Selected Podcast
Pancreatic Cancer: Diagnoses, Treatments and What's New in Research
Featured Speaker:
Laleh G Melstrom, MD
Laleh G. Melstrom, M.D., M.S is an assistant clinical professor in the department of surgery, specializing in hepato-pancreato-biliary (HPB) surgery and melanoma surgery. Dr. Melstrom earned her undergraduate degree from Johns Hopkins University in Baltimore, MD, then went on to receive her medical doctorate from Weill Cornell Medical College in New York. Dr. Melstrom then completed her residency in general surgery at Northwestern Memorial Hospital in Chicago, and also completed a research fellowship in a pancreas lab at the Robert H. Lurie Cancer Center of Northwestern (2005 – 2007). She was awarded a Master of Science degree in Clinical Investigation from Northwestern Feinberg School of Medicine. Dr. Melstrom then went on to Memorial Sloan-Kettering Cancer Center (2010 – 2012), where she completed a Surgical Oncology Fellowship. Transcription:
Pancreatic Cancer: Diagnoses, Treatments and What's New in Research
Melanie Cole (Host): Pancreatic cancer is one of the most challenging diseases to treat since it rarely shows symptoms in its early stages. However, aggressive therapies and specialized care can significantly improve outcomes and increase the likelihood of a cure. City of Hope has one of the most experienced pancreatic cancer programs in the United States with a multidisciplinary team that takes an integrated approach to fighting cancers of the pancreas. My guest today is Dr. Laleh Melstrom. She’s an assistant clinical professor in the department of surgery specializing in liver and pancreatic surgery at City of Hope. Welcome to the show, Dr. Melstrom. Tell us a little bit about pancreatic cancer. What’s the difference? People hear exocrine tumors, eyelet cell tumors. Tell us some of the differences that we might hear so that we can better understand the difficulty and challenge that goes with this disease.
Dr. Laleh Melstrom (Guest): Thank you, Melanie, for having me. Pancreatic cancer comes in several different varieties. The pancreas gland, its job is multifactorial. One, its job is to make hormones like insulin to help you regulate your blood sugar. There are other cells in the gland that make other types of hormones to help regulate blood sugar, and based on that, there are tumors that can arise from those cells. Those are termed neuroendocrine tumors. You can have functional or non-functional neuroendocrine tumors. If they’re functional, they secrete hormones and patients may have symptoms. But those tumors, neuroendocrine tumors, are not what we traditionally consider pancreatic cancer or pancreatic adenocarcinoma. The other job of the pancreas is to make the enzymes to help you digest your food. The cells that make those enzymes are what we call the exocrine function of the pancreas and those cells are the cells that lead or that can develop the traditional pancreatic adenocarcinoma that we so often hear about. The challenge with the disease, pancreatic adenocarcinoma, is that it can be quite insidious, so by the time patients have symptoms, the disease has progressed relatively to the lymph nodes or to other distant sites, particularly that patients often present with pain and abdominal bloating.
On the other hand, occasionally patients will present with jaundice where the tumor is right at the head of the gland, blocking the outflow of bile from the liver. Very, very small tumors can present in this way. So I always encourage patients if you are told you have pancreas cancer, it does not mean that it’s not resectable, it does not mean that it’s late stage. Additional workup and evaluation can better tell us if you could be a candidate for an operation, which truly a 2015 surgery is really the only chance at cure and it’s always not surgery alone. It’s in conjunction with multidisciplinary care, specifically chemotherapy and sometimes radiation.
Melanie: Since it’s so difficult to catch early, is there anything that we might notice or in a loved one? Besides jaundice which means it’s already getting there, what might we notice? Is there any way to tell? Are there any signs and symptoms?
Dr. Melstrom: Well, really, with any malignancy you say, “Listen to your body.” If something is not right and it’s persistently not right, you need to get it evaluated. Sometimes it may take several trips to the physician or potentially to gastroenterology if you’re having abdominal bloating, weight loss, early satiety or getting full very quickly, reflux that’s not alleviated by normal acid blockers. These are all potentially signs that something is not right. I’m not saying that those are definitive signs of potential pancreatic cancer, but if your body’s biology and physiology is not behaving as it has for many, many years, something has changed, I would persist on getting that evaluated. Sometimes, it takes several tries, or sometimes it takes several physicians to sort out that, sure, a CAT scan is warranted to see potentially what’s going on.
