Why Is Pancreatic Cancer So Hard to Treat?

Illustration of human body with pancreas exploded to side and magnified.

The pancreas is located at the intersection of major blood vessels, making surgery difficult.


  • Pancreatic cancer is not common but is very deadly.
  • Standard cancer therapies are largely ineffective.
  • New treatment approaches give reason for hope.

Pancreatic cancer is relatively rare but notoriously lethal. It is currently the third leading cause of cancer deaths in the United States — and it’s projected to move into the second slot by 2020.

The main reason is that pancreatic cancer has proven very difficult to treat compared with many other, more common types of cancer. Despite decades of research, the prospects remain bleak for those diagnosed, with a survival rate of 20% at one year and 6% at five years for all stages combined. Even patients diagnosed and treated at the earliest stage have a 50% chance that the disease will recur.

Below we discuss why this disease has foiled clinicians and researchers for so long and also explain why they have reason to hope that the outlook will soon be brighter.

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Pancreatic Cancer Is Rarely Caught at an Early Stage

MSK pancreatic cancer expert Steven Leach, director of the David M. Rubenstein Center for Pancreatic Cancer Research, explains that the disease usually does not cause symptoms in its early stages. Those that do occur — such as pain or weight loss — are often mistaken for signs of other illnesses. In addition, the pancreas is located in the back of the abdomen behind many other organs, making it hard for doctors to feel during routine examinations and even to conduct imaging tests to detect tumors.

 “It’s not a frequently occurring cancer, so it becomes hard to generate cost-effective screening strategies for early detection, such as the use of mammography or MRI for breast cancer, or colonoscopy for colorectal cancer,” Dr. Leach says. “We have a long way to go when it comes to early diagnosis.”

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Surgery Is Usually Not an Option

Pancreatic cancer is especially aggressive and its location makes it easy for it to spread into adjacent structures and organs such as the liver or stomach. It is usually diagnosed only after it has moved into surrounding tissue, if not other parts of the body. As a result, only about 15% of patients are good candidates for surgery.

“The pancreas sits in a tricky location, with major blood vessels, the bile duct, and the intestine all in the immediate neighborhood,” Dr. Leach explains. “When the tumor involves these major blood vessels, it generally can’t be removed.”

Guy's Story
When 50-year-old Robert “Guy” Davidson received a diagnosis of pancreatic cancer at another hospital, he came to Memorial Sloan Kettering for a second opinion and stayed for chemotherapy, surgery, and radiation.

Even when surgery is an option, the procedure is very difficult and requires a great degree of expertise. “In high-volume centers like MSK, it’s become routine for the surgeons, who may do between 200 and 300 procedures a year, and we have good outcomes,” Dr. Leach says. “For many hospitals, whose doctors might do just ten a year, it is still a fairly high-risk operation.”

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Pancreatic Cancer Resists Drugs That Work in Other Cancers

Chemotherapies that are effective against other cancers don’t seem to work well against pancreatic cancer. Dr. Leach explains that one reason may be that pancreatic tumors are surrounded by a network of nonmalignant cells, called the stroma, which can act as a protective barrier.

“Sometimes as little as 10% of the whole tumor volume is occupied by the cancer cells, while the rest is made up of nonmalignant cells,” Dr. Leach says. In addition, the tumor usually contains a buildup of certain proteins, called matrix proteins, that cause blood vessels to collapse — which in turn prevents chemotherapy from reaching the cancer cells in sufficient amounts.

Sometimes as little as 10% of the whole tumor volume is occupied by the cancer cells, while the rest is made up of nonmalignant cells.
Steven D. Leach physician-scientist

While some cancers have been successfully treated with targeted therapies, which block the products of specific genetic mutations, these drugs have not been developed for pancreatic cancer. Targeted therapies are effective in cancers that have a fairly large percentage of patients with the same cancer-causing mutation, such as EGFR in lung cancer, or BRAF in melanoma. Pancreatic cancer, by contrast, appears to be spread out over a large number of cancer-driving mutations, each involving a small percentage of patients.

