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The PancChat Podcast is a collaborative effort from Let’s Win Pancreatic Cancer and the Pancreatic Cancer Action Network (PanCAN), inspired by the long-running #PancChat Twitter/X chat.
Hosted by award-winning journalist Alisyn Camerota, each episode features conversations with leading researchers, clinicians, patients, and advocates who are shaping the future of pancreatic cancer care and research. Together, we deliver expert insights, personal journeys, and the latest breakthroughs—bridging the gap between science and lived experience.
Whether you’re a patient, caregiver, healthcare professional, or simply want to learn more, join us to connect, be inspired, and learn how you can help to accelerate progress in the fight against pancreatic cancer.
Cindy Gavin: Hi everyone, and welcome back. I'm Cindy Gavin, CEO and co-founder of Let's Win Pancreatic Cancer. On today's podcast, we take a closer look at the link between diabetes and pancreatic cancer.
Over to you, Alisyn.
Alisyn Camerota: Hi, everyone. Welcome to this episode of PancChat. I'm Alisyn Camerota, your host. Today's episode focuses on the relationship between diabetes and pancreatic cancer. We'd like to thank our sponsor, Revolution Medicines.
Let me introduce our guest today: Dr. Suresh Chari. Dr. Chari is a professor of medicine at MD Anderson Cancer Center in Houston, Texas. He is president of the International Association of Pancreatology. His NIH-funded research has focused on new-onset diabetes as an early marker of pancreatic cancer.
Dr. Chari is a PanCAN research grant recipient, a member of PanCAN's Scientific and Medical Advisory Board, and principal investigator for the PanCAN Early Detection Initiative.
Welcome to PancChat, Dr. Chari.
Dr. Suresh Chari: Thank you, Alisyn. Thank you for having me.
Alisyn Camerota: Great to have you here. This is a very important topic that many people — even some doctors — don't yet fully appreciate: the connection between diabetes and pancreatic cancer. Most people with diabetes do not develop pancreatic cancer. However, almost one in four people diagnosed with pancreatic cancer are also diagnosed with diabetes, either long-standing or newly diagnosed. Can you explain the connection between diabetes and how it impacts the pancreas?
Dr. Suresh Chari: It's a complex interaction between diabetes and pancreatic cancer. For a long time, the understanding was that diabetes weakly promotes the development of pancreatic cancer — that link is pretty small. If the average population has a risk of 1, those who have diabetes have a risk of 1.5 to 1.8. So long-standing diabetes slightly increases the risk of pancreatic cancer. That's of interest to us, but not for early detection, because that link is too weak.
But in the course of pancreatic cancer, as it grows, it disturbs glucose metabolism in nearly everybody who gets it. About 85% of people with pancreatic cancer have a disturbance in glucose metabolism, seen as a rise in fasting glucose or A1C. Some of those people already had diabetes, and their diabetes gets worse — starting about a year to a year and a half before the cancer diagnosis. Others who didn't have diabetes before will develop it close to that same time. So nearly everybody sees a shift in their glucose, but those who already have diabetes see a significant worsening close to diagnosis, and some people develop new diabetes before the pancreatic cancer diagnosis.
Alisyn Camerota: This is very personal for me, Dr. Chari, because something like this happened to my husband. His primary care physician noticed that his blood sugar was going up and told him he was at risk of becoming pre-diabetic — I'm going from memory, so I hope I'm being specific enough. His doctor suggested he change his diet, which he did, but his doctor didn't take the extra step of connecting rising blood sugar to pancreatic cancer risk. Looking back, I feel like we could have caught it a year and a half earlier, if that's the timeline you're describing.
I don't want to cast blame, since, as you said, it's a small connection — but when doctors see someone's blood sugar suddenly rising, even prediabetes, should they start investigating what's happening in the pancreas?
Dr. Suresh Chari: It's more complicated than that, because diabetes in general tends to get worse over time. For people who already have established diabetes, we still need to understand how to tell whether their worsening is due to cancer versus the natural progression of the disease — there's work to be done there. What we've shown is that when you look back in time at pancreatic cancer patients' blood sugar, there's a clear inflection point starting about 18 months before diagnosis. But when you compare that to how many people in the general population also see worsening diabetes, that's where it gets hard to tell the two apart.
That's one group. The second group is people who had no diabetes before, and then see a rise in glucose — for them, we have some approaches to try, though even then the risk is small. We recently completed a study of more than 18,000 patients with new-onset diabetes and looked at what proportion developed cancer. It was less than 1%. But that's still six to eight times higher than expected in the general population — a significantly higher risk for patients with new-onset diabetes. Still, more work is needed before we tell primary care physicians to image everyone with new-onset diabetes; we need to better understand who among that 1% is most likely to have pancreatic cancer.