Melanie: Are there certain risk factors? Is there a genetic component to pancreatic cancer?
Dr. Melstrom: Sure. Familial or the genetic pancreatic adenocarcinoma is comprised of very, very small proportion of all pancreas cancer, but there are certain known mutations that increase your risk of developing it, specifically the BRCA mutations that we often associate with breast cancer. Those folks have an increased risk of developing pancreatic cancer and perhaps could be offered surveillance CT scan. That’s number one. Number two, there is something called the p16 mutation. Those folks are also at risk of developing pancreatic adenocarcinoma. When you first meet a patient, as a physician or as an intern, if you do their family history, if they have an extensive history of gastrointestinal cancers, melanoma, and breast cancer, those should all be signals in your mind that potentially this patient could be at risk of developing pancreatic cancer, and imaging or more careful monitoring is warranted.
Melanie: Tell us about the treatments. You mentioned that surgery is definitely something you have to do now along with other multidisciplinary approaches. What is going on in the world of pancreatic cancer? What’s exciting in the research and surgery? Because we hear, Dr. Melstrom, about the Whipple procedure, this big, huge procedure, what’s going on in your world?
Dr. Melstrom: It has been, over decades and decades and decades, where we don’t necessarily change the complications associated with that operation. It’s quite a large operation. We cut a piece of the stomach, we cut a piece of the bile duct, we cut a piece of the pancreas and then we reconstruct all those three areas of division. The operation is certainly safer than it was, 20 to 30 years ago, but the potential complications still occur. We have made great advances in addressing those potential complications with interventional radiology, CAT scan, certain procedures we do in the operating room to minimize the severity of the complication. Now just like pancreas cancer, colon cancer, stomach cancer, the overall care is multidiscipline. So the sooner you can get patients recovered from their operation, the faster they can receive their adjuvant chemotherapy and the more effective it is, because the theory of chemo is you’ve taken out the macroscopic lesion and now the chemotherapy is to kill off the microscopic cell that you cannot see by eye and therefore minimize the risk of the cancer coming back. So for us, minimally invasive surgery is really the next horizon to improving the functional ability of the patient after an operation like a Whipple or a distal pancreatectomy. Whipple is what we do for a cancer in the head of the pancreas, the front part of the pancreas. A distal pancreatectomy is what we do for the tail of the pancreas. The gland itself span from the right side of the abdomen, underneath the rib cage, all the way to the left side of the abdomen. On the left side, it’s immediately adjacent to the spleen and on the right side, it’s at the base of the liver, small intestines, and stomach, so it’s really kind of a very delicate location where a lot of things in the gastrointestinal tract come together. Minimally invasive surgery is what I was getting at. Currently, we’re able to offer distal pancreatectomy and splenectomy either using the da Vinci robot, which is a tool that is, in my mind, far superior than laparoscopy because the da Vinci has the ability to move the instrument in the abdominal cavity like a human wrist so that you have that fine motor capability comparable to your own hand. Actually, the da Vinci is able to correct for any tremor in the surgeon’s hand so it’s almost a super fine detail piece of equipment. Again, we always emphasize that it is a tool; it’s not necessarily kind of an over-reaching technology. You still have to have the basic skill set and familiarity with the anatomy and the disease to do this operation.
At City of Hope, we’re able to offer robotic distal pancreatectomy, laparoscopic distal pancreatectomy and we are progressing to offer robotic pancreaticoduodenectomy or Whipple operation. The operation typically takes about four hours and the length of stay in the hospital is about seven days for a Whipple. Over time, we’ve been able to shorten the time, the duration of the operation and the length of stay, and hasten the recovery so patients can receive their adjuvant chemotherapy faster.
Melanie: Dr. Melstrom, in just the last minute or so, give your best advice on hope for the future of pancreatic cancer for people listening and why they should come to City of Hope for their care.
Dr. Melstrom: Number one, hope in that this disease, I would say after melanoma, has the greatest amount of effort and technological advancement on a molecular level. There are multiple therapies in line currently being evaluated in phase one and phase two trials for patients with specifically metastatic pancreas cancer, several of which are led by City of Hope, that are essentially the next step in care for patients with pancreatic cancer.