“It’s more challenging to develop a drug that will be effective in only a small subset of patients,” Dr. Leach says. “It’s difficult to enroll enough people for a clinical trial, and there is less financial incentive for pharmaceutical companies.”

Immunotherapy, which has revolutionized treatment for many cancers, has also failed to have much effect against pancreatic cancer. Recent research has found that pancreatic tumors seem to evolve mechanisms that prevent the critical immune cells, called T cells, from infiltrating the tumor.

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Turning the Tide

Despite these many hurdles, Dr. Leach says there is ample reason for optimism.

First, researchers now know more about who is more likely to develop pancreatic cancer. Patients who carry mutations in one of the BRCA genes — which have already been primarily linked to breast and ovarian cancers — are now known to be at higher risk for pancreatic cancer, as well as people who suddenly develop diabetes relatively late in life. These groups could be screened through endoscopic ultrasound, in which a gastroenterologist passes an endoscope into the intestine next to the pancreas to capture high-resolution images.

But something even simpler is needed to make screening more cost-effective, Dr. Leach asserts. MSK researchers are investigating liquid biopsies, which look for circulating tumor cells or tumor DNA in the blood. Analyzing this DNA for mutations could help detect pancreatic cancer at an early stage, and also provide critical information about the specific tumor type.

“There also is a lot of excitement about blood tests that measure large numbers of proteins that indicate pancreatic cancer when they are detected in certain patterns — what we call protein arrays,” he says.

In addition, MSK is making progress in developing new forms of imaging, led by radiochemist Jason Lewis and radiologist Richard Do, both to detect pancreatic cancer at an early stage and also to assess how it may be responding to treatment.

Perhaps the most promising development is a new initiative called Precision Promise, a large-scale clinical trial that will investigate multiple treatment options under one clinical trial design. Sponsored by the Pancreatic Cancer Action Network, Precision Promise is a collaboration among MSK and other leading institutions to use each patient’s unique molecular profile to determine the best treatment for that person. The trial will be conducted at 12 sites, including MSK. (Precision Promise will be discussed in more detail in an upcoming OnCancer story.)

“This is a really innovative initiative because we’re getting a wonderful partnership of leading academic centers with pharmaceutical companies that recognize its vast potential, and something they want to be part of,” Dr. Leach says. “It’s going to allow us to try things that simply weren’t possible before, and we’re excited to be able to participate in something that’s this important.”

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Commenting is disabled for this blog post.

Have pancreatic cancer....had Whipple 1 yr ago..Had chemo and radiation. ..first CTs were good. ..last set 2 weeks ago show it came back. .my oncologist wants to try another chemo drug. ..only palliative. .say I may have 11 to 18 month
..i.want to fight this. ..can you help me !!

Dear Miriam, we are sorry to hear about your diagnosis. If you would like to make an appointment with one of our specialists to discuss possible next steps in your care, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

My husband had stage 4 pancreatic cancer and passed away about ayear after his diagnosis. The problem was he also had portal vein thrombosis and varicose veins in his neck which erupted twice. The 2nd time he passed away. So sad. He was only 50.

Dear Jean, we are so sorry for your loss. Thank you for sharing your thoughts and experience on our blog.

My wife passed away from this at the age of 39 and her father at the age of 36. She has a brother and sister and 2 sons. What should we do to be tested ??

Dear Eric, we are sorry for your loss. If your wife’s family is interested in learning more about genetic counseling and possibly being tested for genetic mutations that may predispose them to certain cancers, please visit our Clinical Genetics page: https://www.mskcc.org/cancer-care/risk-assessment-screening/hereditary-…. They can make an appointment for a consultation by calling 646-888-4050.

They may also be interested in learning more about MSK’s Familial Pancreatic Tumor Registry, which is investigating the causes of pancreatic cancer in people with family members who also have the disease: https://www.mskcc.org/cancer-care/types/pancreatic/about/risk-factors

We hope this information is useful. Thank you for reaching out to us.

I am curious, out of how many studies has patients survived with a full whipple surgery (pancreas removed) past 10 years? Or has actually gone through the procedure?

