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Susanne Gray Warner, MD, is here to discuss your options when you or a loved one has been diagnosed with pancreatic cancer.
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Surgery for Pancreatic Cancer
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Learn more about Susanne Gray Warner, MD
Susanne Gray Warner, MD
Susanne Gray Warner, MD, is an Assistant Clinical Professor, Division of Hepatobiliary Surgery and Department of Surgery.Learn more about Susanne Gray Warner, MD
Transcription:
Surgery for Pancreatic Cancer
Melanie Cole (Host): If you or a loved one has been diagnosed with pancreatic cancer or if you’ve been told you’re at high risk for developing the disease talk to City of Hope. It’s important to learn about your options and take action right away. My guest today is Dr. Suzanne Warner. She’s an assistant professor in the Department of Surgery at City of Hope. Welcome to the show, Dr. Warner. Tell us a little bit about pancreatic cancer. What’s going on in the world now? People hear that term and right away they’re very, very scared. Speak about pancreatic cancer. What’s going on today?
Dr. Suzanne Warner (Guest): Well, we are making some really great strides at City of Hope both in our labs and
clinically but the disease remains a very formidable opponent. We’ve been working as scientists and medical care givers for the last 30 to 40 year trying to find the right weapons against pancreatic cancer and we’ve really done kind of a crummy job because we still have a 5-year survival taking all comers of only 7%. We’re trying to push that envelope with new therapies but it’s a slow going process. Right now, what we’re working through with the scientific community is many different things along the disease continuum. What we know is that the vast majority of patients who present with a diagnosis of pancreatic cancer are, unfortunately, already going to have Stage IV disease, meaning that the disease has spread outside of the pancreas. For those people, we don’t have treatments that can cure them right now. We only have treatments that can prolong their lives. What we’re working together as a community, is to try to do is try for things that can give us early detection – laboratory evaluations, imaging and things that are practical for a broad population-based test that we can find. We’re also working to find new treatments that can help patients who already have the cat out of the bag, so to speak, with the disease having spread. What myself and my surgical colleagues are doing is, we’re working in the avenue for those lucky few about 25-30% of patients who present with disease that might be able to come out one day, either when they present or after some chemotherapy. We’re working on new surgery techniques that can minimize the morbidity of the operation, meaning the amount of complications that you can have and how aggressive the operation has to be to get the cancer out.
Melanie: Currently, there’s no early detection screening of any kind. What do you want patients to know about looking for something, symptoms that might signal?
Dr. Warner: It’s really a difficult diagnosis to make because the symptoms themselves are very vague and somewhat general. In many cases, when you start having alarm bells in your body and symptoms that are vigorous enough to seek medical attention, in some cases, it can already be too late. What you really have to do is know your body and listen to your body and if you feel like something’s not right, you’ve to go and tell your doc and you’ve got to be persistent because you’re going to have a vague complaint and a lot of times, we as physicians, like to be optimistic and tell you it’s probably not a big deal. I hate to inspire neurosis amongst the listeners but in many instances people can say, “I just felt like something wasn’t right for the last year or so and then I started losing weight and then I started getting back pain.” I would advocate the minute you feel like something is a little off, just be persistent with your providers and say, “I would really like an investigation.” The problem with investigations for pancreatic cancer is that even if you get a CT scan, for instance, of the abdomen a lot of inexperienced radiologists who don’t look at pancreases all the time might say, “That looks normal. I don’t see a mass there.” That’s the other problem that we have. Even the tools we have in place that are expensive, meaning a CT scan or MRI’s that aren’t appropriate for broad population screening tools, are sometimes not even used appropriately when you’re not seen at a specialty center. The best thing patients can do is listen to their bodies and make sure that when they have a test, if a provider is worried about pancreatic cancer that they make sure that they’re getting second opinions from appropriate places like City of Hope or other institutions that see a lot of pancreatic cancer. Mostly things for patients to watch for, to answer your original question, include things like weight loss that’s not intended, back pain, fullness in what people refer to as the solar plexus or the upper area of the abdomen. Of course, if you turn yellow or your urine starts to darken when you’re not dehydrated, that can be a sign of jaundice which is a sign of a bile duct being blocked off and that sometimes, in lucky patients, is a sign of early pancreatic cancer. Sometimes, it’s a sign of later pancreatic cancer, too. Certainly, turning yellow is a problem. Any kind of change in your stools – a lot of people don’t like to look down there when they’ve had a bowel movement but it can be really important in helping you get clues as to what’s going on inside your abdomen. We look for stools that are lighter in color. We also look for things that would indicate that the pancreas is not working correctly. If the stools float in a funny way or smell different than they normally do for a consistent period of time, I know it’s funny to talk about, but those can be things that need to be brought to the attention of your physician.
