Pancreatic Cancer Awareness Month

Transcript

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00:13 --> 00:16Welcome to Yale Cancer Answers with
00:16 --> 00:18your host doctor Anees Chagpar.
00:18 --> 00:20Yale Cancer Answers features the
00:20 --> 00:22latest information on cancer care by
00:22 --> 00:24welcoming oncologists and specialists
00:24 --> 00:26who are on the forefront of the
00:26 --> 00:28battle to fight cancer. This week
00:28 --> 00:30it's a conversation about pancreatic
00:30 --> 00:31cancer with Doctor Jeremy Kortmansky.
00:31 --> 00:33Doctor Kortmansky
00:33 --> 00:34is an associate professor
00:34 --> 00:36of clinical medicine in medical
00:36 --> 00:38oncology at the Yale School of
00:38 --> 00:40Medicine where Doctor Chagpar is
00:40 --> 00:42a professor of surgical oncology.
00:43 --> 00:45So Jeremy,
00:45 --> 00:48I think we all hear about pancreatic
00:48 --> 00:51cancer when it affects celebrities, right?
00:51 --> 00:54So whether it was Steve Jobs or
00:54 --> 00:57other stars we hear
00:57 --> 00:59about pancreatic cancer,
00:59 --> 01:02once in a blue moon.
01:02 --> 01:05It doesn't seem to be a terribly
01:05 --> 01:07common cancer.
01:07 --> 01:10Can you tell us a little bit
01:10 --> 01:12more about how frequently
01:12 --> 01:14pancreatic cancer is diagnosed?
01:14 --> 01:18How many people get it?
01:18 --> 01:20And who really are the
01:20 --> 01:22people that it most affects?
01:22 --> 01:24Yes,
01:24 --> 01:25pancreatic cancer
01:25 --> 01:28is actually becoming an increasingly
01:28 --> 01:31more common cancer that we see.
01:31 --> 01:33It's now the 5th leading cause
01:33 --> 01:36of cancer in the United States,
01:36 --> 01:39at about 60,000 new cases a year.
01:39 --> 01:43So we're not only seeing increasing numbers,
01:43 --> 01:46but also really moving up the
01:46 --> 01:49rank of how often we see it.
01:49 --> 01:52And you know it's interesting you brought
01:52 --> 01:56up Steve Jobs and and other celebrities.
01:56 --> 02:00Most recently, I think Alex Trebek is one
02:00 --> 02:02and it's important to make distinctions
02:02 --> 02:06when we talk about pancreatic cancer,
02:06 --> 02:08there's two main types there
02:08 --> 02:09is pancreatic adenocarcinoma,
02:09 --> 02:14which is by far the more common one that is
02:14 --> 02:18the disease that we're talking about
02:18 --> 02:22when we think about 60,000 cases per year.
02:22 --> 02:24And then there are pancreatic
02:24 --> 02:25neuroendocrine tumors,
02:25 --> 02:27which are a lot less common.
02:27 --> 02:30They are only seen in a few
02:30 --> 02:32thousand patients a year,
02:32 --> 02:34and it's important
02:34 --> 02:36to make the distinction because
02:36 --> 02:38they behave very differently and
02:38 --> 02:40their treatments are very different.
02:42 --> 02:44So, let's start with
02:44 --> 02:44pancreatic adenocarcinoma,
02:44 --> 02:47because I think that most people,
02:47 --> 02:49when they use the term generically
02:49 --> 02:51pancreatic cancer that tends to
02:51 --> 02:53be what they're referring to.
02:53 --> 02:55Although your point is well taken
02:55 --> 02:57with regards to neuroendocrine tumors,
02:57 --> 03:00but tell us a little bit more
03:00 --> 03:02about who gets these cancers.
03:02 --> 03:05I mean, what are the risk factors?
03:06 --> 03:09So I think like other cancers,
03:09 --> 03:12smoking is a common risk factor.
03:12 --> 03:17It can be related to problems that cause
03:17 --> 03:20chronic inflammation of the pancreas so
03:20 --> 03:23alcoholism can lead to pancreas cancer.
