New technologies and techniques for pancreatic cancer | OSUCCC – James

[Music] a Whipple procedure in and of itself is an undertaking but a robotic approach to it is uh I think a very highly specialized uh surgery and so we have several surgeons who are um I would say World experts in doing uh robotic pancreaticoduodenectomies or robotic Whipple procedures this is the James cancer-free World podcast I'm Steve wartenberg and my guest is Dr Susan Sai Susan is a surgical oncologist who specializes in gastrointestinal cancers and she was recently named director of the James division of Surgical Oncology pancreatic cancer is a rare form of cancer and traditionally the outcomes haven't been that good for patients Susan will fill us in on the new advances being made in the treatment of this type of cancer including Whipple surgery a complex and precise form of surgery in which Susan and the James are leaders and she'll also fill us in on what's next in treating patients with pancreatic cancer welcome to the podcast thanks Steve I'm really excited to be here and I'm happy to talk on my favorite subject okay skiing no pancreatic cancer and treating patients so not only were you recently named director of the division of Surgical Oncology that's what brought you here right so fill us in on what made you decide to come here and what you'll do as division of uh the director of the division of James surgery well it was an incredible opportunity and I think um I'm indebted to Tim poock who's the chair of surgery who reached out to me uh for this opportunity the division of Surgical Oncology has a tremendous amount of talent uh and the researchers there both the clinicians and the researchers are really leading the way in advancing what we can do for patients uh with cancer with all sorts of cancers and so I thought it was a terrific opportunity partly because um I'm committed to the mission of kind of advancing translational research taking kind of bench to bedside approaches and um as quickly as we can treating patients of today but learning and trying to advance um our opportunities for the patients of tomorrow so um and then of course everyone knows that the James is a premier Cancer Institute and it was just a fantastic opportunity to be part of that community and and one of the things I've learned from Tim who was on the the podcast and other surgeons surgery has become incredibly more complicated and yet at the same time less invasive it's really you think that surgery has like reached its peak in what it can do but no not even close yeah I I mean I think that's the next uh Frontier for surgeons um we have certainly trained in a era where we did maximally invasive surgery um but now we're starting to understand with better systemic therapies how we can marry um the surgical aspect of that to provide the best quality of life for patients and sometimes that means that we combine multimodality therapies radiation chemotherapy and or immunotherapy with surgery and we somewhat actually deescalate care um I think that's very much been in the conversation for different cancers like breast cancer how we can actually manage cancers more effectively with Le the least aggressive approach um and certainly in the case of pancreatic cancer we're not exactly thinking about de-escalating care but we have refined our surgical technique to be able to use robotic surgery in a minimally invasive way and I think patients really uh enjoy that okay well let's dive into pancreatic cancer which you do every day and so what is the pancreas what does it do yeah so the pancreas is an organ uh that sits way in the back of your body it sits right over your spine and your aorta and it really does two things it helps you regulate your blood sugars um so when people think about diabetes that's some abnormality of the um the pancreatic endocrine uh cells that are working and the other thing it helps you do is digest foods so when patients start to have issues with their pancreas it again either manifests as some irregularities in their blood sugars such as diabetes or um patients can experience kind of um greasy oily stools uh due to malabsorption of fats oh so those would be symptoms that would lead them to go to their doctor to lead them to go to a specialist they may be symptoms of problems with your pancreas yes but it sounds like they it also might be symptoms of other things which could slow down a diagnosis yeah exactly I mean I think um pancreatic cancer in general uh is a relatively low incident disease so if you think about colon cancer there's maybe 250,000 new cases of colon cancer a year if you think about pancreas cancer it's closer to 60 to 65,000 so not as many people have that so the regular screening recommendations that are in place for like colon cancer and prostate cancer breast cancer those don't exist for the general population there's no screening regular screening there's no recommended Universal screening for pancreatic cancer except in a in a select population of patients who are known to have a strong family history in those patients there definitely are very uh strong recommendations for screening but in the absence of that if you just think about the general population there's not a way that we are actively screening for pancreas cancer and as you were saying the symptoms