Our Treatment Approach
Pancreas, Liver, Gallbladder and Bile Duct Cancers
Radiation and Chemotherapy
Only 25 years ago, major surgery for cancer of the pancreas, liver or biliary tract was very risky. Patients faced death rates that reached 20 percent at many hospitals. But today, Siteman Cancer Center surgeons have managed to attain a safety record that once would have been impossible.
For example, the major operation for pancreatic cancer patients is the intricate Whipple procedure, which involves removal of the pancreas, a portion of the stomach, the duodenum, common bile duct, gallbladder and surrounding lymph nodes. Our surgeons performed 125 Whipple procedures in 2003, making Siteman one of the highest volume centers for this type of surgery nationwide. In a recent study of 185 Whipples done by our group of Washington University physicians, not a single death was reported. The mortality rate for the more than 100 liver cancer surgeries they perform each year also is very low – about 1 percent.
In the area of liver cancer, our surgeons offer several treatments based on the characteristics of the tumor and condition of the liver. The group is developing techniques that allow for bloodless liver surgery. Transplantation also is performed on a growing number of patients, including those with early stage cancer and cirrhosis.
The success of our surgeons has made Siteman one of the top centers in the United States for treating pancreatic cancer and hepatobiliary cancer, which includes cancer of the liver, gallbladder and bile duct. Studies have shown that patients benefit from treatment performed in this kind of specialized, high-volume center, which produces better outcomes for patients.
Siteman surgeons also have excelled at safe surgery because of the clinical innovations they have pioneered. One is a technique used during the Whipple procedure to sew the pancreas to the intestine, an important advance since leakage at this spot had previously been a main cause of patient death. This new procedure has reduced the leak rate from about 15 percent to 1 percent.
With improved safety for these major operations, the next goal of Siteman surgeons is to make procedures more effective. Some 35,000 new cases of pancreatic cancer develop each year in the United States. And because the pancreas is such a deep-seated organ, cancer is very hard to diagnose. It also tends to recur locally and spread to neighboring organs such as the liver, even if only a tiny bit of tumor – as little as one-tenth of 1 percent – remains after surgery.
Even so, survival rates have been increasing. The five-year survival rate for pancreatic cancer has risen – from 5 to 10 percent to 20 or 25 percent. But eliminating that last one-tenth of 1 percent of tumor that remains in the pancreas after surgery might turn those 20 percent survival rates into 80 percent rates and make an extraordinary difference in saving people’s lives.
To push toward this result, Siteman surgeons currently are involved in clinical trials to evaluate new techniques that may help destroy tumors. For several years, they have been using cryosurgery, a procedure that destroys abnormal tissue by freezing it, to eliminate liver tumors. Now they are testing the use of radiofrequency ablation, which uses heat to destroy tissue, for the same purpose.
Siteman also was one of the only centers in the world to study the use of a new agent – marimastat – to prevent the spread of pancreatic cancer. Unlike other chemotherapeutic drugs, which are intended to kill the cancer, marimastat prevents cancer cells from spreading through tissue.
In another study, Siteman researchers are examining protein patterns in pancreas tissue samples in an effort to develop a new way to assess the risk of cancer recurrence.
At Siteman, radiological imaging is critical in the treatment of hepatobiliary and pancreatic cancer. Our radiologists provide some of the best imaging in the United States. In liver cancers, this advanced imaging – particularly PET scanning and ultrasound – has helped to more accurately identify patients who can benefit from surgery, sparing those who cannot from undergoing futile procedures. The three-year survival for people who have had this imaging and then surgery is about 70 percent. This compares to median survival elsewhere of about 45 percent.
Radiation and Chemotherapy
Radiation is useful in attacking cancer cells that may be left behind after surgery in hard-to-access areas around blood vessels. For the past few years, radiation oncologists at Siteman have been supplementing chemotherapy after surgery with radiation for patients with pancreatic cancer. New techniques have allowed them to deliver radiation more precisely to the tumor, sparing normal tissue.
At Siteman, surgeons and radiation oncologists work hand-in-hand with medical oncologists. At any given time, the team participates in several clinical trials testing new combinations of therapy. One recent trial involved patients who received 5-fluorouracil chemotherapy and radiation after surgery. Previously, fewer than half of all patients like these survived for more than a year. With this combined therapy, their median survival jumped to more than two years.
Other trials have involved the use of a new chemotherapy drug called gemcitabine, which was approved by the U.S. Food and Drug Administration for use in pancreatic cancer patients based on research done in part by Siteman medical oncologists.