03:23 --> 03:26Chronic gallstone disease can,
03:26 --> 03:29although that's much less common.
03:29 --> 03:34Obesity can be a risk factor as well.
03:34 --> 03:36And then there is some question
03:36 --> 03:39of the relationship with diabetes
03:39 --> 03:41and whether diabetes could be a
03:41 --> 03:44risk factor or whether the disease
03:44 --> 03:46itself causes the diabetes.
03:46 --> 03:48And that's something that's
03:48 --> 03:50still being worked out.
03:50 --> 03:53And then there is a smaller percentage
03:53 --> 03:56of patients where it's hereditary cancer.
03:56 --> 03:58There are some genetic abnormalities
03:58 --> 04:02that we know of that are associated
04:02 --> 04:04with pancreas cancer and
04:04 --> 04:07one that is of recent importance
04:07 --> 04:10is its relation to the BRCA gene,
04:10 --> 04:12which is a gene that we most
04:12 --> 04:15often think about with breast and
04:15 --> 04:17ovarian cancer syndromes,
04:17 --> 04:20but is also related to pancreas
04:20 --> 04:21cancer as well,
04:21 --> 04:24and that has had some recent
04:24 --> 04:25implications on treatment.
04:27 --> 04:30So when we think
04:30 --> 04:32about these risk factors,
04:32 --> 04:35I'm thinking about a very good friend
04:35 --> 04:39of mine who actually was diagnosed with
04:39 --> 04:42pancreatic cancer just over Thanksgiving.
04:42 --> 04:45And who didn't fit any of those categories.
04:45 --> 04:47She had no family history.
04:47 --> 04:49She is skinny, like a rail,
04:49 --> 04:51she doesn't have diabetes,
04:51 --> 04:53doesn't drink, doesn't have gallstones.
04:53 --> 04:56You know, in those people where
04:56 --> 04:59they don't seem to have any
04:59 --> 05:01of the common risk factors that you
05:01 --> 05:04think about for pancreatic cancer,
05:04 --> 05:06does that tell us anything about
05:06 --> 05:09the biology of their disease?
05:09 --> 05:11I mean, are there other things
05:11 --> 05:13that we can think of
05:13 --> 05:16in terms of their risk factors,
05:16 --> 05:18and does that
05:18 --> 05:20have anything to
05:20 --> 05:22do with their prognosis?
05:23 --> 05:26I think that those are
05:26 --> 05:27all very good questions.
05:27 --> 05:30There are risk
05:30 --> 05:32factors that we can identify and
05:32 --> 05:35then there are patients who get
05:35 --> 05:38cancer for really no good reason.
05:38 --> 05:40And those are people that
05:40 --> 05:44we are still trying to maybe figure
05:44 --> 05:46out whether there was something
05:46 --> 05:48hereditary or environmental or some
05:48 --> 05:51other factor that we just haven't
05:51 --> 05:54identified yet that played a role.
05:54 --> 05:59When it comes to pancreas cancer,
05:59 --> 06:05the implications of how you got it,
06:05 --> 06:06except in in certain circumstances,
06:06 --> 06:08like the BRCA gene but,
06:08 --> 06:11otherwise how you got it doesn't
06:11 --> 06:14play as much of a role into how we
06:14 --> 06:16might think about treating it or
06:16 --> 06:19how we might expect it to behave.
06:20 --> 06:24So the the other question is,
06:27 --> 06:30when you talk about it
06:30 --> 06:33being the fifth most common cancer
06:33 --> 06:36and we think about the list right?
06:36 --> 06:38Breast cancer, prostate cancer,
06:38 --> 06:40colon cancer for all of these,
06:40 --> 06:42more commonly diagnosed cancers,
06:42 --> 06:45there's a screening test we
06:45 --> 06:47can find these cancers early.
06:47 --> 06:49Is there a screening test
06:49 --> 06:50for pancreatic cancer?
06:51 --> 06:54There isn't a good or routine
06:54 --> 06:57screening test for pancreas cancer.
