Pancreatic cancer often goes undetected because symptoms are vague and the pancreas is deeply located.
PDAC accounts for 80–85% of cases; NETs behave differently and have better outcomes.
No population-level screening test exists for average-risk people.
Treatment depends on tumour resectability and biology.
Early detection dramatically increases survival chances.
November is observed globally as Pancreatic Cancer Awareness Month, with organisations such as the Pancreatic Cancer Action Network (PanCAN) and the American Association for Cancer Research (AACR) emphasising public education on symptoms, risk factors, and the need for earlier diagnosis. The third Thursday of November marks World Pancreatic Cancer Day, an initiative supported internationally to increase recognition of pancreatic cancer as one of the most lethal malignancies.
The Pancreas is a long, tapering gland located deep in the upper abdomen. It lies behind the stomach and in front of the spine, extending from the curve of the duodenum (head), through the neck and body, to the tail near the spleen. The gland is divided into distinct parts: head, neck, body, and tail.
The pancreas performs two essential functions:
As an exocrine gland, it produces digestive enzymes that are released into the small intestine (duodenum) through a ductal network. These enzymes are necessary for the digestion of carbohydrates, proteins, and fats.
As an endocrine gland, it contains clusters of cells (islets of Langerhans) that secrete hormones, including insulin and glucagon, into the bloodstream. These hormones regulate glucose, lipid, and protein metabolism.
Thus, the pancreas plays a critical dual role: aiding digestion and maintaining metabolic (blood sugar) balance.
Pancreatic cancer refers to malignant growth within the tissues of the pancreas, most commonly arising from the exocrine ductal cells. Tumours of the pancreas are often aggressive, and because the organ is located deep in the abdomen, early disease typically causes no specific symptoms. As a result, many patients are diagnosed at advanced stages, when treatment options are limited and prognosis is poorer.
Pancreatic cancer carries a high case fatality and remains a major clinical challenge. Recent global estimates show hundreds of thousands of new cases each year and a nearly comparable number of deaths, underlining the poor prognosis of this disease and the need for better awareness and earlier diagnosis.¹
India faces additional challenges, including delays in specialist referral, limited availability of EUS in many districts, and late presentation due to low awareness of early symptoms.
MedBound Times connected with Dr. Venkatesh BS, MBBS, MS in General Surgery, M.Ch in HPB Surgery and Liver Transplant for insights on Pancreatic cancer. He is currently Director and Surgeon at CareVue Health and Abdominal Organ Transplant and HPB Surgeon at MGM Healthcare Chennai, Tamil Nadu.
Anatomic location, symptom profile, tumour biology, and the absence of a validated population screening test all contribute to late diagnosis.
Dr. Venkatesh explains the anatomic and clinical factors in simple terms:
“The pancreas sits deep in the abdomen, tucked behind the stomach and small intestine, like a king hidden on a chessboard. Tumours can grow silently without producing symptoms, and when symptoms do appear, they tend to be vague: indigestion, abdominal discomfort, backache, or loss of appetite. These are frequently misinterpreted as routine gastritis or spine issues, the harmless pawns.”
He adds the biological dimension:
“Adding to this, pancreatic cancers often have highly aggressive biology, spreading early to distant organs like the powerful queen, and there is no reliable population-level screening test. Together, these factors explain the typically late presentation.”
Clinical evidence supports these points. Early pancreatic tumours frequently cause no specific symptoms, and when symptoms occur they are nonspecific. There is currently no population-level screening recommended for average-risk individuals.² ³
Pancreatic cancers are heterogeneous. Dr. Venkatesh summarizes the relative frequencies:
When someone mentions ‘pancreatic cancer,’ they are usually referring to Pancreatic Ductal Adenocarcinoma (PDAC), which makes up 80–85% of all pancreatic cancers, much like the vast oceans covering most of the Earth’s surface.
Pancreatic Neuroendocrine Tumours (NETs) account for 3–5%, akin to the limited freshwater reserves on the planet.
