Surgical Treatment For Pancreatic Cancer Webcast March 22, 2011 Venu Pillarisetty, M.D. Stan Barer. Introduction

Transcription

1 Surgical Treatment For Pancreatic Cancer Webcast March 22, 2011 Venu Pillarisetty, M.D. Stan Barer Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle Cancer Care Alliance, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. Introduction Pancreatic cancer can be very difficult to detect and unfortunately often it is discovered when it is advanced, and that can make therapy quite intricate. Coming up you'll hear about the latest advances in surgical approaches for pancreatic cancer with an expert from the Seattle Cancer Care Alliance and you'll meet an inspiring patient. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by the Seattle Cancer Care Alliance. I'm Andrew Schorr. Every cancer is difficult, every cancer is scary. I'd like to tell you that we've made tremendous progress in treating any and all cancers, but unfortunately it's not that way. One of the ones that's been most difficult has been pancreatic cancer. Some people have surgery. Some people have surgery, radiation and also chemotherapy, sometimes before surgery and after. Sometimes it's so advanced that surgery would not make sense, and it's certainly a difficult, daunting diagnosis. But the Seattle Cancer Care Alliance is one of the centers where they specialize in that. They actually have a pancreatic cancer clinic with a whole multidisciplinary team that deals with just that and then other GI cancers, if you will. They're specialists in that, and that of course, specialty care is so important when you have a diagnosis like that. Stan s Story We're going to meet part of that team in this program, but we're also going to meet a patient that they've been helping, and that's Stan Barer. Stan is Seattle, prominent attorney and businessman in Seattle, 71 years old. Stan, what happened last fall? I know you had some unusual symptoms that your doctor was trying to figure out what it was. Well, I had cramps, severe cramps in the bottom of my feet, my calves, thighs. A couple of years ago I had back surgery because I had a stenosis, and they cleaned out several vertebraes and that was fine, but it was very similar to that except my back was fine. They checked that again. My vascular supply of blood to my legs was fine, and my regular physician was convinced or concerned that these 1

2 symptoms were in fact a systemic response to something going on somewhere else in my body, and he just wouldn't leave it alone. And ultimately after a series of tests they found out that I had a tumor, a malignant tumor on my pancreas, which was quite a shock to me. Oh, no kidding. Now, do you think that his persistence, if you will, identified this tumor at an earlier stage than it would have been otherwise? Absolutely. And then you went to the Seattle Cancer Care Alliance. Correct. I understand they did both chemotherapy and radiation, and then not too long ago, maybe I guess a month and a half ago or so, you had surgery to remove what they could of the tumors. Right. Under the protocol they have at SCCA I had just over 60 days of chemo, the last 10 or 12 days of which I also had radiation at the same time. And then a few weeks later I had the surgery because my scans all showed that at that point it appeared still to not have metastasized. So surgery was a viable option. And then post surgery you're having some clean-up, if you will, chemo again. That's correct. I just started a couple weeks ago. It's a milder form, but it's I guess to make sure that what's ever out there in my bloodstream doesn't land and cause a problem. Stan, how are you feeling today? Well, I'm delighted to be talking to you, so that's good. Right. 2

3 I'm glad, very happy to be on this side of the grass rather than the other side. Amen. And so, yes, I feel pretty good. And let's go back to the diagnosis because people are listening to maybe have just heard. It shakes your life, doesn't it? Well, I would call it an emotional earthquake. And then I know this came at a time when there was illness in your family, and so you were very selective about who you told for a while. That's correct. I had an older sister who was in the late stages of lung cancer, and the last thing I wanted to do was burden her before she passed away with news that I had pancreatic cancer. So I was mum until the day after she passed. So I knew from September 3 to November 1, but I didn't say anything. But then you did, and I know telling your adult children, your family members, your people you work with, that's not easy. No. In fact, you know, I'd known about it for almost two months, so I'd come to some not peace but acceptance of the situation. For them it was brand new, and I think in many ways it's harder on your family than it is on you, but it did bring the family closer together. Now, you've continued to be involved in business. What do you tell your business associates how to treat you? Well, when I finally advised them I told them the most important thing to me was they treat me as if this news didn't exist. I don't want to hear how sorry they are. I'm sorry enough for myself. I don't want them to be afraid of me. I don't want them to shun me. I'm not contagious. Treat me just as you always had, and I'm 3

