Pancreatic Cancer Care in 2019

November is Pancreatic Cancer Awareness Month. Surgical oncologist Jennifer Tseng, MD, MPH, was interviewed about the state of pancreatic cancer care. Dr. Tseng is the Surgeon-in-Chief at Boston Medical Center and the James Utley Professor and Chair of Surgery at Boston University School of Medicine. Dr. Tseng’s main clinical interests are pancreatic cancer and other malignancies of the upper gastrointestinal tract.

 

Has there been any progress in diagnosing pancreatic cancer earlier?

There has, in part because of advances in imaging. We’re finding tumors at more premalignant stages and finding cystic tumors, some of which can degenerate to cancer, earlier. We’re also finding some neuroendocrine tumors, a more curable form of pancreatic cancer, at an earlier stage and are able to remove them, often by minimally invasive means.

How would someone know that they might have pancreatic cancer?

We have to remember that there are only about 50,000 new cases of pancreatic cancer—adenocarcinoma, the most common form—each year in the U.S. Patients can also be diagnosed with premalignant cancer and cysts that require surgery. There are nonspecific symptoms that should worry people, not necessarily because they are signs of pancreatic cancer. Things like weight loss and fatigue. Certainly if you notice jaundice, which is a yellowing of the skin or eyes, that is concerning. Feelings of pain and bloating tend to come later. But basically, if someone is not feeling well, they should go to see their primary care doctor, who may decide to order imaging or to refer the patient to a specialist. But we have to be careful not to do too much imaging because the vast majority of people do not have pancreatic cancer.

Does pancreatic cancer have a genetic component?

Less than 10% of pancreatic cancers have a genetic component, so a relatively small segment of the population falls into this category. But in these families, it is definitely worth seeing a pancreatic cancer subspecialist, with consideration of undergoing genetic counseling and testing. If it’s prudent, family members can be screened with endoscopic ultrasound, potentially alternating with MRI.

Is there a connection between pancreatitis and pancreatic cancer?

We know that inflammatory conditions like pancreatitis do predispose cells to going awry and thus developing into cancer. So there is a connection. The number of people who have pancreatitis far outweighs the number of people with pancreatic cancer, so it’s definitely not a one-to-one association, but it is certainly a risk factor. Another thing to keep in mind is that people with pancreatic cancer can be mistaken for people with pancreatitis, so it’s important to know that the two are connected.

Is the Whipple procedure the only surgical treatment for pancreatic cancer?

The Whipple procedure is performed when there’s a tumor that is removable in the head of the pancreas. But patients who have cancer elsewhere, say in the tail of the pancreas, would have a distal pancreatectomy, which is removal of the left side of the pancreas, with or without the spleen.

Which patients are candidates for surgery?

Pancreatic adenocarcinoma needs to be localized in order for a patient to be a candidate for potentially curative surgery. If the cancer has spread to the lymph nodes, as long as the spread is regional, the patient may still be a candidate, but there needs to be no distant spread of the disease to the liver or the lungs, or to other parts of the body.

How many Whipple procedures have you performed?

I’ve been performing this surgery for a long time, so hundreds.

We hear a lot today about the importance of multidisciplinary care. Is that practiced here at BMC in treating pancreatic cancer patients?

Definitely. We now know that one of the most important aspects of treatment is multidisciplinary care, treating patients as a coordinated team. We have a conference every Wednesday morning, where we all come together—surgical oncologists, medical oncologists, radiologists, radiation oncologists, gastroenterologists, pathologists, and trainees—to discuss our patients and decide on the best care plan. We tailor the therapy to the patient.

We often start with neoadjuvant treatment, meaning we start with chemotherapy and/or radiation, and then we restage the tumor. If the cancer is still localized, we proceed with surgery. The reason for this approach is that most recurrences of pancreatic cancer are systemic, meaning that the cancer has spread. Even if you’re able to get the local disease, there are almost always microscopic cells we don’t see at the time that have spread. So if we can give chemotherapy first to get rid of those “foot soldiers,” as I say to my patients, anywhere they are in the body—even if they’re distant—and then do successful surgery, you’re really bettering the odds of a good outcome.

Have there been any recent advances?

We’re in an exciting era for pancreatic cancer. In the ’80s and ’90s, we were all collectively depressed in the field because there were several trials focused on new advances in chemotherapy that failed. But suddenly in the last decade, it’s like a light has come on, and we have all these new, exciting treatments for pancreatic cancer, including targeted therapy such as erlotinib for advanced pancreatic cancer, combination therapy like Folfirinox for preoperative or postoperative treatment of localized pancreatic adenocarcinoma, and peptide receptor radionuclide therapy for neuroendocrine pancreatic cancers. More and more research is coming out that is giving hope to all of us in our field for the future

What about immunotherapy?

