Brent Xia: Pancreatic Cancer Awareness Month and the fight against a silent killer

Alex Trebek. Steve Jobs. Ruth Bader Ginsburg. Patrick Swayze. All of these renowned individuals passed away from the same disease — pancreatic cancer.

This malignancy is steadily climbing in incidence and is currently the third leading cause of cancer-related deaths in the United States (behind lung and colon cancer), with projections to become the second leading cause by 2030.

This year, an estimated 62,210 Americans will be diagnosed, and an equally grim 49,830 will die from the disease. The age-adjusted incidence rate of pancreatic cancer is slightly higher in Kentucky than the national average.

Despite these unfavorable statistics, the overall survival of patients has improved and doubled in the last two decades. For all stages, the 5-year survival rate is 11%, and for local disease in which patients receive multimodal therapy of surgery and chemotherapy, the 5-year survival is 42%. The majority of this progress is attributed to improvement in the efficacy of systemic chemotherapy options, especially in converting patients into candidates for curative intent surgery.

Dr. Brent Xia

Although having a diagnosis of pancreatic cancer as a patient or becoming a caregiver for someone recently diagnosed can seem like a death sentence, there are treatment options available, especially if the disease is caught in early stages, with a more favorable prognosis and possibility for a cure.

• What are risk factors for pancreatic cancer?

Use of tobacco products, obesity, and diabetes are modifiable factors that remain the strongest risk factors to developing the disease compared to the general population. Some risk factors, such as age (>60% are in patients at least 65 years old) and family history or genetic predisposition to pancreatitis cannot be changed. The majority of patients have no family history, but 5-10% may be related to inherited mutations, such as BRCA1 or BRCA2 (Hereditary breast and ovarian cancer syndrome), PALB2 (Hereditary breast cancer), p16/CDKN2A (Familial atypical multiple mole melanoma), PRSS1 (Familial pancreatitis), or mismatch repair (Lynch syndrome) mutations.

• What are symptoms of pancreatic cancer?

Symptoms may vary, ranging from abdominal pain/back pain, weight loss, new onset diabetes or insulin requirement in patient who is already diabetic, to nausea and early satiety. If the cancer grows large enough to push on neighboring structures, patients may present with obstructive jaundice which comes with a constellation of symptoms such as dark urine, light-colored or greasy stools (steatorrhea), and itchy skin (pruritus). By the time a patient presents with symptoms, the tumor has most likely been present for several years. The transition from a benign cell to a malignant mass takes years.

• Is there screening available to detect pancreatic cancer early?

Currently, there are no screening guidelines on a general population level such as what is available for colon cancer or breast cancer. However, individualized screening protocols are available for high risk individuals with familial syndromes that predispose to a higher likelihood of developing the disease. A discussion with a genetic counselor can help establish which individuals will derive the most benefit from screening with radiologic imaging modalities.

• How often is pancreatic cancer found in early stages?

Only 20% of patients at diagnosis have early resectable (able to be removed by surgery) disease. An additional 20% have borderline resectable – disease that can be resected but leaves an increased chance of a positive margin (tumor left behind). The remaining cases are locally advanced unresectable or metastatic. Determination of resectability is based on the tumor’s relationship with critical vasculature nearby – veins and arteries that are necessary for sustaining organ perfusion and gastrointestinal function.

• Does treatment differ by stage?

Previously, upfront surgery was recommended for early resectable pancreatic cancers, followed by six months of adjuvant (after surgery) chemotherapy. The issue with this paradigm is that 50% of patients do not complete the recommended chemotherapy dose due to complications after surgery, delay in initiation of adjuvant treatment or prolonged recovery from surgery.

Recently, another acceptable option is neoadjuvant (before surgery) chemotherapy, followed by surgery if no evidence of metastatic disease on repeat imaging. This has gained favor as it allows the test of time and tumor biology. Pancreatic cancer is a systemic disease, and a patient whose tumor progresses or metastasizes while on chemotherapy would not have benefited from surgery upfront, and would have been spared the potential morbidity and mortality of a major operation.

Borderline resectable cancers benefit from neoadjuvant therapy. Tumor involvement of major vasculature nearby – portal or superior mesenteric veins, is not a contraindication to curative resection following systemic treatment, as these may be resected and reconstructed.

Locally advanced unresectable cancers and metastatic disease are treated with systemic therapy only, with the role for palliative radiation therapy made on an individual basis.

• Who treats pancreatic cancer?

Due to its aggressive nature, multimodal therapy is needed. Pancreatic cancer is treated in a multidisciplinary fashion by numerous collaborating providers – surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists, genetic counselors, nurse navigators, radiologists and interventional radiologists, and pathologists. Discussions are conducted at tumor board conference in order to receive a consensus opinion on treatment sequencing, as no two patients and tumors are alike.

Patients with optimal survival benefit from the combination of chemotherapy and surgery, with involvement of radiation therapy on a case by case basis. This multi-pronged approach is superior to either chemotherapy or surgery alone in terms of recurrence-free and overall survival.

• Is there a role for precision medicine in pancreatic cancer?

Approximately 5% of pancreatic cancers harbor a genetic mutation that may be targeted with specific therapies. Immunotherapies may be appropriate in certain situations based on genetic mutations. The role for immunotherapy is limited compared to in other cancers such as melanoma due to differences in tumor biology. Currently, national guidelines recommend that all patients undergo genetic testing and meet with a genetic counselor.

• What are great resources for patients and caregivers to utilize?

There are many resources on the internet, but not all are trustworthy or undergo a rigorous vetting process. The National Comprehensive Cancer Network (NCCN) is a reliable resource for providers, patients and caregivers. Their website has a section geared towards patients-caregivers with guidelines as well as webinars and advocacy/support. Additional local resources include the Cancer Support Community of Greater Cincinnati/Northern Kentucky, a national nonprofit organization with local chapters that provides free counseling, support groups, resources and classes/programs for patients and caregivers.

A common misconception is that there is no role for holistic medicine, or that it goes against conventional medicine. Integrative oncology is a patient-centered, evidence-based specialty that addresses holistic aspects in partnership with conventional treatments. Another common misunderstanding is the confusion of palliation with hospice. Palliative Care is an important specialty that focuses on improving the quality of life of patients and their families as they undergo the cancer treatment journey, addressing symptoms of the illness as well as treatment adverse effects. Patients receiving palliative care may still receive curative-intent treatments.

Although a diagnosis of pancreas cancer is understandably overwhelming for patients and families, they are not alone in the fight and are surrounded by a multidisciplinary team of providers as well as community outreach programs and support. Due to its aggressive biology, to successfully fight the disease and increase the chances of long-term survival, a multimodal approach, over the course of several months, is necessary. The treatment course is equivalent to a marathon. To endure this mentally and physically, staying informed is a vital part of the preparation and allows for more meaningful discussions at cancer care visits.

Dr. Brent Xia, MD, is a 
surgical oncologist – Gastrointestinal and Hepato-pancreato-biliary — at St. Elizabeth Cancer Center. He is a graduate of Thomas Jefferson Medical College in Philadelphia and completed his residency in general surgery at the University of Cincinnati. He was awarded a fellowship in Complex General Surgical Oncology at Moffitt Cancer Center in Tampa, FL.