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Surgery: the only chance for cure for pancreas cancer?

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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.

Indeed, large studies performed over the past 3 decades have shown that long-term survival and cure following surgery requires systemic chemotherapy (and, in at least some patients, radiation) to take care of this low-volume, extrapancreatic disease. Administration of chemotherapy and/or radiation following surgery for this purpose is called “adjuvant chemotherapy” and it is designed to prevent recurrence of cancer following surgery and to maximize the chance that surgery will be effective long-term. Although several studies have shown that surgery alone is rarely effective at providing cure, long-term survival rates now approach one-third for patients treated with both surgery and chemotherapy (and/or chemoradiation). Patients who undergo surgery need additional therapy—often 4 to 6 months—to ensure that the favorable results associated with resection are realized.

What is also important to recognize is that treatment options do exist for patients who are not offered an operation. This is critical to emphasize for a disease in which 80 percent of patients cannot undergo surgery for one reason or another. For example, a recent study in the New England Journal of Medicine showed that a novel chemotherapy regimen called FOLFIRINOX can lead to the highest response rates and longest rates of survival ever reported for patients with this disease. Furthermore, new radiation techniques and radiosensitizing agents have led to long-term survival among some patients with localized disease even without surgery. Although clearly there is a long way to go, the statistics are better for patients with pancreatic cancer than they were even 5 years ago.

So to answer the question: “is surgery the only chance for cure with patients with pancreatic cancer?”, the answer is “sort of”. For this reason, I caution all newly-diagnosed patients not to become fixated on surgery as the end-all be-all. Yes, surgery is an important part of treatment. Yes, surgical resection can be used to prolong survival in some patients with localized cancer. But surgery alone is not a quick road to success; chemotherapy and perhaps chemoradiation are also required. Conversely, patients not eligible for surgery have legitimate treatment options at their disposal, and results with non-operative therapies are only getting better.

I look forward to discussing issues relating to pancreatic cancer and its treatment in this forum, and I welcome any specific questions you may have.


9 Responses to Surgery: the only chance for cure for pancreas cancer?

  • dancer2doc says:

    I am excited to begin to learn more about pancreatic cancer and newer treatments options. I am a practicing MD in California and have lost both of my parents to pancreatic cancer, my father then aged 74 and my mother 5 years later, aged 79. I have spoken with a geneticist as well as my internist about possible screening recommendations and neither feel there is any indication for screening in myself (age 52) or my borther (age 56.) What are your thoughts or recomendations here? Thanks so much ..

  • Dr West
    Dr West says:

    Sorry for the delay over the holiday weekend. I’ll ask one of the pancreatic cancer faculty members to comment.

    -Dr. West

  • Dr. Javle says:

    When two or more affected relatives have pancreatic cancer, the risk is certainly high. Your situation is interesting as there are two different lineages (Dad and Mother).
    The one practical suggestion is that if you are a smoker to quit now. Our studies indicate a very high risk of cancer occurrence when familial and environmental risks add up.
    As for screening- there is no standard screening for pancreatic cancer. However, based on a prior screening study, for at risk individuals we advise endoscopic ultrasound and CT scan abdomen. I would suggest this as a one-time study-and further screening will be determined by the results of the same. For instance if a fluid containing mass (cyst) is found, there are specific guidelines to follow that. If you have trouble with insurance reimbursement or if near a clinical trial site, best to enroll in the trial. Below is a link.

    http://www.clinicaltrials.gov/ct2/show/NCT00084357?term=pancreatic+cancer+screening&rank=3

  • dancer2doc says:

    Thanks for your comments… I am a nonsmoker and as a runner have a very healthy lifestyle .. I will continue to search for clinical trials which might be appropriate … I am assuming that you do not see any value in a CA19-9 test as a screeening tool …

  • panas says:

    Dr West and Dr Javle, do you have a comment about this:

    http://www.dailymail.co.uk/sciencetech/article-2270016/The-15-year-old-schoolboy-invention-revolutionise-cancer-detection.html#axzz2KXTnRkbT

  • Dr West
    Dr West says:

    I don’t know enough about it and don’t think that we have really seen enough science to say anything yet. It has become a darling media story, but that doesn’t mean it’s accurate. For instance, Steve Jobs actually had a rare subtype of pancreatic cancer that isn’t the same as almost all others, so I don’t think it’s true that even if this test could detect most forms of pancreatic cancer, it would have detected the one Steve Jobs had.

    I think it’s wise to believe almost nothing about science and medicine that hasn’t been corroborated by actual scientists and physicians. Most journalists are far more motivated to provide a sensational story than to provide a truly accurate one, and the vast majority aren’t remotely knowledgeable enough to know the difference.

    He may be right, and it may be a breakthrough, but the fact that he says it’s amazing and some journalists fawned over the story doesn’t make it true. The media are filled with sensational but completely inaccurate stories about medical breakthroughs, and they never write a follow-up to tell you they were wrong, if they even care to find out by following up on their breathless reports.

    We’ll learn more over time and have more to say then.

    -Dr. West

  • hilai66 says:

    In what circumstances you can think twice before doing chemotherapy after whipple resection, if your surgeon is very sure that he has taken everything out and it hasn’t invaded other organs? He has made a comment that chemo is not necessary.

  • Dr West
    Dr West says:

    I’m not the best person to comment, since I really don’t treat pancreatic cancer with any frequency, but I’ll see if I can get one of the people who sees and treats a lot of pancreatic cancer to offer their thoughts here.

    -Dr. West

  • Dr West
    Dr West says:

    Dr. Katz was kind enough to return his thoughts:

    In general chemotherapy is standard of care following pancreatectomy,
    regardless of the “completeness” of the operation performed. However,
    recommendations for postoperative chemotherapy might be changed depending
    on the recovery process, other healthcare issues, patient wishes and goals
    of treatment, etc. But for young, otherwise healthy patients chemotherapy
    is an important component of potentially curative treatment. If unsure in
    your specific situation I would request a second opinion.

    -Dr. Katz

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