PATIENTS WITH PANCREATIC CANCER will often learn after surgery that their cancer is more advanced than what they were initially told, a research letter published Sept. 5 in JAMA reported.

Pancreatic ductal adenocarcinoma (PDAC) is the most common type of pancreatic cancer. It is an aggressive disease, with an average five-year survival rate of less than 10%. However, patients can have a better prognosis when the cancer is caught early.

People with PDAC are initially given a clinical stage, a description of the cancer’s stage based on medical imaging, with stage I having the best prognosis and stage IV the worst. After surgery to remove the tumor, the health care team is able to use information gathered during the operation to give a more complete description called the pathological stage. According to the JAMA letter, many people who are initially told they have PDAC with a clinical stage of I or II will learn after surgery that they have a later stage of the disease.

The researchers reviewed data from more than 48,000 patients in the National Cancer Database who underwent pancreatic cancer surgery between 2004 and 2020. They discovered that 78.4% of patients with stage I and 29.2% of patients with stage II PDAC were upstaged following surgery. Most patients told they had stage I were updated to stage IIB, in which the cancer is typically found in one to three lymph nodes.

Lymph nodes are small, bean-shaped structures of the immune system that filter foreign substances, such as cancer cells and infections. They are often the first places that cancer cells can be found outside of the original tumor, which makes them important for determining the cancer stage.

Conan Kinsey, an oncologist and researcher at the University of Utah’s Huntsman Cancer Institute in Salt Lake City, who was not involved with the study, says that many patients are diagnosed with PDAC at later stages when it has already metastasized, or spread, to other parts of the body or is involved with major blood vessels that make it difficult to remove. “Pancreatic cancer readily spreads to other parts of the body, such as the liver and lungs, at which point [it] cannot be cured, but only controlled,” he says.

How Doctors and Researchers Are Addressing PDAC Upstaging

The study’s researchers report that the issue with PDAC upstaging could cause “serious implications for treatment.” If PDAC has metastasized, the cancer may be deemed unresectable—meaning that the pancreatic tumor cannot be removed by surgery. In these instances, understaging may lead to missed opportunities for more effective therapies such as multimodal therapy—a combination of surgery, chemotherapy and radiation—a retrospective cohort study published in February 2019 in Surgery reported.

Kevin El-Hayek, a surgical oncologist at MetroHealth in Cleveland, Ohio, says upstaging of early-stage PDAC is well-known among health care providers and is discussed with patients.

“When I counsel patients who have early-stage PDAC, I tell them that even though the CT or MRI doesn’t show disease in the lymph nodes, most of the time, they will have disease in the lymph nodes on the final pathology,” El-Hayek, who was not part of the JAMA study, says. “We don’t know the final stage until after surgery.”

According to Kinsey, researchers are looking for ways to get more accurate information on the cancer before getting to surgery. “Further studies are examining if circulating tumor DNA levels correlate to cancer involvement of lymph nodes to better stage patients,” he says. Circulating tumor DNA levels are a way to measure the presence of cancer in the blood. “Additionally, there may be proteins in the bloodstream that, when elevated, would indicate lymph node involvement with pancreatic cancer in patients that are being investigated.”

What Patients Can Do About Pancreatic Cancer Staging

El-Hayek recommends that patients who know or suspect they have PDAC push for referrals to get specialized care. “They need to encourage their primary care providers to push for early referrals to surgery and medical oncology to start their treatment pathways,” he says. “Since it is an aggressive cancer, early treatment is crucial.”

Kinsey also suggests that PDAC patients seek care from high-volume cancer centers (facilities that treat patients for specific types of cancer) for surgery. “It has been demonstrated that patients’ outcomes are better if they are surgically treated at a high-volume center,” he says. “Additionally, clinical trials may be available that incorporate new strategies with standard-of-care treatments at high-volume centers.”

Taneia Surles is an Alabama-based health writer, editor, and public health professional. You can also find her work in Healthline, Health, Patient Power, and AARP.