Reducing Your Risk of Pancreatic Cancer

Dr. Scott Steele:

Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele:

Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, colorectal surgeon and president of the main campus here at Cleveland Clinic in beautiful Cleveland, Ohio.

It's always nice to welcome back one of our guests and today it's Dr. Robert Simon, general surgeon and hepatobiliary pancreatic specialist here at the Cleveland Clinic at Cleveland Clinic Digestive Disease Institute. Rob, welcome back to Butts & Guts.

Dr. Robert Simon:

Thank you. Thank you for having me.

Dr. Scott Steele:

Today, we're going to talk a little bit about preventing and reducing your risk of pancreatic cancer. But before we jump into there, it's been a while since you've been on the show. So can you give us a little bit of background? Where did you train, where are you from, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Robert Simon:

I was born in Ohio. My dad went to medical school at Ohio State, did his residency and fellowship there in radiology. So I was born in Columbus, Ohio, but moved to Michigan when I was two. So I say that I was from Michigan still. And then went to undergrad at Northwestern University where I majored in biomedical engineering, then did medical school at Ohio State, went up to Michigan for general surgery residency at Beaumont Hospital in Royal Oak. And then I came here for fellowship in HPB and have been here ever since. So I've been here since 2017. Hard to believe.

Dr. Scott Steele:

Fantastic. And we're so glad that you're here and decided to stay. Today, as I said, we're going to talk a little bit about pancreatic cancer, a topic that we've had a few times here on Butts & Guts. But can you walk us through a high-level overview, what exactly is pancreatic cancer? And even, for some people, give me a little bit more about what is the pancreas and feel free to give a high-level overview about what its purpose is, who can get it, and what are some of the most common risk factors for pancreatic cancer?

Dr. Robert Simon:

Sure. Big topic here. The pancreas, in general, is a long, thin, flat organ, it extends all the way over from the right-hand side and goes all the way over to the left-hand side by the spleen. I always tell patients it has two major functions. One is it makes hormones, the most famous one being insulin, it helps with blood sugars. The other thing it does is it makes enzymes and those enzymes drain through the duct into the intestines where it mixes with food and helps you digest it.

Now, patients can get tumors of those two types of cells and they're both very different types of tumors. I know you've talked about this on other episodes, but the hormone-producing cells, the types of tumors that those form, are neuroendocrine tumors. Those tend to be very slow-growing benign tumors. The tumors that can form from the enzyme-producing cells are pancreatic adenocarcinoma. And that's more typical of what people think of when they think of pancreatic cancer. That one is the more aggressive one and that one is the one that the treatment isn't quite as good.

Dr. Scott Steele:

So we're going to talk a little bit about pancreatic cancer today and what are the signs and symptoms. You mentioned that it's way in the back, it's flat. And I got to be honest, when people hear the term pancreatic cancer, they normally associate it with not the best of outcomes. So what are those signs and symptoms? And maybe more importantly, can you have it without having any symptoms?

Dr. Robert Simon:

So yeah, unfortunately, the signs and symptoms that can occur typically occur late. The classic one being jaundice or yellowing of the skin or the eyes, and that's because the tumor has grown to the size and to the point where it blocks that bile duct that goes through the head of the pancreas so bile then backs up into the liver.

And when it does reach that point, that's usually when we find it because it's so hard to find otherwise. Without symptoms, people don't know to look for it. Unfortunately, for pancreatic cancer, surgery is not really a good option once it's metastatic or once it's spread outside the pancreas. So the key is to find it early. And that's one of the things that we're trying to focus on is early identification.

Dr. Scott Steele:

So it begs the question, how is pancreatic cancer diagnosed?

Dr. Robert Simon:

Yeah. Usually, it's diagnosed late, unfortunately. Only about 20% of patients actually get to see me because by the time that it has been diagnosed, it's usually so big that it is involving too many of the blood vessels back there that we can't get it out or it has spread outside of the pancreas. There's a couple of things that we can try and do to try and identify patients that are at risk. There's this International Cancer of the Pancreas Screening Consortium, or CAPS, that tries to identify patients that are at higher risk of getting pancreatic cancer.

