Pancreatic Cancer Awareness Month

November 16, 2020

Information

November 15, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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00:00Support for Yale Cancer Answers
00:03comes from AstraZeneca, dedicated
00:05to providing innovative treatment
00:08options for people living with
00:13cancer. Learn more at astrazeneca-us.com.
00:14Welcome to Yale Cancer Answers with
00:16your host doctor Anees Chagpar.
00:19Yale Cancer Answers features the
00:20latest information on cancer care by
00:23welcoming oncologists and specialists
00:24who are on the forefront of the
00:27battle to fight cancer. This week
00:28it's a conversation about pancreatic
00:30cancer with Doctor Jeremy Kortmansky.
00:32Doctor Kortmansky
00:33is an associate professor
00:35of clinical medicine in medical
00:37oncology at the Yale School of
00:39Medicine where Doctor Chagpar is
00:41a professor of surgical oncology.
00:44So Jeremy,
00:45I think we all hear about pancreatic
00:48cancer when it affects celebrities, right?
00:51So whether it was Steve Jobs or
00:54other stars we hear
00:58about pancreatic cancer,
00:59once in a blue moon.
01:03It doesn't seem to be a terribly
01:06common cancer.
01:08Can you tell us a little bit
01:10more about how frequently
01:12pancreatic cancer is diagnosed?
01:15How many people get it?
01:18And who really are the
01:21people that it most affects?
01:23Yes,
01:25pancreatic cancer
01:26is actually becoming an increasingly
01:28more common cancer that we see.
01:31It's now the 5th leading cause
01:34of cancer in the United States,
01:37at about 60,000 new cases a year.
01:40So we're not only seeing increasing numbers,
01:43but also really moving up the
01:47rank of how often we see it.
01:50And you know it's interesting you brought
01:53up Steve Jobs and and other celebrities.
01:56Most recently, I think Alex Trebek is one
02:00and it's important to make distinctions
02:03when we talk about pancreatic cancer,
02:06there's two main types there
02:08is pancreatic adenocarcinoma,
02:10which is by far the more common one that is
02:14the disease that we're talking about
02:18when we think about 60,000 cases per year.
02:22And then there are pancreatic
02:24neuroendocrine tumors,
02:25which are a lot less common.
02:28They are only seen in a few
02:30thousand patients a year,
02:32and it's important
02:34to make the distinction because
02:36they behave very differently and
02:38their treatments are very different.
02:42So, let's start with
02:44pancreatic adenocarcinoma,
02:45because I think that most people,
02:47when they use the term generically
02:50pancreatic cancer that tends to
02:52be what they're referring to.
02:53Although your point is well taken
02:56with regards to neuroendocrine tumors,
02:57but tell us a little bit more
03:00about who gets these cancers.
03:02I mean, what are the risk factors?
03:06So I think like other cancers,
03:09smoking is a common risk factor.
03:13It can be related to problems that cause
03:17chronic inflammation of the pancreas so
03:21alcoholism can lead to pancreas cancer.
03:24Chronic gallstone disease can,
03:27although that's much less common.
03:30Obesity can be a risk factor as well.
03:34And then there is some question
03:37of the relationship with diabetes
03:39and whether diabetes could be a
03:42risk factor or whether the disease
03:44itself causes the diabetes.
03:47And that's something that's
03:48still being worked out.
03:50And then there is a smaller percentage
03:53of patients where it's hereditary cancer.
03:56There are some genetic abnormalities
03:59that we know of that are associated
04:02with pancreas cancer and
04:04one that is of recent importance
04:07is its relation to the BRCA gene,
04:10which is a gene that we most
04:13often think about with breast and
04:16ovarian cancer syndromes,
04:18but is also related to pancreas
04:20cancer as well,
04:22and that has had some recent
04:24implications on treatment.
04:28So when we think
04:30about these risk factors,
04:32I'm thinking about a very good friend
04:35of mine who actually was diagnosed with
04:39pancreatic cancer just over Thanksgiving.
04:42And who didn't fit any of those categories.
04:45She had no family history.
04:47She is skinny, like a rail,
04:50she doesn't have diabetes,
04:52doesn't drink, doesn't have gallstones.
04:54You know, in those people where
04:56they don't seem to have any
04:59of the common risk factors that you
05:02think about for pancreatic cancer,
05:04does that tell us anything about
05:07the biology of their disease?