Immunotherapy is at a very exciting time in the cancer treatment world. That being said, research is not as advanced for immunotherapy to treat pancreatic cancer as it is for some of the other forms of cancer, such as melanoma. I spent my research postdoctoral training working on dendritic cell vaccines for pancreatic cancer. Today, most immunotherapy for pancreatic cancer should be given in the context of clinical trials. There has been work done at specific centers, such as Johns Hopkins and Penn [University of Pennsylvania], but we’re still on the cusp. A lot of discovery still needs to be made in pancreatic cancer.

What should a patient who is coming to Boston Medical Center for pancreatic cancer treatment know?

They should know that regardless of our subspecialty, we’re all one team centered on caring for that patient. I tell my patients that they’re VIPs. They’re like a rock star who needs an entourage and a VIP bus. Different drivers are required to navigate the unfamiliar terrain that is cancer care. At the beginning, you need your primary care provider [PCP], or potentially, if someone presents in the Emergency Department, an ED physician working with a PCP to be the drivers. Those drivers are going to negotiate through the initial diagnosis and may refer you to a gastroenterologist, an advanced endoscopist, for a biopsy or to insert a stent to relieve symptoms. At this point, the PCP is still on the bus, still fully participating, but the gastroenterologist is driving. If you require chemotherapy, or radiation or surgery, you’re going to need different drivers. When discussion of surgery is on the table, the surgeon—the surgical oncologist or pancreatic surgeon—is the chief driver. The important thing is that everybody else is still on the bus, surrounding that patient with their care, but the different doctors can all confer in real time as to the best route for that particular VIP rock star, the patient. This is what multidisciplinary care is all about and what is embodied in our Wednesday multi conferences. The patient can focus on getting well, and we focus on all of the logistics to get there.

Do patients have an opportunity to participate in clinical trials?

Yes, absolutely. Our Chief of Hematology and Medical Oncology, Dr. Matt Kulke, is a world expert in pancreas tumors, in particular but not limited to neuroendocrine tumors. Dr. Kulke has a wealth of expertise in the area of clinical trials, and I’ve been working with him for many years. We screen all of our patients for clinical trials to see what they might be eligible for, not only here but at other institutions locally and indeed, around the world.

What is the status of pancreatic cancer research at Boston Medical Center (BMC) and Boston University School of Medicine?

Dr. Matt Kulke, whom I mentioned before, has an international reputation in pancreatic cancer research and clinical trials, and he is spearheading all of the efforts taking place here. My own research has been focused on the area of disparities in pancreatic cancer and other related care. We’re working very hard to build models whereby all patients regardless of their socioeconomic status or insurance status are able to get all elements of care. Boston Medical Center is the ideal place for this. Our motto is “Exceptional Care Without Exception.” In our multidisciplinary conference just today, we presented patients who come from around the block and patients who’ve come from the Midwest and southern United States for our care. Through the generosity of wonderful friends of BMC, like Marshall and Missy Carter, we’ve established a BMC Cancer Equity Institute.

We’ve published multiple papers and submitted NIH and foundation grants. And Dr. Teviah Sachs, one of our surgical oncology faculty members, has just been made the Perlman Scholar in Pancreatic Cancer Research through the generosity of longtime friends of Boston Medical Center Marc and Claire Perlman. This means that Dr. Sachs, who has a promising research career as well as great skill in the operating room, in particular in HPB [hepato-pancreato-biliary] surgery, will have protected time to conduct pancreatic cancer research and to focus on this type of surgery. He’ll also mentor research fellows who will be with us for a few years at a time to work on pancreatic cancer research, and hopefully inspire them to pursue future careers to help stamp out these cancers.

What do you see looking toward the future?

Our goal is to have better diagnostic capability and eventually figure out who is at higher risk, so we are able to screen those individuals and take out tumors before they’re even cancerous. We want to put ourselves out of the pancreatic cancer treatment business and put ourselves into the business of preventing it and removing premalignant lesions. That’s my life goal! I see us getting there in 50 years. I know it’s nowhere near fast enough for people who have pancreatic cancer now. But if you don’t start, you’ll never get to your goal.

Final thoughts?

I get tremendously inspired by my patients every day that I do this job. Cancer patients are amazing! I am fortunate because the patients I see as a surgeon are potentially curable or have a good chance at achieving durable long-term survival. I have patients who are 5 years, 7 years, or even more than a decade out after successfully resected and treated pancreatic cancer. It goes without saying that we all wish this were the case for every patient. The point I want to make is that not that long ago, some of these patients would not have been considered as candidates for surgery. So it’s incredibly important not to lose hope.

 

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