So some of those risk factors are patients who have at least one first-degree relative who has had pancreatic cancer or if they've had multiple second-degree relatives with pancreatic cancer, if they have a known genetic mutation such as a BRCA mutation with a family history of pancreatic cancer or Lynch syndrome or Peutz-Jeghers, there's various genetic mutations. And in those patients, there's some benefit to screening those patients, meaning getting an MRI or an EUS, an endoscopic ultrasound, where they take a scope and go down into the stomach with a special probe on the end where they can look through the stomach into the pancreas and get a good picture of it that way. So there's some indications for screening those patients and trying to pick up early pancreatic cancers that way.

Dr. Scott Steele:

You mentioned a little bit about those screening availability and you mentioned either a scope or some imaging. Is there any other types of screening that can be done? Is there a blood test or anything that you can get for pancreatic cancer?

Dr. Robert Simon:

Yeah. There is some, we'll call them liquid biopsies, basically blood tests that look for a bunch of different cancer tumor markers. I wouldn't say they're mainstream at this point in time, but I do think that there's some promising research that is being done down the road that can help some people. The other thing I will point out is pancreatic cysts are very common.

There's some studies that have shown that about one in five people over the age of 80 have some sort of pancreatic cyst. And while there are a variety of different types of pancreatic cysts, there's a couple in particular that are risk factors for turning into cancer. So we follow all of those patients. And I think that is one of the best ways to identify an early pancreatic cancer or even risky features that would lead us to operating on them and getting it out before it even turns into a cancer. That's a win in my book.

Dr. Scott Steele:

Yeah. And certainly, we've shared patients together of somebody who has a CT scan for another reason and they find these cysts and then we send them over to you. So truth or myth, can having chronic pancreatitis, inflammation of the pancreas, lead to pancreatic cancer?

Dr. Robert Simon:

Truth. Chronic pancreatitis is a risk factor for turning into cancer. And in those patients, we don't have a good screening set of guidelines to help us determine which ones are morally could be good actors and which ones are morally could be bad actors, but that is a risk factor. So things to try and do to cut back on the risk is to try and reduce the risk of chronic pancreatitis and that repeated inflammation of the pancreas that can lead to cancer. So cutting back on alcohol, smoking, for sure. Smoking has been shown to be the biggest modifiable risk factor for pancreatic cancer. There's about a two times increase risk of pancreatic cancer in those who smoke, so stopping smoking is extremely important.

Dr. Scott Steele:

Rob, you mentioned in the past that surgery is not a primary treatment for metastatic pancreatic cancer, but is it the treatment of choice, if you will, the primary treatment for other types of pancreatic cancer and why?

Dr. Robert Simon:

For locally controlled pancreatic cancer, the best outcomes are with surgery and chemotherapy. Combining those two modalities improves the survival the best. So yes, surgery is one of the mainstays of pancreatic cancer.

Dr. Scott Steele:

Let's go a little bit more in detail. A tumor can be in different spots along that flat organ way in the back. Are there different types of surgeries, and can you explain a little bit about them?

Dr. Robert Simon:

Yeah. The two biggest operations that we do for pancreatic cancer is if it's involving the body and the tail of the pancreas, meaning the part of the pancreas on the patient's left side, that's a distal pancreatectomy and splenectomy. We want to get all of those lymph nodes in that area, which is why the spleen has to come out.

If it's involving the head of the pancreas or the part of the pancreas on the right side of the patient by the liver, that's when we do a Whipple, the infamous Whipple named after Allen Oldfather Whipple. And that is where we take the head of the pancreas, that first portion of the small intestine called the duodenum, and then the portion of the bile duct that runs through the head of the pancreas. We then bring up a loop of bowel, we sew it back to the rest of the pancreas, the bile duct, and the stomach.

Dr. Scott Steele:

Do you always have to take the first part of the small intestine, the duodenum, with a Whipple?

Dr. Robert Simon:

Yeah, that's a great question. And you do because the pancreas duct and the bile duct drain through the hole into the duodenum and they share a blood supply. They are intimately involved. So being able to get the pancreas out without taking that duodenum is not really feasible. In addition, part of a good cancer operation is to get rid of all those lymph nodes in the area and that's how you get rid of all the lymph nodes in that area.

