Minimally Invasive Surgery Offers Promise for Pancreatic Cancer Patients Recorded on: August 1, 2012 Venu Pillarisetty, M.D. Surgical Oncologist Seattle Cancer Care Alliance 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. Hello and welcome to Patient Power. I'm Andrew Schorr. This program is sponsored by the Seattle Cancer Care Alliance. Well, I think you're familiar with the fact that one of the most deadly cancers is pancreatic cancer. Some call it pancreas cancer. And the hope for a cure comes in part by having a major abdominal surgery, typically known as the Whipple procedure. Wouldn't it be great if that surgery which is often 10 hours or longer if it could be done in a way where you could get out of the hospital quickly, with minimal pain medication and have a higher quality of life and get to the treatment that you need beyond that, typically chemotherapy, in an expedited way? Well, our guest today is going to explain that because he's been working on that now in 2012, making a lot of progress. I want to welcome to the program in Seattle Dr. Venu Pillarisetty, who is a surgical oncologist at the Seattle Cancer Care Alliance. Dr. Pillarisetty, I know you specialize in pancreatic cancer, right?
I do. Thank you, Andrew. I primarily take care of patients with pancreatic cancer although I do surgery for other hepatobiliary diseases and other cancers as well. But my main interest is pancreatic cancer, both from a clinical and a research standpoint. All right. Let's talk about surgery. Typically this Whipple procedure has been, along with chemo and radiation, the best hope for a cure. Am I right? It is. Typically, patients who are able to have an operation to remove the cancer certainly have the best chance of cure, and taking out the cancer, at least the main tumor, does improve the chances that someone is going to live for a reasonable amount of time. However, pancreatic cancer certainly has a high chance of recurring, so we tend to try to combine surgery with chemotherapy and sometimes radiation therapy as well. Now, I know we'll be meeting one of your patients, Mr. McCannel, and he had some systemic therapy before having the surgical procedure and then more systemic therapy after. Did I get that right? Is that usually the way it goes now? The standard treatment for pancreatic cancer, if it is resectable, which means that we can take it out and take out all of it that we can see, is to do surgery first. However, there are patients who we're treating on a research protocol who get treated with chemotherapy followed by chemoradiation and then have surgery, and then after they recover from surgery they have more chemotherapy. The idea is to get rid of any cancer cells that are floating out in the body as soon as possible and then take out the main tumor and then keep trying to kill the cancer cells. Now, I'll mention to our audience we will be visiting with Mr. McCannel, a patient who has gone through this regimen, to talk about his experience in an audio interview that's adjacent to this program. 2
Dr. Pillarisetty, let's talk about using a laparoscopic or less invasive and minimally invasive approach. Where does that come in now with what you've been doing in 2012? What's the benefit of it? Well, this is a relatively new procedure using minimally invasive techniques to do the Whipple or pancreaticoduodenectomy procedure. It's something that a lot of us have been doing fairly regularly for tumors that are in the distal pancreas, just because it is a little bit more of a straightforward procedure, but there are a few people around the country and around the world doing what's called minimally invasive surgery for tumors of the head of the pancreas, so pancreaticoduodenectomies. Seeing that this has been going on for the last few years I thought how can we safely head towards doing that in our own institution. What I decided to do is sort of the initial step I've only been doing this, as you mentioned, in 2012 is to look at what parts of the operation are fairly straightforward to do laparoscopically, and there are some early parts of the operation that require a lot of moving around the abdomen. So if you have an open incision you're really just taking that incision, making it quite large and moving retractors around and really pulling on the abdomen to get to the right side of the abdomen, to the left side and lower down. We can do some of that laparoscopically and then open through a smaller incision than the usual type so that we can do the main part of the operation which is in the middle of the upper abdomen, finish up like that, and find that the incisions are about half the size of what they were before, and patients really need a lot less in terms of pain medication. Now, people are typically in the hospital about five days or a week? 3
Usually around a week as long as they don't have any problems. Complications in pancreatic surgery are actually quite common, so I would say that about half the folks get out of the hospital in less than a week, another 30 or 40 percent are there for another few days, and then there's a small proportion of people who are in the hospital for a few weeks. Now, it used to be with the open surgery, entirely done that way, that people would need a lot of pain meds. What are you finding now as you're taking this less invasive approach? What we're finding is that there are actually quite a few patients who are going home just taking Tylenol or ibuprofen as their pain medication and not needing much in the way of narcotic pain meds. We are not routinely putting in epidural catheters, which are, as many people know are used during childbirth are a little harder to manage for upper abdominal incisions, and we're not needing to use those at this point finding that if you give people a little pain pump with the narcotic pain medicine