06:57 --> 07:00I think that we know that there are
07:00 --> 07:04some patients that have been discovered
07:04 --> 07:07to have either a family history
07:07 --> 07:10or patients that have been found
07:10 --> 07:15to have pancreatic cysts on their
07:15 --> 07:18imaging that may have been obtained
07:18 --> 07:21for some other reason that we can
07:21 --> 07:24follow and certainly here at Yale,
07:24 --> 07:26we have an excellent screening
07:26 --> 07:28program where we can refer patients
07:28 --> 07:31to our gastroenterologists who
07:31 --> 07:33can perform screening procedures,
07:33 --> 07:35but that's really identifying those
07:35 --> 07:38who are already at a heightened risk
07:38 --> 07:41and not for the whole population like
07:41 --> 07:44we think about with colonoscopies
07:44 --> 07:46for colon cancer or mammograms
07:47 --> 07:48for breast cancer,
07:48 --> 07:51it's really an already pre determined
07:51 --> 07:53population because the screening
07:53 --> 07:56includes much more advanced or invasive
07:56 --> 08:00testing like MRI's or endoscopic ultrasound.
08:00 --> 08:03So it's a much more complex
08:03 --> 08:06way to follow patients.
08:06 --> 08:09And so without a screening test for
08:09 --> 08:11asymptomatic people who otherwise,
08:11 --> 08:13haven't had any
08:13 --> 08:15abnormality that's been found
08:15 --> 08:17incidentally, what are
08:17 --> 08:20the ways in
08:20 --> 08:23which they present?
08:23 --> 08:25How is it that somebody
08:25 --> 08:28cues into the fact that, Oh my gosh,
08:28 --> 08:30this could be a pancreatic cancer.
08:30 --> 08:33What are the symptoms and signs to look for?
08:34 --> 08:38I again think this is an area
08:38 --> 08:40that becomes challenging that
08:40 --> 08:43the symptoms that people have,
08:43 --> 08:47at least initially can often be vague.
08:47 --> 08:50There can be some discomfort
08:50 --> 08:52in the abdomen, with eating,
08:52 --> 08:54sometimes increased belching,
08:54 --> 08:58or increased gas may be a symptom.
08:58 --> 09:00Things that are very easily
09:00 --> 09:03attributable to something else until
09:03 --> 09:06the symptoms become more significant.
09:06 --> 09:08Sometimes people present without
09:08 --> 09:10any symptoms but develop jaundice,
09:10 --> 09:13they notice yellowing
09:13 --> 09:15of their eyes or their skin,
09:15 --> 09:18which certainly tips them off,
09:18 --> 09:20their families that there's something
09:20 --> 09:23going on that requires further evaluation.
09:23 --> 09:24But because these symptoms
09:24 --> 09:26can sometimes be vague,
09:26 --> 09:29they can also be attributed to the
09:29 --> 09:32much more common problems that we see,
09:32 --> 09:35irritable bowel or reflux which can
09:35 --> 09:38lead to delays in making a diagnosis.
09:40 --> 09:42And so I mean that really gets
09:42 --> 09:45to the crux of the issue, right?
09:45 --> 09:49Is that without screening and with
09:49 --> 09:52the symptoms that are incredibly vague,
09:52 --> 09:54I would surmise that the vast
09:54 --> 09:57majority of patients who present
09:57 --> 10:00with pancreatic cancer present at a
10:00 --> 10:02more advanced stage so talk
10:02 --> 10:04about the stage
10:04 --> 10:07distribution that you see in terms of
10:07 --> 10:09the proportion of patients who present
10:09 --> 10:12with early versus late stage disease and
10:12 --> 10:15what the implications are in terms of
10:15 --> 10:17prognosis.
10:17 --> 10:19People often think
10:19 --> 10:21about staging for cancer with the
10:21 --> 10:24usual stage one, 2, three or four.
10:24 --> 10:26When I think about pancreas cancer,
10:26 --> 10:28I really try to think about
10:28 --> 10:30it in terms of its
10:30 --> 10:33clinical presentations and so there are
10:33 --> 10:35patients that have resectable disease,
10:35 --> 10:38meaning that a surgeon could go in there at
10:38 --> 10:42the time of diagnosis and take it out.