Other exocrine or rare subtypes: acinar, colloid, mucinous, adenosquamous, or signet-ring tumours collectively contribute 2–10%.
Published reviews and patient resources agree that the majority of pancreatic tumours are exocrine in origin, with PDAC the most common histologic type.4 5 NETs make up a minority of pancreatic tumours and have different clinical behavior and management.5
Dr. Venkatesh uses a simple analogy to contrast behaviour:
“Think of movies featuring identical twins: one virtuous, the other malevolent. Apart from sharing their origin in the pancreas, the similarities end there.”
He explains the clinical implications: NETs are frequently indolent, slow growing, and often remain localized for longer periods. When NETs metastasize, the liver is a common site. NETs can be functioning (hormone producing) or nonfunctioning. With appropriate surgery and systemic therapy when needed, NETs often have substantially better outcomes than PDAC.
PDAC is typically aggressive. Dr. Venkatesh states:
“PDAC, in contrast, behaves like a highly invasive weed: growing rapidly, spreading widely, and leading to early mortality. Curative treatment is possible in only 15–20% of PDAC cases, whereas NETs, even when metastatic, remain far more amenable to treatment and can be cured in a significant proportion.”
Population and registry data show that most PDAC cases present with regional or distant disease, and the proportion of patients who are candidates for immediate curative surgery is limited.6
PDAC is biologically heterogeneous. Dr. Venkatesh lists four subtypes and their general behaviour:
Classic subtype: well differentiated, responds favourably to chemotherapy, best prognosis.
Basal-like / Squamous / Quasi-mesenchymal: poorly differentiated, poor chemotherapy response, worst prognosis.
Aberrantly Differentiated Exocrine/Endocrine (ADEX): intermediate chemotherapy response and prognosis.
Immunogenic subtype: may respond better to immunotherapy.
He adds clinical context with analogies:
classic subtype “like a full-toss ball ready to be hit for six,”
basal-like “like a yorker aimed straight at the stumps,”
ADEX “like a good length ball — manageable but not simple.”
Molecular and transcriptomic studies support the existence of classical and basal-like (also called squamous) PDAC subtypes, with basal-like tumours associated with poorer outcomes. Identifying subtypes is an area of active research because subtype information may guide personalized treatment.7
For NETs, prognosis depends on tumour grade (G1 to G3), with higher-grade NETs showing more aggressive behaviour.
Treatment selection for pancreatic cancer depends primarily on resectability, tumour extent, performance status, and tumour biology. Dr. Venkatesh summarizes standard clinical approaches:
Resectable PDAC: Upfront surgical resection followed by adjuvant chemotherapy, commonly with modified FOLFIRINOX or gemcitabine-based regimens.
Borderline resectable PDAC: Neoadjuvant chemotherapy, often FOLFIRINOX-based, with or without radiotherapy, aiming to increase the chance of complete resection, followed by surgery and adjuvant therapy. Radiation is particularly useful when surgical margins or lymph nodes are positive.
Locally advanced or unresectable PDAC: Attempt downstaging with neoadjuvant chemotherapy plus radiotherapy; if successful, proceed to surgery and adjuvant therapy. If the tumour progresses, offer palliative chemotherapy.
Metastatic PDAC: Palliative chemotherapy or selected immunotherapy approaches to prolong survival and improve quality of life, combined with supportive care.
NETs: Aggressive surgical resection when feasible; systemic therapies for high-grade or biologically aggressive disease.
These approaches are consistent with contemporary clinical practice and guidelines. For example, modified FOLFIRINOX showed superior survival as adjuvant therapy compared with gemcitabine in a randomized trial for resected PDAC.8 National oncology guidelines recommend neoadjuvant therapy for borderline resectable tumours and individualized approaches for locally advanced and metastatic disease.9
Survival for pancreatic cancer varies markedly by stage at diagnosis. Registry data indicate substantially higher survival for localized disease compared with regional or distant disease. For instance, 5-year relative survival for localized pancreatic cancer is substantially higher than for metastatic disease.10 Because only a minority of patients present with localized, resectable tumours, overall population survival remains low.
