Ask the Experts: Treating Pancreatic Diseases
Online Health Chat with Jane Wey, MD and May Abdel-Wahab, MD
November 2, 2012
Cleveland_Clinic_Host: Some people may not give much thought to the pancreas, especially those with normal pancreatic function. But for the 1.2 million Americans diagnosed with pancreatic disease each year, treatment decisions are crucial. The most common pancreatic diseases treated at Cleveland Clinic include acute pancreatitis, chronic pancreatitis and pancreatic cancer.
Pancreatic cancer is the tenth most common cancer in the United States. Did you know that it is also the fourth deadliest? Pancreatic cancer is known to spread ‘silently’, that is, without symptoms. When symptoms are present, pancreatic disease is usually in an advanced stage, which can limit treatment options. It is essential for patients to educate themselves on symptoms, diagnoses and treatment options for pancreatic diseases, so patients can participate in decisions with their physicians about the healthcare that is appropriate for them.
For More Information
On Cleveland Clinic
As the nation’s rate of pancreatic disease continues to climb, Cleveland Clinic’s Pancreas Clinic rises to the challenge of diagnosing and treating pancreas-related diseases. The Pancreas Clinic, part of Cleveland Clinic’s Digestive Disease Institute (DDI), specializes in multidisciplinary, patient-centered treatments and innovative research for all types of pancreatic diseases and disorders.
Our clinic unites specialists from across Cleveland Clinic, including pancreatic surgeons, gastroenterologists, radiologists, anesthesiologists, psychologists and oncologists from Taussig Cancer Institute, when needed, who together work to customize the best possible treatment for patients and give them improved quality of life. This collaboration also means that patients get the care they need right away, rather than waiting for separate appointments with various specialists. Cleveland Clinic’s Pancreas Clinic is one of the few centers in the nation that specializes in patient-centered treatments and frontline research for every type of pancreatic disorder.
The Pancreas Clinic treats disorders such as complicated acute pancreatitis, chronic pancreatitis, and pancreatic cancer. Each year, more than 1,500 patients trust the Pancreas Clinic with their healthcare needs.
The Pancreas Clinic offers a single location for patients to receive the best therapies and treatment options for pancreatic disorders. Patients travel from around the country to receive our innovative treatments and services, including:
- Endoscopic, minimally invasive and radiographic diagnostic imaging
- Islet auto transplantation
- Robotic surgery for pancreatic cancer
- Robotic pancreaticoduodenectomy
- Chronic pain management using pancreatic enzymes, subcutaneous injections of octreotide, and other alternative treatments.
Current Pancreas Clinic research may lead to the development of a new test for the early detection of pancreatic cancer.
U.S. News & World Report’s “America’s Best Hospital’s” survey has ranked Cleveland Clinic #2 in the nation in gastroenterology every year since 2003.
On Your Health
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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult
To make an appointment with Dr. Wey or with any of Cleveland Clinic’s specialists in the Pancreas Clinic, please call 866.798.7963.
For an appointment with Dr. Abdel-Wahab or any other specialist at the Taussig Cancer Institute at Cleveland Clinic, please call 216.444.7923.
About the Speakers
Jane Wey, MD is a board-certified surgeon in Cleveland Clinic’s Department of General Surgery in the Digestive Disease Institute. She is a fellowship-trained surgical oncologist with a focus on upper gastrointestinal and minimally invasive surgery. Her clinical interests include pancreatic and gastric malignancies, heated intraperitoneal chemotherapy for carcinomatosis, retroperitoneal sarcomas and regional therapy for melanoma.
Dr. Wey completed her surgical oncology fellowship at the University of Pittsburgh Medical Center. She also completed a surgical oncology research fellowship at the University of Texas MD Anderson Cancer Center, in Houston, Tex., studying angiogenesis in gastrointestinal malignancies. Dr. Wey completed her general surgery residency at the University of California Davis Medical Center, and received her medical degree from the University of California, San Diego. She graduated magna cum laude from Harvard University, in Cambridge, Mass. as she earned her bachelor’s degree.