Melanie: That’s really important and such great information put so succinctly, Dr. Warner. I really appreciate you saying it like that. People need to hear it like that way. What about if you do get diagnosed? What do you do as far as surgery? They hear these big, long procedures, speak about the surgical interventions necessary.
Dr. Warner: For those lucky few patients, somewhere along the lines of 30% of patients who present with a tumor that can come out, meaning that we have a chance at curing the disease because we can remove it, those patients need to be seen at a center that does at least 10-30 Whipples per year. The tumor can occur anywhere in the pancreas. The pancreas is an organ that fits right in the middle of our abdomen. If you were to pick a midpoint between the belly button and the breast bone, the pancreas hits about right there. It starts in the middle of the abdomen and kind of dives back over towards the left back up under your left rib cage and nestled by your spleen. Tumors can actually occur anywhere where there’s a head, a neck, a body and a tail. There’s also an extra little tongue called the “uncinate process” and the tumors can be anywhere there. If it’s in the head or neck, then you have to have something called a Whipple procedure. That is the crème de la crème of general surgery operations. We take everything apart and put everything back together, basically up in the upper abdomen. If it’s in the tail of the pancreas, that’s a much easier operation. You just have to kind of lop off the tail of the pancreas. Most of the time, you take the spleen with you in the case of cancer because lymph nodes that drain the pancreas live right next to the spleen. Those are your basic two surgical options. There is a very rare procedure called a “central pancreatectomy” that can be appropriate for some more benign lesions or very early stage cancers. That is shied away from in most centers except for places that do it fairly often because what happens if you leave two cut edges of the pancreas is those can cause risks that we’ll talk about here in a minute when we talk about complications related to surgery. In general, once a patient gets a diagnosis, we want to know as physicians is it resectable, meaning can it come out; is it border-line resectable, meaning is there something that’s telling me I shouldn’t go straight to surgery? I should give this patient what we call “neoadjuvant therapy”, which is therapy that happens before surgery. So, chemotherapy or radiation or both. Or, is it metastatic, meaning it has spread somewhere else so we’re not going to get to cure. There’s one last bucket that’s kind of rare and that’s the “locally advanced unresectable” bucket and that’s people whose disease has not spread outside of the pancreas but who are not eligible for resection based on what the tumor is doing to the surrounding structures. That brings us to the next question. How to we decide what is resectable and what isn’t? When we’re looking to see if I can take something out safely, we’re basically looking at some major blood vessels that live right next to the pancreas. I told you before, the pancreas is right in the middle of the abdomen and it’s kind of like union central for blood vessels and lymphatic channels and nerves that do some pretty important things like provide oxygen to all of our small intestines and parts of our colon in addition to providing nutrients to our liver and getting things sent to our liver from our bowels to be cleaned out. One of the big veins that runs there is called the “portal vein” and if a tumor is touching or deforming the portal vein to varying degrees--and there’s a little bit of debate on this in the surgical community--many people consider that borderline resectable. If it’s touching an artery called the “superior mesenteric” artery which supplies our small intestines, then that also kind of lumps it into the borderline resectible group. If it’s encasing either of those structures, mostly the artery, that kind of puts you in that locally advanced unresectible bucket. There’s a few other vessels that, if they are touching in a certain way, that kind of determines which bucket you go in. Bottom line is, if it’s touching a blood vessel, that’s a big deal and many institutions will then sign you up to have chemotherapy and radiation or one or the other or both, depending on the institution. Then, that will take about 4-6 months and then you’ll come to surgery. Some patients, a very lucky few, can go straight to surgery. The most important thing to know is that if you don’t get it out you’re not going to have a chance at cure.