um can be very vague so you either have um oftentimes we look for new onset diabetes so diabetes that's occurred within 2 years of a diagnosis that's often times one of the harbingers of uh pancreatic cancer is that you have someone who maybe doesn't fit the typical phenotype for a diabetic they're not by age or weight they're yep exactly they're not overweight um you know that we're not kind of expecting they're actually losing weight so usually I tell people with with diabetes the weight goes up and your diabetes gets worse and you lose weight and your diabetes gets better and the setting of pancreas cancer it's actually a different type of diabetes and it's actually um related to the disease itself so you may be getting worsening blood sugars but actually you're losing weight from the cancer so it's a paradoxical loss of weight but a worsening of your hypoglycemia or um of your blood sugars so that is really should be considered a a sign of pancreatic cancer until proven otherwise now you mentioned family history which leads me to ask can it be passed on through genetic mutations yeah I again I think we're starting to learn so much more and more about the hereditary risk so when I was a medical student we think that there was any um genetic background for pancreatic cancer but now about we realize about 10 to 15% of pancreatic cancers may be hereditary and the most common cause or the most common Gene associated with that actually is the brca2 gene which is the breast cancer Gene yeah exactly exactly and and that Gene actually also places patients at at higher risk for prostate cancer and other things so we continue to evolve our understanding of these genes but um um as I said about 10 to 15% are hereditary and um either there are some known genes that are associated with that but the great majority of patients may not have a currently known Gene and and we know that it's hereditary only by understanding the family history so um I if gen genetic inherited genetic mutations or I think you said 15% do you know the causes for the majority of the cases yeah so unfortunately we we don't and I think that's the most frustrating thing when you meet a patient with the newly diagnosed pancreatic cancer they always wonder like what could I have done to prevent this and oftentimes we don't know you know what actually caused the pancreatic cancer there's a couple things that we know are risk factors so smoking um probably is the single most um important risk factor that we tell people if you have a strong family history of pancreatic cancer really try and avoid smoking or encourage them to have smoking sensation beyond that um pancreas the pancreas itself sometimes develops Cy um like these are fluid filled collections of the pancreas usually the pancreas is a solid organ so we don't expect to find fluid filled cysts um I always tell people that a cyst is to the pancreas like a pop is to the colon so it's a warning sign it's a warning sign it doesn't mean that you're going to have cancer but it's something that needs to be followed and watched because after a certain size um it's it may be recommended that you have that removed to prevent a future cancer or premalignancy and assist on the pancreas it once it gets to a certain size people will feel some discomfort will feel it or no and again I think going back to the location of the pancreas being so deep within your abdomen often times um you know unless the pancreas is inflamed there's really no symptoms associated with a cyst with pancreatic cancer it's it's kind of this very slow growing and often quiet uh in terms of symptoms disease so how do you diagnose it or or or what are the common ways in which it's diagnosed how do people get to you yeah so the the most common symptom that brings patients in is often times jaundice so um the majority of pancreatic cancer probably 60% or more occur in What's called the head of the pancreas that's the part of the pancreas that intersects with the liver um the GI tract and so when there are some issues in that area it's a very small um area so if there's a mass that develops often times we see a sign of that as a a blockage a blockage of the biler tree or the billary system and so patients present with oftentimes jaundice its blockage between the pancreas and the liver or correct and that's what or the or the liver and the intestine so things get um backed up within the liver and then patients become yellow lower jaundice um often times there's weight loss and abdominal pain but these are pretty non-specific symptoms but the jaundice is probably the single most um easy thing to say like if if someone presents with jaundice then uh clearly there is a specific area in the abdomen we need to be investigating wow so with every Cancer we always talk about how early diagnosis is is vital but it seems with uh pancreatic cancer that's a bit of a challenge and that could lead to you seeing people with a little more advanced cases yeah I think even in in the cases where we think that surgery is possible um so you know we have been doing surgery for pancreatic cancer for many decades and um and we know what the outcomes are when we do surgery Upfront for pancreatic cancer um in probably 70 to 80% of patients will have recurrent disease elsewhere in their body and so when you the cancer