In City of Hope, we have three senior pancreatic surgeons; we have two medical oncologists, one radiation oncologist, and two interventional radiologists whose primary effort and goal is the care of GI malignancies. Two of us have very intensive lab effort including myself, where in every spectrum, both in activism through a pancreatic cancer network, through our research by my lab, and through our clinical care in the full spectrum, we are wholly dedicated to this disease and improving the survival of these patients.
Melanie: Thank you so much for such great information. You are 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.
Pancreatic Cancer: Diagnoses, Treatments and What's New in Research
Melanie Cole (Host): Pancreatic cancer is one of the most challenging diseases to treat since it rarely shows symptoms in its early stages. However, aggressive therapies and specialized care can significantly improve outcomes and increase the likelihood of a cure. City of Hope has one of the most experienced pancreatic cancer programs in the United States with a multidisciplinary team that takes an integrated approach to fighting cancers of the pancreas. My guest today is Dr. Laleh Melstrom. She’s an assistant clinical professor in the department of surgery specializing in liver and pancreatic surgery at City of Hope. Welcome to the show, Dr. Melstrom. Tell us a little bit about pancreatic cancer. What’s the difference? People hear exocrine tumors, eyelet cell tumors. Tell us some of the differences that we might hear so that we can better understand the difficulty and challenge that goes with this disease.
Dr. Laleh Melstrom (Guest): Thank you, Melanie, for having me. Pancreatic cancer comes in several different varieties. The pancreas gland, its job is multifactorial. One, its job is to make hormones like insulin to help you regulate your blood sugar. There are other cells in the gland that make other types of hormones to help regulate blood sugar, and based on that, there are tumors that can arise from those cells. Those are termed neuroendocrine tumors. You can have functional or non-functional neuroendocrine tumors. If they’re functional, they secrete hormones and patients may have symptoms. But those tumors, neuroendocrine tumors, are not what we traditionally consider pancreatic cancer or pancreatic adenocarcinoma. The other job of the pancreas is to make the enzymes to help you digest your food. The cells that make those enzymes are what we call the exocrine function of the pancreas and those cells are the cells that lead or that can develop the traditional pancreatic adenocarcinoma that we so often hear about. The challenge with the disease, pancreatic adenocarcinoma, is that it can be quite insidious, so by the time patients have symptoms, the disease has progressed relatively to the lymph nodes or to other distant sites, particularly that patients often present with pain and abdominal bloating.
On the other hand, occasionally patients will present with jaundice where the tumor is right at the head of the gland, blocking the outflow of bile from the liver. Very, very small tumors can present in this way. So I always encourage patients if you are told you have pancreas cancer, it does not mean that it’s not resectable, it does not mean that it’s late stage. Additional workup and evaluation can better tell us if you could be a candidate for an operation, which truly a 2015 surgery is really the only chance at cure and it’s always not surgery alone. It’s in conjunction with multidisciplinary care, specifically chemotherapy and sometimes radiation.
Melanie: Since it’s so difficult to catch early, is there anything that we might notice or in a loved one? Besides jaundice which means it’s already getting there, what might we notice? Is there any way to tell? Are there any signs and symptoms?
Dr. Melstrom: Well, really, with any malignancy you say, “Listen to your body.” If something is not right and it’s persistently not right, you need to get it evaluated. Sometimes it may take several trips to the physician or potentially to gastroenterology if you’re having abdominal bloating, weight loss, early satiety or getting full very quickly, reflux that’s not alleviated by normal acid blockers. These are all potentially signs that something is not right. I’m not saying that those are definitive signs of potential pancreatic cancer, but if your body’s biology and physiology is not behaving as it has for many, many years, something has changed, I would persist on getting that evaluated. Sometimes, it takes several tries, or sometimes it takes several physicians to sort out that, sure, a CAT scan is warranted to see potentially what’s going on.
Melanie: Are there certain risk factors? Is there a genetic component to pancreatic cancer?