they use it a bit, and we put them on some Tylenol and maybe some ibuprofen, and that usually takes care of the pain pretty well. I'm finding that the increased mobility that comes with a smaller incision is really helping. Especially since a large proportion of our patients are over 70 years old, getting them up out of bed the next day after surgery is really critical to kind of getting them back to life. So improved quality of life coming out of the hospital having had this still major surgery, and also how quickly they can get to systemic therapy yet again, right, because that's what's going to kill whatever cancer cells may be remaining. Are you finding that people can get on with chemotherapy quicker with the approach you're doing now? That's my sense of it. I don't think I've done enough of these cases to be able to really give a statistically useful answer, but my anecdotal feeling, having done about a dozen cases like this we really are moving towards their treatment goals a lot faster. 4
And we could stress I think for our audience that first of all there are not many surgical oncologists who specialize as you do in this area, and even of the ones who do there are not many who are really taking this approach, correct? No, it is pretty uncommon to do these operations laparoscopically or even laparoscopically assisted. It certainly makes the operation a lot more difficult, and I'd have to say that almost every single time I've done one by the end of the operation I think, I don't want to do this anymore and I'm going to have to go back to doing it the open way, and then I go see the patient for the next few days, and then I do wind up doing it again for the next patient Although it makes me tired at the end of the day, and I think I've had more colds because of that I'm just getting over one now just because we've been in the operating room for an extra two, three hours doing these operations that are already difficult. Dr. Pillarisetty, so your devotion to patients has you continuing to do the laparoscopic approach even though it's exhausting for you because you know it's right for the patient, but I know you re interested in immunology as well, and that is how a patient's own body, own immune system, fights the cancer or even tamp it down or defeat it. Where are we with that? Well, it's a really interesting area I think, and a lot of cancers have some immune response to them, and we found through a recent study where we've looked at specimens from patients who have consented to give us a little piece of tumor that the immune response to pancreatic cancer has a large number of T-cells, which are kind of the main anticancer cells in the body, that look like they should be doing something. However, there are also a bunch of other types of cells that are designed to dampen down the immune response in there. We've seen that patients who get the chemotherapy and chemoradiation before surgery tend to have a little bit of a change in the character of that immune response so that there are fewer of the cells that dampen the immune response and more of the ones that activate it, and that seems to correlate with the effect in terms of the killing off the cancer cells. Now, we don't know why that's 5
happening exactly and whether it's causative, but it's certainly led us to be interested in exploring the potential to develop immunotherapy trials where we reeducate T-cells, take them out of a patient's body, reeducate them, and then put them back in so that they can recognize tumor and fight it. So we're actively pursuing that, and probably within the next two to three years we'll actually have a clinical trial set up to do that. Let's talk about that for a minute. So at the Seattle Cancer Care Alliance, your specialty in this area, you have colleagues who specialize in pancreatic cancer. That's sort of action central, isn't it? So it would seem like someone who is diagnosed with this very serious cancer and all cancers are serious, of course, but this one, very troubling that they would be wise to have a consultation at a center like the SCCA because whether it's in a trial or standard practice that's where all the options can be considered. Yes, I definitely agree, and I think that's been borne out by quite a few studies showing, especially in terms of surgical care but also in terms of decision-making regarding chemotherapy, whether to do radiation or not or even practical terms of whether we should not do aggressive treatment, maybe palliative care is the appropriate thing to do. I think if you go to a place where people spend all their time dealing with certain diseases you're going to get a more realistic assessment and set of recommendations on how to proceed and certainly would have a much lower chance of dying after surgery and a much lower chance of having complications after surgery, and that's been shown in multiple studies. As you know from being on Patient Power before I always like to end with this question: For you doing this every day and working on research, are you hopeful that we can do better for the people suffering from this disease? Absolutely. I mean, I think that we are learning so much about the disease and the course of it, and our knowledge is exponentially increasing, and telling us that I don't think it is quite as 6
hopeless as it's always been thought to be. And we are making right now small strides, but I think those strides are going to get a lot bigger in this coming decade. Dr. Venu Pillarisetty, a specialist, a surgical oncologist devoted to helping patients with pancreatic cancer, thank you for being with us on Patient Power once again. Thank you very much, Andrew. Andrew Schorr hoping this program and discussion with a leading specialist gives you knowledge and hope. Thanks 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. 7