What Is Stage 4 Pancreatic Cancer?

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In stage 4 pancreatic cancer, abnormal cells grow into a tumor in the pancreas and then spread through the bloodstream to grow into tumors in distant parts of the body. It is also called metastatic pancreatic cancer. It is not curable, but palliative care and treatments can help improve quality of life and survival time for those who have it. 

According to American Cancer Society projections, 57,600 people received a diagnosis of pancreatic cancer in 2020, and 47,050 people died from it. Half of the people diagnosed with pancreatic cancer get a stage 4 diagnosis. Most people diagnosed with stage 4 pancreatic cancer are no longer alive five years after diagnosis. 

Read on to learn more about pancreatic cancer stages, symptoms, prognosis, and how doctors diagnose and treat stage 4 pancreatic cancer. 

Man receiving a stage 4 pancreatic cancer diagnosis

SDI Productions / E+ / Getty Images

Staging

Doctors use cancer stages to describe how cancer has grown or spread. Stage 4 is the most advanced, and it means that cancer has spread throughout the body (metastasized). 

Cancer stages help researchers study the effectiveness of treatments, track cancer progression, compare patients with similar diagnoses, and estimate survival rates. A classification system developed by the American Joint Committee on Cancer, called the TNM system, is used to stage cancers. The system has three components.

  • T for tumor: Based on the tumor’s size and its spread, the T rating ranges from 0 to 4.
  • N for lymph nodes: Lymph node involvement makes it easier for cancer to spread to other parts of the body. Pancreatic cancer is classified as either N1 or N2—the more lymph nodes involved, the higher the N classification number. N1 represents spread to one to three regional lymph node involvement, while N2 indicates four or more regional lymph nodes.
  • M for metastasis: Metastasis is the spread of cancer to distant organs and lymph nodes. There are only two M stages—0 or 1—and a 1 automatically classifies cancer as stage 4.

In stage 4 pancreatic cancer, the primary tumor can be any size, but it will have spread to a distant organ, such as the liver, in the body.

Cancer’s stage never changes. The stage will always be what it was when diagnosed, even if the patient improves or gets worse. If cancer is re-staged or recurs, the doctor keeps the initial staging diagnosis and adds a new stage to a patient’s diagnosis.

Pancreatic cancer most frequently spreads within the peritoneal cavity, which encloses the organs in the abdomen. It can also spread to the liver, lungs, brain, and bones. 

While some doctors use the TNM staging system, others prefer to categorize pancreatic cancer into four buckets.

  • Resectable: Surgery can remove the tumor.
  • Borderline resectable: The tumor is difficult or impossible to remove, but that could change after other treatments shrink the tumor. 
  • Locally advanced: Doctors can’t remove the tumor surgically because it has spread to areas around the pancreas. 
  • Metastatic: The cancer has spread beyond the area of the pancreas to other organs.

Symptoms

One reason that pancreatic cancer gets diagnosed at an advanced stage is that the primary tumor’s signs and symptoms are relatively mild. Until the cancer spreads to other parts of the body, there might not be any symptoms at all. 

Some of these symptoms can develop at earlier stages, although they typically manifest when the disease has spread to other organs. The most common causes of many of these symptoms are other underlying conditions, not pancreatic cancer. However, be sure to talk to a doctor if you have any of them.

  • Jaundice: Yellowed eyes and skin caused by a buildup of bilirubin because of a blockage in the bile duct. Other symptoms of jaundice include dark urine, light-colored or greasy stools, and itchy skin.
  • Belly or back pain: Tumors press on other organs or nerves and cause pain.
  • Weight loss and poor appetite.
  • Nausea and vomiting: This occurs because of pressure from the tumor on the stomach.
  • Gallbladder or liver enlargement: This is from the buildup of bile.
  • Blood clots: Deep vein thrombosis might be the first clue someone has pancreatic cancer. A blood clot in the limbs can cause pain, swelling, and redness.  
  • Diabetes: If the cancer damages the insulin-making cells of the pancreas, it can result in diabetes.

Many of these symptoms are caused by cancer’s spread, either to the liver or to other abdominal organs.

Diagnosis

The pancreas is a small organ near the stomach that makes enzymes that help the body digest food and control blood sugar.

About 95% of pancreatic cancers come from the cells that produce digestive enzymes. These are called pancreatic adenocarcinomas, or PACs. The other 5% come from the cells that help regulate blood sugar and are called a pancreatic neuroendocrine tumor, or PNET.