is metastasized well after we take out the primary tumor 80 to 80% of patients will recur which really means that if we went in and we surgically excised the pancreatic cancer that we knew was there and cancer comes back and 80% of patients somewhere else in their body that really means that even when we thought we had a localized operable cancer probably there was metast micrometastatic disease and that leads me to ask because I'm trying to picture so give me a sense of how big and the shape of the pancreas and you can't remove the whole thing because people need that function in their body right actually you you can actually remove the entire pancreas and we do do that on select occasions we don't really like to do that because obviously um having a pancreas has important endocrine and exocrine functions to help people digest foods and have uh control over their blood sugars but it is possible to remove the entire pancreas and we do do that selectively um but but to maybe getting back to your point in terms of um how how do we change what we've been doing for for many decades in terms of managing pancreas cancer so one of my um mentors and my former chair at the Medical College of Wisconsin Doug Evans really kind of pioneered this concept of changing the way we treat pancreatic cancer um whereas kind of in the older days we would often Rush patients to the operator room because obviously it's an aggressive cancer and we were motivated to try and remove the cancer as quickly as possible unfortunately because the recurrence rates were so high it wasn't exactly maybe the best way to manage pancreatic cancer these days we understand that giving some systemic therapy upfront to treat not only the cancer that we can see but any invisible cancer or micrometastatic disease might have some benefit and so he was the first person to kind of pioneer that approach where instead of going straight to surgery we would do some other therapy first chemotherapy chemor radiation and then at this point we've kind of done an evolution where in in some practices we do actually surgery last it's a what we would say a surgery last approach instead of a surgery first approach wow I've heard that from other people for different kind of cancers that seems to be a trend that's growing cancer and yep yeah but we're going to take a quick break and we're going to get back to that you just you started gave you gave us a tease about some of the advances in treatment and when we come back we'll we'll really jump in and learn about a lot more the best outcomes for treating cancer come from early detection and early diagnosis the James Cancer Diagnostic Center at Ohio State is designed to provide rapid evaluation and a clear diagnosis we are transforming Care by giving patients direct access to cancer experts who study and treat cancer every day if you think you have cancer the choice is clear choose the James Cancer Diagnostic Center we're back with Susan Sai and we're talking about treatment for pancreatic cancer you gave a great overview of some of the the biology and and what and and gave us a little hint about treatment but let's talk more about the surgery and what you're now doing before surgery yeah so Steve um these days we uh offer what's called a new agement approach for pancreatic cancer and I think kind of contextually to for the listeners and viewers is when we used to think about kind of a surgery first approach the median survival after a surgery first approach is about 2 years um for pancreatic canc for pancreatic cancer yeah and so um as we were kind of exploring these new ways to uh deliver therapy in terms of having upfront therapy rather than a surgery first approach what we started to notice is among those patients who would start that that process they would get their new Aden therapy and then surgery we started to see longer and longer survivals and currently it's almost double what we would see with a surgery first approach and that's with our current chemotherapies and our available Therapeutics so as our our systemic therapies actually start to improve we may see that stretch out longer and longer wow so what does the chemo or the radiation actually do to the cancer in the pancreas that makes that extends people's lives that makes the surgery more effective so we're hopeful that when you get systemic therapy it's not as I said before it's not only treating the cancer that we can see on the CT scan and we know that's there but it can treat any other cancer that may be outside that area and so um giving an effective therapy early um is very helpful in terms of controlling that disease in addition often times we think about also adding radiation as well because the radiation can help kind of control the tumor where where it is so that when we surgically remove it the recurrence rates um from the primary T tumor being removed are reduced as well so those two therapies kind of work in tandem to help us decrease both um distant metastatic disease recurrence as well as local recurrences oh I hadn't thought about that but the system systemwide chemotherapy can uh effectively help your immune system find and attack cancer cells anywhere in the body that you haven't identified yet so you can slow down or prevent metastatic cancer yes exactly and I mean the other flip side of this