Surgical Care of Pancreatic Cancer
June 01, 2021Information
May 30, 2021
Yale Cancer Center
visit: http://www.yalecancercenter.org
email: canceranswers@yale.edu
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- 00:00Support for Yale Cancer Answers
- 00:02comes from AstraZeneca, dedicated
- 00:04to advancing options and providing
- 00:06hope for people living with cancer.
- 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.