How is pancreatic cancer diagnosed?

You are likely to have blood tests to check your general health and see how well your liver and kidneys are working. Some blood tests look for proteins produced by cancer cells. These proteins are known as tumour markers.

Many people with pancreatic cancer have higher levels of the tumour markers CA 19-9 (carbohydrate antigen) and CEA (carcinoembryonic antigen). Other conditions can also raise the levels of these markers in the bloodstream, while some people with pancreatic cancer have normal levels.

The levels of tumour markers can’t be used to diagnose pancreatic cancer on their own, but they may tell your doctor more about the cancer or how well the treatment is working.

It is normal for the levels of these tumour markers to go up and down a little. Your doctor will look for sharp increases and overall patterns.

Imaging scans are tests that create pictures of the inside of the body. Different scans can provide different details about the cancer.

You will usually have at least one of the following scans during diagnosis and treatment.

CT scan

Most people suspected of having pancreatic cancer will have a CT (computerised tomography) scan. This scan uses x-ray beams to take many pictures of the inside of your body and then compiles them into one detailed, cross-sectional picture.

A CT scan is usually done at a hospital or a radiology clinic. Before the scan, a liquid dye (called contrast) will be injected into a vein to help make the pictures clearer. The dye travels through your bloodstream to the pancreas and nearby organs and helps show up any abnormal areas. This may cause you to feel hot all over, may give you a strange taste in your mouth and you could feel as if you need to pass urine (pee). These reactions are temporary and usually go away in a few minutes, but tell the team if you feel unwell.

The CT scanner is large and round like a doughnut. You will need to lie still on an examination table while the scanner moves around you. The scan itself is painless and takes only a few minutes, but the preparation can take 10–30 minutes.

Endoscopic scans

Endoscopic scans can show blockages or inflammation in the common bile duct, stomach and duodenum. For these scans, you will have an endoscopy, a procedure that is usually done as day surgery by a specialist doctor called a gastroenterologist. The doctor passes a long, flexible tube with a light and small camera on the end (endoscope) down your throat into your digestive tract. There are two main types of endoscopic scans:

EUS – An EUS (endoscopic ultrasound) uses an endoscope with an ultrasound probe (transducer) attached. The endoscope is passed through your mouth into the small bowel. The transducer makes soundwaves that create detailed pictures of the pancreas and ducts. This helps to locate small tumours and shows if the cancer has spread into nearby tissue.

ERCP – The endoscopic scan known as an ERCP (endoscopic retrograde cholangiopancreatography) is used to take an x-ray of the common bile duct and pancreatic duct. The doctor uses the endoscope to guide a tube into the bile duct and insert a small amount of dye. The x-ray images show blockages or narrowing that might be caused by cancer. ERCP may also be used to put a thin plastic or metal tube (stent) into the bile duct to keep it open.

During an endoscopic scan, the doctor can also take a tissue or fluid sample (biopsy) to help with the diagnosis.

You will be asked not to eat or drink (fast) for six hours before an endoscopic scan. The doctor will give you medicine to help you relax and feel as comfortable as possible. Because of this medicine, you shouldn’t drive or operate machinery until the next day.

Having an endoscopic scan has some risks, including infection, bleeding and inflammation of the pancreas (pancreatitis). These complications are not common. Your doctor will explain the risks before asking you to agree (consent) to the procedure.

MRI and MRCP scans

In some cases, you may also have another type of scan such as an MRI or MRCP scan. An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed cross-sectional pictures of the pancreas and nearby organs. An MRCP (magnetic resonance cholangiopancreatography) scan is a different type of MRI scan that produces more detailed images and can be used to check the common bile duct for a blockage (obstruction).

An MRI or MRCP takes about an hour and you will be able to go home when it is over. Before the scan, you may be asked not to eat or drink (fast) for a few hours. You may also be given an injection of dye (contrast) to highlight the organs in your body.

During the scan, you will lie on a treatment table that slides into a large metal tube that is open at both ends. The noisy, narrow machine makes some people feel anxious or claustrophobic. If you think you will be distressed, mention this beforehand to your doctor or nurse. You may be given  medicine  to help you relax, and you will usually be offered headphones or earplugs. Also let the doctor or nurse know if you have a pacemaker or any other metallic object in your body, as this can interfere with the scan.

