Pancreatic Cancer: What You Need to Know with Dr. Matthew Walsh

Podcast Transcript

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

Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chairman of the department of colorectal surgery here at Cleveland Clinic in beautiful Cleveland, Ohio. And we're very pleased to have Dr. Matthew Walsh here with us, who's the chairman of the department of general surgery here at Cleveland Clinic. Matt, welcome to Butts & Guts.

Matthew Walsh:  Great, I've never been on Butts & Guts. I can't wait to do it again, I hope.

Scott Steele:  Well, we're very excited to have you here. And what we're going to talk about today is about pancreatic cancer. But before we get into that, we always like to have all of our guests just tell us a little bit about you, where you're from, where'd you train, how to come to the point that you're here at the Cleveland Clinic?

Matthew Walsh:  Wow. Well, I was born and raised in Green Bay, Wisconsin. Sold hotdogs at Lambeau field. That was the first thing on my CV. I went to college at Creighton University in Nebraska before medical school back in Wisconsin, trained in Chicago and Boston, and ended up coming here as a fellow and I've never left, Scott.

Scott Steele:  That's fantastic. Matt, obviously being a hepatobiliary surgeon and dealing with a lot of pancreatic cancer, just for our listeners out there, can you give us the 10,000 foot view on pancreatic cancer? What is pancreatic cancer?

Matthew Walsh:  Pancreatic cancer is, in general, something you don't want to have. Unfortunately, it's a highly lethal cancer. But I will point out in general that there are two main types of cancer that occur in the pancreas because the pancreas is made up of two different types of cells. One, we make juice in our pancreas that helps digest our food, and from that can come the most typical kind of pancreatic cancer, it's adenosquamous carcinoma of the pancreas. But the pancreas also makes insulin and other hormones, and those types of hormones create a different type of cancer called the neuroendocrine tumor, and that's less common. It's much more favorable. We treat it totally differently than we do the more common variety of adenocarcinoma.

And pancreatic cancer is a tough disease in a sense because it's not always diagnosed early and unfortunately, we feel that often as soon as it starts growing it can spread, so the minority of patients actually would qualify for surgery. And our goal is, on one hand, trying to come up with earlier diagnostic testing, treatment of patients who have advanced forms to make them more surgically amendable at some point, because we feel that surgery is always valuable if it can be done to impact survival from the cancer.

Scott Steele:  We're going to go into all of those topics, so what causes pancreatic cancer? Are there certain risk factors that patients have out there? One of the things about pancreatic cancer, as many of our listeners may have heard of, there's been some famous people with pancreatic cancer and unfortunately, have passed away. So the question comes up, can you do anything to get it or can you do anything to prevent it?

Matthew Walsh:  So the only known risk factor is tobacco smoking. And obviously, for a lot of reasons, people shouldn't be doing that. There's probably some genetic component, there's some familiar forms, but we don't have that figured out very well and there isn't a genetic test you can do to look for it. As you mentioned, famous people, if you look at Jimmy Carter and his family, a lot of people have had pancreatic cancer except him, interestingly. So there are increased risk with things like chronic pancreatitis, but the only real risk factor is smoking.

Scott Steele:  So if you have somebody that's a smoker, obviously that's a risk factor for a lot of different things, but if they stopped smoking, is it something that will decrease their risk of getting pancreatic cancer? Do we know anything of that?

Matthew Walsh:  Not really. It probably won't reduce your risk if you're predisposed to have it.

Scott Steele:  You mentioned that unfortunately a lot of these people present when the horse is out of the barn, the cat's out of the bag, whatever cliché you want to use, what are the symptoms of pancreatic cancer and why is it that the patients present when they're maybe at an advanced stage?

Matthew Walsh:  I'll start with that latter part first. So one of the reasons is the pancreas is a long organ that lies along your back, from one side to the other, and depending on where in the pancreas it physically starts, in the geography of the pancreas, will determine what your symptoms are. So you can have a relatively small tumor in the very end of the pancreas, near the opening to the duodenum, that can cause jaundice, which is one of the symptoms and that can occur relatively early because if you pinch off the bile duct with a small tumor. But the farther away you get from there, geographically, you can get a bigger tumor that can spread and not be found.

