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Pancreatic cancer in adults: diagnosis and management 

  • Pancreatic cancer is generally handled by specialist care, this Guidelines summary provides the recommendations from Pancreatic cancer in adults: diagnosis and management (NICE NG85) that are relevant to primary care and also includes some relevant  recommendations from Suspected cancer: recognition and referral (NICE NG12). Please refer to the full guidelines for the complete list of recommendations 

Recognition and referral for suspected pancreatic cancer (from NICE NG12) 

  • The following recommendations are from Suspected cancer: recognition and referral (NICE NG12) 
  • Refer people using a suspected cancer pathway referral* (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 and over and have jaundice
  • Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and any of the following:
    • diarrhoea
    • back pain
    • abdominal pain
    • nausea
    • vomiting
    • constipation
    • new‑onset diabetes

* The patient is seen within the national target for cancer referrals (2 weeks at the time of publication of this guideline)

Diagnosis

People with obstructive jaundice

  • For people with obstructive jaundice and suspected pancreatic cancer, offer a pancreatic protocol CT scan before draining the bile duct
  • If the diagnosis is still unclear, offer fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) and/or endoscopic ultrasound (EUS) with EUS-guided tissue sampling
  • Take a biliary brushing for cytology if:
    • endoscopic retrograde cholangiopancreatography (ERCP) is being used to relieve the biliary obstruction and
    • there is no tissue diagnosis

People without jaundice who have pancreatic abnormalities on imaging

  • Offer a pancreatic protocol CT scan to people with pancreatic abnormalities but no jaundice
  • If the diagnosis is still unclear, offer FDG-PET/CT and/or EUS with EUS-guided tissue sampling
  • If cytological or histological samples are needed, offer EUS with EUS-guided tissue sampling

People with pancreatic cysts

  • Offer a pancreatic protocol CT scan or magnetic resonance cholangiopancreatography (MRI/MRCP) to people with pancreatic cysts. If more information is needed after one of these tests, offer the other one
  • Refer people with any of these high-risk features for resection:
    • obstructive jaundice with cystic lesions in the head of the pancreas
    • enhancing solid component in the cyst
    • a main pancreatic duct that is 10 mm diameter or larger
  • Offer EUS after CT and MRI/MRCP if more information on the likelihood of malignancy is needed, or if it is not clear whether surgery is needed
  • Consider fine-needle aspiration during EUS if more information on the likelihood of malignancy is needed
  • When using fine-needle aspiration, perform carcinoembryonic antigen (CEA) assay in addition to cytology if there is sufficient sample
  • For people with cysts that are thought to be malignant, follow the recommendations on staging

People with inherited high risk of pancreatic cancer

  • Ask people with pancreatic cancer if any of their first-degree relatives has had it
  • Address any concerns the person has about inherited risk
  • Offer surveillance for pancreatic cancer to people with:
    • hereditary pancreatitis and a PRSS1 mutation
    • BRCA1, BRCA2, PALB2 or CDKN2A (p16) mutations, and one or more first-degree relatives with pancreatic cancer
    • Peutz–Jeghers syndrome
    • Consider surveillance for pancreatic cancer for people with:
    • 2 or more first-degree relatives with pancreatic cancer, across 2 or more generations
  • Lynch syndrome (mismatch repair gene [MLH1, MSH2, MSH6 or PMS2] mutations) and any first-degree relatives with pancreatic cancer
  • Consider an MRI/MRCP or EUS for pancreatic cancer surveillance in people without hereditary pancreatitis
  • Consider a pancreatic protocol CT scan for pancreatic cancer surveillance in people with hereditary pancreatitis and a PRSS1 mutation
  • Do not offer EUS to detect pancreatic cancer in people with hereditary pancreatitis

Specialist pancreatic multidisciplinary teams

  • A specialist pancreatic cancer multidisciplinary team should decide what care is needed, and involve the person with suspected or confirmed pancreatic cancer in the decision. Care should be delivered in partnership with local cancer units

Staging

  • For people with newly diagnosed pancreatic cancer who have not had a pancreatic protocol CT scan, offer a pancreatic protocol CT scan that includes the chest, abdomen and pelvis
  • Offer fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) to people with localised disease on CT who will be having cancer treatment (surgery, radiotherapy or systemic therapy)
  • If more information is needed to decide the person’s clinical management, consider one or more of the following:
    • MRI, for suspected liver metastases
    • endoscopic ultrasound, if more information is needed for tumour and node staging
    • laparoscopy with laparoscopic ultrasound, for suspected small-volume peritoneal and/ or liver metastases if resectional surgery is a possibility

Psychological support

  • Throughout the person’s pancreatic cancer care pathway, specifically assess the psychological impact of:
    • fatigue
    • pain
    • gastrointestinal symptoms (including changes to appetite)
    • nutrition
    • anxiety
    • depression
  • Provide people and their family members or carers (as appropriate) with information and support to help them manage the psychological impact of pancreatic cancer on their lives and daily activities. This should be:
    • available on an ongoing basis
    • relevant to the stage of the person’s condition
    • tailored to the person’s needs
  • For more guidance on providing information and support, see the NICE guideline on patient experience in adult NHS services

Pain management

  • Consider EUS-guided or image-guided percutaneous neurolytic coeliac plexus block to manage pain for people with pancreatic cancer who:
    • have uncontrolled pancreatic pain or
    • are experiencing unacceptable opioid adverse effects or
    • are receiving escalating doses of analgesics
  • Do not offer thoracic splanchnicectomy to people with pancreatic cancer

Nutritional management

  • Offer enteric-coated pancreatin for people with unresectable pancreatic cancer
  • Consider enteric-coated pancreatin before and after pancreatic cancer resection
  • Do not use fish oils as a nutritional intervention to manage weight loss in people with unresectable pancreatic cancer
  • For people who have had pancreatoduodenectomy and who have a functioning gut, offer early enteral nutrition (including oral and tube feeding) rather than parenteral nutrition
  • For more guidance on nutrition support, see the NICE guideline on nutrition support in adults

Further information

  • Please refer to the full guideline for recommendations on:
    • relieving biliary and duodenal obstruction
    • managing resectable and borderline resectable pancreatic cancer
    • managing unresectable pancreatic cancer

© NICE 2017. Suspected cancer: recognition and referral. Available from: www.nice.org.uk/guidance/NG12. All rights reserved. Subject to Notice of rights.

© NICE 2018. Pancreatic cancer in adults: diagnosis and management. Available from: www.nice.org.uk/guidance/NG85. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.

First included: June 2018.