Dr. Michael Cavnar discusses the latest treatments for difficult to treat pancreatic cancer.
The Latest Treatments for Pancreatic Cancer
From the Show: UK HealthCast
Summary:
Air Date: 2/19/19
Duration: 10 Minutes
Using state-of-the-art technology and leading-edge medical and surgical interventions, the Pancreas Cancer Team provides advanced and timely diagnosis and individualized, ongoing care for patients.
Transcription:
Melanie Cole (Host): Pancreatic cancer is one of the more challenging diseases to treat since it rarely shows symptoms in its early stages. However, with some of the latest aggressive thespians and specialized care, that can significantly improve outcomes. My guest today is Dr. Michael Cavnar. He's a Surgical Oncologist with UK Healthcare. Dr. Cavnar, explain a little bit about pancreatic cancer. What's the prevalence and burden of this type of cancer today?
Dr. Michael Cavnar (Guest): Pancreatic cancer is one of the more common cancers that we face in surgical oncology. The most common cancer that we have is lung cancer. In both men and women, the most common cause of cancer death is lung cancer, and pancreas actually comes in fourth for both men and women. In 2018, there were about 53,000 cases will be diagnosed, and about 43,000 will die from the same disease.
Host: Wow. Staggering numbers. Tell us about some of the hallmarks of pancreatic cancer, and when does it become apparent? People keep hearing that it doesn't show until the symptoms are far along. Tell us a little bit about that.
Dr. Cavnar: Well, it actually depends on where in the pancreas the disease arises. The pancreas has a pretty complex anatomy, but if you think of it as either the head of the pancreas — which is over on the right side or everything to the left of that, which is the body and tail of the pancreas — cancers that arise in the head of the pancreas tend to be picked up at an earlier stage because they tend to become symptomatic when they block off the bile duct. When the bile duct gets blocked by a tumor, the patient becomes jaundiced and turns yellow, starts itching, they notice changes in their stool color and their urine color.
On the other hand, cancers that arise on the left side of the pancreas tend to grow to a much larger size before they become symptomatic. Those are more likely to have advanced or metastatic disease at the time when they are finally picked up.
Host: Is there a genetic component? Explain some of the risk factors for pancreatic cancer.
Dr. Cavnar: Pancreatic cancer has a number of risk factors. None of them are a one-to-one correlation. Many of them are the typical risk factors that you would think of — so, smoking, alcohol use, high BMI — none of these things have a real high what we call relative risk associated with them. It increases your risk, but it's not like everyone who has those risk factors gets them. High BMI, low physical activity, red meat, dairy, some of these things have been associated, but they're not perfectly proven. Probably the strongest risk factor is chronic pancreatitis, which gives about a 7-fold increase in the risk of pancreatic cancer.
Diabetes has an interesting relationship too because sometimes people are diagnosed with pancreatic cancer after a new onset of diabetes, and so that may happen in someone who is fairly thin and suddenly has weight loss and new diabetes. That may be a sign of pancreatic cancer. On the flip side, some people with long-standing diabetes are at risk of developing pancreatic cancer. It's kind of an interesting relationship there.
Host: It certainly is. Tell us about the diagnostic criteria. If it doesn't show many symptoms, what would send somebody to the doctor, and how do you diagnose it?
Dr. Cavnar: Well, obviously, the people that become jaundiced it's generally a fairly striking change. A lot of the time the patient doesn't notice it themselves. A family member will say, "Hey, you look kind of yellow." The patient may then become itchy; they'll describe their stool changing to a chalky, white color, and their urine becomes dark. That's the profound presentation that's usually not missed. Although, sometimes people are just really not in touch with their health and that may go on for a few weeks.
For people that have cancer coming from the other side of the pancreas it may be very vague symptoms. This might be subtle indigestion-type symptoms, some abdominal pain, constipation. One of the more concerning signs can be back pain. We think this is because the tumor is actually invading into the nerves that supply the visceral system and can be interpreted by the brain as back pain. Another important group is increasing with how many imaging tests we get people will — if you get a hangnail and you go to the Emergency Room and get a CT scan, and they find something. About 70% of pancreas cancer is actually found as incidental discovery when a scan is done for another thing. Those are usually early cancers that are found.
Host: Speak about some treatment options for people diagnosed with pancreatic cancer. As I said in my intro, it's one of the most challenging of diseases for you physicians to treat. Explain some of the treatment options available and some of the adjuvant therapies that you might try. What's the latest? What's going on in pancreatic cancer?
