Dr Thng Yongxian
Medical Director, Senior Consultant Pancreas and Hepatobiliary Surgeon
MBBS (SG), M.Med (Surg), MRCS (Ire), FRCSEd (Gen), FAMS (Surg)
By Dr Thng Yongxian
Medical Director, Senior Consultant Pancreas and Hepatobiliary Surgeon
Pancreatic cancer is the 12th most common type of cancer worldwide, affecting millions of men and women each year.
If you are concerned about potentially having the disease, or if a family member has been diagnosed, understanding the different stages of pancreatic cancer is important in appreciating how treatment decisions are made.
Doctors commonly determine the stage of pancreatic cancer using the TNM staging system, which assesses the size of the tumour (T), whether nearby lymph nodes are involved (N), and whether the cancer has spread to distant organs (M). This classification helps guide discussions about surgery, chemotherapy and other treatment options.
The pancreas is an organ located behind the lower stomach. It plays a crucial role in digestion and in regulating blood sugar. When pancreatic cancer develops, treatment options are heavily influenced by how far the disease has progressed at the time of diagnosis.
In Singapore, pancreatic cancer remains a serious condition because many patients are diagnosed at a later stage, when treatment becomes more complex.
Here is how pancreatic cancer is typically managed depending on its stage at the point of diagnosis:
Stage 1 Pancreatic Cancer
Pancreatic cancer begins in the tissues of the pancreas and may grow and spread if left untreated. Stage I is the earliest stage and is typically defined by a small tumour that remains confined to the pancreas, without involvement of nearby major blood vessels or distant organs.
This stage is commonly referred to as resectable pancreatic cancer, meaning the tumour can be surgically removed.
Treatment
- Surgical removal of the tumour: Tumours in the head of the pancreas are commonly treated with a pancreaticoduodenectomy (Whipple procedure), while tumours in the body or tail may require a distal pancreatectomy.
- Post-operative chemotherapy, which may be recommended to reduce the risk of recurrence
Chemotherapy after pancreatic cancer surgery aims to address microscopic cancer cells that may not be visible on imaging.
Surgical options include the Whipple procedure and pancreatectomy.
Fewer than 20% of patients are diagnosed before the cancer has spread beyond the pancreas. Earlier diagnosis allows for a broader range of treatment options and may be associated with improved long-term outcomes compared to more advanced stages.
Although surgery and chemotherapy can be physically demanding, treatment at this stage is generally more straightforward than in later stages, when the disease has spread to surrounding structures or distant organs.
Stage 2 Pancreatic Cancer
Stage II pancreatic cancer is characterised by tumour spread to nearby tissues and regional lymph nodes within the abdomen, but without distant metastasis.
This stage may include borderline resectable pancreatic cancer, where the tumour is in contact with nearby major blood vessels but has not spread to distant organs.
Treatment
Management often begins with treatment aimed at reducing the size of the tumour. This may include:
- Chemotherapy
- Radiation therapy in selected cases
- Occasionally, targeted therapy, depending on individual factors
If the tumour responds favourably and can be safely removed, surgery may then be performed, similar to Stage I management. Post-operative chemotherapy is often considered to reduce the risk of recurrence.
Treatment at this stage is generally more complex than Stage I. It may involve longer recovery periods and a higher likelihood of treatment-related side effects, depending on the extent of surgery and systemic therapy required.
Stage 3 Pancreatic Cancer Treatment
Stage III pancreatic cancer, also referred to as locally advanced pancreatic cancer or LAPC, is often when patients start to notice symptoms, including pain in the back and abdomen, as well as a loss of appetite.
By now, it has spread to the lymph nodes and major blood vessels. It may have additionally spread to nearby organs, such as the stomach or bowel.
Treatment
Pancreatic cancer at this stage may be treated by first reducing the size of the tumours. This may be done through:
- Chemotherapy
- Radiation therapy
- Targeted therapy
In some cases, intensive chemotherapy may reduce tumours to a size where surgical removal becomes possible.
Additional treatments to stop further spreading include removing a part of the pancreas, radiation therapy, or using anti-cancer drugs. Recurrence of cancer cell growth is quite common even after a successful treatment, which is why annual examinations become a key part of the post-treatment phase.
Stage 4 Pancreatic Cancer Treatment
Metastatic pancreatic cancer, otherwise known as Stage IV pancreatic cancer, is a highly advanced form of pancreatic cancer in which tumours have spread to distant organs such as the liver and lungs, as well as nearby organs. In addition to pain in the back or abdomen, symptoms at this stage may include pale stools, bloating and jaundice.
Stage IV pancreatic cancer is generally not curable, although treatment can be used to prolong survival and reduce symptoms. Chemotherapy is the primary treatment, as it aims to reduce the size of the tumour(s). Palliative care options may include bile duct stenting and, in selected cases, gastric bypass surgery.
Treatment at this stage focuses on slowing disease progression, preventing complications related to further spread and maintaining quality of life where possible.
Concerned About Pancreatic Symptoms or a Raised CA 19-9?
Assessment of Stage I-IV pancreatic cancer can only be made after appropriate investigations and a confirmed diagnosis. Early symptoms are often subtle or non-specific, which may delay medical evaluation.
If you experience persistent abdominal pain, unexplained jaundice, unintended weight loss, or if a recent health screening has shown a raised CA 19-9 tumour marker, further medical assessment may be advisable.
It is important to note that CA 19-9 can be elevated in conditions other than pancreatic cancer, and additional evaluation is required to determine the cause.
Timely review allows suitable investigations to be performed and treatment options to be discussed based on the stage of disease and overall health of the individual.
Consultations are available for evaluation and second opinions where required.
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