorectal screening.


Dr Thng has served on various committees at hospital, cluster and ministry level. Dr Thng served as a member of the Ministry of Health (MOH) Laparoscopic cholecystectomy Clinician workgroup for value-driven care (VDC).

Frequently Asked Questions About Pancreatic Cancer Treatments in Singapore

Can pancreatic cancer be detected early?

Detecting pancreatic cancer early is challenging because symptoms often only appear once the disease is advanced, and its location deep within the body makes it hard to feel or see. Currently, there isn’t a standard screening test recommended for the general population in Singapore or elsewhere.

 

However, for individuals at high risk due to strong family history or certain genetic syndromes, a doctor or specialist might suggest surveillance with imaging tests like Endoscopic Ultrasound (EUS) or MRI. Otherwise, early detection often relies on investigating potential symptoms promptly.

Pancreatic surgery, such as the Whipple procedure or a distal pancreatectomy, is a major operation and carries potential risks. These can include infection, bleeding, blood clots, and leakage from the new connections made during surgery. Other issues might involve delayed stomach emptying or the development/worsening of diabetes.

 

These risks are carefully managed by the surgical team. Choosing an experienced cancer surgeon and hospital is important. Your surgeon will discuss the specific potential risks and benefits related to your treatment plan before you proceed.

Recovery from pancreatic surgery varies greatly depending on the type of operation, the patient’s overall health, and whether any complications occur. Typically, a hospital stay can range from one to two weeks, but sometimes longer.


Full recovery, including regaining strength and adjusting to any dietary changes, can take several months. Your pancreatic cancer doctor and surgeon will provide a detailed recovery plan and support throughout the process.

Related Liver Treatments

Pancreas

The pancreas can develop various conditions requiring expert care. From inflammation (Pancreatitis) to cysts and tumours, our specialist offers comprehensive diagnosis and treatment. This may include medical management or advanced surgery, best determined after consulting a doctor.

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Pancreatitis

Pancreatitis, the inflammation of the pancreas, causes symptoms like severe abdominal pain. Treatment varies based on whether it is acute or chronic and its underlying cause, often requiring management by a specialist to relieve symptoms and prevent complications.

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Pancreatic Cysts

Pancreatic cysts are fluid-filled sacs found in or on the pancreas. While many are benign and only need observation, some can be pre-cancerous or cause symptoms. A surgeon can advise if treatment like drainage or surgery is needed.

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Corporate & Personal Insurance Plans

Clinic Locations

Nexus Surgical @ Mt. Alvernia

Nexus Surgical @ Mt. Elizabeth Orchard

Nexus Surgical @ Mt. Elizabeth Novena

Nexus Surgical @ Parkway East

Nexus Surgical @ Gleneagles Medical Centre

Nexus Surgical @ Mt. Alvernia

Nexus Surgical @ Mt. Elizabeth Orchard

Nexus Surgical @ Mt. Elizabeth Novena

Nexus Surgical @ Parkway East

Nexus Surgical @ Gleneagles Medical Centre

Nexus Surgical @ Mt. Alvernia

Nexus Surgical @ Mt. Elizabeth Orchard

Nexus Surgical @ Mt. Elizabeth Novena

Nexus Surgical @ Parkway East

Nexus Surgical @ Gleneagles Medical Centre

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