05:09I mean, are there other things
05:12that we can think of
05:14in terms of their risk factors,
05:17and does that
05:18have anything to
05:21do with their prognosis?
05:24I think that those are
05:26all very good questions.
05:28There are risk
05:30factors that we can identify and
05:33then there are patients who get
05:36cancer for really no good reason.
05:38And those are people that
05:41we are still trying to maybe figure
05:44out whether there was something
05:46hereditary or environmental or some
05:49other factor that we just haven't
05:51identified yet that played a role.
05:55When it comes to pancreas cancer,
05:59the implications of how you got it,
06:05except in in certain circumstances,
06:07like the BRCA gene but,
06:09otherwise how you got it doesn't
06:11play as much of a role into how we
06:15might think about treating it or
06:17how we might expect it to behave.
06:21So the the other question is,
06:28when you talk about it
06:31being the fifth most common cancer
06:33and we think about the list right?
06:36Breast cancer, prostate cancer,
06:38colon cancer for all of these,
06:41more commonly diagnosed cancers,
06:43there's a screening test we
06:45can find these cancers early.
06:48Is there a screening test
06:49for pancreatic cancer?
06:52There isn't a good or routine
06:55screening test for pancreas cancer.
06:57I think that we know that there are
07:01some patients that have been discovered
07:04to have either a family history
07:07or patients that have been found
07:10to have pancreatic cysts on their
07:15imaging that may have been obtained
07:18for some other reason that we can
07:22follow and certainly here at Yale,
07:24we have an excellent screening
07:26program where we can refer patients
07:29to our gastroenterologists who
07:31can perform screening procedures,
07:33but that's really identifying those
07:35who are already at a heightened risk
07:39and not for the whole population like
07:42we think about with colonoscopies
07:44for colon cancer or mammograms
07:47for breast cancer,
07:49it's really an already pre determined
07:52population because the screening
07:54includes much more advanced or invasive
07:57testing like MRI's or endoscopic ultrasound.
08:00So it's a much more complex
08:03way to follow patients.
08:06And so without a screening test for
08:09asymptomatic people who otherwise,
08:11haven't had any
08:14abnormality that's been found
08:16incidentally, what are
08:18the ways in
08:21which they present?
08:23How is it that somebody
08:26cues into the fact that, Oh my gosh,
08:28this could be a pancreatic cancer.
08:30What are the symptoms and signs to look for?
08:35I again think this is an area
08:38that becomes challenging that
08:40the symptoms that people have,
08:44at least initially can often be vague.
08:47There can be some discomfort
08:50in the abdomen, with eating,
08:53sometimes increased belching,
08:54or increased gas may be a symptom.
08:58Things that are very easily
09:01attributable to something else until
09:03the symptoms become more significant.
09:06Sometimes people present without
09:08any symptoms but develop jaundice,
09:11they notice yellowing
09:13of their eyes or their skin,
09:16which certainly tips them off,
09:18their families that there's something
09:20going on that requires further evaluation.
09:23But because these symptoms
09:25can sometimes be vague,
09:27they can also be attributed to the
09:30much more common problems that we see,
09:33irritable bowel or reflux which can
09:36lead to delays in making a diagnosis.
09:40And so I mean that really gets
09:43to the crux of the issue, right?
09:45Is that without screening and with
09:49the symptoms that are incredibly vague,
09:52I would surmise that the vast
09:55majority of patients who present
09:57with pancreatic cancer present at a
10:00more advanced stage so talk
10:02about the stage
10:05distribution that you see in terms of
10:07the proportion of patients who present
10:10with early versus late stage disease and
10:13what the implications are in terms of
10:15prognosis.
10:17People often think
10:20about staging for cancer with the
10:22usual stage one, 2, three or four.
10:24When I think about pancreas cancer,
10:26I really try to think about
10:29it in terms of its
10:31clinical presentations and so there are
10:33patients that have resectable disease,
10:35meaning that a surgeon could go in there at
10:39the time of diagnosis and take it out.
10:43There are patients that have locally
10:45advanced but unresectable disease,
10:47meaning that it hasn't spread
10:49to other parts of the body,
10:51but it's involving the nearby blood vessels,
10:54and you can't safely take it out.
10:57And then patients with metastatic
11:00disease where it's spread to
11:02other places in the body.
11:04And so the the number or the percentage
11:08of patients that can have surgery
11:11at the time of their diagnosis
11:14is really only about 15 to 20%.