Laura, thank you for reaching out. The five year survival after Whipple procedure for pancreatic cancer is ~20%; at ten years it is approximately 10%

I live in Scotland. My father died of pancreatic cancer 9 years ago. My gran died of breast cancer. My sister and mum have both has breast cancer. My mum doesn't have the gene tho and they won't text me for it. Is there anyway to get tested as I'm very interested now that pancreatic cancer has been linked to the gene.
Thank you

Dear Juliet, we are sorry for your loss. We would recommend that you ask your physician for a referral to a genetic counselor who specializes in cancer. Meeting with a genetic counselor will help give you a reliable assessment of your cancer risk and what steps you can take to reduce your risk. Thank you for reaching out to us.

My husband died a little over a year ago of pancreatic cancer. He survived 14 months after diagnosis. He was only 45. He was perfectly healthy otherwise. He had a Whipple and chemo. Then it went away for a about a month and came back with a vengeance. His mother that had breast cancer testes positive for a gene mutation PALB 2 gene. Which now we think may have caused his. I'm worried now about whether my 2 smalls kids have that bad gene. They are 7 and 4. I've been told I can't find out till they are 18 because they have to consent to it. Now I have to worry . Can you guys offer me any advice. I'm so devastated to think my babies could have to go through what he did. Thanks

Dear Kristie, we are very sorry for your loss. Do speak with your children’s physician to make sure he or she knows about your family history of cancer. It may be helpful to reach out to a grief counselor to discuss ways to manage and cope with the fears you are experiencing with regard to your children’s risk for developing cancer. It also helps to find distractions to help relieve your anxiety - such as meditation, yoga, or enjoying your hobbies and fun activities with your children. Focusing on living a healthy lifestyle by eating healthy and exercising is always recommended and a good way to reduce your family’s overall cancer risk.

Thank you for reaching out to us.

I was diagnosed with pancreatic cancer in 2/16. Had Whippel in April 16. Started Gemzar in may, radiation and 5FU in June and Gemzar for 5 more months. 29 lymph nodes were negative, all organs removed were negative, all borders were clear.
Stage 2A. Will have restaging cat scan on Dec 1. Being this cancer is so aggressive is there anything I can do to stay proactive. I would be willing to come to Sloan. I think my oncologist at Moffitt was part of your team at one time. Hope to hear from you soon. thank you

Dear Carol, we are sorry to hear about your diagnosis. Your oncologist will continue to monitor you for signs of recurrence, and it’s always encouraged for people (whether or not they have been treated for cancer) to make healthy lifestyle choices such as eating a health diet, staying active, and choosing not to smoke.

If you do develop a recurrence, and you would like to make an appointment with one of our specialists to discuss possible next steps in your care, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

It is really sad to hear about the victim-ins who are suffering from cancer. Hope so they will soon get rid from it.

My husband has pancreatic cancer. 2nd round of chemo is breaking him down. Dr. Asked to look BRCA gene....but our oncologist didn't think it was a good idea bc can't go in and take biopsy. Any suggestions?

Dear Fay, we are sorry to hear about your husband’s diagnosis. We can’t suggest a course of action without knowing more about your husband and his disease. If you would like to make an appointment with one of our specialists to discuss possible next steps in his care, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

My mother was diagnosed with stage IV pancreatic cancer in October 2016. She has been on Gemabraxane full dose chemo 3 weeks on and 1 week off with little side effects other than hair loss. Her tumor is on the tail and has shrunk 40% after the second month of chemo. She is currently in the third month of chemo. We are both happy about her response and scared about the future. How soon will you be enrolling patients in the Precision Promise program and would she be a candidate to be included?

Dear Jeff, we’re sorry to hear about your mother’s diagnosis. There are several types of trials that will be part of this initiative, based on the individual characteristics of patients’ tumors. If your mother would like to find out more about participating in a trial at MSK, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment.

Is there an area of the pancreas (head, body, tail) where a tumour is detected harder to treat? It seems most have it in the head hence the Whipple surgery, but what if it is detected in the tail, as it usually doesn't present the same outward symptoms, until it is stage 4.

