GRACE :: Pancreatic Cancer

Dr. Katz on Surgery for Pancreatic Cancer, Common Complications, and Importance of Surgical Volume

Whipple Resection FigureThe fourth part of Dr. Katz’s presentation covered what the surgery for pancreatic cancer entails, the most common complications from this challenging operation, and the critical importance of the experience of the surgical team.  Especially for complex procedures like the “pancreaticoduodenectomy”, or Whipple resection, which is the required curative surgery surgery for pancreatic cancer, the experience of the medical team is remarkably important and correlated with the probability of long-term success.

Here’s the video and audio versions of the podcast, along with the transcript and figures for the program:

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Katz Pt 4 Pancreatic Surgery, Complics, and Surgical Volumes Audio Podcast

Katz Pt 4 Pancreatic Surgery, Complics, and Surgical Volumes Transcript

Katz Pt 4 Pancreatic Surgery, Complics, and Surgical Volumes Figs

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Dr. Matthew Katz on Defining Resectability of Pancreatic Cancer

Resectable Pancreatic Cancer figureThe third part of surgical oncologist and pancreatic cancer surgeon Matthew Katz’s presentation on pancreatic cancer covered how it is determined whether a patient is a good candidate for the rigorous surgery required for localized pancreatic cancer.  This encompasses two important questions: is there a realistic potential to resected all of the cancer, and can a patient safely tolerate the surgery without the surgery causing prohibitive damage, either because of the cancer invading into critical structures or the challenge of the surgery itself? This is always a challenging decision and challenging surgery, and Dr. Katz discusses that important process.

Here are the video and audio versions of the podcast, along with the transcript and figures for them.

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Katz Intro to Panc Cancer Pt 3 Defining Resectability Audio Podcast

Katz Intro to Panc Cancer Pt 3 Defining Resectability Transcript

Katz Intro to Panc Cancer Pt 3 Defining Resectability Figures

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Dr. Matthew Katz on Staging Pancreatic Cancer

As is the case for just about all cancers, the staging of pancreatic cancer is a critical question that has significant implications for its management options and prognosis.  In this portion of the webinar by Dr. Matthew Katz, surgical oncologist with a particular specialty in pancreatic cancer, discusses the process of clarifying the stage of pancreatic cancer, in anticipation of the next step of determining the recommended treatment approach.

Here are the video and audio versions of the podcast, along with the transcript and figures for this program.

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Katz Managing Panc Ca Pt 2 Staging Panc Ca Audio Podcast

Katz Managing Panc Ca Pt 2 Staging Panc Ca Transcript

Katz Managing Panc Ca Pt 2 Staging Panc Ca Figs

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Introduction to Pancreatic Cancer, by Dr. Matthew Katz

Katz Pt 1 Intro to Pancreatic CaHere is the first part of an excellent presentation by oncologic surgeon Dr. Matthew Katz, from MD Anderson Cancer, on pancreatic cancer.  The first portion of his talk provides a background on the function of the pancreas and a general introduction to what pancreatic cancer is and the magnitude of this disease.

Below are the video and audio versions of the podcast, along with the transcript and figures associated with it.

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Katz Pt 1 Intro to Pancreatic Cancer Audio Podcast

Katz Pt 1 Intro to Pancreatic Cancer Transcript

Katz Pt 1 Intro to Pancreatic Cancer Figures

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Why am I not getting FOLFIRINOX after my pancreatectomy?

Over the past two decades, it has been increasingly recognized that patients who undergo pancreatectomy for pancreatic cancer do better when they are administered chemotherapy after their operation.

Prior to the 1990s, there was only one drug administered to patients with pancreatic cancer at all—5FU. In 1997, however, a study showed that patients with inoperable pancreatic cancer lived longer and had fewer symptoms when treated with a new drug called gemcitabine than when they were treated with 5FU. Based on the results of this study, gemcitabine quickly became standard treatment for patients with inoperable pancreatic cancer. But its value when given after surgery was unknown. So over 50% of patients who got an operation in the 80s and 90s never received any treatment after surgery—even at major surgical hospitals. 

In 2007, a large study of over three hundred patients was performed in Germany and Austria. The study randomized patients who had undergone curative surgery to receive either nothing (“observation”) or gemcitabine. The duration of time that elapsed between surgery and cancer relapse of patients who received gemcitabine was significantly longer than that of those who did not. Although another large European study showed that gemcitabine was no better than 5-FU when given after surgery, gemcitabine became standard postoperative therapy worldwide largely based on the results of this trial.

Last year, another European study showed that patients with inoperable pancreatic cancer who received a combination of drugs—called FOLFIRINOX—lived even longer than patients who received gemcitabine. In fact, the survival of patients who received FOLFIRINOX was almost twice as long as that of patients who received gemcitabine! Given the failure of multiple other otherwise promising regimens when compared to gemcitabine, this was remarkable. This was a truly revolutionary study that generated an understandable amount of excitement among doctors and patients worldwide.

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Pancreatic surgery: minimally or maximally invasive?

I recently returned from the 2012 annual meeting of the Pancreas Club. Yes, there is a Pancreas Club- a primarily surgical group dedicated to the study of the pancreas. As a “pancreatologist”, every year this two day meeting is a highlight of my year because it provides an opportunity to get an intensely focused view of new studies designed to improve the lives of patients with pancreatic disease. This year, like last year, the meeting included a huge number of talks and posters presenting “minimally invasive” surgical approaches for pancreatic resection. This interest in minimally invasive surgical techniques has filtered down to patients; every week I have long discussions with new patients with pancreatic tumors who are interested in this approach and want to know if it is right for them.

So what is minimally invasive surgery, and what is its role for patients with pancreatic cancer?

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What is resectable pancreatic cancer?