The other part of the problem is the pancreas, since it lies along the back, lies along a lot of major blood vessels, and the surgical treatment is in all or non-treatment. You have to be able to remove 100% of it or none of it. So because of all these blood vessels, it's not always feasible if it grows to remove those. It's a very thin organ, like a pancake, so it doesn't take much of a tumor when it's lying on these blood vessels to grow to the point that it's inoperable.

So the symptoms. One of the symptoms I should bring up because it should prompt people if they develop diabetes suddenly in an older age, you should look at their pancreas because that can be one of the hallmarks. But otherwise, weight loss, abdominal pain, jaundice, those would be the most common symptoms. They're all later stage in the disease, unfortunately.

Scott Steele:  Patients who have back pain or gallbladder disease, are they linked to pancreatic cancer?

Matthew Walsh:  Gallbladder disease is not linked to it, but I think doctors should be thoughtful. The residents will always say that I have an expression that doing a laparoscopic removal of your gallbladder is not treatment for pancreatic cancer. So occasionally people will present with vague abnormalities that aren't really good for gallbladder, but people think, well maybe it's their gallbladder, so they'll take it out and then several months later they find it's a pancreatic cancer.

Scott Steele:  How common is pancreatic cancer? It's not. It's about 35,000 people a year in the United States. It ranks about the sixth most common cancer, but it's the fourth most common cancer death. So nearly as many people who get it die from it each year.

Matthew Walsh:  So how is pancreatic cancer diagnosed? It's diagnosed usually radiographically, so usually they get a CAT scan. Imaging with CAT scans is is very good, and we find all sorts of things in the pancreas on a lot of imaging studies like CAT scans or MRIs.

Ultimately, you need a biopsy, some sort of pathology to make the diagnosis. A good proportion of patients who get a major operation won't have a biopsy, and the reason for that is if it's a suspicious lesion that's removable and that's your only chance to cure the patient, you'll take it out without a biopsy.

So this is a common discussion I have with patients, do we need a biopsy or not for what we find? And it really depends how you use a negative biopsy. So if you find something that's highly suspicious for cancer, that's not always an easy diagnosis to make with a needle biopsy. So we often end up taking it out with that high likelihood of suspicion that it's cancerous.

Scott Steele:  So one of the questions that patients have out there is do I need a PET scan if I get this or do I always need a scope? Or just do an ultrasound or something noninvasive?

Matthew Walsh:  So part of the need for proof is, what other possibilities could the abnormality be? And if you have a solid growth in the pancreas, there are a few other things that could be that are esoteric, but often we're concerned that it's cancer. So it is based a lot on the imaging. Once we know that it's cancer, meaning that we want to give some sort of treatment, we can't give any chemotherapy, if we need chemotherapy, until we have a biopsy. So the most common route for that is going to be by endoscopy with an ultrasound machine that's attached to it.

And once we have a diagnosis of a cancer in the pancreas, we do stage it. That's where a PET scan sometimes come into play. But for us, usually a CAT scan of the chest and the abdomen, looking at the liver, so the points that usually the tumor spreads to is the liver or the peritoneal cavity, and those we will see on a regular CAT scan. So PET scanning is not typically required for the garden variety type of cancer of the pancreas.

There is a newer scan that patients may hear about that is for a neuroendocrine tumor, and that has been very valuable, but that's the other cancer.

Scott Steele:  So for the patients or people listening that have family members that are newly diagnosed with pancreatic cancer, walk us through a visit to you? What can they expect when they come in for your office visit and then next steps from there?