Dear Tracy, we forwarded your question to Dr. Leach, who replied, “Pancreatic cancers can arise anywhere in the pancreas and are most common in the pancreatic head. When they arise in the pancreatic head, they can occasionally cause obstruction of the bile duct, which makes itself known as jaundice. This occasionally provides the opportunity for earlier diagnosis when the tumor remains localized. When tumors arise in the pancreatic tail, they are not located adjacent to the bile duct, and therefore do not cause bile duct obstruction. As a result, diagnosis is often made at a later stage of the disease, which is frequently associated with metastatic spread.” Thank you for your comment.

I was diagnosed with pancreatic cancer in April 2017. Interested in getting a second opinion from your facility. Currently on chemo at Mayo clinic in Jacksonville Florida. Diagnosed with metastasize adenocarcinoma pancreatic cancer stage 4. Receiving Gem/
Abraxane chemo every other week. RCT and MRQ scheduled for September 20 at Mayo Clinic to evaluate treatment. Would like to schedule an appointment for a second option after the results are received. Who should I contact? My sister lives in New York and feels that I need to be evaluated at your Center. Thanks in advance for your assistance.

My boyfriend was diagnosed with Pancreatic Cancer 6/2016 that had metastasized to lining of abdominal area and into lungs. He was doing well on the gem/abraxane over the past yr. recently (about 2 months) he began feeling sick, not being able to eat and everything has went down hill from there. He's currently in the hospital, they've put in a feeding tube to get him the nutrients he so badly needed however now they feel there is an obstruction (most likely due to the cancer growing (due to him not being able to Have chemo since he got sick). He has lost more weight and they continue to have issues with the feeding tube. His future looks pretty grim. Wondering if it is too late for him to be seen at your hospital. So sad and scare.

Dear Tracy, we’re very sorry to hear about your boyfriend’s diagnosis. If he would like to speak with a referral specialist at MSK about whether it would be appropriate for him to come here for treatment, he can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to both of you.

What is the average time it takes to be admitted to Memorial Sloan Kettering Cancer Center?

Dear Kristin, the time between making your first phone call to MSK and seeing one of our doctors is based on a number of factors. It depends on the type of cancer you have and what type of consultation is needed (for example, with a surgical oncologist, medical oncologist, radiation oncologist, or a combination of these). Once you reach out to us, we will match you with the most appropriate specialist based on your diagnosis. Please note that your insurance plan also may come into play — if your insurance carrier requires an authorization to be seen at MSK, this could lead to a delay.

To speak with one of our referral experts about making an appointment, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information. For more information about insurance, you can go to https://www.mskcc.org/insurance-assistance/insurance-information

Thank you for your comment, and best wishes to you.

My Husband had whipple for pancreatic cancer in April 2008 it gave him the chance of a full normal life for 3 yrs untill it returned in 2011, Sadly he passed away Jan 2013

Dear Jean, we’re very sorry for your loss. Thank you for sharing your story. Best wishes to you.

I have Stage 4 pancreatic cancer metastasized to the liver. It was diagnosed late (August 15, 2017) because it was at the tail. I had no jaundice. I refused chemo and am now enrolled in hospice and palliative care. Any words of wisdom?

My husband had pancreatic cancer in the tail. Had the tail and the spleen removed in August 2017.
Found out in October there were lesians in the liver. They did a biopsy in December and it is in the liver and also now in the stomach lining and lymp nodes. Diagnosed stage 4. Started Chemo now they say he has 6 months to a year. he last lost 15 pounds does not eat much. Any advice on what we can do.

my husband, aged 78, in good health except for pancan and resulting diabetes etc, was diagnosed with stage 2 pancan in head of pancreas.
he is receiving no treatment.
what is involved in signing up for trials

Dear Jane, we’re sorry to hear about your husband’s diagnosis. If he is interested in a trial, he should speak with his doctor about the possibility of participating in one. If the hospital where he is currently being seen does not offer trials or does not have a trial for him, and he would like to come to MSK, the number to call for a consultation is 800-525-2225. If he is not in the NYC area or not able to come to MSK, we recommend that you consult with an expert at a National Cancer Institute-designated cancer center. You can find a list here: https://www.cancer.gov/research/nci-role/cancer-centers Thank you for your comment and best wishes to both of you.