11:16It's a relatively low number
11:19and the other 80% sort of evenly
11:22distributed are either locally
11:23advanced or metastatic disease
11:25at the time of their diagnosis.
11:30And so it was with my my friend who
11:34was diagnosed with a locally advanced,
11:39unresectable pancreatic
11:40cancer that was encasing
11:43important blood vessels,
11:45so she certainly wasn't
11:47a candidate for surgery at
11:50the time of her presentation,
11:52so it sounds like if patients are
11:57fortunate enough to be resectable
11:59at the time of their presentation,
12:03would surgery be the
12:05primary modality upfront?
12:08That is a great question, and one that
12:12we are still trying to figure out.
12:16I think that there is clearly
12:19a standard paradigm of doing
12:21surgery followed by chemotherapy
12:24for about six months afterwards.
12:27There is a lot of interest in giving
12:31chemotherapy prior to surgery or
12:33giving part of the chemotherapy,
12:36then surgery, and then chemotherapy after.
12:39And in fact, here at Smilow we have a
12:42clinical trial which is really looking at
12:46that question of perioperative chemotherapy.
12:49How do patients do getting some of the
12:53chemotherapy treatments before surgery,
12:55and then some after?
12:57And how that might compare to those who get
13:01surgery 1st and then chemotherapy later?
13:05And so this kind of brings
13:08us to the question of, well,
13:10how effective is the chemotherapy?
13:12Because,
13:13I can imagine that many of the
13:15people who are listening to this
13:17show are thinking,
13:19if I have a cancer and you can take this
13:23cancer out and you can get it out of my body,
13:27for many people the simple
13:29logic is that might be better
13:32than having a chemotherapy,
13:34which may or may not
13:36work and they often have some
13:39trepidation about cancer spreading
13:41and then making it unresectable.
13:44So how effective is chemotherapy
13:47that we could potentially use it in
13:51a neoadjuvant fashion to potentially
13:54even shrink the cancer and get some
13:58systemic control prior to resecting it?
14:03So our newer chemotherapy regiments are
14:09good, they're not great,
14:12but they are good and they can shrink
14:15the disease for some and control
14:18the microscopic disease that might
14:20be floating around for others.
14:23I think that the challenge ultimately
14:26is that even with surgery,
14:29the risk of pancreatic cancer coming
14:31back because it has already shed
14:34these microscopic cells is very high,
14:36and so by giving chemotherapy we are
14:39hopefully attacking some of those
14:42microscopic cells that are floating around,
14:44but also making sure that putting
14:47somebody through what would be a
14:50very major operation is ultimately
14:52the right thing to do.
14:55So many complicating moving parts
14:58in the management of pancreatic cancer
15:00and we're going to learn much more
15:03about all of that right after we take
15:07a short break for a medical minute.
15:09Please stay tuned to learn more
15:11about pancreatic cancer with
15:14my guest Doctor Jeremy Kortmansky.
15:15Support for Yale
15:17Cancer Answers comes from AstraZeneca
15:20providing important treatment options
15:22for various types and stages of cancer.
15:25More information at astrazeneca-us.com.
15:28This is a medical minute
15:30about head and neck cancers,
15:31although the percentage of oral
15:33and head and neck cancer patients
15:35in the United States is only
15:37about 5% of all diagnosed cancers,
15:40there are challenging side effects
15:42associated with these types of
15:43cancer and their treatment.
15:45Clinical trials are currently
15:46underway to test innovative new
15:48treatments for head and neck cancers,
15:50and in many cases less radical
15:52surgeries are able to preserve nerves,
15:54arteries and muscles in the neck.
15:57Enabling patients to move speak,
15:59breathe,
16:00and eat normally after surgery.
16:02More information is available at
16:05yalecancercenter.org.
16:05You're listening to Connecticut Public Radio.
16:09Welcome back to Yale Cancer Answers.
16:12This is doctor Anees Chagpar
16:14and I am joined tonight by my
16:17guest doctor Jeremy Kortmansky.
16:19We're talking about pancreatic cancer
16:21and Jeremy right before the break,
16:24you had indicated to us that you really think
16:27about pancreatic cancer in terms of staging,
16:30as whether things are resectable at the
16:32time of presentation or unresectable,
16:35but not metastatic or metastatic
16:37and sadly,
16:3880% of patients or so fall into
16:42the last two buckets.