Both the National Comprehensive Cancer Network (NCCN) and the American Joint Commission on Cancer (AJCC) staging systems suggest that the definition of “resectable” pancreatic cancer is straightforward. However, determining whether a patient is eligible for surgical resection actually requires some fairly complex medical decision-making.

According to the cancer staging systems, “resectable” pancreatic cancers are, first and foremost, those that are not associated with disease outside the pancreas. The reason for this is that the outcome following surgery—even if all disease can be removed—is not associated with a longer lifespan or better quality of life than that associated with chemotherapy alone when there is disease in sites such as the liver or lung. Simply put: patients with any amount of disease outside the pancreas live longer and better without surgery. This is a fact that neither I, nor any other pancreatic oncologist, would dispute. However, the anatomic extent of disease that constitutes “resectable” cancer among patients with cancers localized to the pancreas is more controversial.

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Advanced Pancreatic Cancer: Changing Landscape Signals Hope

Pancreatic cancer, though relatively uncommon, is the fourth most common of cancer-related deaths. In the United States, 44,030 new cases of pancreatic cancer were diagnosed with 37,660 deaths in 2011. The average estimated five-year survival of a pancreatic cancer patient with advanced stage of the cancer is 5% or less. Despite these grim figures, a number of recent developments in basic and clinical research offer hope for the future.

Patients with advanced pancreatic cancer include those with cancer spread to liver or other distant organs. In these cases, surgery or radiations are not feasible and chemotherapy remains the sole treatment option. For the past ten years, gemcitabine chemotherapy has been the mainstay for patients with advanced, stage IV pancreatic cancer. The approval of gemcitabine by the F.D.A. was based on an improved survival over the previous standard, 5-fluorouracil chemotherapy. Gemcitabine also led to a ‘clinical benefit response’, or an improvement in pain, appetite, weight and quality of life. In the past decade, there have been several clinical trials, which combined gemcitabine chemotherapy with other chemotherapy agents used in pancreatic cancer. All of these trials indicated that when gemcitabine was combined with another chemotherapy agent (gemcitabine + drug X), the resultant survival was no better than with gemcitabine alone.

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Surgery: the only chance for cure for pancreas cancer?

Most patients have read, on the internet and elsewhere, that surgery is “the only chance for cure” for patients with pancreatic cancer. If you were to review the scientific literature on pancreatic cancer written over the past 30 years, you would find that almost every paper written for a surgical audience begins with this statement somewhere in the introductory paragraph.

So, is it true?

First, let me start by way of introduction. I am a surgical oncologist who treats—exclusively—patients with tumors in the pancreas. That is, I am a physician who uses surgical resection as my primary therapeutic modality for patients with pancreatic cancer and similar diseases. With that, it may perhaps come as some surprise that although I agree that surgery is an important treatment option for patients with pancreatic cancer, it is not the whole story.

The problem with pancreatic cancer is that it is a systemic disease. In all patients. Even patients who have disease which appears localized to the pancreas on the most advanced imaging studies available. All patients with pancreatic cancer, to some degree, have cancer cells floating around somewhere outside the pancreas. For this reason, surgery cannot possibly be the whole story.

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Dedicating the New Pancreatic Cancer Section, and Welcoming Our New Faculty

It is a big step for GRACE to grow from a community focused all but exclusively on lung cancer to a broader community of people affected by many different cancers.  It took years to have GRACE transition from being a site fueled almost exclusively by one person to a resource with a group of specialists all participating together.   It’s a richer experience for that, and now GRACE faces the challenge of overcoming the hurdle of reaching and integrating more patients and caregivers.  Many people note that “there’s nothing out there like GRACE”, which I agree is true, but it would be unfortunate to have such a valuable source of current knowledge and vibrant support be limited to only or primarily lung cancer.  

And one cancer that faces all too many difficulties is pancreatic cancer, which is understudied, has statistics that can be demoralizing, and overwhelms the tens of thousands of people affected by it.  The opportunities for the latest information and a sense of community are limited, and this has led to the development of the GRACE Pancreatic Cancer section from the generous contributions in support of two special individuals.  

Here are the comments from the Elkes Foundation, who provided very generous support:

The Elkes Foundation is pleased to help fund the Cancer GRACE pancreatic cancer site in honor of Ruth Elkes.  She spent her life volunteering and helping others, including participating in clinical trials through her battle with pancreatic cancer. We would also like to remember the devotion and support given to her by her husband, Terrence Elkes, and hope that this site can serve as a resource for patients and their caregivers alike. 

 

 

 The second gift comes from the parents of Dr. Weiss, who provided the following message in memory of their good friend, Andrea Braunstein:

The new pancreatic section of GRACE has been funded in memorial to our recently departed friend, as well as beloved wife, mother and grandmother, Andrea Braunstein. Andrea spent the last three years of her life valiantly battling pancreatic cancer in the only way that she knew how–with dignity, determination, and perseverance. She empowered herself with as much information about this disease as was possible and thereby enabled herself to play an active role in her treatment. Andrea was born on October 3, 1948 in Brooklyn, NY and graduated from Brooklyn College with a BA in education. She and her husband, Kenny, brought up their children, Joshua and Heather in Rockland County, NY. Her granddaughters, Shayna and Aubrey lit up her life and despite her illness, provided her with the will to keep living. Until her very last days, she lead a fulfilling life, emotionally supporting her children, traveling with her grandchildren, maintaining an active social life and involving herself in others’ lives as much as possible. As a former educator, Andrea embodied everything that GRACE is about and would have been proud and honored to have her name associated with such a worthwhile project. Andrea’s passing leaves an enormous hole in our lives, but she will live forever in our hearts and memories.  –  Sheila and Bruce Weiss

 

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