As a general practitioner at a busy one London surgery, I see thousands of patients every year. Sometimes, even often, without your notes you won’t remember every consultation – but there are some patients and some diagnoses that stay with you for years.
Take Alan – not his real name – who I saw regularly at my practice for more than ten years. During that time I got to know him and his health well as a general practitioner.
So it came as a shock when a letter arrived from the hospital informing him that he had been diagnosed with stage four pancreatic cancer at the age of 77. cancer.
He was extremely ill at the time and unfortunately died within a few months.
I immediately looked through his notes again. Had we missed something?
If he had come to the operating room months earlier with unexplained indigestion weight lossnausea or fatigue – vague complaints that, in retrospect, could have been the first signs of his cancer?
I couldn’t find anything.
Alan’s case illustrates the terrifying truth about pancreatic cancer. It can strike with virtually no warning and cause few obvious symptoms until it has already spread and become much more difficult to treat.
But then I think of another patient, Leroy – not his real name either.
Pancreatic cancer can strike with virtually no warning and cause few obvious symptoms until the disease has already spread and becomes much more difficult to treat
He was a cheerful, generally healthy man in his late sixties who came in every year for his flu shot. He was not overweight, did not smoke and ate quite healthily. Other than the high blood pressure, there was little of note about his medical history.
Then a routine blood test revealed something unexpected: he had developed diabetes.
That in itself was not exceptional. Type 2 diabetes is very common. But Leroy didn’t look like the typical patient I would expect to develop it. He wasn’t overweight, there was no family history of the condition and when we spoke he said something else: he had actually lost weight in recent weeks.
That combination bothered me.
Further investigation eventually revealed the cause. Leroy had pancreatic cancer.
His tumor could not be surgically removed, but because we discovered it relatively early, he was able to receive other treatment and enjoy several more years with his family.
These two men illustrate something important about one of the most brutal forms of cancer I encounter as a physician.
Pancreatic cancer kills about three-quarters of patients within a year of diagnosis, and its reputation as a ‘silent killer’ is not entirely unjustified. The initial symptoms may be absent or so vague that neither the patient nor the doctor has any clear reason to suspect cancer.
But I’m afraid we’ve allowed that message to become too simplistic.
Because pancreatic cancer can give us clues. And sometimes, as with Leroy, the important warning sign isn’t a dramatic symptom at all. It’s just that something about a patient’s health suddenly no longer makes sense.
These are the changes that I pay attention to as a general practitioner.
In Leroy’s case, it was the sudden development of diabetes that first raised the alarm.
And his experience is not unusual. Research shows that approximately one in 100 people with new-onset diabetes will be diagnosed with pancreatic cancer within three years.
I don’t want people with newly diagnosed diabetes to panic. Type 2 diabetes is common and in the vast majority of cases the cause will not be a tumor.
General practitioner, author and presenter Dr. Philippa Kaye
But if someone develops diabetes later in life without the risk factors we usually expect – especially without being overweight or with a family history – then I want to know why.
If they unexpectedly lost weight, like Leroy, I would become even more suspicious.
There is a biological reason for this. The pancreas is a gland that produces insulin – the hormone that helps regulate blood sugar levels.
A tumor can disrupt this process, causing blood sugar levels to rise and, in some cases, diabetes to develop before the more recognizable symptoms of pancreatic cancer appear.
Common type 2 diabetes tends to develop gradually, often over several years. Many people have no obvious symptoms at all and are only diagnosed after a routine blood test.
But diabetes linked to pancreatic cancer may behave differently. Blood sugar levels can rise quickly, within weeks or months, and can be unexpectedly difficult to control.
In some patients, levels continue to rise despite treatment, meaning they require increasingly powerful medications.
It is also important to know that although pancreatic cancer can cause diabetes, having long-term type 2 diabetes itself is associated with an increased risk of developing pancreatic cancer.
Research shows that people who have had type 2 diabetes for more than five years have almost twice the risk of pancreatic cancer compared to people without diabetes.
Again, that needs perspective: Pancreatic cancer remains rare, so the vast majority of people with diabetes will never develop it.
What worries me more as a GP is a sudden, inexplicable change. If someone’s diabetes has been well controlled for years, but their blood sugar levels suddenly start to rise despite treatment, requiring stronger medications or increasing the dose of insulin, I would want to understand why.
However, changes in blood sugar levels aren’t the only early warning sign that can easily be overlooked. Some of the most helpful clues may be visible when you go to the toilet.
It is understandable that patients do not always like to talk to their GP about their bowel movements. But a persistent change in what’s normal for you – especially a change that lasts several weeks – is a symptom I want to know more about.
The pancreas produces enzymes that help us digest food, especially fats. If a tumor interferes with this process, the stool may become unusually greasy or oily, pale, foul-smelling, and prone to floating in the toilet.
There is one more change we should pay attention to. A tumor can block the flow of bile to the intestine. Without the pigments in the bile that normally give feces their brown color, they can become unusually pale or even clay-colored.
At the same time, the urine may become noticeably darker. Research into symptoms recorded in primary care has suggested that dark urine may appear months before the diagnosis of pancreatic cancer.
Finally, many patients with pancreatic cancer describe some type of back pain as one of the first symptoms that they initially dismissed.
Of course, back pain is extremely common and, as with diabetes and changes in bowel habits, in the vast majority of cases it will have nothing to do with pancreatic cancer.
But there is a specific pattern that patients should be aware of.
The pain may start in the upper abdomen and appear to penetrate or radiate to the back. Some patients find that it gets worse after eating or lying flat, while sitting or leaning forward can bring relief.
This can happen because a growing tumor is pressing on nerves and other structures around the pancreas, with eating or changes in position changing that pressure.
None of the symptoms I’ve described automatically mean pancreatic cancer. But we need to stop simply describing pancreatic cancer as a disease without early warning signs.
Yes, it can be frighteningly difficult to detect it early. But difficult is not the same as impossible. If something about your health changes unexpectedly, persists, or simply doesn’t make sense, don’t ignore it.
Tell your doctor as this can lead to a quick diagnosis and a much better outcome.
