Surgical Options for Pancreatic Cancer

Podcast Transcript

Scott Steele: Butts & Guts, a Cleveland Clinic Podcast, exploring your digestive and surgical health from end to end.

Hi, everybody. And welcome to another episode of Butts & Guts. I'm your host Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Very pleased today to be talking with Dr. Robert Simon, who is a surgeon here within our Cleveland Clinic Digestive Disease & Surgery Institute hepatobiliary. And we're going to talk today about something with pancreatic cancer and specifically focusing in on surgical options for pancreatic cancer. Rob, welcome to Butts & Guts.

Robert Simon: Thank you. Happy to be here.

Scott Steele: So we always like to start with each of our guests, just a little bit of background about you, where you're from, where'd you train and how did it come to the point that you're here in beautiful Cleveland, Ohio at the Cleveland Clinic?

Robert Simon: Well, I'm a Midwestern boy through and through. So I grew up in Okemos, Michigan, a small town outside of East Lansing, Michigan State territory. And then I went to undergrad at Northwestern University and managed to go on over to Columbus, Ohio for a medical school at the Ohio State University. And then I did my residency up in Michigan at Beaumont Hospital, just north of Detroit. And then I happened to get matched in the fellowship here at the Cleveland Clinic for a hepatopancreatobiliary surgery and have stayed here since.

Scott Steele: Well that's great. And we're so lucky to have you here. It's been a wonderful journey to date. So it's been a few years since here at Butts & Guts we last discussed pancreatic cancer. So for the listeners who haven't gone back to the back episodes, or don't remember it, can you give us a high level overview of this disease? What it is? Who can get it? What are the risk factors? And then kind of maybe one of the scarier things, what are the symptoms, if any, of pancreatic cancer?

Robert Simon: You know, I like to start by just talking a little bit about the pancreas. The pancreas itself, it's a long, thin, flat organ that sits behind the stomach. It lays right on your back, and extends all the way over from the left side by your spleen all the way over to the right hand side by your liver. And it has two main functions. One is that it produces hormones. The most common one that people think of is insulin to help you manage blood sugars. And then it also makes enzymes and those enzymes drain down the main pancreatic duct into the intestines where it mixes with food and helps you digest it. And so you can have tumors of either the hormone producing cells or of the enzyme producing cells. And when we talk about pancreatic cancer, typically that is talking about the enzyme producing cells causing cancer.

Most recently, you've heard of Alex Trebek and Ruth Bader Ginsburg, and they are the ones that had cancer of the enzyme producing cells or something we call adenocarcinoma and anybody can get it. There is a slight male preponderance of pancreatic cancer, but it's pretty much 50/50. And then there are some risk factors for developing pancreatic cancer. The most common one is smoking. Smoking is known to be two times the risk of having pancreatic cancer. And about a quarter of patients diagnosed with pancreatic cancer are smokers. And so we know that that's kind of the strongest risk factor for developing pancreatic cancer. There's also been some studies lately that have shown that obesity is actually a risk factor for developing pancreatic cancer and actually increases the risk by about 20% as well. And then there are some familial or hereditary or genetic causes of pancreatic cancer.

Patients with a BRCA gene mutation are at risk as are other types of gene mutations. And so those are definitely the more uncommon causes of pancreatic cancer, but still something to keep in mind. And then other risk factors are pancreatic cysts. There's lots of different types of pancreatic cysts, but a couple in particular put people at an increased risk of pancreatic cancer. And so if you do have pancreatic cysts, it's something to keep an eye out for and to keep an eye on because there's a set of guidelines that help us determine which ones are going to be good actors and which ones are going to be bad actors. So pancreatic cyst is a whole other topic and I can go on and on about that, but that is a risk factor. And then you asked about symptoms and unfortunately by the time symptoms arise, it's often too late.

Usually by the time symptoms happen, the tumor has already spread outside the pancreas. And so it's what makes this disease process so difficult to treat, but there are some patients who do present early enough, and symptoms to look out for are yellowing of the skin or eyes, something we call jaundice. And oftentimes that's actually noticed by not the patient themselves, but by their family member, by a neighbor, by a friend, somebody who hasn't seen him in a few days or a week and then notices it and calls them out on it. And so jaundice is definitely one of the most common symptoms. It can also present as pain, particularly radiating to the back. And then another one is change in bowel habits and new onset diabetes. If patients develop diabetes at an older age, that can be a risk factor or a sign of pancreatic cancer.

Scott Steele: So how is pancreatic cancer, as something comes up, they notice the jaundice, they go to their doctor, how is it diagnosed?