May Abdel-Wahab, MD,PhD, is a staff radiation oncologist in the Taussig Cancer Institute at Cleveland Clinic. She is board-certified in radiation oncology. Her specialty interests include gastrointestinal cancer, prostate cancer and research in radiation oncology and hormones.
Dr. Abdel-Wahab completed a fellowship and residency in radiation oncology at the University of Miami. Dr. Wahab also completed a fellowship at Crawford Long Hospital of Emory University in Atlanta. She completed her Masters of Science and doctorate degree and training at the National Cancer Institute at Cairo University. She graduated with honors and earned her medical degree from Cairo University.
Ask the Experts: Treating Pancreatic Diseases
Pancreatitis Diagnosis and Screening
PancreasFail: What are the recommendations for pancreatic cancer screening in someone with hereditary pancreatitis (PRSS1[protease, serine, 1 (trypsin 1)] mutation)?
Dr__Wey: This is a rare enough mutation that there is not a standard screening regimen that has been proven in clinical trials. Certain types of chronic pancreatitis (including that caused by PRSS1) have been associated with premalignant changes found in the pancreas in patients who have had pancreas surgery for other reasons. In my patients, I would recommend periodic imaging (CT or MRI), and possibly endoscopic ultrasound (possibly with biopsy) of the pancreas to evaluate any abnormalities. Checking tumor markers such as CEA (carcinoembryonic antigen) and CA 19-9 (carbohydrate antigen 19-9) may also be helpful, although these can also be elevated in pancreatitis. In certain instances, pancreatectomy may be indicated.
jello_drops: Far about two years now, I have had elevated levels of amylase and lipase. After further testing, everything came back normal. Recently, they spiked real high (around 400). My doctor asked if anything had changed in my life recently that could account for this. I could not think of anything. What can cause this kind of spike? What levels indicate a pancreas problem?
Dr__Wey: Amylase and lipase are enzymes produced by the pancreas which aid in digestion. Normally you do not see high levels in the blood because the enzymes are in the pancreas and go into the intestine. If the levels are high, this suggests pancreatitis—inflammation of the pancreas, which allows the enzymes of the pancreas to leak into the bloodstream. This can be associated with symptoms such as abdominal pain and nausea. Pancreatitis can have a number of causes. The most common causes are gallstones blocking the ducts, alcohol use, certain medications and high triglyceride levels. There are also certain hereditary or autoimmune conditions that may cause pancreatitis. Your doctor may be able to help with ordering imaging or tests to find out the cause of your pancreatitis. The absolute numbers of the amylase and lipase are less important than the symptoms you're having, and why you have the pancreatitis to begin with. Treatment is directed at the causes of the pancreatitis and the symptoms you have after an attack.
PancreasFail: Could you discuss long-term treatment options for a patient with hereditary pancreatitis? I was diagnosed 23 years ago, at the age of 10 years old. I have had several splenic nerve radiofrequency ablations that improved my pain level by about 50 percent. However, I still require regular breakthrough pain relief with oral opiate medications, and I would be interested in a treatment option that did not involve a controlled substance.
Dr__Wey: The issues of treatment of chronic pancreatitis have to do with the symptoms you're having. Some of the long-term issues could include diabetes, pancreatic enzyme insufficiency, pseudocysts (fluid collections) in the pancreas which can cause blockage) and chronic pain. It sounds like pain is your main issue. The nerve ablations can help, but the other causes of pain can include stones or strictures (narrowing) in the pancreas duct. Sometimes surgical treatments to open up the ducts or remove stones can help. It may be useful to have imaging (such as an MRI/MRCP [magnetic resonance cholangiopancreatography]) and consult with a surgeon to see if this is an option for you.
PancreasFail: I have had several types of imaging that have shown significant pancreatic atrophy due to chronic hereditary pancreatitis, but no stones, strictures, pseudocysts or other abnormalities were noted. I would like to eliminate any need for opiates for breakthrough pain control. Other than splanchnic nerve radiofrequency ablations, which I have every five to six months, have you seen any success in pain control with other medications or procedures?