Melanie: Wow. What a great explanation that was. In just the last few minutes, Dr. Warner, kind of cover for us what happens post-surgery. Is this person now at risk for diabetes because the pancreas controls your insulin levels? Speak about post-surgery and give your best advice for people listening.
Dr. Warner: Sure. That is a really great thing to bring up. First and foremost, I want to talk about there’s a few different techniques out there. When you talk about Whipples everybody hears about the robot and the minimally invasive surgical option. There are definitely minimally invasive options for the Whipple. There are just a few centers in the United States that are doing this right now. City of Hope is talking about moving towards doing robotic Whipples but what it really requires is a dedication from the institution and two attending surgeons who want to move that way. We’re working towards that as a group as we get more robotic experience. We’re not going to go there until we know it’s safest for our patients. For distal pancreatectomies, meaning taking out that tail and the spleen like we talked about before, laparoscopic or robotic surgery is essentially the standard of care at this juncture, except for big, huge tumors that might be doing something inventive. For the most part, you should be offered a minimally invasive resection for those and if you’re not then you should ask about why and if you’re not at a specialty center you should get yourself there. What happens after surgery, really the amount of complications and the likelihood of you dying from the operation has actually directly correlated with surgeon volume of pancreatic resection. Again, it’s so important to get yourself to a center that has a lot of experience with this. I know everybody wants to stay close to home because your communities are there but it’s so important to have surgery at a major center. Some of the more common complications after a Whipple procedure, specifically, include something called delayed gastric emptying which just means that the stomach sort of forgets for a little while how it’s supposed work. The stomach is kind of a dumb organ. A lot of the other intestines know that they need to move things forward and they do it in a concerted manner. The stomach is a churner. So, the stomach just sort of has this dopey, march along attitude and sometimes when you cut nerves and arteries that go to the stomach, which you have to do for the Whipple, it kind of forgets it’s job for a little bit. That happens in about 25% of patients. That can be tough because eating is no longer what you thought. You’ll have a new normal, the same way gastric bypass patients have a new normal for exactly how you’re going to eat in the future. As far as the diabetes risk that you asked about, which is a great question, if you already are diabetic and you’re not needing insulin, it depends on how much medicine you’re using, but there’s about a 25-50% risk that you’re going to need insulin once you’re done with the Whipple. If you are not diabetic, you’re going to have about a 10% risk of being diabetic or needing insulin after the surgery. Some people need insulin in the hospital that don’t wind up needing it long term. On the whole, taking all comers, there’s about a 15-20% risk of diabetes after a Whipple procedure. With distal pancreatectomy, it varies based on how much pancreas you wind up having to take. Another big risk that we talk to everybody about is when we take everything apart and put it back together anytime you have a cut edge of the pancreas, that pancreas is designed to help you digest things. The body does a very good job of keeping pancreas juices inside the intestinal tract. Of course, when we go and cut it open in surgery, those juices can get out and because they’re really good at digesting things they can actually hinder the healing process after surgery. You can have leaks from the pancreas edge. That can happen in Whipples and in distal pancreatectomies. After the Whipple, it depends on the data that you read and it also depends on the texture of the pancreas but the risk of leak can be somewhere between 10-25%. After a distal pancreatectomy, it’s the same thing, the risk is a little higher around 20-30%. Those leaks can keep people in the hospital, can make things like delayed gastric emptying happen more frequently and can also cause some more catastrophic consequences in terms of eating away at blood vessels. Those are much more rare but things that the clinicians need to be thinking about. Most of the time, those leaks can be manages with drains but people should not expect but be prepared for the possibility of having kind of a drain live with them for a little while after the resection. In general, to answer what to expect post-operatively, you’ve got to train for this surgery in advance like you’re going to run a marathon because your body is going to be on overdrive for a while. There’s just going to be a new normal. Most people tell us that it takes about 12 weeks to sort of wake up one morning and forget that you had surgery when you’ve had a big Whipple like that. After that, unfortunately, many times we then once you feel better have to hit you with chemo. What people should prepare for is a long road. If you’ve got the right surgeon and the right medical team, they can get you through it and it’s just a very intense experience that we go through together and get people on the other side with a chance at care.
