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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- ~90% are ductal adenocarcinomas; ~60–70% arise in pancreatic head. Most aggressive common solid cancer
- Classic presentation: painless progressive obstructive jaundice + weight loss + new-onset diabetes in an older patient
- Courvoisier law: painless jaundice + palpable gallbladder = unlikely to be gallstones (think pancreatic/periampullary tumour)
- Only ~10–20% are resectable at diagnosis. Curative surgery: pancreaticoduodenectomy (Whipple procedure)
- Five-year survival ~10% overall, ~30% with curative resection + adjuvant chemotherapy (FOLFIRINOX)
Overview
Pancreatic cancer is one of the most lethal malignancies. The vast majority (~85–90%) are pancreatic ductal adenocarcinomas (PDAC). Tumours in the head of the pancreas (~60–70%) present earlier with obstructive jaundice, while body/tail tumours tend to present late with pain and metastatic disease. Risk factors include smoking (strongest modifiable), chronic pancreatitis, diabetes (both a risk factor and an early symptom), obesity, family history (BRCA2, PALB2, CDKN2A mutations, Lynch syndrome), and hereditary pancreatitis.
Epidemiology
Approximately 10,000 new cases per year in the UK — the tenth most common cancer but the fifth most common cause of cancer death. Peak incidence at 70–80 years. Slight male predominance. Incidence is increasing. Only ~10–20% are surgically resectable at diagnosis. Five-year survival remains ~10% despite advances in treatment. It is projected to become the second leading cause of cancer death in the UK by 2030.
Clinical Features
Symptoms
Painless obstructive jaundice (head of pancreas tumour obstructing CBD)
Dark urine and pale stools (conjugated hyperbilirubinaemia)
Pruritus (bile salt deposition in skin)
Unintentional weight loss (often dramatic)
Epigastric or back pain (body/tail tumours, retroperitoneal invasion)
New-onset diabetes (within 2 years of cancer diagnosis — "herald" diabetes)
Anorexia, nausea, steatorrhoea (pancreatic duct obstruction → exocrine insufficiency)
Acute pancreatitis as initial presentation (in ~5%)
Signs
Jaundice
Palpable, non-tender gallbladder (Courvoisier sign — gallbladder distension from distal CBD obstruction)
Cachexia
Hepatomegaly (metastases)
Ascites (peritoneal metastases)
Migratory thrombophlebitis (Trousseau sign — paraneoplastic, associated with pancreatic cancer)
Left supraclavicular lymphadenopathy (Virchow node)
Investigations
First-line
USS abdomenInitial investigation for jaundice — may show dilated intrahepatic and extrahepatic bile ducts, pancreatic mass
LFTsObstructive pattern: raised bilirubin, ALP, GGT >> transaminases
CA 19-9Tumour marker — elevated in ~80% of pancreatic cancers. Useful for monitoring treatment response but not diagnostic (also raised in cholangitis, pancreatitis)
Second-line
CT pancreas (contrast-enhanced, pancreatic protocol)Gold standard for diagnosis and staging — assess tumour size, vascular involvement (SMA, coeliac axis, portal vein), distant metastases, resectability
MRCPBiliary anatomy — particularly useful for biliary obstruction characterisation
EUS ± FNATissue diagnosis — EUS-guided fine needle aspiration/biopsy for histological confirmation
Specialist
Staging laparoscopyBefore curative surgery — detect peritoneal metastases not visible on CT
PET-CTFor borderline resectable disease — assess distant spread before committing to surgery
ERCPTherapeutic: biliary stenting for symptom relief of obstructive jaundice (metallic stent for unresectable; plastic stent pre-operatively)
1
Curative surgery (~10–20%)
- Pancreaticoduodenectomy (Whipple procedure): for head of pancreas tumours — removes head of pancreas, duodenum, distal bile duct, gallbladder, ± distal stomach
- Distal pancreatectomy + splenectomy: for body/tail tumours
- Total pancreatectomy: rarely required
- Requires no major vascular involvement (SMA, coeliac axis) and no metastatic disease
2
Adjuvant/neoadjuvant chemotherapy
- Adjuvant: modified FOLFIRINOX (6 months) post-resection — improves survival vs gemcitabine alone
- Alternative: gemcitabine + capecitabine (ESPAC-4 trial)
- Neoadjuvant chemotherapy: increasingly considered for borderline resectable disease to downstage
3
Palliative treatment
- Biliary stenting (ERCP or PTC) for obstructive jaundice
- Palliative chemotherapy: FOLFIRINOX or gemcitabine + nab-paclitaxel (modest survival benefit)
- Pain management: WHO ladder, coeliac plexus block for refractory pain
- PERT (Creon) for exocrine insufficiency
- Nutritional support and dietitian input
- Early palliative care referral — improves quality of life
Complications
- Biliary obstruction: Jaundice, cholangitis, pruritus — managed with biliary stenting
- Diabetes mellitus: New-onset or worsening — may precede cancer diagnosis by months
- Duodenal obstruction: Gastric outlet obstruction from pancreatic head mass — duodenal stenting or gastrojejunostomy
- VTE: Pancreatic cancer has one of the highest VTE rates of any cancer (Trousseau syndrome)
- Exocrine insufficiency: Steatorrhoea, malnutrition — manage with PERT
UKMLA Exam Tips
- 1Courvoisier law: painless jaundice + palpable gallbladder = NOT gallstones (gallstones cause a fibrotic GB that cannot distend). Think pancreatic/periampullary cancer
- 2New-onset diabetes in a patient >60 with weight loss → consider pancreatic cancer
- 3Trousseau sign (migratory thrombophlebitis) = classic paraneoplastic association with pancreatic cancer
- 4Whipple procedure = pancreaticoduodenectomy — know the anatomy of what is resected
- 5CA 19-9: useful for MONITORING but NOT screening. False positives in cholangitis, pancreatitis, other GI cancers
- 6Only 10–20% resectable at diagnosis — most present too late for curative surgery
practicetest your knowledge on pancreatic cancerApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — gastroenterology and beyond.
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