Dr__Wey: This would be better addressed by individual consultation with a doctor specializing in pancreatitis. Sometimes having an expert review your records and imaging may allow him/her to provide alternative options. Cleveland Clinic has pancreas specialists in gastroenterology and surgery.
Hereditary Factors for Pancreatic Cancer
pmb: I have a very strong family history of various cancers, including pancreatic in my mother. Does pancreatic cancer have any hereditary factors associated with it?
Dr__Wey: There are various hereditary and genetic syndromes that may predispose to pancreatic cancer. Some are specific to pancreas cancer alone, and some are syndromes that can put you at risk for different types of cancers. It may be useful to discuss your family history with your doctor, who can then determine if you need any screening for cancers at this time. He or she may also refer you to see a genetic counselor, who may recommend genetic testing, depending on your specific family history.
Pancreatic Cancer Treatment
holly: If pancreatic cancer is supposed to be so bad, is there any point in seeing a doctor?
Dr_Abdel-Wahab: Although pancreatic cancer has a guarded prognosis, it is still worthwhile to seek medical advice. Survival is lengthened with treatment, depending on the stage and whether or not surgery can be done. Going for an evaluation and getting treatment will allow more time with less symptoms. For example, a patient with borderline, resectable pancreatic cancer can have a survival equivalent to a patient with resectable cancer if radiation and chemotherapy are given to shrink the tumor. Without treatment, this could not be possible. Although much improvement is needed to achieve better results in pancreatic cancer, current treatments are still helpful.
harpo: What are my options for treatment for pancreatic cancer, and how do I know which one is right for me?
Dr_Abdel-Wahab: The options depend on the stage of the cancer and the general condition of the patient. In general, surgery is usually part of the treatment if the tumor is resectable, or borderline resectable. Depending on the stage, preoperative (prior to surgery) or postoperative (following surgery) chemoradiation can be used to improve results. In inoperable cases or in patients who are unable to undergo surgery, radiation and chemotherapy can be used alone.
Radiation Therapy for Pancreatic Cancer
jackson3: What radiation is used for pancreatic cancer?
Dr_Abdel-Wahab: Radiation has many different roles in pancreatic cancer. In general, when radiation is given, chemotherapy is given at the same time to help potentiate (enhance) the effect. The role of radiation can be divided into treatment aimed at treating the cancer (e.g. definitive [the sole treatment] and/or adjuvant or neoadjuvant [applied in conjunction with surgery]) vs. treatment aimed at palliating (relieving) symptoms. Palliative radiation is mainly to relieve obstruction and pain.
Radiation to treat cancer can be given either together with surgery (i.e. preoperatively [before surgery], to shrink the tumor and make the outcome of surgery better, or postoperatively to decrease the recurrence of cancer after surgery). In patients who cannot undergo surgery, radiation can also be used alone (with chemotherapy) to treat an unresectable tumor. However, the results of radiation alone are inferior [not as effective] as the results of radiation in combination with surgery. Radiation can be provided using different techniques.
nyst: What are the different techniques used for radiation treatments?
Dr_Abdel-Wahab: Treatment with radiation has evolved significantly over the years. Current techniques include three-dimensional conformal radiation and intensity modulated radiation therapy (IMRT) as well as radiosurgery (although this is sometimes within the setting of a clinical trial). At Cleveland Clinic, radiation usually includes IMRT and IGRT (image guided radiation) to check the position of the pancreas daily. In addition a four-dimensional CT scan to assess the movement of the pancreas with breathing., this allows better targeting of the pancreas. Breathing can cause the pancreas to move 0.5 cm to 3 cm, which could affect our ability to appropriately treat the tumor with smaller margins. This allows us to lower side effects by treating less normal tissue while targeting the tumor well.
jackson3: What are the side effects of radiation?