Melanie: Wonderful information. Thank you so much, Dr. Warner, for being with us today. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.
Surgery for Pancreatic Cancer
Melanie Cole (Host): If you or a loved one has been diagnosed with pancreatic cancer or if you’ve been told you’re at high risk for developing the disease talk to City of Hope. It’s important to learn about your options and take action right away. My guest today is Dr. Suzanne Warner. She’s an assistant professor in the Department of Surgery at City of Hope. Welcome to the show, Dr. Warner. Tell us a little bit about pancreatic cancer. What’s going on in the world now? People hear that term and right away they’re very, very scared. Speak about pancreatic cancer. What’s going on today?
Dr. Suzanne Warner (Guest): Well, we are making some really great strides at City of Hope both in our labs and
clinically but the disease remains a very formidable opponent. We’ve been working as scientists and medical care givers for the last 30 to 40 year trying to find the right weapons against pancreatic cancer and we’ve really done kind of a crummy job because we still have a 5-year survival taking all comers of only 7%. We’re trying to push that envelope with new therapies but it’s a slow going process. Right now, what we’re working through with the scientific community is many different things along the disease continuum. What we know is that the vast majority of patients who present with a diagnosis of pancreatic cancer are, unfortunately, already going to have Stage IV disease, meaning that the disease has spread outside of the pancreas. For those people, we don’t have treatments that can cure them right now. We only have treatments that can prolong their lives. What we’re working together as a community, is to try to do is try for things that can give us early detection – laboratory evaluations, imaging and things that are practical for a broad population-based test that we can find. We’re also working to find new treatments that can help patients who already have the cat out of the bag, so to speak, with the disease having spread. What myself and my surgical colleagues are doing is, we’re working in the avenue for those lucky few about 25-30% of patients who present with disease that might be able to come out one day, either when they present or after some chemotherapy. We’re working on new surgery techniques that can minimize the morbidity of the operation, meaning the amount of complications that you can have and how aggressive the operation has to be to get the cancer out.
Melanie: Currently, there’s no early detection screening of any kind. What do you want patients to know about looking for something, symptoms that might signal?
Dr. Warner: It’s really a difficult diagnosis to make because the symptoms themselves are very vague and somewhat general. In many cases, when you start having alarm bells in your body and symptoms that are vigorous enough to seek medical attention, in some cases, it can already be too late. What you really have to do is know your body and listen to your body and if you feel like something’s not right, you’ve to go and tell your doc and you’ve got to be persistent because you’re going to have a vague complaint and a lot of times, we as physicians, like to be optimistic and tell you it’s probably not a big deal. I hate to inspire neurosis amongst the listeners but in many instances people can say, “I just felt like something wasn’t right for the last year or so and then I started losing weight and then I started getting back pain.” I would advocate the minute you feel like something is a little off, just be persistent with your providers and say, “I would really like an investigation.” The problem with investigations for pancreatic cancer is that even if you get a CT scan, for instance, of the abdomen a lot of inexperienced radiologists who don’t look at pancreases all the time might say, “That looks normal. I don’t see a mass there.” That’s the other problem that we have. Even the tools we have in place that are expensive, meaning a CT scan or MRI’s that aren’t appropriate for broad population screening tools, are sometimes not even used appropriately when you’re not seen at a specialty center. The best thing patients can do is listen to their bodies and make sure that when they have a test, if a provider is worried about pancreatic cancer that they make sure that they’re getting second opinions from appropriate places like City of Hope or other institutions that see a lot of pancreatic cancer. Mostly things for patients to watch for, to answer your original question, include things like weight loss that’s not intended, back pain, fullness in what people refer to as the solar plexus or the upper area of the abdomen. Of course, if you turn yellow or your urine starts to darken when you’re not dehydrated, that can be a sign of jaundice which is a sign of a bile duct being blocked off and that sometimes, in lucky patients, is a sign of early pancreatic cancer. Sometimes, it’s a sign of later pancreatic cancer, too. Certainly, turning yellow is a problem. Any kind of change in your stools – a lot of people don’t like to look down there when they’ve had a bowel movement but it can be really important in helping you get clues as to what’s going on inside your abdomen. We look for stools that are lighter in color. We also look for things that would indicate that the pancreas is not working correctly. If the stools float in a funny way or smell different than they normally do for a consistent period of time, I know it’s funny to talk about, but those can be things that need to be brought to the attention of your physician.
