Real expectations in treating pancreatic cancer – and the power to prevent it
December 30, 2019
Over the last decade, public awareness of pancreatic cancer has increased as several celebrities have succumbed to the disease, including ’80s and ’90s heartthrob Patrick Swayze (2009) and actor Alan Rickman (2011), who millennials fondly remember as Severus Snape from the Harry Potter film series.
Alex Trebek, longtime host of “Jeopardy,” announced in March 2019 that he has stage 4 pancreatic cancer – a diagnosis in which treatment means improving symptoms and extending life rather than curative therapy. Most recently, Supreme Court Justice Ruth Bader Ginsburg made public that she had received radiation therapy in August 2019 for a new tumor on her pancreas, 10 years after she had surgery for pancreatic cancer (and 20 years after a diagnosis of colon cancer).
And in late December, civil rights icon Rep. John Lewis, D-Ga., announced he has advanced pancreatic cancer.
But news coverage of high-profile pancreatic cancer cases such as these don’t always provide the necessary context to understand the effects of the disease and relevant treatment options. One story suggests the condition is hopeless; another provides false hope about treatment outcomes. The truth is somewhere in the middle.
Pancreatic cancer is among the most formidable cancers – while mortality rates of nearly all other cancer types have remained stable or decreased over time, pancreatic cancer rates have increased by 0.3% a year. In Texas, pancreatic cancer is responsible for 7% of the 41,300 recorded cancer deaths according to 2019 data from the American Cancer Society.
It is also one of the rarest of organ-based cancers. The average lifetime risk of pancreatic cancer in the general population is approximately 1% compared with breast cancer at 12%. Because of this veritable rarity, screening the general population is impractical.
However, UT Southwestern has made a profound impact on pancreatic cancer prevention through our campus-wide high risk identification program. To date, we’ve alerted more than 1,700 patients to genetic risk factors and "incidentalomas" – pancreas cysts found incidentally during unrelated abdominal scans.
For those who have developed cancer before entering our care, sophisticated treatments such as the Whipple procedure, or surgery to remove tumors in the head of the pancreas, and advancements in clinical trials can offer more quality time with loved ones. Based on the patient’s cancer stage at diagnosis, doctors and patients should define realistic expectations together of what successful treatment means for them.
Pancreatic cancer prevention
Learn more about UT Southwestern's pancreatic cancer program, which is founded on the premise that we know that patients who are cared for by an integrated provider team have the best outcomes for early detection, tumor removal and symptom control.
Successful treatment in pancreatic cancer
Early stage pancreatic cancer symptoms are typically not significant, so they can easily be overlooked or attributed to common ailments such as a strained abdominal muscle or a stomach bug. Unfortunately, this leads to approximately 70% of patients being diagnosed after the cancer spreads beyond the pancreas. At that point, there is currently no cure. Treatment for these patients is focused on managing symptoms and improving the quality of their remaining years.
For those who are diagnosed before the cancer spreads, treatment is focused on reducing the risk of metastasis or removing the tumor, depending on its size and location. Fewer than 20% of patients are eligible for surgery. Approximately 20% to 40% of patients whose tumors are surgically removed live five years or longer after surgery. Most of these patients will develop another pancreatic tumor in their lifetime.
Related reading: Can pancreatic cancer be prevented?
In either situation, collaboration among providers is key. The UT Southwestern pancreatic cancer program is founded on this premise – we know that patients who are cared for by an integrated provider team have the best outcomes for tumor removal and symptom control.
Nurse navigators guide our patients’ experiences from the first day. These providers, who have advanced training in pancreatic cancer, review new patients’ records to help determine whether they might benefit from seeing a radiation or medical oncologist or surgeon, or all of the above. The nurse navigator will work to schedule these appointments in one day, if possible, to reduce patients’ travel time and the stress of waiting weeks for the next appointment.
Patients will be invited to lunch with our pancreatic cancer care support staff, which includes dietitians, pain management doctors, physical therapists, and more. Doctors, surgeons, and nurses will also attend this lunch to meet patients and answer their questions.
Advancements in pancreatic cancer treatment
Whipple procedure: The pancreas is in a tricky area of the body, making the Whipple procedure one of the most complex cancer surgeries. Situated behind the stomach at the back of the abdomen, the pancreas is connected to the small intestine by the pancreatic duct – a small and complicated tubal structure through which pancreatic juices and bile pass. The duct is where the majority of pancreatic cancers begin.
What’s more, some of the most important blood vessels in the body are very close to the pancreas and might be involved with the tumor. Separating these components or removing part of the organ is difficult enough – then the surgeon must put the pancreas back together and retain its functionality.
- The surgeon removes the head of the pancreas.
- Next, they remove parts of the small intestine, bile duct, and gallbladder, as well as lymph nodes near the pancreas. In some cases, part of the stomach may be removed.