4 confident I'm going to take my best shot at this. And I don't need more sympathy, I just need you to treat me the way you always have. If I say something dumb, say that's really dumb, Stan. You know, that's fine. Let's hear about what it means to take your best shot and hear from a member of your healthcare team, Stan. That's Dr. Venu Pillarisetty. He is a surgical oncologist at the Seattle Cancer Care Alliance, also an assistant professor of surgery at the University of Washington, and part of his specialization is in surgery for pancreas cancer. Doctor, first of all, it being discovered a little earlier we hope with Stan, tell us about what was discovered in his case and what surgery you did. Well, actually, you know, in his case by the time we knew that this was a pancreatic cancer we were actually a little concerned that it could have been locally invasive, meaning involving the stomach, possibly spreading to lymph nodes, so we actually did a lot of work-up before even embarking on the treatment pathway that he had. Before we really, you know, went on that he had an endoscopic ultrasound with biopsy of lymph nodes in the area. Then I did a diagnostic laparoscopy where we looked in the area and biopsied more lymph nodes, made sure there wasn't spread of tumor, and then actually got him on to a plan for chemotherapy and radiation treatments. The protocol that he went on is actually a research protocol where patients do get chemotherapy and chemoradiation prior to surgery, and that's a little different from the standard treatment which has always been traditionally the case where you--if you can take out pancreatic cancer essentially the standard has always been do the surgery, get the tumor out. The reason we've--and a lot of people actually are trying these kinds of approaches, to give chemotherapy ahead of time, is that the success rate in the sense of not having tumor come back is not that high without any extra treatment. So when surgery is done by itself, most likely cancers are likely to come back. So the idea is if small amounts of cancer are in other parts of the body we want to get rid of them as soon as we can and then take out the tumor and then give more chemotherapy, as we did in Stan's case. Pancreas Surgery Now, we're going to talk about different surgeries for pancreatic cancer. In his case what were you able to do? Where is the pancreas, how big is it, and what part do you cut out, if you will? Yes. So the pancreas is a gland. It has a couple of parts. One is the part that--the cells that make insulin and other hormones that spread throughout the body, and 4

5 then the other function is to make enzymes to digest food. It sits behind the stomach really almost on top of the spine, and it's sort of shaped like a fish and runs from about the right side of the upper abdomen all the way towards the back and the left diaphragm where the spleen is. And the back part of it is pretty intimately connected to the spleen. We think about the pancreas as essentially being divided into a head, body and a tail. So the head is that part on the right side that is right behind the stomach and the first part of the intestine. Stan's tumor was on the distal pancreas, so the left side of the pancreas, a little bit closer to the spleen. So the operation that he had involved removing the entire left side of the pancreas as well as the spleen and all the lymph nodes and other tissue in that area. So is that the tail? Correct. That's the body and tail of the pancreas were removed. Now, when you take that out, how does somebody get along without that part of the pancreas? Is it special diet? Typically there is not a lot of change in the long run. The things that we tend to see is diabetes is much more likely in people who have that part of the pancreas taken out, and also sometimes they can have difficulty with digestion, but that can be helped by just taking some pills that are enzymes that help digest food, pretty similar to the Lactaid tablets that people take if they're lactose intolerant. Doctor, I know that I had a relative who had another procedure, a surgical procedure, some people have heard about it, the Whipple procedure I believe named after Dr. Whipple from the 30s, and that surgery continues to be done. That's a, maybe a more intricate procedure. What is that? Right. So that, the former name for it is pancreaticoduodenectomy, and it's called that because it's removal of the head of the pancreas as well as the duodenum, typically part of the stomach and a little bit more of the intestine beyond that, and it also cuts through the bile duct. That's a much bigger operation in the sense that you take out that entire area, which includes cutting through the intestine in two places, the bile duct and the pancreas, and then you have to reconnect everything because you still need drainage of all these fluids so when you eat foods it needs to go somewhere and we cut through the stomach. So we have to reconnect the intestine to the stomach, to the bile duct and to the pancreas so that all those fluids can drain and be eliminated eventually. 5

