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INFORMATION FOR

Surgical Care of Pancreatic Cancer

June 01, 2021
  • 00:00Support for Yale Cancer Answers
  • 00:02comes from AstraZeneca, dedicated
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  • 00:09More information at
  • 00:12astrazeneca-us.com.
  • 00:15Welcome to Yale Cancer Answers with
  • 00:17your host doctor Anees Chagpar.
  • 00:19Yale Cancer Answers features the
  • 00:21latest information on cancer care by
  • 00:23welcoming oncologists and specialists
  • 00:25who are on the forefront of the
  • 00:27battle to fight cancer. This week
  • 00:29it's a conversation about pancreatic
  • 00:31cancer with Doctor John Kunstman.
  • 00:33Doctor Kunstman is assistant
  • 00:34professor of surgical oncology
  • 00:36at the Yale School of Medicine,
  • 00:38where Doctor Chagpar is a
  • 00:40professor of surgical oncology.
  • 00:43John, maybe we can start off by you
  • 00:45telling us a little bit more about
  • 00:47pancreatic cancer. How common is it?
  • 00:49Who gets it, and why should we care?
  • 00:52Well, I think there's several
  • 00:54components to that answer.
  • 00:56Anybody can get pancreas cancer,
  • 00:59but it is generally a disease that,
  • 01:00like most cancers, occurs as we age.
  • 01:03There is a little bit more
  • 01:04likelihood for men to get it,
  • 01:05but of course women can
  • 01:07get pancreas cancer too.
  • 01:08I think it's a disease that
  • 01:10we should all be aware of,
  • 01:11because as most cancers can be
  • 01:14screened for nowadays, pancreas
  • 01:16cancer is one that we really don't
  • 01:18have an effective screening test for.
  • 01:19So we want everybody to be aware of it.
  • 01:22Also, by 2030,
  • 01:23the National Cancer Institute
  • 01:25predicts that pancreas cancer will
  • 01:27be the second leading cause of
  • 01:29cancer death in the United States,
  • 01:31so I think it's something that's
  • 01:33worth our attention.
  • 01:34John, why is that?
  • 01:36Why is it going to be the second
  • 01:39leading cause of cancer related deaths?
  • 01:41I hadn't heard that before.
  • 01:43Is it because it's getting more common,
  • 01:45or is it because it's getting more lethal?
  • 01:48There is an increase in the
  • 01:50prevalence of pancreas cancer,
  • 01:52although it's not the main reason.
  • 01:53The main reason is that
  • 01:54the more common cancers that
  • 01:57currently are more apt to cause
  • 01:59cancer deaths in the United States,
  • 02:01the treatment of those cancers,
  • 02:03such as breast cancer or
  • 02:04lung cancer or colon cancer,
  • 02:06which are all more common
  • 02:07than pancreas cancer,
  • 02:08are improving and the death rate is falling.
  • 02:10Whereas in pancreas cancer the death
  • 02:12rate hasn't improved at the same rate.
  • 02:15So let's talk a little bit about
  • 02:18pancreatic cancer and you
  • 02:20mentioned that we don't
  • 02:23have screening for pancreatic cancer,
  • 02:26but it certainly is a cancer
  • 02:28that people should be aware of.
  • 02:30How can people
  • 02:32understand whether or not they
  • 02:34have pancreatic cancer when
  • 02:36there is no screening test.
  • 02:38Can you tell us what the symptoms
  • 02:40are that we might be looking out for?
  • 02:42That's a terrific question,
  • 02:44and because that is one of the
  • 02:46main reasons that the death rate
  • 02:48for pancreas cancer is so high,
  • 02:49and it's viewed as such an aggressive cancer.
  • 02:52Many times patients are unaware
  • 02:53when they have a pancreas cancer
  • 02:55until it's become quite advanced
  • 02:57and the symptoms are quite subtle.
  • 02:59In terms of the symptoms that most
  • 03:02people will experience there are very mild
  • 03:04things like abdominal discomfort,
  • 03:06things that could easily be
  • 03:08attributed to something else,
  • 03:09such as a stomachache or just eating
  • 03:11a bad meal or something like that.