10:42 --> 10:45There are patients that have locally
10:45 --> 10:46advanced but unresectable disease,
10:46 --> 10:48meaning that it hasn't spread
10:48 --> 10:51to other parts of the body,
10:51 --> 10:53but it's involving the nearby blood vessels,
10:53 --> 10:57and you can't safely take it out.
10:57 --> 10:59And then patients with metastatic
10:59 --> 11:02disease where it's spread to
11:02 --> 11:04other places in the body.
11:04 --> 11:07And so the the number or the percentage
11:07 --> 11:10of patients that can have surgery
11:10 --> 11:13at the time of their diagnosis
11:13 --> 11:16is really only about 15 to 20%.
11:16 --> 11:18It's a relatively low number
11:18 --> 11:21and the other 80% sort of evenly
11:21 --> 11:23distributed are either locally
11:23 --> 11:25advanced or metastatic disease
11:25 --> 11:29at the time of their diagnosis.
11:29 --> 11:34And so it was with my my friend who
11:34 --> 11:38was diagnosed with a locally advanced,
11:38 --> 11:40unresectable pancreatic
11:40 --> 11:43cancer that was encasing
11:43 --> 11:45important blood vessels,
11:45 --> 11:47so she certainly wasn't
11:47 --> 11:50a candidate for surgery at
11:50 --> 11:52the time of her presentation,
11:52 --> 11:56so it sounds like if patients are
11:56 --> 11:59fortunate enough to be resectable
11:59 --> 12:02at the time of their presentation,
12:02 --> 12:04would surgery be the
12:04 --> 12:06primary modality upfront?
12:08 --> 12:12That is a great question, and one that
12:12 --> 12:16we are still trying to figure out.
12:16 --> 12:18I think that there is clearly
12:18 --> 12:21a standard paradigm of doing
12:21 --> 12:23surgery followed by chemotherapy
12:23 --> 12:26for about six months afterwards.
12:26 --> 12:30There is a lot of interest in giving
12:30 --> 12:33chemotherapy prior to surgery or
12:33 --> 12:35giving part of the chemotherapy,
12:35 --> 12:38then surgery, and then chemotherapy after.
12:38 --> 12:42And in fact, here at Smilow we have a
12:42 --> 12:46clinical trial which is really looking at
12:46 --> 12:49that question of perioperative chemotherapy.
12:49 --> 12:53How do patients do getting some of the
12:53 --> 12:55chemotherapy treatments before surgery,
12:55 --> 12:57and then some after?
12:57 --> 13:01And how that might compare to those who get
13:01 --> 13:04surgery 1st and then chemotherapy later?
13:05 --> 13:07And so this kind of brings
13:07 --> 13:09us to the question of, well,
13:09 --> 13:11how effective is the chemotherapy?
13:11 --> 13:12Because,
13:12 --> 13:14I can imagine that many of the
13:15 --> 13:17people who are listening to this
13:17 --> 13:19show are thinking,
13:19 --> 13:22if I have a cancer and you can take this
13:22 --> 13:27cancer out and you can get it out of my body,
13:27 --> 13:29for many people the simple
13:29 --> 13:32logic is that might be better
13:32 --> 13:33than having a chemotherapy,
13:33 --> 13:35which may or may not
13:35 --> 13:38work and they often have some
13:38 --> 13:41trepidation about cancer spreading
13:41 --> 13:44and then making it unresectable.
13:44 --> 13:46So how effective is chemotherapy
13:46 --> 13:51that we could potentially use it in
13:51 --> 13:53a neoadjuvant fashion to potentially
13:53 --> 13:57even shrink the cancer and get some
13:57 --> 14:01systemic control prior to resecting it?
14:02 --> 14:09So our newer chemotherapy regiments are
14:09 --> 14:11good, they're not great,
14:11 --> 14:15but they are good and they can shrink
14:15 --> 14:17the disease for some and control
14:17 --> 14:20the microscopic disease that might
14:20 --> 14:22be floating around for others.
