The stage of a pancreatic cancer (extent of disease at diagnosis) is the most important factor in choosing treatment options and predicting a patient's outlook. The tests described above (see the section, "How is pancreatic cancer diagnosed?") are the ones used to determine the stage of the cancer.

The American Joint Committee on Cancer (AJCC) TNM staging system

A staging system is a standardized way in which the cancer care team describes the extent that a cancer has spread. The main system used to describe the stages of cancers of the exocrine pancreas is the American Joint Committee on Cancer (AJCC) TNM system. The TNM system for staging contains 3 key pieces of information:

• T describes the size of the primary tumor(s), measured in centimeters (cm), and whether the cancer has spread within the pancreas or to nearby organs.

• N describes the spread to nearby (regional) lymph nodes.

• M indicates whether the cancer has metastasized (spread) to other organs of the body. (The most common sites of pancreatic cancer spread are the liver, lungs, and the peritoneum - the space around the digestive organs.)

Numbers or letters appear after T, N, and M to provide more details about each of these factors:

• The numbers 0 through 4 indicate increasing severity.
• The letter X means "cannot be assessed" because the information is not available.
• The letters "is" mean "carcinoma in situ," which means the tumor is contained within the top layers of pancreatic duct cells and has not yet invaded deeper layers of tissue.

T categories

• TX: The main tumor cannot be assessed.
• T0: No evidence of a primary tumor.
• Tis: Carcinoma in situ (very few tumors are found at this stage)
• T1: The cancer has not spread beyond the pancreas and is smaller than 2 cm (about ¾ inch) across.
• T2: The cancer has not spread beyond the pancreas but is larger than 2 cm across.
• T3: The cancer has spread from the pancreas to surrounding tissues near the pancreas but not to major blood vessels or nerves.
• T4: The cancer has extended further beyond the pancreas into nearby large blood vessels or nerves.

N categories

• NX: Regional lymph nodes cannot be assessed.
• N0: Regional lymph nodes (lymph nodes near the pancreas) are not involved.
• N1: Cancer has spread to regional lymph nodes.

M categories

• MX: Spread to distant organs cannot be assessed.
• M0: The cancer has not spread to distant lymph nodes (other than those near the pancreas) or to distant organs such as the liver, lungs, brain, etc.
• M1: Distant metastasis is present.

Stage grouping for pancreatic cancer

After the T, N, and M categories of the cancer have been determined, this information is combined to assign a stage, which is expressed in Roman numerals I through IV. The process of assigning a stage number based on TNM stages is called stage grouping.

• Stage 0 (Tis, N0, M0): The tumor is confined to the top layers of pancreatic duct cells and has not invaded deeper tissues. It has not spread outside of the pancreas. These tumors are sometimes referred to as pancreatic carcinoma in situ or pancreatic intraepithelial neoplasia III (PanIn III).

• Stage IA (T1, N0, M0): The tumor is confined to the pancreas and is less than 2 cm in size. It has not spread to nearby lymph nodes or distant sites.

• Stage IB (T2, N0, M0): The tumor is confined to the pancreas and is larger than 2 cm in size. It has not spread to nearby lymph nodes or distant sites.

• Stage IIA (T3, N0, M0): The tumor is growing outside the pancreas but not into large blood vessels. It has not spread to nearby lymph nodes or distant sites.

• Stage IIB (T1-3, N1, M0): The tumor is either confined to the pancreas or growing outside the pancreas but not into nearby large blood vessels or major nerves. It has spread to nearby lymph nodes but not distant sites.

• Stage III (T4, Any N, M0): The tumor is growing outside the pancreas into nearby large blood vessels or major nerves. It may or may not have spread to nearby lymph nodes. It has not spread to distant sites.

• Stage IV (Any T, Any N, M1): The cancer has spread to distant sites.

Other factors

Although not formally part of the TNM system, other factors are also important in determining prognosis (outlook). The grade of the cancer (how abnormal the cells look under the microscope) is sometimes listed on a scale from G1 to G4, with G1 cancers looking the most like normal cells and having the best outlook.

For patients who have surgery, another important factor is the extent of the resection -- whether or not all of the tumor is removed. This is sometimes listed on a scale from R0 (where all visible and microscopic tumor was removed) to R2 (where some visible tumor could not be removed).

Terms commonly used to describe pancreatic cancer

From a practical standpoint, how far the cancer has spread often can't be determined accurately without surgery. That's why doctors often use a simpler staging system, which divides cancers into groups based on whether or not it is likely they can be removed surgically. These groups are called resectable, locally advanced (unresectable), and metastatic. These terms can be used to describe both exocrine and endocrine pancreatic cancers.

Resectable

If the cancer is only in the pancreas (or has spread just beyond it) and the surgeon can remove the entire tumor, it is called resectable.

Locally advanced (unresectable)

If the cancer has not yet spread to distant organs but it still can't be completely removed with surgery, it is called locally advanced. Often the reason the cancer can't be removed is because too much of it is present in nearby blood vessels. Since the cancer cannot be removed entirely by surgery, it is also called unresectable. For these tumors, surgery would only be done to relieve symptoms or problems like a blocked bile duct or intestinal tract.

Metastatic

When the cancer has spread to distant organs, it is called metastatic. Surgery may still be done, but the goal would be to relieve symptoms, not to cure the cancer.

Pancreatic cancer survival by stage

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Of course, some people live much longer than 5 years. Five-year rates are used as a standard way of discussing prognosis. Five-year relative survival rates compare the survival of people with the cancer to the survival for people without the cancer. Since some people will die of causes other than cancer, this is a way to look only at deaths from the cancer in question. The 5-year relative survival rate is a more accurate way to describe the outlook for patients with a particular type and stage of cancer. Remember that these numbers are based on patients that were diagnosed at least 5 years ago. Improvements in treatment since that time may have improved survival for those diagnosed more recently.

5-year relative survival for exocrine pancreatic cancer

Overall, about 20% of people with pancreatic cancer live at least 1 year after diagnosis, while less than 4% will be alive after 5 years.

Pancreatic neuroendocrine cancers are not staged like cancers of the exocrine pancreas. Instead the statistics are broken down into different sages: localized (only in the pancreas), regional (spread to nearby lymph nodes or tissues), and distant (spread to distant sites, such as the liver).

Relative 5-year survival for pancreatic neuroendocrine tumors

The relative 5-year survival for all patients taken together is 42%.

Last Medical Review: 10/13/2009
Last Revised: 10/13/2009