Dr. Cavnar: I would say the first, and most important thing with pancreatic cancer is you need to be treated at a place that has a really strong, multidisciplinary treatment plan. The reason for that is pancreas cancer is complicated. It requires working together with many different groups of physicians — not just that. It's radiologists, oncologists, radiation doctors, nutritionists, many other people — and even palliative medicine.
The treatment varies again by the location of the tumor and by some of the different staging criteria. There's a couple of different ways to look at this, but clinically, the way that we use — and that I use in my practice — is there are some criteria that basically group pancreas cancer into four different categories. This is whether they're resectable, meaning at the very outset, they can have an operation to remove it completely. Borderline resectable, which is there is involvement of some of the big vessels around the pancreas that make it hard to resect but could be resected potentially. And then there's a locally advanced, unresectable, meaning those that have too advanced of a tumor to remove by surgery, but it hasn't spread beyond the pancreas. And then finally, there's metastatic, which means it's spread to either the liver, or lungs, or somewhere else.
Only about 15 to 20% of pancreas cancers are in those first two groups, those that could qualify for surgery at some point. The reality of this is about 80% of pancreas cancers will never be able to undergo surgery. That doesn't mean there's no treatment. It just means that curative intent treatment is not possible. If it's in stage four or metastatic setting, the treatment is generally chemotherapy as the main treatment. For those that are just localized and advanced and can't be removed by surgery, there's chemotherapy and radiation. And then, the details of how to approach the surgery is a whole other, separate topic — for those first two categories.
Host: Well, it certainly is, and we could do a whole segment just on the surgical interventions for pancreatic cancer. Tell us a little bit about some of the new approaches or the new looks to cancer research. What are you out there looking for? What are you seeing on the horizon — coming down the pike?
Dr. Cavnar: Well, I would say the biggest thing that has affected my practice — and remember, I'm a surgeon, so I tend to generally see the patients that are in the resectable or borderline resectable group. This is a favorable subset of pancreas cancers. The thing that we're coming to realize more and more is that this is a disease that is systemic meaning that it is more than just a local problem even in those that have a small, quote-unquote early tumor. Even a small tumor, we think, has microscopic cancer cells that have spread to other parts of the body. The operation that you need to remove even a 1-centimeter tumor in the head of the pancreas is a big operation. It may take eight hours to do that operation, and if everything goes really well, the patient may be able to get chemotherapy in six or eight weeks.
The major complication rate of that surgery is 30 to 40%, and so a lot of those people can never get chemotherapy or are very delayed. What we realize now, is the thing that can help extend people's lives more — we think, and it's in the course of being proven by research — is giving chemotherapy first, before surgery. This has a lot of potential benefits because it could kill those cancer cells that are in the bloodstream before even entertaining the idea of surgery. It allows more people to get chemotherapy because you get the chemo in before surgery, and some people who have a complication never get chemotherapy.
It also allows us to select out and save some people from having surgery because of someone has a very rapid progression during chemotherapy, surgery would have never helped that person. This whole concept is called neoadjuvant chemotherapy. There are many different ways that it's being sliced and diced right now. There are a bunch of different trials that are underway to figure out the best sequence, best drugs, the best way of going about it. That's probably the biggest clinical application research that's going on right now.
Host: Wow, that is absolutely fascinating. Wrap it up for us, Dr. Cavnar, if you would — with your best information what you would like listeners to take away from this segment on what most people consider a very scary disease — what you would want them to know about hope for future research and what you can do for them at UK Healthcare.
Dr. Cavnar: Well, I can tell you that here at UK Healthcare, we have a very comprehensive approach to pancreas cancer that involves really strong multidisciplinary review, which as I said earlier, is critical in this disease. We take that very seriously, and that's whether the patient is in one of those groups that can undergo surgery or whether they're in a more advanced stage. Are there other treatments that we can direct people to to enhance the quality of life and prolong life in those cases.
In terms of hope and research, this is a disease that is actively being worked on all across the world. There is increasing work on the role of the immune system within pancreas cancer and a bunch of ways to prevent the immune system from hiding the cancer cells and making it so that we can't treat those cancer cells. I really believe that in the next five to ten years there's going to be a major breakthrough from the medical oncology standpoint because this operation hasn't changed a lot in the last 20 years. There has been fine-tuning, but what's really going to make the big splash here is when we can get some new drugs that work even better than the ones we have now. I think that's coming soon.