14:22 --> 14:25I think that the challenge ultimately
14:25 --> 14:28is that even with surgery,
14:28 --> 14:31the risk of pancreatic cancer coming
14:31 --> 14:33back because it has already shed
14:33 --> 14:36these microscopic cells is very high,
14:36 --> 14:39and so by giving chemotherapy we are
14:39 --> 14:41hopefully attacking some of those
14:41 --> 14:44microscopic cells that are floating around,
14:44 --> 14:47but also making sure that putting
14:47 --> 14:50somebody through what would be a
14:50 --> 14:52very major operation is ultimately
14:52 --> 14:54the right thing to do.
14:54 --> 14:57So many complicating moving parts
14:57 --> 15:00in the management of pancreatic cancer
15:00 --> 15:03and we're going to learn much more
15:03 --> 15:06about all of that right after we take
15:06 --> 15:09a short break for a medical minute.
15:09 --> 15:11Please stay tuned to learn more
15:11 --> 15:13about pancreatic cancer with
15:13 --> 15:14my guest Doctor Jeremy Kortmansky.
15:14 --> 15:17Support for Yale
15:17 --> 15:19Cancer Answers comes from AstraZeneca
15:19 --> 15:21providing important treatment options
15:21 --> 15:24for various types and stages of cancer.
15:24 --> 15:27More information at astrazeneca-us.com.
15:27 --> 15:29This is a medical minute
15:29 --> 15:31about head and neck cancers,
15:31 --> 15:33although the percentage of oral
15:33 --> 15:35and head and neck cancer patients
15:35 --> 15:37in the United States is only
15:37 --> 15:39about 5% of all diagnosed cancers,
15:39 --> 15:41there are challenging side effects
15:41 --> 15:43associated with these types of
15:43 --> 15:44cancer and their treatment.
15:44 --> 15:46Clinical trials are currently
15:46 --> 15:48underway to test innovative new
15:48 --> 15:50treatments for head and neck cancers,
15:50 --> 15:52and in many cases less radical
15:52 --> 15:54surgeries are able to preserve nerves,
15:54 --> 15:56arteries and muscles in the neck.
15:56 --> 15:59Enabling patients to move speak,
15:59 --> 15:59breathe,
15:59 --> 16:02and eat normally after surgery.
16:02 --> 16:04More information is available at
16:04 --> 16:05yalecancercenter.org.
16:05 --> 16:08You're listening to Connecticut Public Radio.
16:09 --> 16:11Welcome back to Yale Cancer Answers.
16:11 --> 16:14This is doctor Anees Chagpar
16:14 --> 16:16and I am joined tonight by my
16:16 --> 16:19guest doctor Jeremy Kortmansky.
16:19 --> 16:21We're talking about pancreatic cancer
16:21 --> 16:23and Jeremy right before the break,
16:23 --> 16:26you had indicated to us that you really think
16:26 --> 16:29about pancreatic cancer in terms of staging,
16:29 --> 16:32as whether things are resectable at the
16:32 --> 16:34time of presentation or unresectable,
16:34 --> 16:36but not metastatic or metastatic
16:36 --> 16:38and sadly,
16:38 --> 16:4280% of patients or so fall into
16:42 --> 16:44the last two buckets.
16:44 --> 16:45And you know,
16:45 --> 16:47that's really unfortunate,
16:47 --> 16:50because what is the prognosis for
16:50 --> 16:52patients who have locally advanced
16:52 --> 16:55unresectable disease at presentation?
16:55 --> 16:58And what is the prognosis for patients
16:58 --> 17:01who present with metastatic disease?
17:03 --> 17:06For those patients who have advanced disease,
17:06 --> 17:08unfortunately we view those
17:08 --> 17:09as incurable cancers.
17:09 --> 17:15We can't make it go away and never come back.
17:15 --> 17:18For patients that have locally
17:18 --> 17:20advanced disease on occasion and
17:20 --> 17:22it's not the expectation,
17:22 --> 17:25but on occasion they have a
17:25 --> 17:28great response to the chemotherapy
17:28 --> 17:31and we can revisit that question
17:31 --> 17:34of surgery but without surgery,
17:34 --> 17:37ultimately, patients succumb to their
17:37 --> 17:41disease and the goals of our treatment
17:41 --> 17:43are to control the disease
17:43 --> 17:45for as long as possible.