  • 03:13But for patients with pancreas cancer,
  • 03:15that discomfort persists for a long time.
  • 03:17It's not episodic, it's not going away.
  • 03:19It's something that really should
  • 03:21lead to a visit to the doctor.
  • 03:23Also, things that are not subtle
  • 03:25but can sometimes go unrecognized by
  • 03:27patients as being very important,
  • 03:29are things like jaundice or pancreatitis.
  • 03:32Those are obviously big time medical
  • 03:34issues that deserve attention,
  • 03:35but many times can go on unappreciated
  • 03:38as pancreas cancer being the cause
  • 03:40of those findings for too long.
  • 03:43I'd also like to mention weight loss.
  • 03:45Unfortunately, in the United States,
  • 03:47many people have trouble,
  • 03:49myself included,
  • 03:49losing weight and when we're adults
  • 03:52it's difficult to lose weight durably
  • 03:54without a major lifestyle change,
  • 03:57and many patients with pancreas cancer
  • 03:58We noticed over the past weeks to
  • 04:01months that they've lost weight without
  • 04:03making any major lifestyle changes.
  • 04:05Many patients with pancreas cancer
  • 04:07find that the first sign was that
  • 04:09unrecognized weight loss when they go
  • 04:10back and think about what might have
  • 04:12happened prior to their diagnosis.
  • 04:14After what duration of time should
  • 04:18people with these symptoms go in and
  • 04:20seek medical advice?
  • 04:23Is that a day, a week, a month, a year?
  • 04:26I think it really gets into the weeks,
  • 04:28something that
  • 04:30can be attributed to one of those
  • 04:33other causes like a stomach bug.
  • 04:35Usually we're feeling better within
  • 04:37a week once we start having those
  • 04:39vague symptoms and they're really
  • 04:40starting to affect our lives once
  • 04:42we get to the weeks time frame,
  • 04:44it's time to go see your doctor.
  • 04:46Also same thing with the weight loss.
  • 04:48A few pounds is not a big deal and it
  • 04:50might just be that you're doing better
  • 04:51with your exercise regimen or watching
  • 04:53what you eat a little bit better.
  • 04:55But when we start losing 10,15
  • 04:57or 20 pounds without making a
  • 05:00major major lifestyle change,
  • 05:01that should start to wave
  • 05:02the red flag a little bit.
  • 05:04And so when we go to our doctor, what
  • 05:07should we be expecting our doctor to do?
  • 05:10It really should be a lot of questions,
  • 05:14detailed questions when
  • 05:15you go to see your doctor,
  • 05:17a physical examination for possible
  • 05:19diagnosis of pancreas cancer.
  • 05:21Apart from jaundice or the weight
  • 05:23loss might not reveal a lot,
  • 05:25but those careful questions about
  • 05:27the nature of the symptoms,
  • 05:29their duration and some of the specifics
  • 05:32is really where the attention may
  • 05:34bring up a possible diagnosis of a
  • 05:36cancer you might want to prepare yourself
  • 05:39for some uncomfortable questions too,
  • 05:41about things like your bowel function
  • 05:43because those can be affected by a pancreas cancer.
  • 05:45And those are just your
  • 05:47doctor trying to get to the bottom
  • 05:49of those symptoms or findings.
  • 06:08Should we be more concerned
  • 06:09if we have a family history?
  • 06:11Is pancreatic cancer one of those
  • 06:13where we should get to know our family
  • 06:16history and who's got what?
  • 06:18Because that might increase our risk.
  • 06:21It is actually that's one of the
  • 06:23major risk factors for pancreas cancer.
  • 06:26There are some minor risk
  • 06:28factors that we can affect
  • 06:29with our own lives, for instance,
  • 06:31cigarette smoking or exposure to
  • 06:33certain chemicals like asbestos
  • 06:35do have a correlation with a
  • 06:37higher risk for pancreas cancer.
  • 06:39But that increase in risk
  • 06:41is actually rather small.
  • 06:43However, family history is a very
  • 06:45strong risk factor for pancreas cancer,
  • 06:48and it's thought that about 10% or maybe
  • 06:51even a little more than that cases of
  • 06:53pancreas cancer are hereditary in nature.
