- So my name is Flip Bednar.
I'm one of the pancreatic surgeons here
at University of Michigan, and this is a cancer
that I treat daily, and have come to do some research
on in my laboratory as well.
So today, we'll just sort of give the highlights
of what we know about this cancer, how it works,
and how we treat it.
And I'll actually tie in a little bit
into what Dr. Gerard already presented in her talk,
she laid a really nice groundwork for me,
so thank you for that.
So I think the first thing that
we really need to discuss is what the pancreas is.
It's sort of something that most people sort of know about,
or may have heard about a little bit,
but few really know where it is and what it does.
And if you kinda look at these pictures,
the pancreas is sort of this yellow organ
that's in the back of everything else in your upper abdomen.
Its sits sort of in the middle upper belly,
and then it extends over to the left side
towards your spleen.
And the pancreas in the body has two main functions.
Part of the pancreas secretes digestive juices
that then gets sent into your intestine
through this little tube that runs along
the entire length of the gland.
And the other function that the pancreas carries out
is to make hormones that control your metabolism.
So your pancreas is the source of hormones
like insulin, for instance.
And it's critical in maintaining how your body
responds to the food that you eat, how it processes it,
and obviously plays a role
in problems like diabetes, for instance.
Pancreatic cancer is, what we're talking about now
is sort of the quote unquote, bad pancreatic cancer.
And it's a cancer that arises in the portion of the pancreas
that creates the digestive juices.
It has the ability to spread to other organs fairly early.
And what you see here on the left is a picture
of a liver from a patient who died from pancreatic cancer,
and all these white spots are actually tumors
that have cropped up in the liver once the tumor
had spread from the pancreas itself.
It can also spread to lymph nodes, lung,
and rarely to other sites in the body.
The other part to pancreatic cancer
and the way most people know about it,
it's the people that they've heard being affected by it.
And this included famous folks like Alex Trebek,
Patrick Swayze, Aretha Franklin, as well as Sally Ride.
And unfortunately, it is one of the cancers
that is continuing to increase in its incidence,
meaning how many new patients we diagnose
every year with this disease, despite all
the hard work that people are doing on this disease.
So let's talk a little about the risk factors for patients.
So we can break them down into two main groups,
in sort of one bucket are the demographic
or genetic risk factors.
These are things that are unique to each individual,
and uniquely affect what the chances
that they will develop pancreatic cancer in their lifetime.
A key risk factor obviously is age, the longer we live,
the more likely the chances that we will actually
develop pancreatic cancer in our life.
And most folks that get diagnosed with pancreatic cancer
tend to be in their 60s and 70s.
Men have a higher risk of developing this than women.
And unfortunately, out of the sort of racial breakdown
in the United States, we know that black Americans
are at a higher risk of receiving this terrible diagnosis
compared to most other racial groups.
Obviously, these are things that you have no control over.
It's sort of what you're born with,
and these are just the things that we know
are associated with an increased risk.
The other part to kind of intrinsic factors
or things that are particular for each individual person,
are these ideas and concepts of genetic syndromes
and pancreatic cysts.
Now, Dr. Gerard already spoke was about
some of these genetic syndromes that predispose folks
to colon cancer and breast cancer
and occasionally lung cancer.
But it turns out that a lot of them actually
also increase your risk of pancreatic cancer development.
So in particular, for instance, the BRCA gene
was already mentioned, that tends to be a gene mutation
that patients know most of because of its association
with breast cancer and again famous celebrities
that have had BRCA associated breast cancer
that had to be treated like Angelina Jolie.
But the other side of this is that
the same patients also have increased risk of other cancers,
including pancreatic cancer.
And there are other multiple syndromes that exists
that increase this and these include, for instance,
a familial melanoma syndrome where patients
can have an increased risk of pancreatic cancer
and melanoma at the same time.
Actually, the Li-Fraumeni syndrome also has slightly
increased risk of pancreatic cancer,
that was already mentioned in Dr. Gerard's talk.
But I think the main idea here is that
it is important for folks out in the community
to be aware that there are genetic risks,
although they are relatively rare to develop this disease
and it's worthwhile knowing your family history,
and understanding what sort of cancers are present
in your family and how they've been treated.
And when the time comes, in the right scenario
or right context with the right history
the primary care doctors as well as cancer specialists
should be aware of these and actually should
refer folks for genetic counseling,
which is a very key service that certainly
our local cancer center provides.
And it is worthwhile to consider thinking about
a genetic counseling discussion to see
if you could understand what the risk to you
as well as your family members is,
if there's a history of multiple types
of these cancers in the family.
The other thing worth mentioning is
this idea of pancreatic cysts.
These are findings that we're seeing more and more
as we do more CAT scans and MRIs for our patients
for various reasons.
They often tend to be incidentally identified.
Many of these turned out to be benign
and don't cause any problems.
But there is a subset of these cysts that
if left in the body long enough,
will require or can turn into cancer
and will require treatment for cancer.
And so for patients with these genetic syndromes
and pancreatic cysts, for instance,
there are actually surveillance and screening programs
with a combination of MRI and endoscopic ultrasounds,
that will look for cancers.