16:44And you know,
16:46that's really unfortunate,
16:48because what is the prognosis for
16:50patients who have locally advanced
16:53unresectable disease at presentation?
16:55And what is the prognosis for patients
16:58who present with metastatic disease?
17:03For those patients who have advanced disease,
17:07unfortunately we view those
17:08as incurable cancers.
17:10We can't make it go away and never come back.
17:16For patients that have locally
17:18advanced disease on occasion and
17:21it's not the expectation,
17:23but on occasion they have a
17:26great response to the chemotherapy
17:29and we can revisit that question
17:32of surgery but without surgery,
17:35ultimately, patients succumb to their
17:37disease and the goals of our treatment
17:41are to control the disease
17:43for as long as possible.
17:45Help people live as long as possible and
17:48feel as well as possible knowing that
17:52the disease can be symptomatic as well.
17:56For people who are
18:01listening to this and who may have had
18:04friends or even seen celebrities
18:06go through their own journeys
18:09with pancreatic cancer,
18:13when we say the goal is really
18:15to try to control the cancer for as
18:18long as possible and the quality
18:21of life for as long as possible,
18:24in some cancers
18:25we've discussed on this
18:27show,
18:29medical management has come a really long
18:31way such that even in those settings,
18:35people live for a long time and
18:38they talk about this being incurable,
18:40but really making it more of a
18:43chronic disease then something
18:45that is imminently fatal.
18:46Where are we in the spectrum of
18:49pancreatic cancer towards getting to
18:52oK, so I've got pancreatic cancer and
18:55I know that I can't get rid of it,
18:59but
19:00I can live with it versus this
19:03is something that
19:05is more of an imminent concern.
19:11It's still a very challenging disease and
19:15there are for a lot of other cancers,
19:19a lot of exciting new therapies and
19:23targeted therapies and immunotherapy's
19:26that have become available.
19:28But for pancreas cancer,
19:30the majority of patients are still treated
19:33with versions of chemotherapy and
19:37those chemotherapy drugs are modest.
19:39There are some who are
19:42exceptional responders.
19:43People who do really well for a long time,
19:47but for the majority of patients,
19:50the survival is still only
19:53measured in in months or years.
19:57And doing better and finding better
20:00therapies is of such great
20:02importance for this disease.
20:04I think we are really hoping
20:07and trying every day to find
20:10therapies that are better than what
20:12we have currently.
20:14Do we have any factors that can
20:17predict who is going to respond
20:20better to chemotherapy versus not?
20:25So we are still trying to figure that out.
20:30I had mentioned
20:34this earlier, patients that have a BRCA
20:38mutation or a similar type mutation,
20:41we find that they are more sensitive
20:45to platinum based chemotherapy.
20:47So a drug like oxaliplatin or cisplatin.
20:52And that we can see better responses
20:55there that can sometimes last longer
20:57than we might see with a patient who
21:01doesn't have one of those abnormalities.
21:04We know that there is a class of
21:07drugs called PARP inhibitors,
21:10which for this mutated population
21:12can benefit from this targeted therapy.
21:15At the end of the day, that only makes
21:19up about 7% of the patients that we see.
21:24So it's still not a not a big number and
21:29we know about 1% have another abnormality,
21:32called microsatellite instability,
21:34for which immunotherapy
21:35drugs have been helpful.
21:37And so we always test for that.
21:40But again, it's one out of 100 that we see.
21:45So the majority of the patients that
21:48we take care of are still treated
21:52similarly with these more generic
21:54chemotherapy programs with a strong
21:57emphasis in trying to encourage patients
22:00to participate in clinical trials
22:02that can help us move the field.
22:07And I want to get into
22:10the clinical trials in a minute.
22:13But before we get there,
22:15if you're treated with standard
22:17chemotherapy and all of the side
22:20effects that go along with that,
22:23knowing that you're
22:25presented with a locally advanced,
22:27unresectable or metastatic cancer,
22:29what is really the efficacy
22:31of these chemotherapies?
22:32I mean, how do patients balance the risk
22:36and the benefit of the therapy?
22:39Is this something that for
22:42some patients the therapy is
22:45worse than the disease itself?
22:48Or are these actually things that
22:51are tolerable with more modern
22:53day treatments and additional
22:56factors that you can give patients?
23:00And that has really been shown
23:02to make a difference in terms of
23:04both survival and quality of life.
23:07My job is to make
23:11the treatments tolerable.