Matthew Walsh:  I would say most commonly ... So the most common single symptom is jaundice, and most patients will present to their regular doctor with jaundice or to the emergency room, and they'll be evaluated and chances are they'll have a scan and may get a scope to help relieve the jaundice. And that'll give them either a clear diagnosis, because you can do a type of brush biopsy of a bile duct in someone who has jaundice, and jaundice is just blockage of the bile duct in this case that causes yellowing of the skin and eyes and often very irritating itching. And they'll first notice it actually in their urine. Your urine will turn dark. So if you have those symptoms, obviously see your doctor promptly. And often it's not the patient that notices it, it's a family member. So it's always good to know that.

But they'll typically be evaluated by someone other than myself, get a test to look at the bile duct, get a CAT scan, and then depending on what that shows for instance, unfortunately a large proportion of patients when they get the CAT scan we'll find something somewhere else like the liver, and then we always biopsy that, and that person's going to see an oncologist. They may see me, and we'll go through the imaging because that's a big part of it and how well the patient is doing in terms of their nutrition and all of those things. And typically I'll go over the CAT scan with the patient and their family, describing what we find.

I also use a model to show what the pancreas looks like because it also incorporates all these blood vessels that I think it's helpful for the patient to see really what's involved. And then after we look at what a normal model is like, we bring that to their CAT scan. And I think patients do appreciate seeing their own imaging so they know what it looks like. And then we talk about whether we think this is cancerous, if surgery is going to be upfront or if we're going to need some other treatment like chemotherapy. We try as much as possible to have coordinated visits with the oncologist. We do have a combined clinic where you see the oncologist, you see me together, and I think which is very helpful for the patient so we can come up with a plan. And then that plan will be verified or discussed in our tumor board, which we have every week, so every patient's discussed there.

So I hope the patients get a sense that there's a comprehensive treatment to their care and a plan forward.

Scott Steele:  So understanding there's a little bit of an individualization for the particular patient, can you talk about broadly the treatments for pancreatic cancer? You mentioned a little bit about surgery, what's the surgery that happens and what about the chemotherapy and the order that it comes in?

Matthew Walsh:  The surgery depends on which part of the pancreas is involved. The majority of pancreatic cancer tends to be in the part we call the head, which is closer to the liver. That's the kind that's going to cause jaundice. And that operation, to take that out, patients may have heard of, many people who come in know the name, which is a Whipple procedure. What that requires is taking out the pancreas and the part of the small intestine that's attached to the pancreas called the duodenum, the gallbladder, the end of the bile duct. So the way I describe that is because it's a lot of things that have to come out, Scott, not just the colon like you're used to. So I say it's like a bowl of jello, assume the cancer is a strawberry in the middle of the bowl of jello, but I have to take out the whole bowl of jello to get at the tumor that's in the center. And there are lymph nodes that are next to the strawberry and the jello as well. Those all come out. So that's an operation that takes about six or seven hours to do because you have to reattach everything.

And then the other major operation is in the back half, we call it of the pancreas or the tail, and that is where the spleen is. So often that part of the pancreas comes out with the spleen, and that's a shorter operation.

We've had trouble coming up with effective chemotherapy for pancreatic cancer, and it typically was one drug. The current most aggressive form is four drugs, and we can give that ahead of time. There are always new trials on chemotherapy, especially right now the four drug versus a two drug combination. Patients may have heard of something like immunotherapy, that hasn't been useful so far in pancreatic cancer. It's sort of standard chemotherapy type drugs that are not necessarily the easiest, but it has been shown to be effective. And effective for us means prolonged survival.

Scott Steele:  For the patients that are facing a Whipple, or again a family member that may do this, how long can they expect to be in the hospital and what's their recovery like?

Matthew Walsh:  So there are two basic ways to do that same operation. One is with an incision or an open traditional technique. The other is with laparoscopy and robotics. And not every hospital does both. We happen to do both. The average length in the hospital is about six to eight days. I would say for most patients across the country, having it done, let's say robotically, will reduce the days by a day or two. And hopefully it will apply to their recovery because it takes a good two months to recover. And we would recommend in people with pancreatic cancer, they get chemotherapy afterwards. So we like people to start their chemotherapy in six to eight weeks after.