Staging of pancreatic cancers requires many tests and procedures to determine how large the original tumor is and how far it has spread. The tests may differ based on whether they’re testing for a PAC or PNET.

It is always a good option to seek a second opinion if you get a stage 4 pancreatic cancer diagnosis. Find a doctor at a National Cancer Institute (NCI) registered cancer center to make sure you’re aware of the latest treatments. 

First, blood tests are used to check on the patient’s general health and can include testing for enzymes or analyzing the blood cells:

  • High levels of the enzyme amylase in the blood, for example, may indicate PAC.
  • Abnormal blood levels of insulin, gastrin, glucagon, somatostatin, pancreatic polypeptide, VIP, chromogranin A, glucose, or C-peptide may indicate a PNET.
  • Liver function tests can help determine how much cancer has affected the liver.

Tumor markers in the blood can tell doctors about your cancer. For pancreatic cancer, lower levels of tumor marker CA 19-9 correlate with better outcomes.

A biopsy is when a doctor cuts off a small piece of the potential tumor and looks at it under a microscope to determine if it’s cancerous. For pancreatic cancer, a doctor might do this following invasive imaging tests or during surgery.

Imaging tests, such as X-ray, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and positron emission tomography (PET) scans, help doctors visualize a tumor and determine how it affects other organs and blood flow:

  • For pancreatic cancer, a multiphase CT scan or a pancreatic protocol CT scan can help visualize the tumor.
  • Abdominal ultrasound and endoscopic ultrasound use ultrasound waves to analyze the tumor. Endoscopic ultrasounds can be more accurate and better for diagnosing pancreatic cancer, but they involve inserting a tube down the throat. 
  • Angiography can look at the blood vessels around the pancreas and other abdominal organs. It can be performed using X-ray imaging or an MRI to see how the cancer has affected blood vessels.
  • Magnetic resonance cholangiopancreatography uses an MRI machine to get a non-invasive peek at the bile and pancreatic ducts. 
  • Endoscopic retrograde cholangiopancreatography (ERCP) requires a tube down your esophagus and into your stomach. The doctors will use the tube to take pictures and even biopsy a sample or perform other treatments, like placing a stent. Percutaneous transhepatic cholangiography may be used in place of an ERCP. 

Treatment

Because it has spread throughout the body, doctors cannot cure stage 4 pancreatic cancer, but they can manage it. The goal of stage 4 pancreatic cancer treatments is to increase life span and decrease symptoms. Palliative care can help increase quality of life for as long as possible.

Stage 4 pancreatic cancer is not curable, but it isn’t terminal cancer. Terminal means the patient is actively dying, usually within months. The disease is better described as advanced or late-stage cancer.

Surgery

Surgery is unlikely in stage 4, because cancer has spread throughout the body and would be impossible to remove altogether. However, doctors may operate on the pancreatic tumor to increase quality of life or ease pain.

Types of surgery for pancreatic cancer include:

  • Whipple surgery removes the head of the pancreas, the gallbladder, and parts of the stomach and small intestine. 
  • Total pancreatectomy removes the entire pancreas, along with the gallbladder, bile duct, the spleen, and parts of the stomach, small intestine, and nearby lymph nodes.
  • Distal pancreatectomy removes only the pancreas’ body and tail, but may also remove the spleen if the tumor affects it.
  • Biliary or gastric bypass are palliative care surgeries to relieve symptoms caused by a tumor blocking how food moves through the digestive system.
  • A stent is another palliative care option similar to a bypass, in which doctors insert a drain to move built-up fluids out of a blocked area.

Chemotherapy

Chemotherapy can improve quality of life and lessen cancer symptoms, though it comes with side effects. Chemotherapy kills cancer cells with toxic chemicals. Below are several common chemotherapy drugs prescribed for pancreatic cancer, but there are many others.

  • Gemzar (gemcitabine)
  • Abraxane (albumin-bound paclitaxel)
  • 5-Fluorouracil
  • Oxaliplatin
  • Irinotecan

Radiation 

Radiation kills cancer cells with beams of energy, either locally with an implant or from outside the body. Doctors often use radiation in combination with chemotherapy to shrink a tumor.

Immunotherapies 

Immunotherapies are drugs that support the immune system in its fight against cancer. Keytruda (pembrolizumab) is a monoclonal antibody used to help your immune system attack cancer cells to stop or slow their growth. However, only about 1% of patients have the specific features needed in their cancer to use these particular drugs. As a result, outside of clinical trials, these drugs are used very rarely in pancreatic cancer.