is actually going back to a surgery first approach and we'll get into this a little bit but the Whipple procedure the fancy name that we often say is a pancreaticoduodenectomy that operation involves in part of the pancreas but because it's in a high real estate area we have to remove a bile duct and some intestines sometimes part of the stomach and then that is all reconnected that is a a very major surgery the recovery from which about 50% of people after they've had that surgery cannot receive any additional chemotherapy afterwards they the recovery is significant so that it's difficult to give additional therapy on the back end after surgery but it's very easy easy to deliver that surgery um that therapy upfront prior to surgery so if we know that someone is at high risk for developing a metastatic disease recurrence but only 50% of patients if you if you have surgery first end up being able to receive any chemotherapy then that in it of itself is a limitation of that that approach of a surgery first approach if that makes sense so you have to determine that for each person but what would Pro what would make it so that can't get chemotherapy later what happens in the body that you can't give chemotherapy again it's just the limitation of the the impact of combining the surgery and then having to do chemotherapy afterwards this the surgery is a sign there's a significant recovery from the surgery and many patients who develop pancreatic cancer are often older the median age is often chemotherapy would impact quality of life and and their ability to to tolerate it not exactly actually it's just that patients really don't recover enough to be strong enough to even receive additional therapy so it's that significant of a surgical procedure that um it's very challenging to give additional therapy after surgery but it's very well tolerated to give it prior to surgery okay well that leads you're talking about complicated surgery and that means Whipple so what is this Whipple surgery that i' I've heard about a lot and and the name kind of stays with you yes yeah so the Whipple procedure is is a pretty complicated procedure it involves removing the head of the pancreas um the head of the pancreas is attached to small the first part of your small intestine or the duodenum so that has to be removed as well and the head of the pancreas is also attached to the end of the bile duct from your liver so you have to reconstruct the biliary uh system and often times sometimes a sto a small portion of stomach is removed with all that so um when the specimen comes out there are three different um systems that need to be reconnected the intestine has to be reconnected to the pancreas to the liver and then to the rest of the intestinal systems or the stomach so the operation usually is about a five to six hour Endeavor usually half of the operation is removing that part of your body and the other half is dedicated to reconstructing everything so this is a a how how is Whipple different than how you did it in the past so um the whip so the pancreas is actually because it's deep in in your body it's actually adjacent to some very critical blood structures and the pancreas itself honestly is a is a pretty finicky organ um it's designed to digest um tissues so um when you're trying to recreate an uh connection of the pancreas to a part of your intestines um you you obviously want your con connections to heal but the pancreas itself is trying to digest those connections so it's kind of fraught with some some Peril I would say to begin with um what we so originally a a pancreatic du denomy or a Whipple procedure carried about a 30% mortality rate like you know 30% of patients would not survive the procedure now over time there have been incredible advancements in surgical technique and so now at a at a high volume Institution it's the mortality is less than 3% it that's something that's very important for people to understand because it's such a complicated surgery We There are strong recommendations that those kinds of surgeries be concentrated at high volume centers where like here yep like like at the James where there are surgeons who really just specialize in that operation they do it day in and day out and they can manage the complications they understand how to kind of most expeditiously kind of perform those surgery and take care of the patients afterwards I think the differences that we have done in that we've come across in the last 10 years that have helped as Beyond surgical technique is sometimes we've all we've been using radiation to help sterilize um the pancreas itself before we surgically remove it I I think I mentioned before this helps to make sure that the pancreas doesn't recur or the pancreatic cancer doesn't recur after the surgery so it minimizes recur local recurrences but it that radiation also serves to make the pancreas a little bit firmer and easier to to sew to and so the pancreatic leaks where the pancreas juices are going where they're not supposed to be and they're causing some Havoc that actually decreases that's the single um kind of most feared complication after a Whipple procedure is having a pancreatic leak and those rates with the addition of radiation actually are are go from um 20 20 to 30% down to 10% or l so I'm trying to imagine because you