23:12When we we pick a regimen,
23:15there are two common
23:17regiments that we use.
23:19We are already thinking about
23:21what are the side effects that are
23:24associated with those regimens and
23:26whether the patient who's about
23:28to receive it is going to be able
23:31to tolerate it based on their age and
23:34other medical problems that they may
23:36have and when we give the treatments,
23:39we do so very carefully and we pay
23:42attention to those side effects to make
23:45adjustments in the dosing or give
23:49supportive medications to really
23:51make it as tolerable as we can.
23:54It's never a desired situation that the
23:58treatment is worse than the disease.
24:01And the reality is,
24:03that for the vast majority of
24:05patients when they do start feeling poorly,
24:08it's more often the disease
24:10than it is the treatments.
24:12But we make sure we see patients
24:14every time before they get their
24:16treatments to review the side effects
24:19and give the right medications and
24:21give the supportive medications or
24:23dose adjustments that we need to do.
24:27And how do we know
24:29that the chemotherapies are working?
24:31Many patients ask about well are
24:34you going to do more blood work?
24:37Are there tumor markers?
24:39How do you know?
24:41Because you had mentioned that for
24:43some patients who present
24:46without metastatic disease,
24:47that is unresectable that
24:49potentially in some of those patients,
24:52you can reassess whether they
24:54may be candidates for resection.
24:58The best way to follow the disease is
25:02with imaging so usually a CAT scan.
25:06Sometimes an MRI or a PET scan,
25:08but usually a CAT scan gives us
25:11the level of detail that we need,
25:14including the relationship of
25:15the tumor to the vessels nearby.
25:17For those who have locally advanced
25:20disease and there is a tumor
25:22marker that we can use as well,
25:27that can be helpful,
25:29although sometimes it is not as
25:31reliable as the scans and then also
25:34really listening to the patient.
25:37Patients can have symptoms that can be a
25:40tipoff that something is getting better
25:43or getting worse even before CAT
25:46Scan tell you what's going on.
25:50And back to
25:52the story of my friend.
25:55She had chemotherapy as you suggested,
25:58and her tumor markers went down,
26:01which was great,
26:02but the imaging still showed that
26:06she had unresectable disease.
26:10She was quite happy to be done with
26:14chemo and really didn't want to
26:18do much more, but was certainly
26:21interested in clinical trials.
26:23So let's talk about clinical trials,
26:26both in that setting,
26:27after you don't respond
26:29to standard chemotherapy as well
26:31as clinical trials that might
26:34be offered to patients upfront
26:36as new therapies are developed.
26:38So what are you most excited about?
26:43I think it's interesting that you
26:45say that, I find that when I talk
26:48to a patient
26:50about a clinical trial
26:51sometimes they say to me, do you think
26:54I'm ready for a clinical trial?
26:57As if it's something that we wait
26:59until we don't have other options,
27:02and clinical trials are important at
27:04every phase of someone's disease,
27:06whether they are initially diagnosed
27:08or whether they have progressed
27:10on one or two prior therapies.
27:12We are always trying to figure
27:14out what's the best thing to do.
27:17And so the clinical trials that we are
27:20working on that we're excited about,
27:23I think we are still trying to find a
27:26role for immunotherapy in pancreas cancer,
27:29the same as in other diseases
27:32like lung cancer or Melanoma.
27:34But it's been a challenge,
27:36and so we are doing clinical trials
27:39that are looking at immunotherapy
27:41combinations as opposed to just a
27:44single drug to see if it might be
27:49better and we're looking at clinical trials that are
27:52trying to attack not just the tumor itself,
27:56but the scar tissue in the
27:58environment around the cancer cells.
28:01One of the challenging things about
28:03pancreas cancer is that it almost builds
28:06this protective shell around itself
28:09that can potentially make it more
28:11difficult for our treatments to get in,
28:14and so looking at drugs that can potentially
28:18eat away at that might help our
28:21more standard therapies be more
28:23effective.
28:25Doctor Jeremy Kortmansky is an associate professor of
28:28clinical medicine in medical oncology
28:29at the Yale School of Medicine.
28:32If you have questions,
28:33the address is canceranswers@yale.edu
28:35and past editions of the program
28:37are available in audio and written
28:39form at yalecancercenter.org.
28:40We hope you'll join us next week to
28:43learn more about the fight against
28:46cancer here on Connecticut Public Radio.