That work is ongoing, and we hope to have a strategy in place — which is what the Early Detection Initiative is about — using imaging in this group. We can get into that in a bit. But at this point, we understand the risk in patients with new-onset diabetes, and we're working on how to further narrow that population before recommending a CT scan or endoscopic ultrasound. It's a work in progress, but the data clearly shows this group has a much higher risk of pancreatic cancer than the general population.
Alisyn Camerota: It's actually comforting to hear how low the numbers are — I've kicked myself over this, but I couldn't have known, and I'm still a little frustrated with his doctor for not going a step further. But what harm would there be in investigating further, even though it's less than one percent of people who suddenly —
Dr. Suresh Chari: That's a very good question — one we've had to grapple with. First is cost: the number of people who'd get imaged would be extraordinary. Second, every time you do a CT scan, you tend to pick up something else — it's like imaging 20 organs at once, and some organ will show a finding that requires further testing that ultimately leads nowhere. That's the “incidental finding” dilemma. But the most important harm, I'd say, is that it can be falsely reassuring.
At 18 months, or even 12 months, before diagnosis, more than half of CT scans will look normal. To address that, we've looked at an AI read of the CT scan. When AI reads the scan, it picks up on abnormalities in 80% of the visually normal CT scans in people who go on to be diagnosed. So we're making progress on identifying pancreatic cancer even when the CT looks normal. But today, if you went out and got CT scans done, the results would be disappointing in terms of how poorly CT picks up cancer at this stage. It's a great challenge.
Alisyn Camerota: That's very good information to have. I appreciate you explaining that, because there's always regret with pancreatic cancer — with any cancer, really — wondering, did we do enough? So thank you for explaining that.
Dr. Suresh Chari: It's not yet ready for prime time, but the data is compellingly building toward that point.
Alisyn Camerota: I'm happy to hear we're moving in that direction. So, on the flip side — for people already diagnosed with diabetes, what symptoms or changes should they watch for that might indicate pancreatic cancer?
Dr. Suresh Chari: The haystack is big, and finding the needle in it has always been a challenge. Most people who have what I'm about to describe will not have pancreatic cancer — that's the problem. But the classic signature of pancreatic cancer is: you're losing weight, but your A1C is going up. You lose 20 pounds, you're feeling great, you pat yourself on the back for losing the weight — but your A1C rises from 6.7 to 7.0.
Your doctor's normal response would be, “Good job, keep doing what you're doing.” That's where we think the opportunity lies — in differentiating these two situations. When cancer causes diabetes, it also causes weight loss, whereas normally, weight loss should improve diabetes, especially after losing 20 pounds. We think we can exploit that paradox and bring it into clinical use.
Alisyn Camerota: That's helpful.
Dr. Suresh Chari: But technically, we're looking at a phase in the cancer's growth when the patient is feeling well — so nobody suspects cancer, and nobody recommends a CT scan. It's a difficult phase because everyone is happy about losing weight, and unless there are biomarkers or something else to guide next steps, by the time symptoms develop, it's too late.
Alisyn Camerota: When you say biomarkers — if a CT scan is too expensive or opens up too many incidental findings, could someone diagnosed with prediabetes and rising blood sugar just get a blood test, like one that measures CA 19-9?
Dr. Suresh Chari: The challenge with biomarkers is that they're most useful in the last six to eight months before diagnosis — they're volume-dependent, so as the tumor grows, the markers rise. Go back further than that — to 18 months — and while some will be positive, the majority will be negative. Nothing about pancreatic cancer is easy. Biomarkers have repeatedly shown that how well they perform at the time of a clinical diagnosis tells you nothing about how they'll perform a year earlier. What we've seen so far is that whatever performs well at diagnosis still fails at minus one year.
Alisyn Camerota: Wow — that's the same as—
Dr. Suresh Chari: —a CT scan. Why is a CT scan normal a year before? Same reason a biomarker is normal a year before: tumor volume grows rapidly closer to diagnosis, and that's what drives these tests positive. When the tumor is small — and most beneficial to catch — these signals are absent.
Alisyn Camerota: I didn't know that — that's challenging. Is there a difference in risk between type 1, type 2, and type 3c diabetes? I'm not even sure I know the difference.
Dr. Suresh Chari: Until recently, type 1 patients often didn't survive long enough to get pancreatic cancer — you'd need to reach your seventies, since type 1 starts in childhood. So the cohorts haven't been big enough to get a clear signal, and we don't have a clear answer for type 1.
Type 3c is a term that's difficult to apply in this context, because there's no test for it. Type 3c means diabetes caused by some disease of the pancreas, which, in this case, would literally mean diabetes caused by pancreatic cancer. But we don't have a way to diagnose that directly. So type 3c is really a label for diabetes caused by diseases of the pancreas, without a specific test behind it. We think the risk isn't high in type 1; it exists in type 2, which we've discussed; and type 3c is essentially the cancer-induced diabetes we've been talking about. If you have new-onset diabetes, a proportion of that group has type 3c — cancer-induced diabetes — and that turns out to be less than 1%.