said it's located in the back near the spine so where would you make your incision and and go in to get to it yeah so the incision is um through the front of the abdomen um so which means you have to get through a lot of things to get a lot of things to get to the back and I think amazingly one of the advances that we've been able to do is um I have Partners here are who are experts at robotic surgery and you know a a Whipple procedure in and of itself is an undertaking but a robotic approach to it is uh I think a very highly specialized uh surgery and so we have several surgeons who are um I would say World experts in doing uh robotic pancreaticoduodenectomies or robotic Whipple procedures and so that I think is a tremendous asset of the program clinical trials are always the way to the future and I'm guessing that there's got to be something here at the James there's so many clinical trials are you working on any uh in in this area yeah I mean I think this is a really exciting time for cancer in general but also in pancreatic cancer especially um I would say one of the most significant advances we've had is um the idea of being able to Target a gene called Ras so um pink say that Gan again it's Ras r s r r I've heard okay or Kass is another word so um kasas is a it's an enene meaning it's a gene that often drives cancer development um it's present that Gene is mutated in many different cancers particularly in pancreatic cancer though over 90% of pancreatic cancers have a kayas mutation so it is very very important in pancreatic cancer in the past they have thought that car this Gene was undruggable it was never going to be a Target it had to do with um kind of the on and off rate of the the enzyme activity and it was I think you know impossible to be able to develop a drug that could Target uh that that Gene but the NIH had a rash initiative where they really challenged our you know best and brightest Minds to approach how to Target Ras and out of uh somewhat out of that effort and among some other independent effort that work that was done we have now a series of Ras uh targeting agents so um Kass has that mutation that Gene has many different forms of mutation but there are um Therapeutics that are being developed for maybe each individual mutation as well as a group of those mutations so multiple drugs yes okay because there's multiple genetic mutations within k y so a single patient may have one mutation or another mutation so the most common is g12d mutation the first KES um targeted agent was the g12c mutation it was actually developed a little bit more for lung cancer um very very few patients with pancreatic cancer have a g12c mutation um but many have a g12d mutation so those drugs are in therapy are in clinical trials right now so that's a very very exciting time for us to be able to see how we can partner using now Precision medicine where we actually are targeting the tumor itself with conventional chemotherapies which um of course Target cancer but also Target your normal cells as well so we're combining kind of this Precision medicine and conventional chemotherapeutic approach and I think that's going to be a really exciting advancement in pancreatic cancer wow that's pretty amazing a a genetic mutation that was considered impossible to Target has now been targeted yes exactly yeah so um I think they always say nothing's impossible right so that that is a really for for us that's a huge achievement um on the on the aspect of um operable disease so the kras targeted agents really are being tested in metastic patients on on the operable operable side of the disease um we H we're really excited to hopefully open a clinical trial here soon where we are actually using molecular profiling to try and determine which convention chemotherapy would be best for for patients with pancreatic cancer in the Neo adant setting giving it before surgery so right now um there are two main uh chemotherapeutic options um and we don't know which one is better for each patient one could be better for you and one could be better for me but really we don't know how to choose that at this point there's no test correct but there has coupled with that there has been a lot of Advan advancements in understanding um pancreatic cancer in general and we think there's broadly two major types of pancreatic cancer there's a a classical type and a basil type this is not uncommon to other cancers such as um breast cancer col rectal cancer there's these subtypes of the cancer where we can tell just by the the proteins and the genes that are being expressed that even though it is a pancreatic cancer it's a type A pancreatic cancer or a type B pancreatic cancer that's the same concept here where we we're just calling it a classical subtype or a basil subtype so a great investigator uh J J who first characterized the two different subtypes of pancreatic cancer also noticed that interestingly one subtype seemed to respond to chemotherapy and the other a certain type of chemotherapy and the other subtype did not and so in knowing that what we're testing in a clinical trial here is when we see a patient who's newly diagnosed with pancreatic cancer we'll take biopsies those biopsies will then tell us what subtype that patient is and based on that subtype we're going to give a specific