Diagnosis of pancreatic cancer

Diagnosis is the process of finding out the cause of a health problem. Diagnosing cancer often means first ruling out other health conditions that share similar symptoms with cancer. It can be a very worrying time for you and your loved ones. Sometimes this process is quick. Sometimes it can feel long and frustrating. But it's important for doctors to get all the information they need before making a diagnosis of cancer.

Diagnosing pancreatic cancer usually begins with a visit to your family doctor. Your doctor will ask you about any symptoms you have and do a physical exam. Based on this information, your doctor will refer you to a specialist or order tests to check for pancreatic cancer or other health problems.

The following tests are usually used to rule out or diagnose pancreatic cancer. Many of the tests that are used to diagnose cancer are also used to find out the stage (how far the cancer has spread). Your doctor may also order other tests to check your general health and to help plan your treatment.

Your health history is a record of your symptoms, risk factors and all the medical events and problems you have had in the past. Your doctor will ask questions about your history of:

• symptoms that suggest pancreatic cancer
• smoking tobacco
• obesity
• diabetes
• chronic pancreatitis (inflammation or infection of the pancreas)
• certain genetic conditions, such as hereditary breast and ovarian cancer (HBOC) syndrome or familial atypical multiple mole melanoma (FAMMM) syndrome
• eating red meat
• drinking alcohol

Your doctor may also ask about a family history of:

• pancreatic cancer
• risks for pancreatic cancer( for example, diabetes or genetic disorders such as HBOC or FAMMM)
• other cancers

A physical exam allows your doctor to look for any signs of pancreatic cancer. During a physical exam, your doctor may:

• feel your abdomen for any lumps, tenderness, swelling or fluid
• look at your skin and the whites of your eyes for yellowing (a sign of jaundice)
• listen to your abdomen and chest to see if anything sounds abnormal
• feel the lymph nodes in your neck and groin

Find out more about physical exams.

Blood chemistry tests measure certain chemicals in the blood. They show how well certain organs are working and can help find problems. Blood chemistry tests used to help diagnose pancreatic cancer include the following.

Glycated hemoglobin (HbA1c) is a form of hemoglobin that has sugar (glucose) attached. HbA1c forms when there is more glucose in your blood than your cells can absorb (called high blood sugar). High HbA1c may be a sign of pancreatic cancer, or that the pancreas is damaged or not working properly.

Blood glucose is the amount of sugar you have in your blood. When you eat, your blood glucose increases then decreases with time as insulin is released to tell your cells to absorb sugar. A high blood glucose level long after you’ve eaten or when you haven't eaten may be a sign of pancreatic cancer, or that the pancreas is damaged or not working properly.

Liver function tests (also called a liver panel) are a group of blood chemistry tests that are often ordered together. These tests can tell the healthcare team that there is a problem with the liver and biliary tract that may be caused by pancreatic cancer.

Albumin is a protein made by the liver. Low levels of albumin may be a sign that the liver is damaged or not working normally.

Alkaline phosphatase (ALP) is an enzyme found in the liver and other tissues in the body. A high level of ALP in the blood may be a sign that the liver is not working normally.

Alanine aminotransferase (ALT) is an enzyme found in the liver and kidneys. A high level of ALT in the blood may signal the liver is not working normally.

Aspartate aminotransferase (AST) is an enzyme found in liver and heart cells. When liver or heart cells are damaged, they release AST into the blood. A high level of AST may be a sign of a problem with the liver.

Bilirubin( a chemical in bile) is made when old red blood cells (RBCs) break down. High levels of bilirubin may signal a problem with the liver or gallbladder, or that the bile ducts are blocked.

Lactate dehydrogenase (LDH) is an enzyme found in the liver and other tissues in the body. A high level of LDH may indicate the liver is not working normally.

Gamma-glutamyl transferase (GGT) is an enzyme found in the liver, bile ducts and other tissues in the body. When liver or bile duct cells are damaged, they release GGT into the blood. High levels of GGT may be a sign of a problem with the liver or biliary tract.

Find out more about blood chemistry tests.

Tumour markers are substances found in the blood, tissues or fluids removed from the body. An abnormal amount of a tumour marker may mean that a person has pancreatic cancer.

Tumour marker tests can be used to diagnose pancreatic cancer, but they are generally used to check how treatment is working, or the cancer's response to treatment.

The following tumour markers may be measured for pancreatic cancer:

• carbohydrate antigen 19-9 (CA19-9)
• carcinoembryonic antigen (CEA)

Find out more about tumour marker tests.

A complete blood count (CBC) measures the number and quality of white blood cells, red blood cells and platelets. A CBC is done to look at your overall health (for example, bone marrow health and kidney function).

Find out more about a complete blood count (CBC).

A computed tomography (CT) scan uses special x-ray equipment to make 3D and cross-sectional images of organs, tissues, bones and blood vessels inside the body. A computer turns the images into detailed pictures.

A CT scan of the abdomen, chest and pelvis is often the first imaging test done when your healthcare team thinks you have pancreatic cancer. It is used to:

• check for a tumour in the pancreas in people who have signs and symptoms of pancreatic cancer
• find out the size of a tumour
• see if cancer has spread outside of the pancreas
• stage pancreatic cancer
• find out whether a tumour can be completely removed with surgery (is resectable)

The biphasic pancreatic protocol is a method of CT that takes repeated images of the abdomen to look at the pancreas over a period of a few minutes. It is used to see exactly where in the pancreas the tumour is, and if cancer has spread into any of the blood vessels in the pancreas. A special dye (contrast medium) is injected into an artery before the scan to better see the blood vessels. You may have a biphasic pancreatic protocol CT scan to diagnose pancreatic cancer.