  • 06:56If you have a primary relative,
  • 06:58in other words,
  • 06:59a sibling or parent that has pancreas cancer,
  • 07:02your risk of getting pancreas cancer
  • 07:05yourself is about four or five times higher.
  • 07:07And if you have two first degree relatives,
  • 07:10that risk goes up to six
  • 07:11to seven times higher,
  • 07:12so it is something that we
  • 07:14should be aware of.
  • 07:15And that we should be thinking about
  • 07:17in terms of what our family knows.
  • 07:19The other thing I just want to mention
  • 07:21is that we talked about screening briefly
  • 07:24before and for asymptomatic patients
  • 07:26or patients with those vague symptoms,
  • 07:28there's really no role with our current
  • 07:31tools for screening for pancreas cancer.
  • 07:33However,
  • 07:34those patients that do have
  • 07:36a strong family history,
  • 07:38there are screening programs available,
  • 07:41and it appears even in these early
  • 07:42stages of those screening programs
  • 07:44that they might be effective
  • 07:46at improving outcomes for patients.
  • 07:48What do they screen with?
  • 07:49So that's a little bit of a debate right now.
  • 07:53When we started screening for
  • 07:55pancreas cancer and by we I
  • 07:57mean the medical community,
  • 07:59there was a very big debate
  • 08:01about the best way to do it,
  • 08:02and there's a few modalities
  • 08:04that are available.
  • 08:05Most of them are centered on imaging,
  • 08:07such as CT or MRI,
  • 08:10and right now we think that MRI is
  • 08:12probably the better way to screen
  • 08:15simply because there's less radiation
  • 08:17exposure compared to CT scans.
  • 08:19Also,
  • 08:19endoscopy using a particular technique
  • 08:22called endoscopic ultrasound,
  • 08:24where a gastroenterologist uses a
  • 08:26tiny ultrasound probe at the end
  • 08:29of their endoscope to actually
  • 08:31look through the walls of your
  • 08:33stomach at the pancreas itself.
  • 08:35Now, of course, that's a procedure,
  • 08:37but it's a day procedure and most people
  • 08:39can go home immediately thereafter,
  • 08:40not unlike a colonoscopy.
  • 08:43Those screening programs right now
  • 08:45generally use a combination of those
  • 08:48two techniques and imaging
  • 08:51and some programs alternate them.
  • 08:55And so John, a couple of questions on that.
  • 08:58First, how often are these
  • 09:01done in the screening programs?
  • 09:04Like is this an annual thing or
  • 09:05is it more like a colonoscopy
  • 09:07where you can go for 10 years?
  • 09:09So right now it's an annual
  • 09:11thing or even semiannual,
  • 09:13depending on the risk,
  • 09:14and I just want to point out that this
  • 09:17is an area of active investigation right now.
  • 09:21There are several trials ongoing
  • 09:24at major centers that do these
  • 09:27screening programs investigating
  • 09:28what the best modality is for
  • 09:31not only detecting the cancer
  • 09:33but using the information that's
  • 09:35generated from that screening.
  • 09:38And so that brings up
  • 09:40another question which is that many screening tests,
  • 09:45mammograms, colonoscopies,
  • 09:47PAP tests, are covered by insurance.
  • 09:52It sounds like this MRI and endoscopic
  • 09:55ultrasound might be really expensive tests.
  • 09:59Are they covered by insurance or is this
  • 10:01all considered experimental right now?
  • 10:04That's a great question too.
  • 10:06In general they are covered.
  • 10:08There are some active research protocols.
  • 10:12If you are included in those
  • 10:15active research protocols,
  • 10:16generally the research
  • 10:17study pays for the test,
  • 10:19but most patients will find that
  • 10:21it's covered one way or the other.
  • 10:24My other question is,
  • 10:27are there any blood tests for
  • 10:29screening of pancreatic cancer?
  • 10:31Many people are interested
  • 10:32in the least invasive way to
  • 10:35screen for cancer and are
  • 10:36always thinking about tumor
  • 10:37markers that might show up that
  • 10:39might tell them that they are
  • 10:41at increased risk for cancer.
