Dr. Patrick Jackson: Pancreatic Cancer and the Latest Treatments - [Video Transcription]
- Do I have pancreatic cancer?
Most patients show up in my office or to some physician’s office with some vague symptoms. It may be abdominal pain or all of a sudden they have become jaundiced and they notice it in their eyes. It could be weight loss or swelling in their abdomen. Through that process, they will get a CT scan. That scan will usually show a mass in the pancreas. Then they will be referred or sent to my office. So, most patients who show up in my office don’t have a documented diagnosis of pancreatic cancer. They just have a mass in their pancreas. Most of the discussion is about what causes masses in the pancreas. Unfortunately, if it is a solid mass that means there is a very very high likelihood that it is pancreatic cancer. By a solid mass, I mean that the CT scan showed something solid more like a golf ball than cystic which would be more like a water balloon. Cystic things are fluid filled and solid things are not. So solid masses in the pancreas are incredibly likely to be pancreatic cancer. Although, most of the patients who show up in my office don’t have that documented under a microscope as proven cancer. - What did I do to get pancreatic cancer?
There is no real way to avoid this as opposed to for instance colon cancer where regular screening colonoscopies can reduce your risk of getting colon cancer. There is nothing that you can actively do except try to eliminate things that are risk factors in your life. The risk factors are smoking. Smoking significantly increases your risk of developing a pancreatic cancer among other cancers. The other risks are obesity and a sedentary lifestyle, not being active not doing a lot physical activity. Those are three things that you can choose to do to try and reduce your risk, but you can’t eliminate your risk of pancreatic cancer. - Are my children at risk?
If you have developed pancreatic cancer, your children are about twice as likely as an average person in the United States to develop pancreatic cancer. That is as long as you don’t have a long family history of multiple generations of people who have developed pancreatic cancer. If you had a number of people in your family who have developed pancreatic cancer, then you are at a much higher risk because you are likely to have a genetic predisposition to developing it. Without that family history, your children are about twice as likely to develop pancreatic cancer. - What are my options?
Your treatment options are to just get chemotherapy or surgery with chemotherapy. Surgery with chemotherapy has a much longer survival. In fact, it is only a small population of patients that present with pancreatic cancer who are going to live a very long time all of those have gotten operations. So what I tell people in the office is that you want to do everything you can to try to get an operation for pancreatic cancer because that puts you in the subset to have a longer life expectancy. - How do you get to have surgery?
Your ability to get an operation is going to be based on your CT scan that you will receive prior to coming to a surgeon’s office. There are three things that we look for. These three criteria are what we would consider absolute contraindications to an operation. Meaning if you have any of these three, then you can’t get an operation for pancreatic cancer. Those three are: spread to another organ like the liver which is the most common site of spread for pancreatic cancer, involvement of an artery that runs right through the pancreas, or involvement of the corresponding vein that runs right through the pancreas. Any of those three are considered contraindications to an operation which means I can’t offer you an operation. There are however treatment strategies to try and shrink the tumor off the artery or shrink the tumor off the vein. Therefore, involvement of a multidisciplinary team is to the patient’s benefit. A multidisciplinary team involves surgeons, medial oncologists, and radiation therapists. Each one of those three having their input to try to get the patient to the operating room because it is well known that the only patients who have a long term survival from pancreatic cancer are those who have gotten an operation. - What is your experience with pancreatic surgery?
It has been well shown in the literature and medical studies that experience matters. The higher volume of surgery you do the better your outcome is going to be. This is only common sense. The more pancreatic surgery you do the better you are at it. The literature breaks down volume of surgery into people who do it only once a year, people who do it more than once a year but less than once a month, and people who do it more than once a month. That is a hospital experience. That has also shown up as individual surgeon experience. We do between 50 to 100 Whipple procedures here a year which would qualify us as a very high volume center in that a high volume center is more than ten. - What are the options for treatment?
All of the treatment for pancreatic cancer is considered multi-modal therapy. There is no one treatment that is universal. We use surgery, chemotherapy, and radiation in some combination. Unfortunately, most patients who have pancreatic cancer don’t qualify for surgical intervention. I say that is unfortunate because the people who are going to have a longer survival are those that are eligible for surgery. All patients regardless of whether or not they have gotten an operation will benefit from chemotherapy and some will also benefit from radiation. - If I'm diagnosed with pancreatic cancer, what are you going to do?
People who come to my office with pancreatic caner will be offered an operation if they don’t have any of those three absolute contraindications with follow up therapy meaning chemotherapy and sometimes radiation depending upon the patient and the actual details of what the cancer looks like under the microscope. People who have no evidence of spread to another organ like the liver, but have involvement of the vein or artery will undergo chemotherapy and radiation in an attempt to shrink the tumor off of either of those structures and then proceed to the operating room. If there is spread to another organ, you can not get an operation for pancreatic cancer that will significantly extend your life. The only operations then are considered palliative. By palliative we mean improving your symptoms, but not extending your life. - What happens if my pancreatic cancer has spread to other organs?
If there is spread to another organ, you can not get an operation for pancreatic cancer that will significantly extend your life. The only operations then are considered palliative. By palliative we mean improving your symptoms although not extending your life. Just recently, we started a trial involving the use of CyberKnife in conjunction with regular chemotherapy and some standard radiation in an attempt to improve outcomes from that group that we are trying to shrink the tumor off the artery/vein. So in people who have involvement in an artery or a vein that goes through the pancreas, we will discuss their case at a multidisciplinary conference involving medical oncologists and radiation therapists and decide if they are the appropriate person to put into the study in order to try and shrink the tumor off those structure to get them to the operating room. - How can CyberKnife be part of my treatment for pancreatic cancer?
Just recently, we started a trial involving the use of CyberKnife in conjunction with regular chemotherapy and some standard radiation in an attempt to improve outcomes from that group that we are trying to shrink the tumor off the artery or vein. So in people who have involvement of an artery or vein that goes through the pancreas, we will discuss their case at a multidisciplinary conference involving medical oncologists and radiation therapists and decide if they are the appropriate person to put into the study in order to try and shrink the tumor off those structures to get them to the operating room. - What are the risk factors?
Risk factors for developing pancreatic cancer are smoking, age, obesity, history of chronic pancreatitis, sedentary lifestyle, and some people say various diets slightly increase your risk but this has been debated. African-Americans and males are slightly more likely to develop pancreatic cancer. - What is the benefit of coming to Georgtown for pancreatic cancer treatment?
The benefits focus on two different aspects of treatment. One is experience because it is clear that not only with surgery but experience with chemotherapy and radiation matters in the management of pancreatic cancer in the outcome. Also, the fact that Georgetown has a multidisciplinary team approach. When you see any one of the members of the team your case will be discussed among the multiple members of the team. Those team members include surgeon, medical oncologists who give chemotherapy, radiation therapy, gastroenterologists who help us make the diagnosis and take care of patients after surgery, and the radiologists who provide us the images to determine whether or not somebody will benefit from an operation. Once a week, we have a multidisciplinary meeting in which pancreatic cancer and other gastrointestinal cancers are discussed. - Personal Note
I love what I do, but that is because I get so emotionally vested with my patients. What I get out of medicine is the bonding with patients and taking them through a challenging diagnosis. Pancreatic cancer easily fits that mold. Sometimes we are going to be successful and sometimes we are not. Taking the team approach with the patient rather than just telling them what they need done. Forming a bond with the patient and the family member to get them through therapy and try to achieve those goals is what I get out of medicine.