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Improvements in Pancreatic Surgery

         

April 14, 2008 — Advances in surgical treatments for pancreatic cancer have given new hope to those diagnosed with this dangerous disease. Siteman Cancer Center surgeon William Hawkins, MD, discusses these techniques, including the Whipple Procedure and the new RAMPS procedure. Hawkins also explains the different types of pancreatic cancer, what makes them unique and the difference in typical prognosis for each.

 

 

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TRANSCRIPT OF AUDIO FILE

On this edition of Cancer Connection, we’ll talk about pancreatic cancer and surgical procedures for the disease with greatly improved mortality rates.

Host: Thanks for downloading this podcast from the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St Louis. I’m Jason Merrill. After news broke of Patrick Swayze’s pancreatic cancer diagnosis, awareness of a disease diagnosed in over 30,000 Americans a year was heightened. To talk with us about the disease is William Hawkins, an assistant professor of surgery at Washington University who is also a pancreatic cancer specialist at the Siteman Cancer Center. Dr. Hawkins, thank you for joining us.

Hawkins: It’s my pleasure.

Host: There are two types of pancreatic cancer. Talk about the differences between the two.

Hawkins: There’s probably actually more than two types of pancreatic cancer, but we break them into two broad categories. One is adenocarcinoma. This is the garden variety, most common and most aggressive form of pancreatic cancer. And then there are other cells within the pancreas that are within the neuroendocrine family. These are the ones that come from the lineage of the hormones, not the enzymes that help digest food. These hormone-lineage cancers tend to be better behaved, more well-differentiated and slower to grow. And so the two main groups are adenocarcinoma originating from the exocrine function of the pancreas, or digestive function of the pancreas, and neuroendocrine, originating in the hormone-secreting portion of the pancreas.

Host: And one form of cancer is more deadly, correct?

Hawkins: Absolutely. The adenocarcinoma form is much more aggressive than the neuroendocrine form.

Host: And why is that?

Hawkins: That’s not entirely clear. It may have to do with how primitive the tumor is, how close it is to one of these so-called “cancer stem cells,” where it lies in terms of its ability to break off, go someplace else and set up shop in a distant tissue. And so we know that adenocarcinoma of the pancreas is one of the most aggressive forms of cancer of any type, any place in the body with regard to those properties. And the neuroendocrine form of cancer is much less aggressive with regard to those properties.

Host: There are a couple of surgical procedures for patients who are diagnosed with pancreatic cancer, and the first one we’ll talk about is the Whipple procedure. Talk about that.

Hawkins: Sure. So the Whipple procedure we use when we have a tumor in the head of the pancreas. This involves removing a small piece of the small bowel and the first portion of the intestine, removing the head of the pancreas and removing a small section of the bile duct. This operation is called the Whipple operation after Allen O. Whipple, the first guy who did the operation. The operation has gotten a lot better since then. The first couple of times this brave man tried it, he was not successful. I think in his lifetime he may have only done three or four, and half the patients didn’t make it. But since then it’s become a very safe operation. The other operation we do for the pancreas is called a distal pancreatectomy, or distal pancreatectomy and splenectomy. We often do that using a specific technique derived here called the RAMPS procedure, where we do a radical node dissection and concentrate on getting really good margins with that operation.

Host: For the layman, Whipple would be for the head of the pancreas, and RAMPS would be for the body and tail?

Hawkins: Correct.

Host: Survival rates have dramatically improved for a procedure like the Whipple. As you said, the first few didn’t go so well. How have they improved over the years?

Hawkins: So the technical portion of the operation, what surgeons can do, has become very, very safe. Particularly in selected centers that do lots of these procedures a year, the mortality rate has gone even over my lifetime from 15 or 20 percent down to less than 2 percent. In our hands, if you look at the last couple hundred patients, it’s probably, you know, in the 1 percent range – 1 percent of patients not making it in the months after their operation. The survival from cancer has also started to improve. So if we get the tumor out and the margins are negative and the node’s not involved, we give chemotherapy, adjuvant radiation therapy, adjuvant biologic therapy, experimental therapy, and we’re seeing survivals that we’ve never seen before after surgery.

Unfortunately, for those patients who can’t come to surgery, not much has changed. So if you can’t get an operation to get rid of your cancer, unfortunately we’re not doing as well in that category. We do have some small improvements, but they’re modest. We gain a few weeks here, a couple months there, but we really haven’t answered the question about the disease once it has spread.

Host: So when does chemotherapy play a role for pancreatic cancer?

Hawkins: We have two forms of chemotherapy. Chemotherapy used as the primary treatment that helps prolong somebody’s life – that’s when we can’t take the tumor out. And then we have chemotherapy used to try to keep the cancer from coming back in combination with surgery. So those two forms of chemotherapy are, one for treatment and one for sort of prevention or as part of a multidisciplinary approach. The multidisciplinary chemo – chemo plus surgery plus biologic therapy – is what’s making the difference.

Host: Overall, what’s the message you want to get out to patients who are diagnosed?

Hawkins: So overall we’d like to say that things are not as bad as they used to be, but we still have a long way to go. Probably the best thing you can do is take a deep breath and see a couple of different doctors about your disease, get some expert opinions. It always seems like an emergency, but you have a couple weeks to become well-educated, get all the information and then make the best and most intelligent decisions you can.

And we need help from the researcher and the clinician standpoint. We need help trying to beat this disease. So we would ask that you if have an interest or passion or if it’s you or a loved one, get active in fighting this disease. If you have the means, donate. If you don’t have the means, give your time. Call your senators and congressmen. Tell them we need money for this because it’s been shown in cancer after cancer that if we invest our time and money, we can make this problem go away.

Host: With breast cancer, there are so many survivors, and they have events like the Race for the Cure. But with pancreatic cancer being so deadly in a lot of cases, there aren’t a lot of survivors to take up that cause, correct?

Hawkins: This is true. I mean pancreas cancer, although it’s the fourth leading cause of cancer  death, its incidence is not that big. So fewer people get it, but more people die from it. And the treatment is still very toxic. So a lot of our patients, after suffering from pancreas cancer, aren’t feeling up to going out there and fighting for the cause. They’re just happy to be alive, you know.

But if you really think about it historically, I think it’s a bit of an excuse to say it’s not like breast cancer or not like this. It’s not that long ago that breast cancer was a much more deadly disease, and people clamored for research and really got behind the bandwagon. We had cosmetic companies and things that had needed a woman’s cause. They promoted this, and it became a special interest group. That provided research dollars, and research dollars drove things to the point today where breast cancer still happens, but 80 or 90 percent of people are living as survivors of breast cancer. That’s not true yet in pancreas cancer, but I hope that with your help, we’ll get there.

Host: Dr. Hawkins, thanks for your time.

Hawkins: You’re very welcome. It was a pleasure to speak with you.

Host: One of the ways to help is the Pancreatic Cancer Action Network, or PANCAN, a patient advocacy organization focused on pancreatic cancer. You can find them online at www.pancan.org. Or for more information about pancreatic cancer, you can visit the Siteman Cancer Center online at www.siteman.wustl.edu or call 800-600-3606. Thanks for downloading. Until next time, I’m Jason Merrill.