6 So that's a really big operation because it has the part where you're taking out a tumor, and then it has a part where you're rebuilding. I've heard that maybe that's one of the most extensive abdominal surgeries. Would that be true? Yes, it's a pretty long operation. It typically takes people who do it regularly, it takes usually about four to seven hours to do the operation, and patients are--who don't have any problems are usually in the hospital for about a week, but the rate of complications even in expert hands is very high. Stan, how long were you in the hospital recovering from your not insignificant but more limited surgery? I think I was in there five and a half days or six days. I thought it was going to be longer but I wanted to get out of there because it was full of sick people. Chemotherapy Right. So, Doctor, in either case at the Seattle Cancer Care Alliance now are you typically doing some more chemo afterwards? Well, it's really variable, and I think the biggest strength that I've found since I've been here is that we have a really good working relationship among the different doctors in the specialties taking care of patients with pancreatic cancer. So we really talk a lot to each other and even more importantly talk a lot to the patient and listen to the patient and figure out what do they want, what are their goals, and how much of our interference in their life are they willing to put up with. So in Stan's case, he really wanted to have an aggressive approach and do whatever he could to try to obviously extend his life while having a good quality of life. The standard is to do chemotherapy afterwards, but in Stan's case because we were going for an aggressive approach he got chemotherapy and radiation ahead of time and then chemotherapy afterwards. But that's in consultation with the team and what is the interest of the patient, what do they want to do. 6

7 Correct. So typically the standard treatment would be surgery followed by chemotherapy. The idea is if you get the chemotherapy in ahead of time you can kill cells that are out there before you even have the operation. The problem with these operations is that people often do have complications, and that can delay starting chemotherapy. Based on a lot of randomized trials, it's thought and have been proven that chemotherapy at least does improve survival to some extent. The majority of patients I would say do opt for chemotherapy, though. We're going to talk much more about it and also about the variability among patients, even that there are different cancer types that's discovered at different stages, how advanced it may be and what that could mean for you, and how this dialogue goes on between you and your team, multidisciplinary team in the case of the Seattle Cancer Care Alliance, and how this dialogue can go on, and how we can be aware of statistics but also put statistics aside and talk about your individual situation. We'll continue our discussion on this right after this. A Look Ahead Welcome back to Patient Power as we're discussing the latest treatments really particularly the surgical approaches in pancreatic cancer. And we have with us a surgical oncologist at the Seattle Cancer Care Alliance who specializes in gastrointestinal cancers and of course as part of that pancreatic cancer. That's Dr. Venu Pillarisetty, and he's also an assistant professor of surgery at the University of Washington School of Medicine. And also with us is Stan Barer, 71 year--years old and doing pretty well now, an attorney and businessman from Seattle. He was diagnosed with pancreas cancer in the fall of 2010 and about a month and a half ago or so had surgery. He's previously had chemo and radiation, and now he's on some chemo again. So, Stan, you were aware of the statistics, and you were fighting pancreatic cancer. How do you view statistics for yourself? How do you think about it? How do you get your brain around it in thinking, well, what's ahead for me? Well, you're quite correct. I was familiar with pancreatic cancer, and in fact two of my dear colleagues at work, their wives died of pancreatic cancer because they hadn't detected it in time because the symptoms tend not to be from your pancreas. And so, yes, I knew that somewhere over 80 percent it was a death sentence. And I didn't know whether I was part of that 80 percent, but my feeling on statistics is mixed. I know theoretically you flip a coin 20 times and it comes up tails, on the 21st time the odds theoretically are still 50/50. So the questions are is it a specific case different than the statistics. 7

8 In my case I wanted to maximize that I wasn't part of the overall statistic, and it really turned on exactly what was happening with me, but I didn't know for sure what was happening. All I knew was I had pancreatic cancer, and that was not a happy discovery. Variations in Pancreatic Cancer: Treatment Decisions Right. Right. Doctor, you are there and you consult with patients who come from far and wide with this very serious illness. I've had the opportunity to interview some people along the way who beat the odds for extended times. Is there any way to know up front, if it's discovered early or if it's this type of cancer, whether it's in the head or the tail or the body, are there any things that sort of break it down more that are better factors rather than more negative? Yes, typically a lot of it relates to the size of the tumor. Imaging in this disease is extremely important, in other words typically CAT scans that show us the size the tumor, if there's any sign of spread to lymph nodes or to the liver. Unfortunately the majority of patients, unlike Stan, when they're finally diagnosed with pancreatic cancer already have signs of spread of the tumor to the liver or elsewhere. That makes surgical resection pretty much completely contraindicated because we're not going to help that person live any longer and they're just going to expose them to the risks of the operation. So, you know, typically smaller tumors, I mean, that's obviously going to be a better situation. Typically the tumors that are in the head of the pancreas tend to present earlier because that's where the bile duct enters the intestine, so when the tumor starts growing and it's sitting next to the bile duct it blocks the bile duct and patients become jaundiced or yellow. So, you know, those are more often cases where we're able to operate. So we talked about where the cancer is, but I understand there are more common types, I guess adenocarcinoma, as far as pancreatic cancer, but there can be a variety of different types. Does the cell type, the cancer cell type make a difference? Well, that makes a very big difference. Typically we really only refer to adenocarcinomas in the pancreas as pancreatic cancer or pancreas cancer. There are various other types of tumors, including neuroendocrine tumors of the pancreas as well as acinar cell tumors, and we can name a bunch of other things including cystic tumors. Most of those, while they can be malignant don't have quite as an aggressive course as standard pancreatic cancer or pancreatic adenocarcinoma. 8

