Diagnosis and Treatment, Featured, Pancreatic Cancer

Pancreatic cancer: Risk, treatment and clinical trials

By Nicole Ferrara • November 12, 2024

Estimated reading time: 6 minutes

Photo of a Black woman wearing a headscarf seated on a couch.

By Nicole Brudos Ferrara

Pancreatic cancer has a reputation for being challenging to treat. "It's a serious and life-threatening cancer, no matter what stage it's caught in — even if it's caught early," says Robert McWilliams, M.D., a Mayo Clinic Comprehensive Cancer Center medical oncologist specializing in pancreatic cancer.

Pancreatic cancer is aggressive, and the pancreas is deep inside the body, where tumors can form and grow unnoticed. There is no screening test for people of average risk, and by the time the disease causes symptoms that prompt a diagnosis, it has typically grown to an advanced stage that may not be curable.

Of the 66,440 cases of pancreatic cancer estimated to be diagnosed in 2024, 29% will have spread to nearby lymph nodes, and 51% will have spread to distant parts of the body, according to the National Cancer Institute. Despite this, Dr. McWilliams is optimistic about new treatment options and those being tested in clinical trials. "I think it is the most hopeful time for pancreatic cancer treatments in my career," he says.

Here's what Dr. McWilliams wants you to know about pancreatic cancer and its treatment:

Who is at risk of pancreatic cancer?

About 1 in 56 men and about 1 in 60 women are at average lifetime risk of pancreatic cancer.

Dr. McWilliams says Mayo Clinic researchers have studied pancreatic cancer for decades to identify groups of people at higher risk of the disease. "We know it's a cancer associated with increasing age. But there also is a growing group of people diagnosed at a younger age, and we don't have a great explanation for that. Active and former smokers and people with obesity and diabetes are at higher risk. African Americans are at a slightly higher risk, and no one understands why that is," he says.

Genetic testing is helping healthcare professionals identify more people at high risk of pancreatic cancer. "For adenocarcinoma, the most common type, we know there are genetic risks tied to changes or mutations in genes such as BRCA1 and BRCA2," says Dr. McWilliams. "There also are genes slightly more specific to pancreatic cancer called ATM or p16/CDKN2A. While fairly rare, people with those mutations are at much higher risk for developing pancreatic cancer."

People with a strong family history of pancreatic cancer or an inherited DNA change that increases risk can be screened using imaging tests, such as MRI and ultrasound. If you believe you are at high risk of pancreatic cancer, talk to your healthcare professional about genetic testing and the benefits and risks of screening.

Pancreatic cancer treatment varies by stage and location.

Pancreatic cancer is staged based on the extent of spread at diagnosis. As the cancer grows, the stage increases. "If the cancer is limited to the pancreas, it's often stage 1, 2 or 3, depending on its involvement with blood vessels and how big the tumor is. If it's spread anywhere else in the body, that would make it stage 4," says Dr. McWilliams. He says common places for pancreatic cancer to spread include the liver, lungs, abdomen and peritoneum — the membrane that lines the abdomen.

Pancreatic cancer treatment involves working with a multidisciplinary team of oncologists, surgeons and radiation specialists to create a comprehensive treatment plan to remove as much of the cancer as possible while also minimizing the risk of spread to other parts of the body. Pancreatic cancer treatments may involve chemotherapy, surgery, radiation or a combination of all three.

A comprehensive treatment plan also includes palliative care, which is specialized medical care focused on relieving pain and other symptoms caused by an illness or its treatment. "Pancreatic cancer causes so many symptoms, whether it's weight loss, pain or fatigue. Having palliative care involved in the patient's care can really be helpful for maximizing quality of life, regardless of stage," says Dr. McWilliams.

While surgery can cure pancreatic cancer, it isn't always an option, particularly in cases when the tumor is large or extends into nearby blood vessels. Dr. McWilliams stresses the need for an experienced pancreatic cancer surgeon on your care team. "If someone has localized pancreatic cancer, it's important to have a surgeon determine if the tumor can be removed. I encourage people to see a highly qualified pancreas surgeon to get an expert opinion because the ability to do surgery varies between centers and between experts," he says. Research shows that pancreatic cancer surgery tends to cause fewer complications when performed by highly experienced surgeons at centers that perform many of these operations.

Pancreatic cancer treatment often includes chemotherapy, regardless of stage.

If your cancer is confined to the pancreas and can be removed with surgery, your treatment will likely still include chemotherapy. "Even if it looks like the cancer is early-stage (confined to the pancreas and still small) on the scan, we start chemotherapy up front to make sure that when we do surgery down the road, it will be as successful as possible," says Dr. McWilliams.

Dr. McWilliams says most people with pancreatic cancer will receive chemotherapy before or after surgery, or both, to try to minimize the risk of spread and recurrence. "Treatment is aggressive because even in the most favorable situations, there's still a high risk of recurrence and spread," he says.

Genetic testing can help your care team find the best treatment option for you. "Testing the germline DNA, or the blood DNA, is a really important part of the work-up for every patient with pancreatic cancer," says Dr. McWilliams. "The other component is genomic testing on the tumor biopsy. There are DNA changes in the cancer cells that can be potential targets for therapy."

People with pancreatic cancer will typically receive one of two chemotherapy options: FOLFIRINOX, or a variant of FOLFIRINOX called NALIRIFOX, and a combination of gemcitabine and nab-paclitaxel. "Those are viable options for patients and close to equivalent as far as how well they work," says Dr. McWilliams. Your care team may recommend one type of chemotherapy over the other depending on your genetic testing results.

If the cancer is stage 4 and removing it isn't possible, your care team will focus on keeping the cancer from growing and causing more harm while improving or maintaining your quality of life. At this stage, chemotherapy can help control the cancer. "If it's widespread, sometimes our only option is chemotherapy," says Dr. McWilliams.

Clinical trials can expand treatment options.

While new treatment options for pancreatic cancer haven't expanded as rapidly as for other cancers, Dr. McWilliams says that's beginning to change thanks to research and clinical trials. Immunotherapy, which uses drugs that help your immune system attack cancer cells, is now available for some people with specific genetic mutations, and other promising treatments are in development.

"There's a gene called KRAS that's mutated or 'turned on' in about 95% of pancreatic cancers. There has been a flurry of activity as people target that mutation with medications, and we're starting to see success. More common mutations are also being targeted with newer therapies. Those drugs are coming into the clinical trial system. If you can participate in clinical trials, it will expand your options," he says.

Pancreatic cancer is a challenging diagnosis, but Dr. McWilliams has faith in the teams at Mayo Clinic and across the nation who are dedicated to improving treatment for the disease. "The future isn't written," he says. "Therapies are always improving. The therapies we have today may not be the same a year or even six months from now. I can't wait to see what the future brings."