Host: That's excellent news. Thank you so much, Dr. Cavnar, for joining us today, and sharing your expertise, and explaining a little bit about pancreatic cancer. This is UK Health Cast with the University of Kentucky Healthcare. For more information, you can go to UKHealthcare.uky.edu, that's UKHEalthcare.uky.edu. I'm Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Pancreatic cancer is one of the more challenging diseases to treat since it rarely shows symptoms in its early stages. However, with some of the latest aggressive thespians and specialized care, that can significantly improve outcomes. My guest today is Dr. Michael Cavnar. He's a Surgical Oncologist with UK Healthcare. Dr. Cavnar, explain a little bit about pancreatic cancer. What's the prevalence and burden of this type of cancer today?
Dr. Michael Cavnar (Guest): Pancreatic cancer is one of the more common cancers that we face in surgical oncology. The most common cancer that we have is lung cancer. In both men and women, the most common cause of cancer death is lung cancer, and pancreas actually comes in fourth for both men and women. In 2018, there were about 53,000 cases will be diagnosed, and about 43,000 will die from the same disease.
Host: Wow. Staggering numbers. Tell us about some of the hallmarks of pancreatic cancer, and when does it become apparent? People keep hearing that it doesn't show until the symptoms are far along. Tell us a little bit about that.
Dr. Cavnar: Well, it actually depends on where in the pancreas the disease arises. The pancreas has a pretty complex anatomy, but if you think of it as either the head of the pancreas — which is over on the right side or everything to the left of that, which is the body and tail of the pancreas — cancers that arise in the head of the pancreas tend to be picked up at an earlier stage because they tend to become symptomatic when they block off the bile duct. When the bile duct gets blocked by a tumor, the patient becomes jaundiced and turns yellow, starts itching, they notice changes in their stool color and their urine color.
On the other hand, cancers that arise on the left side of the pancreas tend to grow to a much larger size before they become symptomatic. Those are more likely to have advanced or metastatic disease at the time when they are finally picked up.
Host: Is there a genetic component? Explain some of the risk factors for pancreatic cancer.
Dr. Cavnar: Pancreatic cancer has a number of risk factors. None of them are a one-to-one correlation. Many of them are the typical risk factors that you would think of — so, smoking, alcohol use, high BMI — none of these things have a real high what we call relative risk associated with them. It increases your risk, but it's not like everyone who has those risk factors gets them. High BMI, low physical activity, red meat, dairy, some of these things have been associated, but they're not perfectly proven. Probably the strongest risk factor is chronic pancreatitis, which gives about a 7-fold increase in the risk of pancreatic cancer.
Diabetes has an interesting relationship too because sometimes people are diagnosed with pancreatic cancer after a new onset of diabetes, and so that may happen in someone who is fairly thin and suddenly has weight loss and new diabetes. That may be a sign of pancreatic cancer. On the flip side, some people with long-standing diabetes are at risk of developing pancreatic cancer. It's kind of an interesting relationship there.
Host: It certainly is. Tell us about the diagnostic criteria. If it doesn't show many symptoms, what would send somebody to the doctor, and how do you diagnose it?
Dr. Cavnar: Well, obviously, the people that become jaundiced it's generally a fairly striking change. A lot of the time the patient doesn't notice it themselves. A family member will say, "Hey, you look kind of yellow." The patient may then become itchy; they'll describe their stool changing to a chalky, white color, and their urine becomes dark. That's the profound presentation that's usually not missed. Although, sometimes people are just really not in touch with their health and that may go on for a few weeks.
For people that have cancer coming from the other side of the pancreas it may be very vague symptoms. This might be subtle indigestion-type symptoms, some abdominal pain, constipation. One of the more concerning signs can be back pain. We think this is because the tumor is actually invading into the nerves that supply the visceral system and can be interpreted by the brain as back pain. Another important group is increasing with how many imaging tests we get people will — if you get a hangnail and you go to the Emergency Room and get a CT scan, and they find something. About 70% of pancreas cancer is actually found as incidental discovery when a scan is done for another thing. Those are usually early cancers that are found.
Host: Speak about some treatment options for people diagnosed with pancreatic cancer. As I said in my intro, it's one of the most challenging of diseases for you physicians to treat. Explain some of the treatment options available and some of the adjuvant therapies that you might try. What's the latest? What's going on in pancreatic cancer?
Dr. Cavnar: I would say the first, and most important thing with pancreatic cancer is you need to be treated at a place that has a really strong, multidisciplinary treatment plan. The reason for that is pancreas cancer is complicated. It requires working together with many different groups of physicians — not just that. It's radiologists, oncologists, radiation doctors, nutritionists, many other people — and even palliative medicine.