The other parts of this is environment and lifestyle.
And these are things that people have
a little bit more control over.
And we know that at least there's some potential link
between all of these factors that are listed here,
and the chance of developing pancreatic cancer.
So smoking and tobacco use certainly is,
and it's known, it's been a very well studied,
and the link is established there.
Diet is a little bit more controversial.
But we do think that Western style diet,
essentially what we eat in the United States, in general,
tends to make us more predisposed to these cancers,
along with obesity.
We do know that having pancreatitis,
whether it's alcohol related or for other reasons,
does significantly increase your risk down
the road of pancreatic cancer.
The risk when it was studied is about 40 to 50 fold,
especially for folks that have
repeat episodes of pancreatitis.
And if a person has received radiation for other reasons,
either through treatment or because of
some sort of work exposure, that may also affect
the risk of pancreatic cancer in the future.
So how do we know if you have a pancreatic cancer?
These are typically the most common symptoms
that are associated with it, and it really has to do
with where the pancreas as the gland is located,
again in the upper part of the abdomen.
So folks that get diagnosed with pancreatic cancer
often have fairly vague symptoms.
I wish that there was one particular symptom
that will always tell patients,
you need to worry about this type of cancer.
Unfortunately, there is not.
The closest we get to that is when folks develop
unexplained jaundice, meaning yellowing
of the skin, eyes or nails without pain.
That is very concerning and that typically forebodes
or marks the development of a cancer in the pancreas
or in the bile ducts.
But a combination and constellation of any of these symptoms
including vague abdominal pain, unexplained weight loss,
loss of appetite, nausea, as I mentioned, jaundice already,
New onset diabetes actually, this is a key part,
which I'll touch on a little bit more here,
and new pancreatitis without clear risk factors.
All of these and any of these can mark
potential development of pancreatic cancer.
It's worth talking about the idea of new onset diabetes.
This is something that we really become more aware of
over the last 5-10 years as we've studied it more,
especially in folks that really
don't have a lot of other risk factors
for diabetes development, and especially in folks
that have actual weight loss associated
with unexplained onset diabetes,
there should be very low threshold for the patient
and the physicians that take care of him or her
to think about pancreatic cancer on the,
sort of list of diagnoses to consider and look for.
So how do we diagnose and treat pancreatic cancer?
Typically, when there's concern that pancreatic cancer
is present, you will undergo a combination of these tests,
there will typically be CAT scans or MRIs performed
to look at the pancreas and the other organs in the body.
There'll be an upper endoscopy done, which allows us
to do a biopsy of any mass that'd be fine.
And there will be blood work to establish
some baselines of tests that we can sometimes use
in patients to treat, when we treat pancreatic cancer
to follow their response.
In particular, you may hear about
a blood test called CA19-9.
This is a substance that a lot of the pancreatic tumors,
although not all, that they make and release
into the blood and we can actually use as a marker
to follow the treatment progress because
it will drop as the tumor gets treated,
if it's responding to therapy, and it will actually
go back up if new tumors are developing
or if new spread is happening in the body.
For most patients, unfortunately, pancreatic cancer
is diagnosed at a point where it's already started
to spread to other parts of their body.
And again, this is partly the reason because
we do not have good screening tests,
as Dr. Gerard had already noted,
and the symptoms are very vague.
So often the disease is diagnosed late in its course.
However, there is about a 15 to 20% group of patients
who at some point either get diagnosed early or their tumor,
because of its response to therapy
becomes removable by surgery.
And this is where patients come and see me,
and we perform a couple of different types of procedures
to remove the different parts of the pancreas
that may be affected by the cancer.
It's less important to understand
what those procedures and terms are,
but I think the key part here is that
we are trying to work very hard in trying to understand
how we can sort of help folks get into the treatment bucket
that contains surgery more frequently.
Because really, the operation has to be part
of the treatment for us to be able to try for a cure.
And unfortunately, as again, Dr. Gerard noted already,
the rate of success with pancreatic cancer
tends to be lower than for cancers like colon
or lung cancer, where the treatments
are a little bit more effective,
and the surgeries done more often.
So unfortunately, our five year survival rates,
if you look at all the patients
that are diagnosed with pancreatic cancer
still are on a range of about 10%.
Even in fact just crossed 10% mark
in the last couple of years here.
Last little bit I wanna talk about is just
the clinical trials, there's sort of four main areas
that clinical trials are targeting
this disease are being running.
And then includes combinations of immunotherapy treatments,
new ways of delivering, and new mixes of chemotherapy,
new ways to integrate radiation into it.
And there are exciting trials which are very early
in their stages but showing some promise
that look at how the tumor is
treated metabolic metabolically.
Meaning the tumor sort of uses your body's energy
and sugar and proteins in a different way
than the rest of the body.
And we're hoping that we can leverage that
to treat the disease specifically.
These are some key resources, which I think are helpful
and these will be available,
I'm told after the presentation.
So I'll leave the links here with the,
in my presentation and with that I will end and,
hopefully give a little bit of time
to other folks for the rest of the talks here.