Melanie: That’s really important and such great information put so succinctly, Dr. Warner. I really appreciate you saying it like that. People need to hear it like that way. What about if you do get diagnosed? What do you do as far as surgery? They hear these big, long procedures, speak about the surgical interventions necessary.
Dr. Warner: For those lucky few patients, somewhere along the lines of 30% of patients who present with a tumor that can come out, meaning that we have a chance at curing the disease because we can remove it, those patients need to be seen at a center that does at least 10-30 Whipples per year. The tumor can occur anywhere in the pancreas. The pancreas is an organ that fits right in the middle of our abdomen. If you were to pick a midpoint between the belly button and the breast bone, the pancreas hits about right there. It starts in the middle of the abdomen and kind of dives back over towards the left back up under your left rib cage and nestled by your spleen. Tumors can actually occur anywhere where there’s a head, a neck, a body and a tail. There’s also an extra little tongue called the “uncinate process” and the tumors can be anywhere there. If it’s in the head or neck, then you have to have something called a Whipple procedure. That is the crème de la crème of general surgery operations. We take everything apart and put everything back together, basically up in the upper abdomen. If it’s in the tail of the pancreas, that’s a much easier operation. You just have to kind of lop off the tail of the pancreas. Most of the time, you take the spleen with you in the case of cancer because lymph nodes that drain the pancreas live right next to the spleen. Those are your basic two surgical options. There is a very rare procedure called a “central pancreatectomy” that can be appropriate for some more benign lesions or very early stage cancers. That is shied away from in most centers except for places that do it fairly often because what happens if you leave two cut edges of the pancreas is those can cause risks that we’ll talk about here in a minute when we talk about complications related to surgery. In general, once a patient gets a diagnosis, we want to know as physicians is it resectable, meaning can it come out; is it border-line resectable, meaning is there something that’s telling me I shouldn’t go straight to surgery? I should give this patient what we call “neoadjuvant therapy”, which is therapy that happens before surgery. So, chemotherapy or radiation or both. Or, is it metastatic, meaning it has spread somewhere else so we’re not going to get to cure. There’s one last bucket that’s kind of rare and that’s the “locally advanced unresectable” bucket and that’s people whose disease has not spread outside of the pancreas but who are not eligible for resection based on what the tumor is doing to the surrounding structures. That brings us to the next question. How to we decide what is resectable and what isn’t? When we’re looking to see if I can take something out safely, we’re basically looking at some major blood vessels that live right next to the pancreas. I told you before, the pancreas is right in the middle of the abdomen and it’s kind of like union central for blood vessels and lymphatic channels and nerves that do some pretty important things like provide oxygen to all of our small intestines and parts of our colon in addition to providing nutrients to our liver and getting things sent to our liver from our bowels to be cleaned out. One of the big veins that runs there is called the “portal vein” and if a tumor is touching or deforming the portal vein to varying degrees--and there’s a little bit of debate on this in the surgical community--many people consider that borderline resectable. If it’s touching an artery called the “superior mesenteric” artery which supplies our small intestines, then that also kind of lumps it into the borderline resectible group. If it’s encasing either of those structures, mostly the artery, that kind of puts you in that locally advanced unresectible bucket. There’s a few other vessels that, if they are touching in a certain way, that kind of determines which bucket you go in. Bottom line is, if it’s touching a blood vessel, that’s a big deal and many institutions will then sign you up to have chemotherapy and radiation or one or the other or both, depending on the institution. Then, that will take about 4-6 months and then you’ll come to surgery. Some patients, a very lucky few, can go straight to surgery. The most important thing to know is that if you don’t get it out you’re not going to have a chance at cure.
Melanie: Wow. What a great explanation that was. In just the last few minutes, Dr. Warner, kind of cover for us what happens post-surgery. Is this person now at risk for diabetes because the pancreas controls your insulin levels? Speak about post-surgery and give your best advice for people listening.