9 How many people are we talking about? If I've got it right, it seems like there are about 40,000 cases In the United States every year. Oh, my. Okay. And then far beyond that the mortality is high versus other cancers. The mortality in total is very close to 100 percent. Wow. Wow. So it's really very different from most of the other cancers that we deal with. Even other ones that have always been thought of as bad, such as colon cancer, it--you know, it's really not exactly in the same league. So we're doing a lot of work even trying to understand that in terms of, you know, how the biology of the tumor is different. You know, myself I'm studying the immune response to the disease, and in fact Stan was kind enough to give us permission to use part of his tumor as well as some of his spleen to study the immune response to the tumor. Let's talk about that for a minute. So you are a research center as well as providing advanced treatment. So how does the research then work in giving new patients benefit from that and what otherwise is such a scary diagnosis? Well, you know, it's the kind of thing where obviously, you know, in the short term we don't know what we're going to get out of the studies that we're doing, but we are seeing already certain new drugs coming through the pipeline that are now starting to be tested for pancreatic cancer. As I mentioned, the work I'm looking at at the immune response to the disease we see that there is quite a unique immune response to the tumor in the sense that there's a lot of immune cells that normally would fight tumors or fight foreign pathogens that go into the tumor but the types of cells that we see tend to be more immunosuppressive. So it means that even though there's an immune response the tumor is somehow convincing these immune cells that, yes, it belongs there. So you mentioned Dr. Whiting and the whole idea of giving chemo and radiation ahead of surgery, and that's what Stan went through. So it sounds like part of the 9

10 discussion that you have with patients who come to your pancreatic cancer clinic is are there trials or protocols, as you called them, that might be right for you that hopefully will give you a better chance at beating back this disease. Yes. Yes. That's part of the discussion. Absolutely. And the nice thing about our group is that because we have a multidisciplinary clinic where we all meet together, even when we see patients independently I think we all think very similarly in that we kind of know what the other docs from other disciplines are going to suggest also, so it's not that different. If you come here and you see a medical oncologist you're going to get a very similar answer as, you know, if you came and saw me first. Let's talk about what's going on behind the scenes, too. You all discuss cases as a group, as well. Yes. So you've got yourself as a gastrointestinal surgical oncologist. Right. We've got medical oncologists like, Dr. Whiting, Dr. Hingorani. You have radiation oncologists. Correct. And maybe there are pathologists and other members of the team. And then I know as far as care for people we get nutritionists involved. So it truly is quite a group. Right. And gastroenterologists are also heavily involved, yes. And we tend to do a lot of ing and phone calling, and, you know, as soon as we hear about somebody we're already sort of starting to make plans. And sometimes even 10

11 before we see patients because we have a lot of patients who come from very far away, so once we get an with some information about the patient we're already setting up which scans should we get, we're getting our radiologist to review things and setting up endoscopic ultrasound. So it's a pretty nice system in that we're, you know, we interact so much. Stan, I want to ask from your perspective. Now, we should say anything that says University of Washington on it is near and dear to your a heart because you've been on the Board of Regents, so you're one of the citizen leaders, if you will, but also just deciding where you were going to go for care and then hearing about a team like this coming into play, how has that worked out for you? Ah. At this point I can only say fantastically well. I was quite familiar with Seattle Cancer Care Alliance, which is a joint venture of the UW physicians, the Hutch, and Children's Hospital. So I was quite familiar with it for a number of years, so I knew how lucky I was to have one of the best in the world right here. So to me it was kind of a no-brainer. If this group couldn't fix me I wasn't sure anybody else could. And so that was not really an issue in my mind. To me the issue was, quite frankly, my age. I have had the perception that on some issues age is a determining factor. Like, hey, you don't have that much time left, you may not be strong enough for this. We don't like really ancient people in this process. And I believe that I was the oldest person to go into this protocol, and I felt very fortunate about that. So that was wonderful. My great concern at the outset as a layman was, look, if you think it hasn't metastasized yet get that damn thing out of me right now. Right. Do the chemo later. But if during this next three, four months while you give me the radiation, chemo, you know, it spreads, then, you know, that's the end of it. But they were right. It didn't spread. It shrunk the tumor. There was no sign of metastasizing at the end of the three-plus months, so I think they actually knew what they were doing. I hope so. Well, let's hope so, hope we can talk to you a long time from now and you can say that, too. Doctor, so it--you're really working hard, I can hear, to try to change the landscape when it comes to this disease because it's been, as I said at the beginning, so 11