Dr_Abdel-Wahab: The side effects of radiation depend on many factors, including the technique of radiation given, the radiation dose and coexisting medical conditions (e.g., inflammatory bowel disease). There is a laundry list of side effects. However, with newer techniques, radiation is better tolerated. I will touch on the most common side effects here rather than a comprehensive list. For example, radiosurgery (stereotactic body radiation) causes more duodenal complications if given in a single dose. However, the common effects seen are as follows:
- Acute effects can occur during radiation, including skin darkening in the area treated and diarrhea, which is usually mild and in some patients may not occur, as well as decreased appetite, nausea and fatigue.
- Chemotherapy could cause a decrease in blood counts that must be monitored. Nausea is also related to chemotherapy and, uncommonly, vomiting.
- Long-term effects include bowel-related symptoms. Organ dysfunction is rare, since we generally keep the radiation dose to the kidneys, liver and spinal cord to tolerable levels.
Surgery for Pancreatic Cancer
simple: What are the standard surgical treatments used for pancreas cancer?
Dr__Wey: The standard surgical treatments are determined by the location of the cancer. If the cancer is in the tail (end) of the pancreas, we perform a distal pancreatectomy, usually with removal of the spleen. If the cancer is in the head (front) of the pancreas, a pancreaticoduodenectomy (Whipple procedure) is performed. This includes removal of the front of the pancreas, the duodenum, the gallbladder and a portion of the bile ducts. The intestine is then brought back up and connected to the stomach, bile duct and pancreas at the end of the operation.
suzette: My brother has been diagnosed with pancreatic insufficiency. What exactly does this mean and how is it treated?
Dr__Wey: Pancreatic insufficiency usually refers to a situation where someone's pancreas is not producing enough digestive enzymes—either because of damage to the pancreas from pancreatitis or due to surgical removal. This would cause the person to have diarrhea and possibly malnutrition because he or she is not absorbing nutrients properly. This can be diagnosed with a stool test. Usually this is treated with oral pills prescribed by the doctor, which are taken with meals to replace the enzymes that the pancreas is supposed to make to help with digestion. Sometimes the patient also has diabetes because the part of the pancreas which makes insulin is not working well, either.
VIPoma of the Pancreas
vp_status: My grandmother was just diagnosed with VIPoma (Verner Morrison syndrome) of the pancreas. She is 85 years old. What is the general prognosis for someone with this and what are suggested treatment options?
Dr__Wey: VIPoma refers to a functional neuroendocrine tumor of the pancreas—a tumor which makes hormones, which may cause her to have certain symptoms such as diarrhea. These may or may not be malignant, meaning that they may or may not spread outside the pancreas and recur after they have been removed. The usual treatment for this would be surgical resection of the tumor. The prognosis relates to her overall health status right now and how extensive the tumor appears to be right now. If she is in good health and there appears to be just one localized tumor, she would probably do well after surgery.
Clinical Trials for Pancreatic Cancer
no_joke: Are there any current promising clinical trials for pancreatic cancer?
Dr_Abdel-Wahab: Most clinical trials for pancreatic cancer are related to immunotherapy or various targeted therapies. A future trial that I find quite interesting will be opened at the Cleveland Clinic. It involves treatment with a target to a hormone receptor that is present in pancreatic cancer, and this compound is attached to a type of chemotherapy. Thus, it targets the tumor directly and lessens the effect of chemotherapy on other areas. The subsequent step is to use it in conjunction with radiation to improve results. To learn more about cancer clinical trials, you can also visit www.clevelandclinic.org/cancer.
Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Jane Wey, MD and May Abdel-Wahab, MD,PhD is now over. Thank you Dr. Wey and Dr. Abdel-Wahab for taking the time to answer our questions today about Pancreatic Diseases.
Dr__Wey: Thank you for participating in the web chat. Pancreatic problems can be extremely complex and cause lifelong issues. Many of the surgical problems are best addressed by surgeons with experience and an interest in the pancreas. If your questions have not been adequately addressed by your own physician, a second opinion may help to clarify questions and ensure that you feel like you are getting the most appropriate care.
Dr_Abdel-Wahab: Thank you very much for joining the web chat; We hope this was helpful in answering some of your questions. We wish you the best of luck with management of your/your loved one's pancreatic cancer.
For more information about pancreatic diseases, please visit www.clevelandclinic.org/pancreasguide
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