17:45 --> 17:48Help people live as long as possible and
17:48 --> 17:51feel as well as possible knowing that
17:51 --> 17:54the disease can be symptomatic as well.
17:55 --> 18:00For people who are
18:00 --> 18:03listening to this and who may have had
18:03 --> 18:06friends or even seen celebrities
18:06 --> 18:08go through their own journeys
18:08 --> 18:12with pancreatic cancer,
18:12 --> 18:15when we say the goal is really
18:15 --> 18:18to try to control the cancer for as
18:18 --> 18:21long as possible and the quality
18:21 --> 18:23of life for as long as possible,
18:23 --> 18:24in some cancers
18:24 --> 18:26we've discussed on this
18:26 --> 18:28show,
18:28 --> 18:31medical management has come a really long
18:31 --> 18:33way such that even in those settings,
18:34 --> 18:37people live for a long time and
18:37 --> 18:40they talk about this being incurable,
18:40 --> 18:42but really making it more of a
18:42 --> 18:44chronic disease then something
18:44 --> 18:46that is imminently fatal.
18:46 --> 18:49Where are we in the spectrum of
18:49 --> 18:51pancreatic cancer towards getting to
18:52 --> 18:55oK, so I've got pancreatic cancer and
18:55 --> 18:58I know that I can't get rid of it,
18:58 --> 19:00but
19:00 --> 19:02I can live with it versus this
19:02 --> 19:05is something that
19:05 --> 19:08is more of an imminent concern.
19:10 --> 19:14It's still a very challenging disease and
19:14 --> 19:19there are for a lot of other cancers,
19:19 --> 19:23a lot of exciting new therapies and
19:23 --> 19:25targeted therapies and immunotherapy's
19:25 --> 19:28that have become available.
19:28 --> 19:29But for pancreas cancer,
19:29 --> 19:33the majority of patients are still treated
19:33 --> 19:36with versions of chemotherapy and
19:36 --> 19:39those chemotherapy drugs are modest.
19:39 --> 19:41There are some who are
19:41 --> 19:42exceptional responders.
19:42 --> 19:47People who do really well for a long time,
19:47 --> 19:50but for the majority of patients,
19:50 --> 19:53the survival is still only
19:53 --> 19:56measured in in months or years.
19:56 --> 20:00And doing better and finding better
20:00 --> 20:02therapies is of such great
20:02 --> 20:04importance for this disease.
20:04 --> 20:06I think we are really hoping
20:06 --> 20:09and trying every day to find
20:09 --> 20:12therapies that are better than what
20:12 --> 20:13we have currently.
20:13 --> 20:16Do we have any factors that can
20:16 --> 20:19predict who is going to respond
20:19 --> 20:21better to chemotherapy versus not?
20:24 --> 20:29So we are still trying to figure that out.
20:29 --> 20:33I had mentioned
20:33 --> 20:37this earlier, patients that have a BRCA
20:37 --> 20:41mutation or a similar type mutation,
20:41 --> 20:44we find that they are more sensitive
20:44 --> 20:47to platinum based chemotherapy.
20:47 --> 20:51So a drug like oxaliplatin or cisplatin.
20:51 --> 20:54And that we can see better responses
20:54 --> 20:57there that can sometimes last longer
20:57 --> 21:00than we might see with a patient who
21:00 --> 21:03doesn't have one of those abnormalities.
21:03 --> 21:07We know that there is a class of
21:07 --> 21:09drugs called PARP inhibitors,
21:09 --> 21:12which for this mutated population
21:12 --> 21:15can benefit from this targeted therapy.
21:15 --> 21:19At the end of the day, that only makes
21:19 --> 21:23up about 7% of the patients that we see.
21:23 --> 21:28So it's still not a not a big number and
21:28 --> 21:32we know about 1% have another abnormality,
21:32 --> 21:33called microsatellite instability,
21:33 --> 21:34for which immunotherapy
21:34 --> 21:36drugs have been helpful.
21:36 --> 21:40And so we always test for that.
21:40 --> 21:45But again, it's one out of 100 that we see.
