There are several types of pancreatic cancer, and treatment depends on where the cancer began and the stage of disease. In this video, Dr. Andrew Ko discusses diagnosis, staging, and treatment options for pancreatic cancer.
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Pancreatic Cancer: An Introduction
Voiceover: The pancreas is a gland located deep within the abdomen, between the stomach and the spine. It is part of the body's digestive system and endocrine system. Pancreatic cancer forms when healthy cells in the pancreas stop working correctly, and grow out of control, forming a mass.
Andrew Ko, MD, FASCO; Medical Oncologist; Member, American Society of Clinical Oncology: There are several different types of pancreatic cancer. The most common type is 1 that arises from the cells that line the ducts. So the pancreas has both what we call an exocrine and an endocrine function. The exocrine function is the production of various digestive enzymes, that after you eat, those enzymes spill into your gut, your GI tract, to help you digest foods. And so the cells that line the ducts of the pancreas where the enzymes channel through to get to the intestines can transform—become cancerous—and can develop into pancreatic cancer.
The other type, which is a little bit less common, are so-called neuroendocrine, or islet cell tumors, and that's from the cells in the pancreas that produce various hormones, such as insulin.
Voiceover: Once pancreatic cancer has been diagnosed, the cancer will be staged. Staging describes where the cancer is located, and if or where it has spread. Doctors use diagnostic tests to determine the stage. And the stage of the cancer helps determine what the treatment will be. The most advanced stage is called “metastatic,” and it means the cancer has spread beyond the area of the pancreas, to another part of the body.
Dr. Ko: As with any type of cancer, you want to get a sense of, what stage is it? So various staging studies, including CT scans, are done to assess how large it's grown; has it spread to nearby lymph nodes; or has it spread to other parts of the body, what we call metastases.
And for pancreatic cancer, it's a disease that if it does spread, can go to other parts of the body such as the liver, elsewhere in the abdominal cavity, sometimes the lungs. There are different types of pancreatic cancer, so certainly a biopsy to determine the type of pancreatic cancer it is.
Voiceover: Once the type and stage of the cancer has been determined, the oncology team can begin to plan the treatment. This may include an operation to remove the tumor, called a surgical resection, and other types of cancer treatment, including radiation therapy and chemotherapy.
Dr. Ko: For a patient with pancreatic cancer who's diagnosed at an early stage—meaning the cancer remains confined to the pancreas, or it may have even gone to some nearby lymph nodes—those individuals may be candidates for surgical resection. And for most pancreatic cancers that arise in what we call the “head” of the pancreas, which is where the pancreas is nestled right within the loop of the small intestine, that surgical procedure is called a whipple procedure.
That's a very large operation, and traditionally or historically, localized or earlier stage pancreatic cancers have been treated upfront with a major surgical resection, followed afterwards by adjuvant chemotherapy, with or without radiation treatment.
There's a shifting paradigm now whereby even individuals who are diagnosed with very early-stage disease actually start with chemotherapy first: what we call neoadjuvant treatment. That really allows, sometimes, the cancer to shrink, but even more importantly, to address any microscopic metastatic disease that might be present, even if you can't see it on CT scans.
So there's an increasing shift for early-stage disease to receive upfront chemotherapy, to be followed thereafter, a few months later, by surgery. And that's done with curative intent, so with that combination of surgery and systemic therapy or chemotherapy, we can cure a proportion of those individuals.
Voiceover: When detected at an early stage, pancreatic cancer has a much higher chance of being successfully treated. However, there are also treatments that can help control the disease for patients with later-stage pancreatic cancer, to help them live longer.
Dr. Ko: When you get to more advanced stages of the disease, so sometimes the cancer grows to a degree and a size where it starts involving or encasing nearby blood vessels, major arteries that come off the descending aorta. At that point, an operation may not be possible, even if it hasn't spread to other parts of the body, just by virtue of the anatomy and how it's involving the adjacent blood vessels. That doesn't allow an operation with clean margins. And again, often in that situation we'll start with chemotherapy; maybe include radiation, though radiation is a very controversial still in pancreatic cancer, and then perhaps readdress their surgical prospects later on.
At that point, surgery really doesn't have a defined role, and there, the mainstay of treatment becomes systemic therapy. And when I say “systemic,” I mean treatment, like chemotherapy, that goes all over the body to treat the cancer in the pancreas, but also in the liver, or the lungs, or wherever else the cancer may be throughout the body. At that point, the goals of treatment become more to try to achieve as good a remission as possible, to try to keep the disease from growing or spreading further, and to help individuals live longer, and sometimes a lot longer.
Voiceover: New developments in pancreatic cancer research in the areas of early detection, chemotherapy, targeted therapies, and immunotherapy, may offer new treatment options for patients in the form of clinical trials. A main area of clinical trials for pancreatic cancer involves genetic and molecular testing of pancreatic tumors. This includes studies looking at genes known as BRCA, that are linked to other cancers, including some breast, ovarian, and prostate cancers.
Dr. Ko: It turns out that these individuals who have germline, which means inherited, BRCA mutations are at increased risk for developing pancreatic cancer as well. And it happens that these individuals are susceptible to particular types of treatments. So for example, we know that certain chemotherapy drugs, such as platinum agents—individuals with BRCA-associated pancreatic cancers are particularly sensitive to.
And then there's a whole class of drugs called PARP inhibitors, which are an oral agent, they are a form of oral targeted therapy, that a large international study has demonstrated that for individuals who have advanced, metastatic BRCA-associated pancreatic cancers, that using this drug, a PARP inhibitor, following chemotherapy, can significantly prolong the time for the disease to progress.
And so that's really a whole new class of agents that should gain traction in pancreatic cancer. Now again, right now, that's only for a small, defined subset of individuals with pancreatic cancer, but it's a pretty major advance, and with promise for expanding even beyond that small subset of individuals. And I think it speaks a little bit to our getting smarter and using this precision medicine approach for treating pancreatic cancer. We're really trying to educate, more broadly, providers and patients on doing genetic testing on all individuals with pancreatic cancer.
So there's that, there's also other broad realms in terms of classes of drugs. Obviously immunotherapy is a huge arena across the cancer landscape. So far, in pancreatic cancer, the gains have been perhaps on the more modest side, so the immune checkpoint inhibitors that have transformed other types of cancers haven't really done the same for pancreatic cancer yet. So really, some strategies to combine different immunotherapy agents together to harness various aspects of the immune system in a synergistic fashion is really where we're going, with some pretty exciting studies. Or combining immunotherapy with chemotherapy.
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