  • 10:43Anything like that in pancreatic cancer?
  • 10:48There are some tumor markers that are fairly
  • 10:52specific and sensitive for pancreas cancer,
  • 10:55but those markers can also be
  • 10:58elevated in patients without cancer,
  • 11:00just as part of their day-to-day life.
  • 11:02So for that reason, in asymptomatic
  • 11:04patients or patients at average risk,
  • 11:07we don't recommend any blood tests right now.
  • 11:10That may sound a little bit strange to have
  • 11:13a marker that we don't use in routine tests,
  • 11:16but I'll give you an example.
  • 11:18One of those markers is called CA 19-9,
  • 11:21which is a blood marker,
  • 11:23and that marker is elevated in most
  • 11:26patients with pancreas cancer. However,
  • 11:28that marker is secreted by the Biome.
  • 11:31That's how it's metabolised in the body.
  • 11:33So that means somebody that may
  • 11:35have a little bit of sludge in
  • 11:37their bile or even a gallstone
  • 11:39which has nothing to do at all with pancreas
  • 11:42cancer could have a very high C 19-9.
  • 11:44So we don't want to have patients
  • 11:47get screened and go through
  • 11:48an enormous amount of testing,
  • 11:50some of which might be invasive for
  • 11:52something that's just a red herring.
  • 11:54The other question that I have is you
  • 11:57talked about people having a family
  • 11:59history of pancreatic cancer being at
  • 12:01four or five times the average population
  • 12:04risk of developing pancreatic cancer.
  • 12:06What if you don't have a family
  • 12:09history of pancreatic cancer,
  • 12:10but you might have a family
  • 12:12history of other cancers,
  • 12:14say more common cancers like
  • 12:16breast cancer or prostate cancer?
  • 12:19Does that increase your
  • 12:20risk of pancreatic cancer?
  • 12:22Sometimes it does,
  • 12:25and the two genes that are most closely
  • 12:28correlated that people know about with
  • 12:30breast cancer or ovarian cancer and some
  • 12:33others is the BRCA one and two genes,
  • 12:36and those do convey a risk,
  • 12:38particularly BRCA 2 for pancreas cancer.
  • 12:41For patients that have family that
  • 12:44have those other types of cancers,
  • 12:46especially multiple family members.
  • 12:48And I'm talking about again
  • 12:51breast or ovarian cancer.
  • 12:52It's worth talking to your doctor
  • 12:55about considering a genetics referral.
  • 12:57The medical genetics services at
  • 12:59most centers now are well aware of
  • 13:01these associations and can very
  • 13:03easily with the blood test determine
  • 13:05whether or not you have one of those
  • 13:07mutations that you might be carrying
  • 13:09that could increase your risk.
  • 13:11Well, we're going to pick up this
  • 13:13conversation right after we take a
  • 13:15short break for a medical minute.
  • 13:17Please stay tuned to learn more
  • 13:18about the surgical care of
  • 13:20pancreatic cancer with my guest
  • 13:22Doctor John Kunstman.
  • 13:23Support for Yale Cancer Answers comes
  • 13:26from AstraZeneca, working to eliminate
  • 13:28cancer as a cause of death. Learn more at
  • 13:33astrazeneca-us.com.
  • 13:35This is a medical minute about genetic
  • 13:37testing which can be useful for
  • 13:39people with certain types of cancer
  • 13:41that seem to run in their families.
  • 13:43Patients that are considered at risk
  • 13:46receive genetic counseling and testing so
  • 13:48informed medical decisions can be based
  • 13:50on their own personal risk assessment.
  • 13:53Resources for genetic counseling and
  • 13:55testing are available at federally
  • 13:57designated comprehensive Cancer centers.
  • 13:59Interdisciplinary teams include geneticists,
  • 14:02genetic counselors,
  • 14:04physicians, and nurses
  • 14:05who work together to provide
  • 14:07risk assessment and steps to
  • 14:09prevent the development of cancer.
  • 14:11More information is available
  • 14:13at yalecancercenter.org.
  • 14:15You're listening to Connecticut public radio.