Alisyn Camerota: In terms of this connection, tell us about the research and clinical trials happening right now to give us more visibility into how this works.
Dr. Suresh Chari: We're involved in two trials. One is the Early Detection Initiative you mentioned, sponsored by PanCAN. It grew out of an NIH-sponsored study identifying new-onset diabetes cases; we piggybacked on that by saying: now that we've found these patients, let's image them.
To decide whom to image, we use a score called EndPac — Enriching New-Onset Diabetes for Pancreatic Cancer. It leverages the paradox between weight loss and rising glucose, combined with age. You look at the difference between last year's glucose and this year's, last year's weight and this year's, and the patient's age, and that creates a score. Above a certain cutoff, the score doubles — sometimes triples — the risk of pancreatic cancer, depending on which cutoff you use. We chose the cutoff that doubles the risk, and the goal was to do a CT scan on all these patients to look for pancreatic cancer.
The challenge we keep facing across all our studies is that patients don't come in for these studies — they're feeling well and have no reason to go looking for cancer. They're also processing a life-changing diagnosis of diabetes, so they have little interest in pursuing something they don't feel yet, and their primary care physicians don't push them toward a CT scan either.
So this trial has become a test of validating the EndPac score, and our preliminary results show that it does double the risk of pancreatic cancer. We've imaged 200 patients so far, but that needs to expand to tell us more. EDI 2.0, an advanced version of this trial, now uses AI-assisted CT — the same CT scans done in patients with a high EndPac score will also be read by AI, so we can catch pancreatic cancer as soon as the CT is done, rather than waiting for it to become visible, which would be too late. That trial is ongoing now at Mayo Clinic, with Dr. Goenka as principal investigator. It's an AI-assisted CT protocol for patients with new-onset diabetes and a high EndPac score.
Alisyn Camerota: So you've just outlined the PanCAN Early Detection Initiative and the Mayo Clinic trial that builds on it.
Dr. Suresh Chari: Yes. There's also a trial in Australia doing the same thing we did in EDI, and one in the UK reproducing this new-onset-diabetes-followed-by-CT-scan approach. Multiple centers are trying to reproduce it — some are using a biomarker as the next step rather than a CT scan. A novel biomarker is being tested in new-onset diabetes patients to see if it can help decide whether a CT scan is warranted. So different approaches are being tried, all built around new-onset diabetes, but with slightly different methods for narrowing down who to test.
Alisyn Camerota: Everyone recognizes that early detection is so challenging with this disease, and yet it's one of the answers.
Dr. Suresh Chari: Yes. And we recognize that new-onset diabetes, as you mentioned, is a smaller slice of all pancreatic cancers. But if we extend this strategy to patients with established diabetes that's suddenly deteriorating, or people with new-onset but advanced prediabetes, we end up capturing nearly 60% of pancreatic cancer cases. So our goal is to expand the strategy beyond new-onset diabetes to other abnormalities that cancer causes, and hopefully reach a larger share of pancreatic cancer patients.
Alisyn Camerota: That would be great. So those are the major research efforts and clinical trials we should know about. What have I missed? What else should we cover?
Dr. Suresh Chari: Let me step back. Most people running clinical trials in early detection are focused on either familial pancreatic cancer or cystic lesions of the pancreas — two conditions that predispose people to pancreatic cancer, where something is visible on imaging and can be followed: a precancerous lesion visible on CT or MRI. In our case, when you do a CT beforehand, you don't see anything — these cancers are sporadic. There's no family history, no cysts. That's 85% of all pancreatic cancers, and there's been no strategy for this group beyond what I've described.
There have been strategies in place for 25 to 30 years for familial pancreatic cancer and cystic lesions. Our goal has been to focus on the larger share of pancreatic cancers that have neither a cyst nor a family history.
Alisyn Camerota: Thank you for all this information. We really appreciate you being on PancChat today.
Dr. Suresh Chari: Take care. Thank you.
Alisyn Camerota: And thanks to all of our listeners — wonderful to have you here. We also want to thank our sponsor, Revolution Medicines. I'm your host, Alisyn Camerota. I'll see you next time on PancChat.
Julie Fleshman: Hi, I'm Julie Fleshman, President and CEO of PanCAN. If you or a loved one has been diagnosed with pancreatic cancer, navigating this journey can feel overwhelming, but you don't have to do it alone. To learn more about the latest breakthroughs in pancreatic cancer treatment, explore the resources available for patients and caregivers.
You can find PanCAN at pancan.org and Let's Win at letswinpc.org. Together, PanCAN and Let's Win are committed to guiding you through every step of the pancreatic cancer journey, offering support, information, and hope.
In our next episode, we'll be speaking with Dr. Afreen Shariff on managing diabetes throughout pancreatic cancer treatment.
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