Robert Simon: So pancreatic cancer is often diagnosed with imaging. Usually a CT scan is the first thing that is obtained. Some mass is seen on the pancreas and then the best way to diagnose it is with endoscopy. So they go down with the scope, there's a special probe on the end of it that has an ultrasound machine that allows them to look through the stomach into the pancreas, and then they can biopsy it that way. And that's the best way to get a tissue diagnosis and confirm the suspicion because there are some benign non-cancerous masses that can show up in the pancreas. And so the ultrasound and the biopsy is the best way to diagnose it.

Scott Steele: Rob, so we are trying to contrast the two options of maybe not a lot of symptoms and also may present late. So I would ask you, is there a screening test for pancreatic cancer? Should we be getting an incident or a CT scan on everybody at a certain age? Or what is the volume of these or what is the incidence of these? Why aren't we doing that?

Robert Simon: Yeah, I wish. But unfortunately that's not high yield and that's not really done. The incidence of pancreatic cancer is it's fairly low. It's ranked as the ninth or 10th most common cancer. It does account for some of the more common cancer deaths so it's rated at about the fourth common cause of cancer deaths, but because it's rare incidents, getting a CT scan is pretty low yield. And so the best thing to do is pay attention to symptoms and act on them early. And the other thing too is, I mentioned about pancreatic cysts and if you do have pancreatic cysts, it's important not to ignore those. Because the best thing to do is to catch it before they turn into cancer.

Scott Steele: So Truth or Myth: Chronic pancreatitis can often lead to pancreatic cancer development?

Robert Simon: That is true. There is some evidence that chronic pancreatitis can lead to pancreatic cancer and can put patients at an increased risk of pancreatic cancer.

Scott Steele: Truth or Myth: Surgery is the primary treatment method for pancreatic cancer?

Robert Simon: Again, truth. So in terms of treating pancreatic cancer, we know that the best outcomes in terms of overall survival includes surgery in addition to chemotherapy. Chemotherapy alone does not do as well as surgery plus chemotherapy. And so surgery is the mainstay of treatment and we like to operate on patients if that's possible. Unfortunately only about 20% of patients make it to see a surgeon because oftentimes by the time their cancer is diagnosed, it has already spread outside of the pancreas. And once that has happened, we know that surgery is not beneficial. And so it's important to catch it early so that we can get the entire cancer out before it has spread.

Scott Steele: So three procedures, I'd like you to go maybe into a little bit of detail. You don't have to go too technical on us or our listeners out there. But you said that surgery is a primary treatment for pancreatic cancer. So a couple of different things that are out there. We talk about the Whipple procedure, the total pancreatectomy, I guess I would ask you with that one, can you live without your pancreas? And then finally the distal or removal of the tail, that distal pancreatectomy. Can you tell us about each of those different procedures?

Robert Simon: Sure. The type of surgery all depends on where the cancer is. So we break up the pancreas into three sections, the head of the pancreas, which is over on the right hand side by the liver, the body of the pancreas, which is the middle section of the pancreas. And then the tail of the pancreas, which is the end of the pancreas. And that's over on the left-hand side, kind of nestled up inside the spleen. And so if the cancer is on the right hand side in the head, that is when we talk about doing a Whipple operation. And that involves taking the head of the pancreas, the first portion of the small intestine called the duodenum, and part of the bile duct, and the reason why we have to take all that other stuff is because they share a blood supply as well as the bile duct runs right through the head of the pancreas.

So it's an innocent bystander that has to go. In addition, we want to get all of those lymph nodes in that area to help us stage the patient and treat them better. And so that's a big operation. It's a big resection. Lots of stuff is coming out. But then in addition, we have to put everything back together. So you have to bring up a loop of bowel. We have to sew it back to the stomach, the pancreas, and the bile duct. And anytime we take something apart and put it back together, there's a risk that it can leak. And so that's one of the biggest operations that we do. So moving on, if the cancer is in the body, and the tail, then we talk about doing a distal pancreatectomy where we take out that end of the pancreas and the spleen comes with it.

And the reason is the pancreas is tucked into that spleen and the blood vessels that go to and from the spleen travel right behind the pancreas. And so again, it's an innocent bystander, but it has to go plus we want to get all those lymph nodes in that area too. And then lastly, a total pancreatectomy, short answer, yes, you can live without your pancreas. Like I mentioned before, it has two main functions. It helps you with your insulin and blood sugars and then it makes enzymes. And so taking out the pancreas means that patients are going to be a diabetic. And so they have to learn how to manage their blood sugars. And then in addition, they're going to have to take pancreatic enzymes for the rest of their life.

So anytime they eat, they're going to have to take pancreatic enzymes to help them absorb and digest their food properly. It's definitely a lifestyle modification, but it is doable. And the reason we take out the entire pancreas is if the cancer is kind of right at the neck or if it's in the head and kind of extending over to the body. And so if it's just a little bit too extensive in that aspect and involving a little bit too much of the pancreas then we kind of have to do both a distal and a Whipple, which means taken out the entire pancreas.

Scott Steele: So can you use minimally invasive procedures or robotics within these surgeries? They sound pretty complex.