  • 14:19Welcome
  • 14:19back to Yale Cancer Answers.
  • 14:21This is doctor Anees Chagpar and
  • 14:23I'm joined tonight by my guest Doctor
  • 14:26John Kunstman and we are talking about the
  • 14:28surgical care of pancreatic cancer
  • 14:29and John right before the break
  • 14:31you were mentioning that patients
  • 14:33who might not have a family history
  • 14:36of pancreatic cancer but might
  • 14:38have a family history of other
  • 14:40cancers like breast and ovarian
  • 14:42cancer should probably go and seek
  • 14:45genetic counseling because those
  • 14:48BRCA one and two gene mutations
  • 14:51may increase their risk of
  • 14:53pancreatic cancer as well,
  • 14:55so are there other genetic
  • 14:57syndromes that might also have
  • 14:59implications for pancreatic cancer?
  • 15:03Yeah, there are a few and some
  • 15:05of them are quite rare, but one that
  • 15:07also comes up not too infrequently
  • 15:09is something called Lynch syndrome or
  • 15:12hereditary nonpolyposis colon cancer.
  • 15:14Now this disease is actually a
  • 15:17constellation of genes that may or may
  • 15:19not be mutated in a particular patient.
  • 15:22And they are typically associated
  • 15:24with colon cancer, hence the name.
  • 15:26However, those screening programs we
  • 15:29were talking about before for patients
  • 15:31that do carry one of those mutations,
  • 15:34again, screening programs would include
  • 15:36them looking for pancreas cancer too,
  • 15:40so I think it just underscores
  • 15:43as you mentioned before,
  • 15:44the need to really be in touch with
  • 15:46your family medical history if you can,
  • 15:48and if there is a strong family history,
  • 15:51consider talking about it with your
  • 15:53doctor and whether or not a genetics
  • 15:55referral would be a good idea.
  • 15:57John, I was
  • 15:59wondering before the break
  • 16:01you had mentioned the fact that
  • 16:04pancreatic cancer can be increased
  • 16:06in smokers and people who
  • 16:08have been exposed to asbestos.
  • 16:11We often think of those factors
  • 16:13really playing into lung cancer
  • 16:15as opposed to pancreatic cancer.
  • 16:17But you also mentioned that one of the
  • 16:21tumor markers for pancreatic cancer
  • 16:24that CA 19-9 was one that was
  • 16:28involved with the bile,
  • 16:31and so I wonder whether things that
  • 16:34affect the liver and the biliary
  • 16:37system also affect pancreatic cancer?
  • 16:40So are you at increased risk
  • 16:41for example, if you are heavy on alcohol,
  • 16:48or if you are obese,
  • 16:51or if you have diabetes,
  • 16:53any of those things that we think of
  • 16:55that go along with liver disease also?
  • 16:58affect the pancreas and increase
  • 16:59your risk of pancreatic cancer.
  • 17:02So let's take those one at a time.
  • 17:04In terms of lifestyle risk,
  • 17:06there's been a tremendous amount
  • 17:08of study on pancreas cancer and
  • 17:11those lifestyle considerations,
  • 17:13and some have really not played out
  • 17:15or have shown contradictory results.
  • 17:17Depending on which study you read.
  • 17:19And these are things like certain
  • 17:21kinds of tea, red meat, vitamin D, etc.
  • 17:26However, alcohol, the chief risk comes
  • 17:28from those patients that develop
  • 17:30pancreatitis as a result
  • 17:33of their alcohol use,
  • 17:34as many of your listeners may know,
  • 17:36folks can get pancreatitis
  • 17:38from heavy alcohol use,
  • 17:40or some patients can get it
  • 17:42even with mild alcohol use.
  • 17:43Now it's not a subtle thing
  • 17:45when you get pancreatitis,
  • 17:46but for folks that have
  • 17:47had multiple episodes,
  • 17:48chronic pancreatitis if you will,
  • 17:51the risk for pancreas cancer is much,
  • 17:53much higher, extremely elevated.
  • 17:55That can also happen to patients
  • 17:57that have problems with recurrent
  • 17:59gallstones that can create a
  • 18:01phenomenon called gallstone
  • 18:03pancreatitis quite different than the
  • 18:05typical benign gallstones that lead
  • 18:06to the discomfort people think about
  • 18:08when they consider their gallbladder.