12 daunting. So it sounds like a partnership, if you will. Nobody wants to be part of that partnership as a patient, but they are your partner in this in trying with protocols, with new approaches, trying to do better. Right. Oh, absolutely. And I think the other thing is that those of us who take care of patients with pancreatic cancer often also have a--beyond our hopeful approach and this idea that we'd like to cure the disease, we look at it also from a realist standpoint when we need to, so we do get palliative care services involved early on. We have pretty frank discussions with patients about, you know, what is this treatment likely to give them just so they--when they go into these treatments they, they, you know, get what they're expecting. Maybe they'll get a little more, but we don't fill them with sort of false hope either. And I think that that's important because most people really do need to know, you know, what's likely to happen and then what we can try to accomplish. Advice for Others I think the important point is, though, when it comes from you and the rest of the team there or any center where they have this specialization, you're talking to people who deal with it from a clinical side all the time. Unfortunately there are people who maybe seek treatment elsewhere where they don't have this experience and maybe it's not as well informed. So I always say to people, the name of this program is Patient Power, and I think job one is connect with people who specialize in what you have. That's certainly the case here with our guest today and the team he represents. Stan, so there are people listening who, you know, want to be realistic, but they're kind of picking themselves off the floor, you know, having heard this diagnosis. What would you say to them? I mean, cases vary, one--either how someone wants to proceed or what their specific situation is may be different, but are there any suggestions you would make to them or for them and their family as they try to do as well as they can? Yes. You know, I think there's two levels emotionally there. One is, well, I'm not going to be just a statistic. I wanted to deal with the specifics of my situation, and my view at the outset indicated that it had not metastasized, so I felt I had a real shot at, you know, qualifying for surgery and hopefully extending my life. On the other hand, there's another part of this says, look, you're going to give it your best shot, but some things are bigger than with your attitude or all of this great team, and that's fate. And if it's over, it's over. And so there was sort of a two-stage. I'm going to maximize my situation, but if it's beyond my ability and the team's I'm going to have to accept that. But I didn't want to move to the second level until I had exhausted the first level. 12

13 Right. And you're on that journey now. And well said. I want to wish you all the best with this, Stan. I hope we get to talk about your recovery and going on with your life a long time from now, but I understand it's a challenge. But I guess you celebrate every day, and it sounds like you've picked a great team to work with you. I have. Dr. Pillarisetty, any comment about statistics? Stan and I have mentioned that along the way. What about from your point of view? Well, I just remember the first time I met with him he mentioned that he was a statistics guy, a numbers guy, and he wanted to know all the numbers. And then many months later after he had had a diagnostic laparoscopy, chemotherapy, radiation, we were talking about his distal pancreatectomy operation and how I had to estimate to him that there was probably about a one percent chance of dying from the operation. And his immediate deadpan response was, how did your last 99 patients do? Which I thought was pretty funny and very insightful, but obviously, you know, it's as he mentioned, you can flip the coin as many times as you want, it's never going to change. So just to sum up, Doctor, you've got--we talked about the multidisciplinary team. We talked about realism, and Stan has spoken about that, as you have. And I know we don't want to inject false hope, but it sounds like you all are working every single day to do better. Absolutely. And we really do try to give hope, and I think that's based on experience and having a good team together to really address all of the types of issues that patients with pancreatic cancer have. And, you know, I think that that really does help them one way or the other. I want to wish you all the best with your research and a lot of other research that goes on there. Thank you. And your caring for people on a personal level. And, Stan, I want to wish you all the best. 13

14 Thank you. And we hope that our information today related to surgical approaches and sort of an overview with--of pancreatic cancer, knowing that we have other programs, certainly, we urge you to listen to related to drug therapies and radiation, all comes together in going to a center that specialized in it, and we would advise that for you and certainly you've heard they have that at the Seattle Cancer Care Alliance. I'm Andrew Schorr. Thank you for joining us. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of Seattle Cancer Care Alliance, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That s how you ll get care that s most appropriate for you. 14