Dr. Melstrom: Sure. Familial or the genetic pancreatic adenocarcinoma is comprised of very, very small proportion of all pancreas cancer, but there are certain known mutations that increase your risk of developing it, specifically the BRCA mutations that we often associate with breast cancer. Those folks have an increased risk of developing pancreatic cancer and perhaps could be offered surveillance CT scan. That’s number one. Number two, there is something called the p16 mutation. Those folks are also at risk of developing pancreatic adenocarcinoma. When you first meet a patient, as a physician or as an intern, if you do their family history, if they have an extensive history of gastrointestinal cancers, melanoma, and breast cancer, those should all be signals in your mind that potentially this patient could be at risk of developing pancreatic cancer, and imaging or more careful monitoring is warranted.
Melanie: Tell us about the treatments. You mentioned that surgery is definitely something you have to do now along with other multidisciplinary approaches. What is going on in the world of pancreatic cancer? What’s exciting in the research and surgery? Because we hear, Dr. Melstrom, about the Whipple procedure, this big, huge procedure, what’s going on in your world?
Dr. Melstrom: It has been, over decades and decades and decades, where we don’t necessarily change the complications associated with that operation. It’s quite a large operation. We cut a piece of the stomach, we cut a piece of the bile duct, we cut a piece of the pancreas and then we reconstruct all those three areas of division. The operation is certainly safer than it was, 20 to 30 years ago, but the potential complications still occur. We have made great advances in addressing those potential complications with interventional radiology, CAT scan, certain procedures we do in the operating room to minimize the severity of the complication. Now just like pancreas cancer, colon cancer, stomach cancer, the overall care is multidiscipline. So the sooner you can get patients recovered from their operation, the faster they can receive their adjuvant chemotherapy and the more effective it is, because the theory of chemo is you’ve taken out the macroscopic lesion and now the chemotherapy is to kill off the microscopic cell that you cannot see by eye and therefore minimize the risk of the cancer coming back. So for us, minimally invasive surgery is really the next horizon to improving the functional ability of the patient after an operation like a Whipple or a distal pancreatectomy. Whipple is what we do for a cancer in the head of the pancreas, the front part of the pancreas. A distal pancreatectomy is what we do for the tail of the pancreas. The gland itself span from the right side of the abdomen, underneath the rib cage, all the way to the left side of the abdomen. On the left side, it’s immediately adjacent to the spleen and on the right side, it’s at the base of the liver, small intestines, and stomach, so it’s really kind of a very delicate location where a lot of things in the gastrointestinal tract come together. Minimally invasive surgery is what I was getting at. Currently, we’re able to offer distal pancreatectomy and splenectomy either using the da Vinci robot, which is a tool that is, in my mind, far superior than laparoscopy because the da Vinci has the ability to move the instrument in the abdominal cavity like a human wrist so that you have that fine motor capability comparable to your own hand. Actually, the da Vinci is able to correct for any tremor in the surgeon’s hand so it’s almost a super fine detail piece of equipment. Again, we always emphasize that it is a tool; it’s not necessarily kind of an over-reaching technology. You still have to have the basic skill set and familiarity with the anatomy and the disease to do this operation.
At City of Hope, we’re able to offer robotic distal pancreatectomy, laparoscopic distal pancreatectomy and we are progressing to offer robotic pancreaticoduodenectomy or Whipple operation. The operation typically takes about four hours and the length of stay in the hospital is about seven days for a Whipple. Over time, we’ve been able to shorten the time, the duration of the operation and the length of stay, and hasten the recovery so patients can receive their adjuvant chemotherapy faster.
Melanie: Dr. Melstrom, in just the last minute or so, give your best advice on hope for the future of pancreatic cancer for people listening and why they should come to City of Hope for their care.
Dr. Melstrom: Number one, hope in that this disease, I would say after melanoma, has the greatest amount of effort and technological advancement on a molecular level. There are multiple therapies in line currently being evaluated in phase one and phase two trials for patients with specifically metastatic pancreas cancer, several of which are led by City of Hope, that are essentially the next step in care for patients with pancreatic cancer.
In City of Hope, we have three senior pancreatic surgeons; we have two medical oncologists, one radiation oncologist, and two interventional radiologists whose primary effort and goal is the care of GI malignancies. Two of us have very intensive lab effort including myself, where in every spectrum, both in activism through a pancreatic cancer network, through our research by my lab, and through our clinical care in the full spectrum, we are wholly dedicated to this disease and improving the survival of these patients.
Melanie: Thank you so much for such great information. You are 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.