21:45 --> 21:48So the majority of the patients that
21:48 --> 21:51we take care of are still treated
21:51 --> 21:54similarly with these more generic
21:54 --> 21:57chemotherapy programs with a strong
21:57 --> 22:00emphasis in trying to encourage patients
22:00 --> 22:02to participate in clinical trials
22:02 --> 22:05that can help us move the field.
22:06 --> 22:10And I want to get into
22:10 --> 22:13the clinical trials in a minute.
22:13 --> 22:15But before we get there,
22:15 --> 22:17if you're treated with standard
22:17 --> 22:20chemotherapy and all of the side
22:20 --> 22:22effects that go along with that,
22:22 --> 22:24knowing that you're
22:24 --> 22:27presented with a locally advanced,
22:27 --> 22:28unresectable or metastatic cancer,
22:28 --> 22:30what is really the efficacy
22:30 --> 22:32of these chemotherapies?
22:32 --> 22:35I mean, how do patients balance the risk
22:35 --> 22:39and the benefit of the therapy?
22:39 --> 22:41Is this something that for
22:41 --> 22:45some patients the therapy is
22:45 --> 22:47worse than the disease itself?
22:47 --> 22:50Or are these actually things that
22:50 --> 22:53are tolerable with more modern
22:53 --> 22:56day treatments and additional
22:56 --> 22:59factors that you can give patients?
22:59 --> 23:01And that has really been shown
23:01 --> 23:03to make a difference in terms of
23:03 --> 23:05both survival and quality of life.
23:07 --> 23:10My job is to make
23:10 --> 23:12the treatments tolerable.
23:12 --> 23:14When we we pick a regimen,
23:14 --> 23:17there are two common
23:17 --> 23:18regiments that we use.
23:18 --> 23:20We are already thinking about
23:20 --> 23:23what are the side effects that are
23:23 --> 23:26associated with those regimens and
23:26 --> 23:28whether the patient who's about
23:28 --> 23:30to receive it is going to be able
23:30 --> 23:33to tolerate it based on their age and
23:33 --> 23:35other medical problems that they may
23:35 --> 23:38have and when we give the treatments,
23:38 --> 23:42we do so very carefully and we pay
23:42 --> 23:45attention to those side effects to make
23:45 --> 23:49adjustments in the dosing or give
23:49 --> 23:51supportive medications to really
23:51 --> 23:53make it as tolerable as we can.
23:53 --> 23:57It's never a desired situation that the
23:57 --> 24:01treatment is worse than the disease.
24:01 --> 24:02And the reality is,
24:02 --> 24:05that for the vast majority of
24:05 --> 24:08patients when they do start feeling poorly,
24:08 --> 24:10it's more often the disease
24:10 --> 24:11than it is the treatments.
24:11 --> 24:14But we make sure we see patients
24:14 --> 24:16every time before they get their
24:16 --> 24:18treatments to review the side effects
24:18 --> 24:21and give the right medications and
24:21 --> 24:23give the supportive medications or
24:23 --> 24:25dose adjustments that we need to do.
24:26 --> 24:29And how do we know
24:29 --> 24:31that the chemotherapies are working?
24:31 --> 24:34Many patients ask about well are
24:34 --> 24:36you going to do more blood work?
24:36 --> 24:39Are there tumor markers?
24:39 --> 24:40How do you know?
24:40 --> 24:42Because you had mentioned that for
24:42 --> 24:45some patients who present
24:45 --> 24:47without metastatic disease,
24:47 --> 24:49that is unresectable that
24:49 --> 24:52potentially in some of those patients,
24:52 --> 24:54you can reassess whether they
24:54 --> 24:56may be candidates for resection.
24:57 --> 25:01The best way to follow the disease is
25:01 --> 25:05with imaging so usually a CAT scan.
25:05 --> 25:08Sometimes an MRI or a PET scan,
25:08 --> 25:10but usually a CAT scan gives us
25:10 --> 25:13the level of detail that we need,
25:13 --> 25:15including the relationship of
25:15 --> 25:17the tumor to the vessels nearby.