Targeted Therapies 

Targeted therapies are drugs that find and attack cancer cells based on their unique features. Specifically for pancreatic adenocarcinoma, the following treatments, which block the action of tyrosine kinases, can help slow cancer growth in some cases:

  • Lyparza (olaparib)
  • Rozlytrek (entrectinib)
  • Tarceva (erlotinib)
  • Vitrakvi (larotrectinib)

Patients can get access to other, often experimental treatment options through clinical trials. Clinical trials are how researchers test new drugs and treatments.

Participation in clinical trials can help add to what we know about this disease and help researchers develop alternative ways of treating it that can help future patients survive longer.

If you're interested in participating in a trial, first talk to your doctor to get all the information you can about your diagnosis. Then, to find clinical trials, look in the National Cancer Institute’s clinical trial database and other national databases. Clinical trials will include new treatments that might not be available otherwise, though there’s no promise they’ll work or work better than the standard treatments.

It's also important for stage 4 pancreatic patients to work with a palliative care team. When treatments will not cure the cancer, palliative care therapies can improve quality of life. Specialized doctors, nurses, and social workers work to relieve symptoms of cancer in seriously ill patients.

Palliative care is not hospice or end-of-life care; these treatments improve patients’ stress levels and daily discomfort and pain, including radiation therapy, to reduce tumor size and symptoms. For pancreatic cancer, a palliative care treatment plan might include injections or cutting nerves to treat pain from a cancerous pancreas. 

Prognosis

Stage 4 pancreatic cancers are aggressive and have few treatment options. Even with treatment, survival beyond a year or two is low. Survival rates help doctors estimate how long a person with a diagnosis will survive, given how well other people with that diagnosis have done.

The cancer-specific survival rate is the percentage of people with a particular diagnosis that survived until a specific time. The NCI’s Surveillance, Epidemiology, and End Results (SEER) Program database includes cancer survival statistics from 19 states.

The SEER database does not use the TNM staging system. Instead, they use a three-stage approach:

  • Localized cancers are only present around the area in which it first developed. 
  • Regional cancers have spread to nearby lymph nodes, tissues, or organs.
  • Distant cancers have metastasized to remote parts of the body—this is where stage 4 pancreatic cancer would land. 

Based on SEER’s data, the five-year survival rate for patients diagnosed with distant pancreatic cancer is 2.9%. That means 2.9% of people diagnosed with metastatic pancreatic cancer are alive five years later.

This number varies by age. Patients diagnosed at a younger age have better survival odds. For example, those diagnosed with distant pancreatic adenocarcinoma when they are less than 50 years old have a 10.4% chance of surviving at least five years. 

The survival rates in the table below are specifically for the more common type of pancreatic cancer, caused by mutations to the cells that make digestive enzymes (pancreatic adenocarcinoma).

Survival Rates for Distant Pancreatic Cancer, by Age
Age Survival Rate
All  2.9%
Under 50  10.4%
50-64 3.6%
65 or over 1.8%
Data from SEER database

The less common pancreatic cancer, caused by mutations in the blood-sugar-regulating cells (pancreatic neuroendocrine cancer), has a survival rate of about 15% after five years for non-operable tumors. Survival rates for operable tumors are around 55%.

There are some limitations in survival rates. Some people live well longer than the survival statistics. They also don’t accurately portray newer treatments and advancements in care, since they’re based on numbers from 2010 to 2016.

Coping

A 2.9% survival rate is a hard number to swallow. The great majority of patients diagnosed with stage 4 pancreatic cancer will die within a few years. Coping with this is essential for quality of life:

  • If you’re in pain, talk to your palliative care team about options. 
  • Get mental health care to deal with the stress of diagnosis and treatment. 
  • Make sure you’re eating the right foods and have the right medications to help you digest food. Pancreatic cancer patients often need enzymes to help with digestion.
  • Look into clinical trials. New treatments might work better than the standard of care (but they also might not).
  • Eat a healthy diet and keep active, if you can. These contribute to your performance status—a rating of how easily a patient performs daily tasks—which may contribute to overall survival and quality of life.
  • Make a will and plan for what life might be like for family and loved ones after you’re gone.
  • Spend time with friends and family.

If you or a loved one has been diagnosed with stage 4 pancreatic cancer, don’t be afraid to ask for support from your community:

A Word From Verywell

Stage 4 pancreatic cancer is one of the toughest diagnoses someone can receive. Focus on educating yourself and being an advocate for your own care. Enlist family and friends to help you move forward. Now is the time to lean on your support network.

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