Dr. Scott Steele:

So you mentioned a little bit about some of the risk factors and some of the ones that are modifiable, things that are a little bit more in our control. Let's look a little bit about those type of things that people can do in their daily lives to reduce their risk of pancreatic cancer. Can you talk about diet, nutrition, and maybe some of the other controllable risk factors that people can work on to reduce their risk?

Dr. Robert Simon:

Yeah. I wish there was more that I could say that people could do. We all like to take control of our bodies and take control of our future, but unfortunately, pancreas cancer, we haven't really identified a lot of great modifiable risk factors. Again, the big things I can just reiterate are smoking, maintaining a good healthy weight, and just paying attention to your body. That's about it.

Dr. Scott Steele:

Yeah. The things that maybe grandma told you a long time ago. On the other hand, you mentioned some other things and that is your family history and genetics and what role they play in there. You mentioned some big words there for some of the syndromes that are there. Can you talk about the role of genetics when it comes to this disease?

Dr. Robert Simon:

For patients that are diagnosed with pancreatic cancer, there's a set of guidelines that we follow for all different types of cancers called the NCCN Guidelines. And one of those guidelines recommends that everybody that gets a newly diagnosed pancreatic cancer gets genetic testing. And a big part of that is, one, we're trying to learn more about this disease, trying to figure out areas that we can help, but also to give patients and their families an idea of if there is a hereditary component to it.

Dr. Scott Steele:

Rob, are there any exciting new advances in pancreatic cancer research, treatment, or even prevention that you think our listeners should know about?

Dr. Robert Simon:

Yeah. I think that there's some good research that's on the horizon for mRNA vaccines to try and help treat pancreatic cancer that I think is really promising work. I think there's some monoclonal antibodies out there that is going to be really promising work and some immunotherapy. I think that is really exciting stuff to watch.

Dr. Scott Steele:

So if somebody at home is listening to this and they believe that they're an increased risk of pancreatic cancer, what should their first steps be?

Dr. Robert Simon:

I think the first step is if you're concerned, reach out to your primary care doc, talk to them, have them help guide you in terms of getting a good, thorough family history and really analyzing your symptoms and your concerns and determining if you are truly at high risk. I think the big thing is know your family history, don't ignore pancreatic cysts, and avoid the few modifiable risk factors that we know are harmful, such as smoking and obesity.

Dr. Scott Steele:

Now it's time for a quick hitter. It's a chance to get to know our guest just a little bit better. So first of all, for you, salt or sweet?

Dr. Robert Simon:

Ooh, definitely salt.

Dr. Scott Steele:

What was your first car?

Dr. Robert Simon:

Oof, fun question. My first car was a bright blue Subaru WRX hatchback.

Dr. Scott Steele:

So a special question for you. When's the last time you shaved that beard?

Dr. Robert Simon:

I'm going on two months now.

Dr. Scott Steele:

Oh, fantastic. Do you have any special powers that people should know about?

Dr. Robert Simon:

I do enjoy up close card magic. So if you want to see a card trick, just let me know.

Dr. Scott Steele:

I did not know that. That's fantastic. And then finally, do you have a favorite cartoon character?

Dr. Robert Simon:

My favorite cartoon character, I would say, when I was a kid, I used to love watching Rocky and Bullwinkle.

Dr. Scott Steele:

Fantastic. Give us a final take-home message for our listeners regarding preventing or reducing your risk of pancreatic cancer.

Dr. Robert Simon:

I think, just to reiterate, pancreatic cancer is a rare disease so try not to stress about it too much. I think the big thing is really stop smoking. If you have pancreatic cysts, make sure that you're continuing to follow those up. And if you do have a strong family history of pancreatic cancer, reach out and we'll start screening you.

Dr. Scott Steele:

Fantastic. To learn more about Cleveland Clinic's pancreatic cancer program, please call 866.223.8100. That's 866.223.8100. You can also visit clevelandclinic.org/pancreaticcancer for more information. That's clevelandclinic.org/pancreaticcancer. Rob, thanks so much for joining us here on Butts & Guts.

Dr. Robert Simon:

Thanks for having me.

Dr. Scott Steele:

That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.