Scott Steele:  What's the typical survival for patients with pancreatic cancer?

Matthew Walsh:  Overall, if you take everybody with pancreatic cancer, as I said, unfortunately almost as many patients who are diagnosed will die with the disease. 85 or so percent of patients aren't able to get surgery, so that puts you in a bad category. And so we're looking at the people who get surgery, and of those about 25% at most will be around at five years.

Scott Steele:  And so if we take a step back then, I mean, what do you say to the people out there like, "Whoa, if this is diagnosed so late and these survival's statistics are so poor, maybe I just need to go get a CAT scan when I'm 30 years old or when I'm 40 years old." Is there any role for that?

Matthew Walsh:  There isn't. When you put it in the context of other diseases and the cost of scanning, and it's really hard to pick things up at the right point. Even with people who seem to have a strong family history, we don't have a great way of how to survey those people. So unfortunately, unless we come up with better tests, hopefully blood testing, looking for even cancer cells in the blood, things like that, that's going to, in the end, be more effective I think. But we don't have a good way right now.

Scott Steele:  Matt, I'm sure you've also seen patients or patients that travel in and say, "My other doctor told me that I'm not an operative candidate, I can't undergo surgery, and can you just operate on me? I mean, he's talking about a node or something's up in the liver, can't you just take it out?"

Matthew Walsh:  So pancreatic cancer is an all or none operation. If you take out 99% but knowingly leave 1% behind, you won't gain a day. Unfortunately, the treatment isn't that effective. So our plan right now is to try and get it operable, but it's 100% operable, and that's why we give chemotherapy more and more upfront to make them operable so that we can truly put people through these very major operations but still get a true benefit because our goal is to really benefit the patient.

Scott Steele:  So Matt, you're one of the thought leaders in this realm, and so what does the future look like and are there any upcoming advancements or things here at the Cleveland Clinic in the treatment of pancreatic cancer?

Matthew Walsh:  So I think the ultimate advancement's going to be early diagnosis. We're very interested in looking at free cancer cells in the blood as a screening tool, so that's one of our goals. One of the other avenues that may be helpful is people who have precancerous conditions, like you may have heard of IPMN, it's a type of cystic disease that predisposes some types of cancers in the pancreas. And so we have a big interest in that as well. In terms of chemotherapy, we're always looking and we're participating in some trials on that. But I can't pick out something that's going to revolutionize the field, I don't think, within the next year or two.

Scott Steele:  Well that's fantastic information. And Matt, we always like to end with our guests with some quick hitters. So what's your favorite food?

Matthew Walsh:  Pizza.

Scott Steele:  What's your favorite sport?

Matthew Walsh:  To play?

Scott Steele:  Yeah.

Matthew Walsh:  Tennis.

Scott Steele:  And to watch or follow?

Matthew Walsh:  Football.

Scott Steele:  And what is the last nonmedical book that you've read?

Matthew Walsh:  I just read the biography on Grant, which is really interesting.

Scott Steele:  Yeah, that's fantastic. The author also wrote one on Hamilton, I believe as well. And then finally, tell us something that you like about here in Cleveland. You said you've been here a long time, you got sucked in and you've been here a long time.

Matthew Walsh:  What I like, especially in this ... It's a summer activity, but there's a ring of parks called an Emerald necklace that you can bike very easily, start on the west side on the lake and end up on the east side on the lake. And it's a great in between bike trails, which are fun.

Scott Steele:  Well, that's fantastic. And so for more information on pancreatic cancer and to download our free online treatment guide, visit clevelandclinic.org/pancreaticcancer. That's clevelandclinic.org/pancreaticcancer. And to make an appointment with a Cleveland clinic specialist, please call (866) 223-8100. That's (866) 223-8100. Matt, thanks so much for joining us on Butts & Guts.

Matthew Walsh:  Thanks, Scott. It's been great.

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