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Strategy for Survival

Team Approach Improves Treatment, Life Expectancyfor Patients with Pancreatic Cancer
By Phil Sahm

Few diseases stack the odds so heavily against survival as pancreatic cancer: historically only 18 percent of pancreatic cancer patients have lived a year, and just 4 percent have lived five years.

Such grim numbers have produced a sort of nihilism in the medical world - a belief among some physicians and researchers that it's futile to battle a disease seldom detected until the cancer has spread and the patient is sure to die.

But physicians at the University of Utah are not giving up the fight. In fact, they've redoubled their efforts through a team approach with specialists from surgery, gastroenterology, radiation oncology, medical oncology, nursing, pain care, dietary services, and social work treating people at all stages of the disease.

Despite the dismal survival statistics, the U doctors see hope.

"There has been substantial progress made in the past 10-15 years," said Sean J. Mulvihill, M.D., professor and chair of the Department of Surgery at the School of Medicine.

Among the advancements:

  • The average survival expectancy for patients with inoperable pancreatic cancer is now 10 months - a startlingly low figure, but still twice as long as a decade ago.
  • Endoscopic ultrasound helps doctors recognize and stage pancreatic cancer from within the body, allowing better diagnoses and sometimes revealing small tumors that can be operated on.
  • Advances in radiation therapy give physicians greater accuracy to shrink tumors in and around the pancreas without harming healthy tissue.
  • New chemotherapy drugs are being developed to target tumors genetically to kill cancer cells.
  • Families with an inherited form of the cancer who may benefit from screening and be of help to researchers in finding a genetic cause of the disease are being identified.
  • The outcome for pancreatic cancer surgery - a difficult and dangerous procedure that is the only potentially curative measure - has improved markedly.

Nationally, 10 percent of people who undergo pancreatic cancer surgery die from the surgery. At the U, that figure is 2 percent, due largely to the fact that University Hospital is one of the primary facilities in the Intermountain West for pancreatic cancer surgery. Studies, including one Mulvihill co-authored, have shown that the more pancreatic cancer operations a hospital performs, the lower the surgery mortality rate.

The average hospital sees two or three pancreatic cancer patients a year. Mulvihill, who learned the surgery at the University of California, San Francisco, and became chair of the U's surgery department in November 2000, treated more than 50 pancreatic cancer patients his first year at the U.

In 2001, pancreatic cancer ranked fifth for fatalities among all cancers, behind lung, colorectal, breast, and prostate cancer, according to the American Cancer Society. But pancreatic cancer occurs far less often than those other cancers, making it a rare disease and a common killer. Smoking is the most significant known risk factor for the disease.

The most common type of pancreatic cancer is ductal adenocarcinoma, which starts in the lining or inner surface of the pancreas and accounts for up to 95 percent of pancreatic cancer cases. Ductal adenocarcinoma is divided into four stages, with declining rates of survival in each stage:

Stage 1 - localized with the tumor limited to the pancreas and a five-year post-operative survival rate of 38 percent;

Stage 2 - regional disease with direct extension of the tumor to adjacent tissues or organs and a five-year survival rate of 15 percent;

Stage 3 - metastasis to regional lymph nodes and a five-year survival rate of 10 percent;

Stage 4 - distant metastasis and a five-year survival rate of 4 percent.

One of the most disheartening aspects of pancreatic cancer is that doctors rarely diagnose the disease early, because, in Stage 1, there are no clear symptoms and there is no meaningful screening test. People with pancreatic cancer often experience vague ailments, such as stomach problems, well before the disease is diagnosed. But the most telling symptom is jaundice, caused when a tumor in the pancreas presses on the bile duct and blocks bile from going to the digestive tract. By the time this occurs, it's too late for surgery in four of five cases.

Absent a screening test, physicians have depended on seemingly unrelated symptoms, intuition - or even chance - to diagnose the disease. But technology now gives doctors a better way to find tumors from inside the body through endoscopic ultrasound, according to gastroenterologist Iqbal S. Sandhu, M.D., assistant professor of internal medicine.

"We can study tumors from much closer and can obtain tissue to confirm diagnosis of cancer," Sandhu said.