chemotherapy to see if we can actually tailor the chemotherapy to the subtype and if that improves outcomes oh so you're you're combining personalized and precision cancer medicine for one patient correct yep for for individual patients so that is in the context of a clinical trial and hopefully that trial will be open uh soon at at o and so if this works that means you'll know you'll be able to determine what chemotherapy to give patients and KN going would you get better outcomes exactly because I you know I think what's done in the clinics now is we choose one chemotherapy and we give it to the patient if it doesn't work then we switch to the other so there's that trial and error and hopefully this will expedite it so we don't have the error part of it we just give the right chemotherapy from the beginning wow so you've talked you talked before about how some people are higher at higher risk R based on um family history so I understand you have something for them you have a highrisk uh Pancreatic Cancer Clinic here yes and that has been in establishment for a long time it's actually a great uh resource for um those who come to the James and and um it's really led by Phil Hart who's uh one of our gastroenterologists um but high-risk screening entails usually an annual followup either with an MRI or endoscopy so that we can follow the pain for structural changes in the near future there also may be blood tests that we can do to help with early detection or early screening for pancreatic cancer but those individuals who have a very strong family history or a known genetic mut mutation that puts them at risk for pancreatic cancer those are the perfect people to be um seen in this clinic so if they're seen in this clinic and screened regularly the odds are you would catch it very early very early like so we the purpose would be to catch it before there is a cancer how do how do you catch it before there's a oh when it has those those small growths yep if you have a cystic change that is starting to change and becomes worrisome if you start to see any anatomic features just to be able to catch it right before it becomes a cancer in a premalignant state or if or catching it as an early cancer it's like a colonoscopy when you catch pre-cancer PPS remove them before they come become cancer same thing on the pancreas exactly wow it's amazing what's what's going on here and that that sort of leads me to another you talked about this is one of the reasons you came here to be at a high volume Comprehensive Cancer Center where with clinical trials it's uh it it just you must get people from all over to come here because you offer services that no one else does in the state yeah and I think one of the things that's very attractive to patients if they're coming from afar and they're trying expedite kind of their their referral and work up here is we do have a a multidisiplinary clinic um and this is a clinic where uh in a single day you can see all the Specialists that you would need and more so it really takes a village to care for patients is not just the surgeon or just the medical oncologist or just the radiation oncologist but certain certainly those three Specialists are available but there's also a genetic counselor who who is a present uh Physical Therapy a dietitian to kind of address the holistic needs of that patient all in one day it can be a long day because there can be Imaging that's involved but basically patients will be able to come and have an expedited workup of uh for pancreatic cancer this has been a great not just overview but we've really dived in and and it sounds like there's a lot of great things happening and that you're at the Forefront of them and that you came here to be even more at the Forefront and to push things forward even more so what drives you to do that to take Le leadership roles to to create clinical trials to do more for your patients yeah I think when you treat a disease like pancreatic cancer you know it's very humbling because you develop these really close relationships with your patients and you really want the best outcome from them so I think for me we always think about our patients of today and how much we want to care for them but we always think about you know what if we could have done something a little bit more and what's the next step and just thinking about that patient of tomorrow that's I think a huge driver of how we should evolve medicine to kind of think about holistically how we can care for patients not only um you know their their disease but also you know the complete patient in terms of uh their ability to engage and return to the life that they had before the disease so to me that's very very important and that's the single most important thing for me in terms of pushing both the translational research forward the clinical trials mentoring uh young faculty that it's always about the patient of tomorrow thank you for joining us and maybe you'll come back one day and fill us in some more thanks Steve it's been a pleasure this podcast is brought to you by the Ohio State University Comprehensive Cancer Center Arthur G James cancer hospital and Richard J solav Research Institute for more information check out our website cancer. osu.edu [Music]

2024-12-08 11:13

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