Early detection improves the chance for curative surgery and better long-term outcomes. However, the absence of validated screening for average-risk populations and the nonspecific nature of early symptoms mean that heightened clinical suspicion and prompt evaluation of possible symptoms and risk factors remain critical.11 Research into blood-based tests and other early-detection methods is ongoing.12
Be aware that early symptoms may be vague. Persistent indigestion, unexplained abdominal discomfort, back pain, or loss of appetite should prompt evaluation, especially if new or progressive.
Understand that “pancreatic cancer” includes different diseases. PDAC is the most common and the most aggressive overall, while NETs are less common and often behave differently.
Recognize that only a subset of patients are immediately eligible for curative surgery, and multidisciplinary care is essential to determine the best sequence of surgery, chemotherapy, and radiation.
Support research and clinical trials of early detection and new therapies. Advances in molecular subtyping, biomarkers, and systemic treatments aim to improve outcomes for more patients.
Pancreatic cancer is diagnosed late because the organ is anatomically hidden, symptoms are nonspecific, and screening tools for average-risk people do not exist. Improved public awareness, timely primary-care referrals, and continued research into early-detection methods are critical for improving outcomes.
References:
International Agency for Research on Cancer, GLOBOCAN 2022, Global Cancer Observatory, “World Fact Sheet” (Lyon: IARC, 2022), https://gco.iarc.who.int/media/globocan/factsheets/populations/900-world-fact-sheet.pdf.
C. Adamska, S. Domenichini, and J. Falasca, “Pancreatic Ductal Adenocarcinoma: Current and Evolving Therapies,” British Journal of Cancer 117, no. 5 (2017): 1–18, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5535831/.
P. C. Sijithra et al., “A Review on Early Detection of Pancreatic Ductal Adenocarcinoma,” European Journal of Radiology (2023), https://www.sciencedirect.com/science/article/abs/pii/S0720048X23002863.
American Cancer Society, “Pancreatic Cancer Survival Rates,” updated January 16, 2025, https://www.cancer.org/cancer/types/pancreatic-cancer/detection-diagnosis-staging/survival-rates.html.
Pancreatic Cancer Action Network (PanCAN), “Types of Pancreatic Cancer,” PanCAN patient resources, https://pancan.org/facing-pancreatic-cancer/about-pancreatic-cancer/types-of-pancreatic-cancer/.
J. X. Hu, X. Wang, and L. Zeng, “Pancreatic Cancer: A Review of Epidemiology, Trend, and Risk,” Journal of Clinical Medicine (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8316912/.
C. Torres et al., “Pancreatic Cancer Subtypes: A Roadmap for Precision Medicine,” Nature Reviews Clinical Oncology (2018), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6151873/.
T. Conroy et al., “FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer,” New England Journal of Medicine 379 (2018): 2395–2406, https://www.nejm.org/doi/full/10.1056/NEJMoa1809775.
National Comprehensive Cancer Network, NCCN Guidelines for Patients: Pancreatic Cancer, (NCCN Foundation), https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdf.
Surveillance, Epidemiology, and End Results (SEER) Program, “Pancreas Cancer Stat Facts,” National Cancer Institute, https://seer.cancer.gov/statfacts/html/pancreas.html.
P. C. Sijithra et al., “Early Detection of PDAC,” European Journal of Radiology (2023).
R. Marcus, “PAC-MANN blood test aims to detect pancreatic cancer early,” Live Science, July 2025, https://www.livescience.com/health/cancer/pac-mann-blood-test-aims-to-detect-pancreatic-cancer-early.
International Agency for Research on Cancer. GLOBOCAN 2022: World Fact Sheet. Lyon: IARC, 2022.
Cleveland Clinic. “Pancreas: Anatomy & Function.” https://my.clevelandclinic.org/health/body/21743-pancreas.