Until recently, a CT scan was the best way to get images of cancerous tumors in the pancreas. But, by the time a ductal carcinoma shows up on a CT scan, the cancer usually has spread to surrounding tissue or organs, and it may be too late to operate. With endoscopic ultrasound, physicians sometimes find tumors when they're small enough to be surgically removed, and the patient has a better chance of survival.

Tumor size is a critical predictor of survival in patients who undergo surgery for ductal carcinomas. The five-year survival rate for tumors greater than 2.5 centimeters (1 inch) is approximately 20 percent, while the survival rate in patients with smaller tumors is 40 percent.

Other types of pancreatic cancer tumors can be successfully operated on when they are larger than 2.5 centimeters, but those are in the minority.

Not only can endoscopic ultrasound assist in detecting relatively smaller and earlier stage tumors, but confirmation of cancer can be obtained by fine needle aspiration of tumor cells. A cytologist analyzes the cells at the bedside to yield an immediate diagnosis.

This is one of the biggest advantages of endoscopic ultrasound over other imaging modalities, according to Sandhu.

In addition, endoscopic ultrasound can save both cost and morbidity of unnecessary surgery by identifying patients with inoperable tumors. Instead, efforts can be focused on improving quality of life by providing palliative care.

Once pancreatic cancer has been diagnosed, endoscopy enables physicians to give supportive care, said James A. DiSario, M.D., gastroenterologist and associate professor of internal medicine. DiSario often sees patients after they've had a CT scan or ultrasound and need help for blocked bile ducts, which not only cause jaundice but can make the skin itch. To relieve this, he performs a procedure called ERCP (Endoscopic Retrograde Collangio Pancreatography), in which an endoscope is used to place stents - either plastic tubes or expandable metal springs - that open the ducts and allow passage of bile and enzymes from the pancreas to the digestive tract. ERCP also is used to diagnose cancer and obtain biopsies.

DiSario believes researchers have ignored pancreatic cancer. "It is alarmingly understudied," he said. But he doesn't believe the disease is hopeless.

He recently received a grant from the National Institutes of Health to study the inheritance of pancreatic cancer in Utah families. The state's extensive genealogical records, which have been cross-referenced with death certificates, indicate that 55 Utah families have a statistically increased risk of this cancer.

The grant will enable DiSario to contact these families to collect data about where they live, what they eat, and their lifestyle habits, and to draw blood to look for genetic mutations. These families also will receive counseling regarding their increased risk for pancreatic cancer and recommendations for screening.

Ultimately, genetic studies may help in the development of drugs targeted to prevent or eliminate pre-cancerous conditions, according to DiSario. "We need to find this before it turns into cancer," he said.

Until that day, U physicians will treat pancreatic cancer with the best medicine and technology available, and chemotherapy and radiation will play large roles in that treatment.

Advances in genetics and medicinal chemistry have given hope that chemo-therapeutic drugs one day will target DNA in cancer cells to eradicate the disease at the most basic level, according to Ruey-Min Lee, M.D., Ph.D., medical oncologist and assistant professor of internal medicine. "Hopefully, we'll be able to kill cancer cells better than today," he said.

Chemotherapy also can be used in conjunction with radiation therapy. Combined with new techniques that allow radiation beams to target cancer without harming healthy cells, the two therapies are useful in nearly every case of pancreatic cancer, according to Dennis C. Shrieve, M.D., Ph.D., professor and chair of the Department of Radiation Oncology.

"Radiation and chemotherapy have doubled the average survival time for patients with inoperable disease, from five to 10 months, and from 11 months to nearly two years, when used following surgery," Shrieve said.

Although advances have been made in every aspect of treating pancreatic cancer, the U physicians agree that the best hope for beating the disease lies in developing screening tests. Clues to the disease's presence may be in blood, or fluid from the pancreas, but, so far, remain elusive. When an effective screening test will be developed is anyone's guess.

In the meantime, U of U physicians will fight pancreatic cancer the best way they know how - working together one case at a time.

We always welcome your comments about the magazine. Address letters to: Editor, Health Sciences Report, Office of Public Affairs, University of Utah Health Sciences Center, 50 North Medical Drive, Salt Lake City, UT 84132. FAX: (801) 585-5188. E-mail: Susan.Sample@hsc.utah.edu.

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