Robert Simon: Yeah. For distal pancreatectomies, oftentimes they are able to be done laparoscopic or robotically. That is an easier operation because you don't have to put anything back together. And the blood vessels that you're working around aren't quite as big. A Whipple, again, is able to be done laparoscopically and robotically, and we do that occasionally here in the right patient. But still the vast majority of patients are done the old fashioned open.

Scott Steele: So when patients are on this journey, they come to meet with you, how do you decide, or how does their surgeon decide what's the best surgical option or in some cases that maybe they go on and they get chemotherapy or radiation therapy or surgery is on hold. How do you decide on that?

Robert Simon: So that's a great question too. You know, we talk about patients being resectable, meaning we can take it out right away, borderline resectable, meaning maybe we can take it out, but let's give them some chemotherapy first to try and shrink it and try and improve our chances of getting a negative margin or locally advanced or unresectable, meaning it's too involved and it's not able to be removed. And the way we put those patients into those categories is the relationship of the tumor to the surrounding blood vessels. And so for resectable patients, we tend to take that out from the get-go and then give them chemotherapy. If it's borderline resectable or locally advanced, I usually give them chemotherapy first and then reassess with some more imaging and determine if we can take it out at that time.

Scott Steele: So what is on the horizon as far as surgical innovations or anything really to treat pancreatic cancer and improve the quality of life?

Robert Simon: In terms of treating pancreatic cancer, we're really looking for better chemotherapy to help us basically kill that microscopic disease, kill that disease that we can't see, that we can't take out with surgery. And so that's kind of the big thing that we're waiting for. In terms of surgery, you know, the surgical options that we have are pretty good and well established. That being said, there is a newer technology out that is being used in some locally advanced, unresectable patients that allows us to basically kill those tumor cells.

And so if it's wrapped around too many blood vessels and we can't get it out from a technical standpoint, what we do is this thing called NanoKnife or irreversible electroporation where we put probes surrounding the tumor. And then we inject current in between those probes. And what that does is it basically shocks the cells and pokes holes in the cells, the tumor cells, and kills them. And so we've seen some pretty good evidence that it's not as good as surgery, but it's better than chemotherapy alone. And so that is something that is kind of on the horizon that's being studied and being established now that we actually do here to try and help treat more patients than we used to be able to.

Scott Steele: Sounds pretty incredible stuff. And so we always like to kind of finish up with each of our experts get to know you a little bit better, a segment I like to call Quick Hitter. So what's your favorite meal?

Robert Simon: I love meatloaf, love meatloaf.

Scott Steele: Buddy of mine said whenever you see meatloaf on a restaurant, always order it because it wouldn't be on the menu if it wasn't great.

Robert Simon: Exactly.

Scott Steele: [crosstalk 00:15:03] by that. So what's your favorite sport?

Robert Simon: I love to play soccer and I love to watch football.

Scott Steele: And what is the last non-medical book that you read?

Robert Simon: I actually read this interesting book it's called Into the Black. It's about the history of the space shuttle program and how that kind of came to be. And it's just fascinating, especially with the technology that they had at the time.

Scott Steele: There was also a really good Netflix [program] for all of you Netflix junkies out there. That is on there. And so finally, what is something that you like about being here in Cleveland?

Robert Simon: I think the best part about Cleveland is the Metroparks system. I think it's kind of a hidden gem. Cleveland is great because you get all the perks of a big city, lots of good restaurants and bars, and yet you can kind of get out in nature and go for some awesome hikes and bike rides and see some waterfalls and yeah, it's great.

Scott Steele: Rob, give us a final take home message for our listeners regarding pancreas, pancreatic cancer, and surgery for pancreatic cancer.

Robert Simon: You know, I think that the big takeaway is that there's hope. And I think that we have options to help patients and make them comfortable and help treat them the best we can. There's a great website PanCan.org that I encourage patients to look at and use as a resource. You know, it has everything from support groups to nutrition, ideas to various medications that can help make them more comfortable. And so I think that's kind of the big thing is that there's hope, and talk to people and reach out and come see us if you need us.

Scott Steele: That's fantastic stuff. And so for more information on Cleveland Clinic's pancreatic cancer program, please visit ClevelandClinic.org/PancreaticCancer. That's ClevelandClinic.org/PancreaticCancer, P-A-N-C-R-E-A-T-I-C C-A-N-C-E-R. You can also call our Cancer Answer Line at 866.223.8100. That's 866.223.8100. And again, you've heard me say before, in times like these, please remember it is absolutely important for you and your family to continue to receive medical care. And please be rest assured that here at the Cleveland Clinic, we're taking all the necessary precautions to sterilize our facilities and protect our patients and our caregivers. Rob, thanks for joining us on Butts & Guts.

Robert Simon: Thanks for having me. I really appreciate it.

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