- The surgeon reconnects the remaining parts of the pancreas, stomach, and bile duct with the small intestine to allow for digestion.
Due to its complexity, the procedure has an approximately 20% mortality rate when performed at non-specialized centers. However, outcomes can be as low as 1% to 2% mortality rate at high-volume pancreatic cancer centers of excellence such as UT Southwestern. For optimal outcomes, the Pancreatic Cancer Action Network recommends that eligible patients have the Whipple procedure at a high-volume center.
Robotic surgery: Herbert Zeh, M.D., chairman of the Department of Surgery, spearheads the robotic pancreatic cancer surgery program at UT Southwestern. He is one of a handful of experts in the world who has performed hundreds of these cases.
Today, most pancreas surgeries are open procedures. Robotic pancreas surgery is incredibly intricate given the location of the pancreas and the delicacy of the tissues that surround it. However, depending on the location of the tumor, robotic surgery can be an option.
Early reports suggest the robotic approach may have some advantages for eligible patients.
Chemotherapy: Doctors recommended the same drugs for years without seeing dramatic tumor shrinkage in most patients. However, in the past few years, we’ve begun to implement chemotherapy strategies that deliver more impactful responses for patients. So much so that we sometimes use chemo prior to surgery to shrink the tumor and reduce surgical complexity.
Radiation: We can deliver incredibly focused radiation today that is much more targeted than even five to 10 years ago. Today’s techniques can shrink tumors with limited damage to the surrounding tissue. At UT Southwestern, the gastrointestinal radiation oncology group collaborates with the pancreas cancer surgery team to provide radiation therapy when other localized treatments cannot be used.
Pancreatic cancer research and clinical trials
UT Southwestern is enrolling patients in three pancreatic cancer clinical trials.
Our researchers are studying how a drug that inhibits a specific receptor called tyrosine kinase AXL can make chemotherapy more effective. We will collect biopsies from patients to help us discover why treatments do and don’t work. The study is a multicenter project, and it is open and enrolling patients. Explore the trial.
In another exciting study, we are investigating whether immunotherapy medications that don’t work well alone against pancreatic cancer might be effective in shrinking tumors when combined. Preliminary data are promising. Learn more.
We are also enrolling patients in a trial to determine whether warfarin, a drug most commonly used as a blood thinner, can be combined with chemotherapy to improve overall survival. Learn more.
Empowering patients to prevent pancreatic cancer
UT Southwestern's pancreatic cancer prevention program is one of the most sophisticated in the world. This campus-wide collaboration was founded to catch and inform every patient deemed at high risk for pancreatic cancer, regardless of what brought them to the doctor in the first place.
To date, we have enrolled more than 1,700 patients through direct outreach to the patient, their primary care physician (PCP), or their referring doctor. Our goal is to educate patients about their risk status and empower them with the information and pathways to potentially prevent pancreatic cancer through active monitoring or surgery, if necessary.
Patients may join the program in one of three ways:
1. Any patient who has a potential pancreatic cyst after an abdominal scan.
Patients who have belly or back pain (think suspected gallbladder or appendix issues) likely will have an abdominal MRI or CT scan to diagnose the issue. These images typically capture other abdominal organs, such as the pancreas.
Our abdominal radiologists automatically check these scans for pancreatic cysts. When they detect a cyst, they add a link to the patient’s digital medical chart. This link alerts our pancreatic cancer prevention team to reach out to the patient or their doctor for follow-up.
2. Patients with genetic risk factors.
Certain gene mutations are associated with increased risk of pancreatic cancer. Perhaps the most commonly known gene association is BRCA, which is also tied to breast and ovarian cancers.
For example, among patients of Ashkenazi Jewish ethnicity, BRCA1 mutation increases the risk of pancreatic cancer two to four times and BRCA2 mutations have been associated with an approximately 5% to 10% lifetime risk – up to 10 times the risk of the general population.
3. Self-referrals based on family or personal history.
Patients with a personal or family history of any type of cancer are welcome to self-refer to our program. We can connect patients with imaging experts and cancer geneticists who can determine the patient’s individual risk score and identify the optimal path for monitoring or treatment, if necessary.
This program is successful only because of the multidisciplinary approach we take to cancer prevention. Our team includes geneticists, surgeons, interventional gastroenterologists, and radiologists who only analyze abdominal imaging. We meet regularly to discuss findings and create appropriate intervention plans for our patients.
Our goal is to use routine screening to prevent patients from ever developing pancreatic cancer. Active monitoring – regular check-ins to examine the pancreas and check for growths – has been highly effective. Preventative surgery, in which we remove part of the pancreas, can be performed to remove worrisome areas of the pancreas before they turn into cancer.
Even with early detection, pancreatic cancer is a formidable condition. The Pancreatic Cancer Prevention Program at UT Southwestern takes a pro-active approach to preventing this deadly cancer before it can start.