  • 18:10But when any of those risk
  • 18:12factors leads to pancreatitis,
  • 18:14the risk for pancreas cancer
  • 18:16goes up considerably.
  • 18:18With regards to obesity,
  • 18:20there is an association with a higher
  • 18:23body mass index or risk of obesity
  • 18:26that goes along with pancreas cancer.
  • 18:29It's not as strong as,
  • 18:31say,
  • 18:31family history or history of pancreatitis,
  • 18:34but it is there and it's particularly
  • 18:37notable in patients that have a
  • 18:39high BMI or obesity younger in life.
  • 18:42And then I believe,
  • 18:43the other one you mentioned was diabetes,
  • 18:45and this is actually a bit
  • 18:47of a confusing area.
  • 18:49There is a very strong link with new
  • 18:52onset diabetes and pancreas cancer,
  • 18:54but all is not as it seems.
  • 18:57Certainly that link is there,
  • 19:00but most people that have newly diagnosed
  • 19:03diabetes do not have pancreas cancer.
  • 19:06However,
  • 19:06for patients with the pancreas cancer,
  • 19:09many of them will develop diabetes,
  • 19:11hence the link.
  • 19:12It turns out that it probably is
  • 19:15not the diabetes itself that is
  • 19:17creating the pancreas cancer,
  • 19:19but the effect
  • 19:20the cancer that's growing in the
  • 19:23pancreas has on our ability to
  • 19:26metabolize glucose effectively.
  • 19:27So in other words,
  • 19:28it's not the diabetes that seems
  • 19:30to lead to the pancreas cancer.
  • 19:32Rather,
  • 19:32it's the pancreas cancer leading
  • 19:35to the new diabetes.
  • 19:36However,
  • 19:37that link is not completely clear.
  • 19:40It's still again an area of
  • 19:42pretty active research.
  • 19:43The other thing that is interesting,
  • 19:46I had a friend who not long ago
  • 19:50was diagnosed with pancreatic cancer,
  • 19:52and she had been a diabetic all her
  • 19:55life and one of the things that tipped
  • 19:58off her doctor to the diagnosis
  • 20:01was the fact that her diabetes
  • 20:03became more difficult to control.
  • 20:05Is that something that people who are
  • 20:07diabetics should be paying
  • 20:09attention to as well?
  • 20:11Yes, and I think that
  • 20:13illustrates the point perfectly.
  • 20:15It's not so much that the diabetes was there,
  • 20:18but it's a sudden change.
  • 20:19In other words, somebody that wasn't
  • 20:22diabetic may be in very good shape.
  • 20:25No other risk factors for diabetes
  • 20:27suddenly becomes diabetic or somebody
  • 20:29that had a longtime case of diabetes
  • 20:32with the medication management being
  • 20:34very stable,
  • 20:36suddenly worsening.
  • 20:38And so all of these are good things to be
  • 20:40looking for when you go to see your doctor.
  • 20:43If you're concerned about a potential
  • 20:46diagnosis of pancreatic cancer,
  • 20:47which otherwise is a pretty sneaky cancer
  • 20:50in terms of not really revealing itself.
  • 20:53How is the diagnosis made?
  • 20:55Well, generally speaking,
  • 20:57the diagnosis is made in patients
  • 20:59that have only subtle symptoms,
  • 21:01with imaging many times those
  • 21:03findings that we talked about, say,
  • 21:06worsening diabetes coupled with weight loss.
  • 21:09Or new abdominal complaints coupled
  • 21:11with weight loss will lead to a scan,
  • 21:13typically a CAT scan or sometimes an MRI,
  • 21:16and that's usually the first hint that
  • 21:18there could be something wrong now in
  • 21:21patients that have new jaundice or
  • 21:23something that's a little bit more obvious,
  • 21:25sometimes the diagnosis is
  • 21:26made in other ways,
  • 21:27but typically it's imaging.
  • 21:29And then what happens?
  • 21:30Do these patients get a biopsy?