Dr. Warner: Sure. That is a really great thing to bring up. First and foremost, I want to talk about there’s a few different techniques out there. When you talk about Whipples everybody hears about the robot and the minimally invasive surgical option. There are definitely minimally invasive options for the Whipple. There are just a few centers in the United States that are doing this right now. City of Hope is talking about moving towards doing robotic Whipples but what it really requires is a dedication from the institution and two attending surgeons who want to move that way. We’re working towards that as a group as we get more robotic experience. We’re not going to go there until we know it’s safest for our patients. For distal pancreatectomies, meaning taking out that tail and the spleen like we talked about before, laparoscopic or robotic surgery is essentially the standard of care at this juncture, except for big, huge tumors that might be doing something inventive. For the most part, you should be offered a minimally invasive resection for those and if you’re not then you should ask about why and if you’re not at a specialty center you should get yourself there. What happens after surgery, really the amount of complications and the likelihood of you dying from the operation has actually directly correlated with surgeon volume of pancreatic resection. Again, it’s so important to get yourself to a center that has a lot of experience with this. I know everybody wants to stay close to home because your communities are there but it’s so important to have surgery at a major center. Some of the more common complications after a Whipple procedure, specifically, include something called delayed gastric emptying which just means that the stomach sort of forgets for a little while how it’s supposed work. The stomach is kind of a dumb organ. A lot of the other intestines know that they need to move things forward and they do it in a concerted manner. The stomach is a churner. So, the stomach just sort of has this dopey, march along attitude and sometimes when you cut nerves and arteries that go to the stomach, which you have to do for the Whipple, it kind of forgets it’s job for a little bit. That happens in about 25% of patients. That can be tough because eating is no longer what you thought. You’ll have a new normal, the same way gastric bypass patients have a new normal for exactly how you’re going to eat in the future. As far as the diabetes risk that you asked about, which is a great question, if you already are diabetic and you’re not needing insulin, it depends on how much medicine you’re using, but there’s about a 25-50% risk that you’re going to need insulin once you’re done with the Whipple. If you are not diabetic, you’re going to have about a 10% risk of being diabetic or needing insulin after the surgery. Some people need insulin in the hospital that don’t wind up needing it long term. On the whole, taking all comers, there’s about a 15-20% risk of diabetes after a Whipple procedure. With distal pancreatectomy, it varies based on how much pancreas you wind up having to take. Another big risk that we talk to everybody about is when we take everything apart and put it back together anytime you have a cut edge of the pancreas, that pancreas is designed to help you digest things. The body does a very good job of keeping pancreas juices inside the intestinal tract. Of course, when we go and cut it open in surgery, those juices can get out and because they’re really good at digesting things they can actually hinder the healing process after surgery. You can have leaks from the pancreas edge. That can happen in Whipples and in distal pancreatectomies. After the Whipple, it depends on the data that you read and it also depends on the texture of the pancreas but the risk of leak can be somewhere between 10-25%. After a distal pancreatectomy, it’s the same thing, the risk is a little higher around 20-30%. Those leaks can keep people in the hospital, can make things like delayed gastric emptying happen more frequently and can also cause some more catastrophic consequences in terms of eating away at blood vessels. Those are much more rare but things that the clinicians need to be thinking about. Most of the time, those leaks can be manages with drains but people should not expect but be prepared for the possibility of having kind of a drain live with them for a little while after the resection. In general, to answer what to expect post-operatively, you’ve got to train for this surgery in advance like you’re going to run a marathon because your body is going to be on overdrive for a while. There’s just going to be a new normal. Most people tell us that it takes about 12 weeks to sort of wake up one morning and forget that you had surgery when you’ve had a big Whipple like that. After that, unfortunately, many times we then once you feel better have to hit you with chemo. What people should prepare for is a long road. If you’ve got the right surgeon and the right medical team, they can get you through it and it’s just a very intense experience that we go through together and get people on the other side with a chance at care.
Melanie: Wonderful information. Thank you so much, Dr. Warner, for being with us today. You’re listening to City of Hope Radio. For more information you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.