Has ANY Chemotherapy been shown to prolong life or improve quality of life after diagnosis of Stage 4 Adenocarcinoma Pancreatic Cancer? Wondering if there are statistics available. Is chemo in stage 4 adenocarcinoma of the pancreas worth the side effects?

Dear Mike, we sent your question to MSK medical oncologist and pancreatic cancer expert Eileen O’Reilly, who responded: “Several treatment programs have been shown to prolong life following a diagnosis of pancreas adenocarcinoma. These include FOLFIRINOX (5-fluorouracil, oxaliplatin, irinotecan, leucovorin), gemcitabine and nab-paclitaxel (abraxane) and liposomal irinotecan/5-fluorouracil. Typically if the cancer responds to treatment, an individual’s quality of life is improved. As an example, data with FOLFIRINOX support this latter point of quality of life improvement. In addition, there are many drugs in early to mid-stage development that are being evaluated for pancreas cancer that hold promise for the future.”

Thank you for your comment, and best wishes to you.

As a human physiology textbook author, I am endeavoring to answer questions in a social forum for people with pancreatic cancer. Your site has been extremely helpful, and I've referred readers to this page. One thing not addressed here is why (assuming such to be the case) radiation therapy is not an option for pancreatic cancer. If I can get any insight into that, I can edit my existing answer to add this. Thank you.

Thank you for posting this and answering questions. My aunt on my mother's side died of pancreatic cancer at the age of 52. This was over 30 years ago. My dad passed of this at the age of 86. I do not carry the BRCA gene, however I did have stage I breast cancer. What should I do to be proactive for prevention and/or screening? Thanks!

Dear Phyllis, we’re sorry to hear about your family history. We recommend that you consult with a clinical geneticist who is knowledgeable about inherited cancer genes. If you’re in the New York City-area and are interested in speaking with someone at MSK, you can go to https://www.mskcc.org/cancer-care/risk-assessment-screening/hereditary-… for more information. Thank you for your comment and best wishes to you.

My mother, Susan (62) was diagnosed with pancreatic cancer Sept 2017. After the Whipple and chemo she was doing well. It spread to her lung. After being allergic to some chemo meds and her levels spiking, her dr recommended Hospice.
And suggestions?

Thank you

My mother was recently diagnosed with pancreatic cancer. She has a 5cm mass in the head of the pancreas. It has not spread anywhere else. Currently undergoing first round chemo treatment at Mt. Sinai. If needed, I would want her to continue chemo treatment or surgery at your facility. My question for your experienced doctors is have they removed a 5cm pancreatic mass or larger ? Any recommendation ?
Thank you.

Dear Alicia, we’re very sorry to hear about your mother’s diagnosis. If she would like to come to MSK for a consultation about surgical and other treatment options, the number to call is 800-525-2225. You can go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you and your mother.

My mom was just diagnosed with Stage 4 pancreatic cancer. She was hospitalized 3 times now and has only been able to receive 2 treatments. We just met with an oncologist and he says chemo is not an option. I know I am not a doctor but I can't get over how we can not at least try. Is there anything you guys can do?

Dear Jodi, we’re very sorry to hear about your mom’s diagnosis. If she would like to come to MSK for a consultation to learn what treatment options may be available. you can make an appointment online or call 800-525-2225. Thank you for your comment and best wishes to you and your family.

My grandmother was diagnosed with pancreatic cancer 6 weeks ago. Her doctor said if there was a such thing as a stage 5, she would be well into that stage. She only lived for 2 days after her diagnosis. She had only been "feeling sick" for 4 weeks prior to her death. Is it possible for a cancer to develop and spread so quickly?

Dear Clara, we are very sorry for your loss. We recommend you discuss this with your grandmother’s medical team. Thank you for your comment and best wishes to you.

Father recently diagnosed with pancreatic hepatoid carcinoma. So rare I'm having trouble finding anyone who researches it or who has had any success treating it. Does anyone at MSK have any experience?