  • 21:32Nowadays they typically do,
  • 21:33and one thing I think that's
  • 21:35important to highlight here and
  • 21:37we're sort of segueing into this
  • 21:39is that this is a cancer that really
  • 21:42requires a large expert team to manage.
  • 21:45Now we're talking about radiology here
  • 21:47with regards to CAT scans and MRIs
  • 21:49but ultimately when you
  • 21:50do get a new diagnosis,
  • 21:51it needs special cat scans and Mris,
  • 21:55an expert radiologist to interpret
  • 21:57them with regards to biopsy.
  • 21:59It's typically done by a gastroenterologist
  • 22:01and the techniques that they use
  • 22:03are not the typical techniques they
  • 22:05use that and discovered ultrasound
  • 22:06that we were talking about before,
  • 22:08or they may even need to do a procedure
  • 22:10on the bile duct or pancreas.
  • 22:12So these are all expert procedures
  • 22:14and they really do require a big
  • 22:16team even before you get to the
  • 22:18involvement of an oncologist or surgeon.
  • 22:21And presumably you know these days
  • 22:23we talk on this show so much about
  • 22:27personalized medicine and genomics
  • 22:29and all of the fancy tests and assays.
  • 22:32Is pancreatic cancer in that realm as well?
  • 22:35Where
  • 22:36we've moved so far in terms of the medical
  • 22:39and surgical management of this disease,
  • 22:41that there are nuances in
  • 22:43terms of the pathology?
  • 22:45That's a great point,
  • 22:47and it certainly applies for pancreas cancer.
  • 22:51Just in the last year,
  • 22:52I guess a little over a year,
  • 22:54the recommendation has come down
  • 22:56from the NCI and the National
  • 22:58Comprehensive Cancer Network,
  • 23:00that every patient with a
  • 23:04diagnosis of pancreas cancer,
  • 23:06should have a genetics referral
  • 23:08so that they can see whether any
  • 23:10of those mutations are present.
  • 23:12Why are we doing that?
  • 23:13Well, we have all these new advances,
  • 23:15including immunotherapy
  • 23:16and targeted therapies.
  • 23:18And we're finding that more and
  • 23:20more patients may have something
  • 23:22particular to their case that
  • 23:24will ultimately direct the
  • 23:26treatment in a specific way.
  • 23:31And I think the other thing that's
  • 23:34important to point out here,
  • 23:36and certainly was the case with
  • 23:38my friend was she was actually
  • 23:41diagnosed in a smaller center.
  • 23:44But I encouraged her to get a second opinion,
  • 23:47and it changed the diagnosis from
  • 23:51the perception that this may be
  • 23:54metastatic to the perception that
  • 23:57this might not be metastatic and
  • 24:01could potentially be resectable with
  • 24:03a bit of chemotherapy 1st to see if
  • 24:06we could could shrink the disease.
  • 24:08So can you talk about kind of
  • 24:11getting a second opinion and how
  • 24:13important that is and whether it
  • 24:16changes things and how frequently?
  • 24:20It's important for a couple of reasons
  • 24:22and I don't want to minimize the role
  • 24:26that every health care provider in system
  • 24:29has in regards to battling this disease.
  • 24:32Certainly the diagnosis can be made anywhere,
  • 24:35but I think the important thing
  • 24:37is you want to be managed,
  • 24:39or at least have an opinion from a group
  • 24:42that treats this disease frequently.
  • 24:44Because there are a lot of nuances
  • 24:46and one of them that you mentioned is
  • 24:48determining whether or not a cancer
  • 24:50of pancreas cancer can be removed
  • 24:52with an operation we know with utter
  • 24:55certainty that the patients that do
  • 24:57the best are those that can have
  • 24:59surgery to remove the tumor,
  • 25:01and sometimes that
  • 25:02opinion may change depending on
  • 25:04whether you're at an experienced
  • 25:06center and quite honestly,
  • 25:08it might change from one
  • 25:11experienced center to another.
  • 25:13The other thing too is that
  • 25:16multidisciplinary management,
  • 25:17even if a cancer cannot necessarily
  • 25:19be removed in pancreas cancer.