25:17 --> 25:19For those who have locally advanced
25:19 --> 25:22disease and there is a tumor
25:22 --> 25:24marker that we can use as well,
25:27 --> 25:29that can be helpful,
25:29 --> 25:31although sometimes it is not as
25:31 --> 25:34reliable as the scans and then also
25:34 --> 25:36really listening to the patient.
25:36 --> 25:39Patients can have symptoms that can be a
25:39 --> 25:42tipoff that something is getting better
25:42 --> 25:45or getting worse even before CAT
25:45 --> 25:48Scan tell you what's going on.
25:49 --> 25:52And back to
25:52 --> 25:55the story of my friend.
25:55 --> 25:58She had chemotherapy as you suggested,
25:58 --> 26:01and her tumor markers went down,
26:01 --> 26:02which was great,
26:02 --> 26:05but the imaging still showed that
26:05 --> 26:08she had unresectable disease.
26:09 --> 26:14She was quite happy to be done with
26:14 --> 26:18chemo and really didn't want to
26:18 --> 26:20do much more, but was certainly
26:20 --> 26:22interested in clinical trials.
26:22 --> 26:25So let's talk about clinical trials,
26:25 --> 26:27both in that setting,
26:27 --> 26:29after you don't respond
26:29 --> 26:31to standard chemotherapy as well
26:31 --> 26:33as clinical trials that might
26:33 --> 26:35be offered to patients upfront
26:35 --> 26:37as new therapies are developed.
26:37 --> 26:40So what are you most excited about?
26:43 --> 26:45I think it's interesting that you
26:45 --> 26:48say that, I find that when I talk
26:48 --> 26:49to a patient
26:49 --> 26:51about a clinical trial
26:51 --> 26:54sometimes they say to me, do you think
26:54 --> 26:56I'm ready for a clinical trial?
26:56 --> 26:59As if it's something that we wait
26:59 --> 27:01until we don't have other options,
27:01 --> 27:03and clinical trials are important at
27:03 --> 27:05every phase of someone's disease,
27:05 --> 27:07whether they are initially diagnosed
27:07 --> 27:09or whether they have progressed
27:09 --> 27:11on one or two prior therapies.
27:11 --> 27:14We are always trying to figure
27:14 --> 27:17out what's the best thing to do.
27:17 --> 27:20And so the clinical trials that we are
27:20 --> 27:22working on that we're excited about,
27:22 --> 27:25I think we are still trying to find a
27:25 --> 27:29role for immunotherapy in pancreas cancer,
27:29 --> 27:31the same as in other diseases
27:31 --> 27:33like lung cancer or Melanoma.
27:33 --> 27:36But it's been a challenge,
27:36 --> 27:39and so we are doing clinical trials
27:39 --> 27:41that are looking at immunotherapy
27:41 --> 27:44combinations as opposed to just a
27:44 --> 27:47single drug to see if it might be
27:48 --> 27:52better and we're looking at clinical trials that are
27:52 --> 27:55trying to attack not just the tumor itself,
27:55 --> 27:58but the scar tissue in the
27:58 --> 28:00environment around the cancer cells.
28:00 --> 28:03One of the challenging things about
28:03 --> 28:06pancreas cancer is that it almost builds
28:06 --> 28:08this protective shell around itself
28:08 --> 28:11that can potentially make it more
28:11 --> 28:14difficult for our treatments to get in,
28:14 --> 28:18and so looking at drugs that can potentially
28:18 --> 28:21eat away at that might help our
28:21 --> 28:23more standard therapies be more
28:23 --> 28:25effective.
28:25 --> 28:27Doctor Jeremy Kortmansky is an associate professor of
28:27 --> 28:29clinical medicine in medical oncology
28:29 --> 28:31at the Yale School of Medicine.
28:31 --> 28:33If you have questions,
28:33 --> 28:34the address is canceranswers@yale.edu
28:34 --> 28:36and past editions of the program
28:36 --> 28:38are available in audio and written
28:38 --> 28:40form at yalecancercenter.org.
28:40 --> 28:43We hope you'll join us next week to
28:43 --> 28:45learn more about the fight against
28:45 --> 28:48cancer here on Connecticut Public Radio.

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November 15, 2020

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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