The treatment varies again by the location of the tumor and by some of the different staging criteria. There's a couple of different ways to look at this, but clinically, the way that we use — and that I use in my practice — is there are some criteria that basically group pancreas cancer into four different categories. This is whether they're resectable, meaning at the very outset, they can have an operation to remove it completely. Borderline resectable, which is there is involvement of some of the big vessels around the pancreas that make it hard to resect but could be resected potentially. And then there's a locally advanced, unresectable, meaning those that have too advanced of a tumor to remove by surgery, but it hasn't spread beyond the pancreas. And then finally, there's metastatic, which means it's spread to either the liver, or lungs, or somewhere else.
Only about 15 to 20% of pancreas cancers are in those first two groups, those that could qualify for surgery at some point. The reality of this is about 80% of pancreas cancers will never be able to undergo surgery. That doesn't mean there's no treatment. It just means that curative intent treatment is not possible. If it's in stage four or metastatic setting, the treatment is generally chemotherapy as the main treatment. For those that are just localized and advanced and can't be removed by surgery, there's chemotherapy and radiation. And then, the details of how to approach the surgery is a whole other, separate topic — for those first two categories.
Host: Well, it certainly is, and we could do a whole segment just on the surgical interventions for pancreatic cancer. Tell us a little bit about some of the new approaches or the new looks to cancer research. What are you out there looking for? What are you seeing on the horizon — coming down the pike?
Dr. Cavnar: Well, I would say the biggest thing that has affected my practice — and remember, I'm a surgeon, so I tend to generally see the patients that are in the resectable or borderline resectable group. This is a favorable subset of pancreas cancers. The thing that we're coming to realize more and more is that this is a disease that is systemic meaning that it is more than just a local problem even in those that have a small, quote-unquote early tumor. Even a small tumor, we think, has microscopic cancer cells that have spread to other parts of the body. The operation that you need to remove even a 1-centimeter tumor in the head of the pancreas is a big operation. It may take eight hours to do that operation, and if everything goes really well, the patient may be able to get chemotherapy in six or eight weeks.
The major complication rate of that surgery is 30 to 40%, and so a lot of those people can never get chemotherapy or are very delayed. What we realize now, is the thing that can help extend people's lives more — we think, and it's in the course of being proven by research — is giving chemotherapy first, before surgery. This has a lot of potential benefits because it could kill those cancer cells that are in the bloodstream before even entertaining the idea of surgery. It allows more people to get chemotherapy because you get the chemo in before surgery, and some people who have a complication never get chemotherapy.
It also allows us to select out and save some people from having surgery because of someone has a very rapid progression during chemotherapy, surgery would have never helped that person. This whole concept is called neoadjuvant chemotherapy. There are many different ways that it's being sliced and diced right now. There are a bunch of different trials that are underway to figure out the best sequence, best drugs, the best way of going about it. That's probably the biggest clinical application research that's going on right now.
Host: Wow, that is absolutely fascinating. Wrap it up for us, Dr. Cavnar, if you would — with your best information what you would like listeners to take away from this segment on what most people consider a very scary disease — what you would want them to know about hope for future research and what you can do for them at UK Healthcare.
Dr. Cavnar: Well, I can tell you that here at UK Healthcare, we have a very comprehensive approach to pancreas cancer that involves really strong multidisciplinary review, which as I said earlier, is critical in this disease. We take that very seriously, and that's whether the patient is in one of those groups that can undergo surgery or whether they're in a more advanced stage. Are there other treatments that we can direct people to to enhance the quality of life and prolong life in those cases.
In terms of hope and research, this is a disease that is actively being worked on all across the world. There is increasing work on the role of the immune system within pancreas cancer and a bunch of ways to prevent the immune system from hiding the cancer cells and making it so that we can't treat those cancer cells. I really believe that in the next five to ten years there's going to be a major breakthrough from the medical oncology standpoint because this operation hasn't changed a lot in the last 20 years. There has been fine-tuning, but what's really going to make the big splash here is when we can get some new drugs that work even better than the ones we have now. I think that's coming soon.
Host: That's excellent news. Thank you so much, Dr. Cavnar, for joining us today, and sharing your expertise, and explaining a little bit about pancreatic cancer. This is UK Health Cast with the University of Kentucky Healthcare. For more information, you can go to UKHealthcare.uky.edu, that's UKHEalthcare.uky.edu. I'm Melanie Cole. Thanks so much for listening.