MRIs for pancreatic cancer are not always covered by Medicare. If this test is recommended, check with your treatment team what you will have to pay

PET–CT scan

Doctors sometimes use a PET (positron emission tomography) scan combined with a CT scan to help work out if the pancreatic cancer has spread or how it is responding to treatment.

It may take several hours to prepare for and complete a PET–CT scan. Before the scan you will be injected with a small amount of radioactive  material, usually a glucose solution called fluorodeoxyglucose (FDG). Some cancer cells will show up brighter on the scan because they take up more of this solution than normal cells do.

PET–CT scans are specialised tests. They are not available in every hospital and may not be covered by Medicare, so talk to your medical team for more information.

Before having scans, tell the doctor if you have any allergies or have had a reaction to dyes during previous scans. You should also let them know if you have diabetes or kidney disease or are pregnant or breastfeeding.

If imaging scans show there is a tumour in the pancreas, your doctor may remove a sample of cells or tissue from the tumour (biopsy). This is the main way to confirm if the tumour is cancer and to work out exactly what type of cancer it is. A specialist doctor called a pathologist will examine the sample under a microscope to check for signs of cancer.

A biopsy can be taken with a needle or during different types of surgical procedures:

With a needle – A sample of cells may be collected with a fine needle (fine needle biopsy), or a tissue sample may be collected with a larger needle (core biopsy). A fine needle or core biopsy can be done during an endoscopic scan. Another method is to insert the needle through the skin of the abdomen, using an ultrasound or CT scan for guidance. You will be awake during the procedure, but you will be given a local anaesthetic so you do not feel any pain.

During a laparoscopy – Also called keyhole or minimally invasive surgery, a laparoscopy is sometimes used to look inside the abdomen to see if the cancer has spread to other parts of the body. It can also be done to take tissue samples before any further surgery.

A laparoscopy is done under general anaesthetic, so you will be asked not to eat or drink (fast) for six hours beforehand. If you take blood-thinning medicines or have diabetes, let your doctor or nurse know before the laparoscopy as they may need to adjust your medicines in the days leading up to the procedure.

The procedure uses an instrument called a laparoscope, which is a long tube with a light and camera on the end. The camera projects images onto a TV screen so the doctor can see the inside of your body. The doctor will guide the laparoscope through a small cut near your bellybutton. The doctor can insert other instruments through other small cuts to take the biopsy.

You will have stitches where the cuts were made. You may feel sore while you heal, so you will be given pain medicine during and after the operation,  and to take at home. There is a small risk of infection or damage to an organ with a laparoscopy. Your doctor will explain the risks before asking you to agree to the procedure.

During surgery to remove the tumour – If you are having a larger operation to remove the tumour, your surgeon may take the tissue sample at that time.

Each human cell has about 20,000 genes, which tell the cell what to do and when to grow and divide. Cancer starts because of changes to the genes (known as mutations).

Some people are born with a gene change that increases their risk of cancer (an inherited faulty gene), but most gene changes that cause cancer build up during a person’s lifetime (acquired gene changes).

In some circumstances, your doctors may recommend extra tests to look for acquired gene changes (molecular tests) or inherited gene changes (genetic tests).

Molecular testing

If you have pancreatic cancer, you may be offered extra tests on the biopsy sample known as molecular or genomic testing. This looks for gene   changes and other features in the cancer cells that may help your doctors decide which treatments to recommend.

Molecular testing for pancreatic cancer is not covered by Medicare and can be expensive, so check what costs are involved and how helpful it would be. If you are having molecular testing as part of a clinical trial, the costs may be covered.

Genetic testing

Your doctor may suspect you have developed pancreatic cancer because you have inherited a faulty gene – for example, because other members of your family have also had pancreatic cancer. In this case, they may refer you to a family cancer clinic for genetic counselling and extra tests.

These tests are known as genetic or germline tests. The results may help your doctor work out what treatment to recommend and can also provide important information for your blood relatives.

Genetic counselling can help you understand what tests are available to you and what the results mean for you and your family.

Medicare may cover the costs of genetic tests or you may need to pay for them – check this with your treatment team.