  • 25:22There are many, many,
  • 25:23many clinical trials with some
  • 25:25of the newest agents that could
  • 25:27be available to a patient,
  • 25:28especially if they're treated at
  • 25:31a comprehensive Cancer Center.
  • 25:33I think that's a great point.
  • 25:35And also we know in particular with
  • 25:38the surgical outcomes folks do better
  • 25:40if they're at not just a surgeon that
  • 25:43does a lot of pancreas cancer surgery,
  • 25:46but at a center that does a lot of surgery
  • 25:48because of that multi disciplinary component,
  • 25:51it's the intensive care units,
  • 25:53the radiologist,
  • 25:54the gastro neurologist that are
  • 25:55at a big center that does,
  • 25:58you know 20-30 ,forty,
  • 26:00sometimes 100 plus cases a year.
  • 26:03Those resources will be available
  • 26:05at those centers and the outcomes
  • 26:07are better in a commensurate way.
  • 26:11And the other thing is,
  • 26:12are all pancreatic cancers the same?
  • 26:14I mean is this a homogeneous kind
  • 26:17of disease or are there nuances
  • 26:19and subtleties in terms of the
  • 26:21different types of pancreatic cancer?
  • 26:25There are and I think we talked a little
  • 26:28bit about how some of the genetics of
  • 26:31an individual tumor may actually change
  • 26:33management from patient to patient.
  • 26:35One thing I would like to mention
  • 26:38really quickly is that about 75
  • 26:41to 85% of cancers in the pancreas
  • 26:44arise with association with a small
  • 26:46polyp like lesion in the pancreas.
  • 26:49But about 15 to 20% arise in coordination
  • 26:54with something called intraductal
  • 26:57papillary mucinous neoplasms.
  • 26:59And these pancreas cysts are unique
  • 27:01because unlike most pancreas cancers,
  • 27:03we can't detect them prior to
  • 27:06the emergence of the cancer.
  • 27:08But these lesions,
  • 27:10these precancerous cysts can be
  • 27:13detected on endoscopy or on CAT scans,
  • 27:17and we really think this might be a
  • 27:18way to start making a dent in a certain
  • 27:21fraction of these patients that have
  • 27:23I PMNS,
  • 27:23where we might be able to treat them
  • 27:25prior to the emergence of the cancer.
  • 27:29So how would that work John?
  • 27:31Is that like you go for
  • 27:33your yearly MRI because you're at
  • 27:35high risk and they find this cystic
  • 27:37lesion and you're able to remove
  • 27:39it before it becomes a cancer.
  • 27:42That's one scenario,
  • 27:43another scenario that we're seeing
  • 27:45very commonly as a patient might get a
  • 27:47CAT scan or an MRI for something else.
  • 27:49Whether it's back pain or they're
  • 27:51in a car accident, or any reason.
  • 27:53And there's a cyst seen in the pancreas,
  • 27:56and one thing I just want to make sure
  • 27:58your listeners understand is most
  • 28:00pancreatic cysts are not precancerous,
  • 28:04and these precancerous lesions won't
  • 28:07actually turn into a cancer,
  • 28:09but some will, so risk stratification,
  • 28:13and careful decision-making,
  • 28:14which again takes an experienced,
  • 28:17multidisciplinary group,
  • 28:18is really the key to managing them.
  • 28:21And when we do see one of these
  • 28:24precancerous cysts, or I PMNS,
  • 28:25that looks like it might be
  • 28:27turning into a cancer,
  • 28:28or perhaps even have a small cancer present,
  • 28:31we can act on it to remove it
  • 28:33prior to the emergence of an
  • 28:36aggressive metastatic cancer.
  • 28:38Doctor John Kuntsman is an assistant
  • 28:40professor of surgical oncology
  • 28:42at the Yale School of Medicine.
  • 28:44If you have questions,
  • 28:46the address is canceranswers@yale.edu
  • 28:48and past editions of the program
  • 28:51are available in audio and written
  • 28:53form at yalecancercenter.org.
  • 28:54We hope you'll join us next week to
  • 28:57learn more about the fight against
  • 29:00cancer here on Connecticut Public Radio.