Find out more about CT scans.

An ultrasound uses high-frequency sound waves to make images of parts of the body. It is used to look for cancer or other problems in the pancreas. An ultrasound can also be used to see if cancer has spread to the liver.

An abdominal ultrasound may be done if the cause of your symptoms is unclear. It can be used to rule out cancer or other problems in the pancreas or nearby organs that could be causing your symptoms.

An endoscopic ultrasound (EUS) is a type of ultrasound that uses an endoscope (a thin, tube-like instrument with a light and lens that is passed through the mouth or rectum) with an ultrasound probe attached to the end. It is used to get a closer look at the pancreas and help stage a tumour. An EUS is most commonly used to look at small tumours. An EUS is done under general anesthesia.

A biopsy can also be done by fine needle aspiration (FNA) during an EUS when needed.

Find out more about ultrasounds.

Magnetic resonance imaging (MRI) uses powerful magnetic forces and radiofrequency waves to make cross-sectional images of organs, tissues, bones and blood vessels. A computer turns the images into 3D pictures.

Sometimes, an MRI is used after a CT scan to see if pancreatic cancer has spread to other organs and tissues, such as the liver.

Find out more about MRIs.

A positron emission tomography (PET) scan uses radioactive materials called radiopharmaceuticals to look for changes in the metabolic activity of body tissues. A computer analyzes the radioactive patterns and makes 3D colour images of the area being scanned. A PET scan may also be combined with other imaging tests to give your healthcare team more information.

A PET-CT is when a PET scan is combined with a CT scan using the same machine.

A PET-MRI is when a PET scan is combined with an MRI. It requires a specialized MRI machine.

In some cases, a PET, PET-CT or PET-MRI scan is used after a CT scan to help stage a pancreatic tumour and see if the cancer has spread outside of the pancreas.

Find out more about PET scans.

Cholangiography is a procedure used to view the inside of biliary tract to look for blockages, such as pancreatic cancer. There are several types of cholangiography that use different imaging techniques to view the pancreatic ducts and the ducts from the liver and gallbladder (called bile ducts).

An ERCP (endoscopic retrograde cholangiopancreatography) is a type of cholangiography that uses an endoscope and x-ray to look at the biliary tract and pancreatic ducts.

You may have an ERCP to:

• check for a tumour that may be causing a blockage in the bile or pancreatic duct
• collect a sample of cells for biopsy by scraping the inside of the pancreatic duct using a special brush (a type of biopsy called brushing)
• place a small tube (stent) into the bile duct to relieve a blockage

An MRCP (magnetic resonance cholangiopancreatography) is type of cholangiography that uses MRI to take detailed pictures of the biliary tract and pancreatic ducts.

A PTC (percutaneous transhepatic cholangiography) is another type of cholangiography that uses x-ray to look at the biliary tract. During a PTC, a surgeon pushes a thin needle through the skin into the abdomen around the gallbladder and bile ducts. The needle injects a special dye into the ducts so they can be seen more clearly on the x-ray.

MRCP and PTC are not commonly used to diagnose pancreatic cancer.

A laparoscopy is a procedure used to view the inside of the abdomen or pelvis using an endoscope that is passed through a small cut (incision) in the abdomen.

A laparoscopy is not commonly used to diagnose pancreatic cancer. It may be used to get a closer look at a tumour when your healthcare team needs more information about the tumour to stage the cancer or plan treatment.

Find out more about laparoscopy.

During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab. A report from a pathologist will show whether or not cancer cells are found in the sample.

Not everyone with pancreatic cancer will need a biopsy. Other tests, such as an ultrasound and a CT scan, can often provide enough information to show there is pancreatic cancer and decide how to treat it. A biopsy is only necessary when the tumour cannot be surgically removed (is unresectable) and will be treated with any non-surgical therapies (such as chemotherapy or targeted therapy).

A biopsy for pancreatic cancer can be done by ERCP, laparoscopy or fine needle aspiration (FNA).

Find out more about biopsies.

To do a fine needle aspiration (FNA), the surgeon inserts a very fine needle through the skin of the abdomen and into the pancreas or other tissue. An endoscopic ultrasound or CT scan is used to guide the needle during the procedure.

FNA may be used to confirm the diagnosis of pancreatic cancer if other tests have shown that the cancer has already spread to other organs (metastasized) or cannot be completely removed with surgery (is unresectable).

Find out more about fine needle aspiration (FNA).

Genetic tests look for changes in DNA and proteins that are sometimes found in people with cancer. The results of genetic tests can help doctors better understand how cancer cells will behave, predict prognosis and plan treatment for pancreatic cancer. Genetic tests can be done on a sample of cells taken during a biopsy or on tissue removed during surgery.

Genetic testing for pancreatic cancer may include looking for mutations in the following genes:

• ALK
• BRAF
• BRCA1/2
• FGFR2
• HER2
• KRAS
• NRG1
• NTRK
• PALB2
• RET
• ROS1

Genetic testing requires very specialized technology and experts to perform. It may not be available at all treatment centres or hospitals.

Find out more about genetic testing.

To make the decisions that are right for you, ask your healthcare team questions about a diagnosis.