Joey Wahler (Host): It's a disease for which early detection is crucial. So, we're discussing pancreatic cancer screening. Our guest, Dr. Constantine Melitas. He's an advanced therapeutic endoscopist and gastroenterologist for Dignity Health. This is Hello Healthy, a podcast from Dignity Health. Thanks for listening. I'm Joey Wahler. Hi there, Dr. Melitas. Thanks for joining us.

Dr. Constantine Melitas: Hey, Joey. Thank you so much for having me on.

Host: Great to have you. So first, what is an advanced therapeutic endoscopist/gastroenterologist, and what conditions does someone like yourself address?

Dr. Constantine Melitas: Yeah. Thanks for asking the question. So, advanced therapeutic endoscopy is another specialty within the field of gastroenterology where we're trained to focus on more detailed procedures of the entire GI tract. We treat anything from cancer procedures. We diagnose a lot of cancer. We remove cancers. We remove precancerous lesions. And we sometimes even perform weight loss procedures endoscopically through the scope, which doesn't require any surgery.

Host: Very interesting. So, speaking of cancer, we mentioned we're focusing on screening for pancreatic cancer. First, who's generally most at risk for getting it in the first place?

Dr. Constantine Melitas: So, pancreatic cancer in general, just to set the record straight, is a fairly rare cancer. It only affects 1.6% of the general population. But we all know that it can be extremely detrimental and lethal. It only has a 10% 5-year survival rate, and its poor prognosis is thought to be due to aggressive behavior, often advanced stage at the time of diagnosis, and poor response to currently available therapies.

And so, there are no current pancreatic cancer screening guidelines for the general population. However, there are some guidelines that recommend screening for certain patient populations which are at high risk for developing pancreatic cancer. There's a multitude of genetic diseases and findings as well as syndromes that put certain patients at a higher risk for pancreatic cancer.

Host: And so, who would some of those people be?

Dr. Constantine Melitas: So, patients that meet criteria for pancreatic cancer screening are patients who have a family history of pancreatic cancer, which includes two first-degree relatives with pancreatic cancer and first degree relatives, mean, mother, father, sister and brother. Other things that would qualify for pancreatic cancer screening are PALB2 mutations, Lynch syndrome.

And one of the most interesting mutations are BRCA1 or 2 mutations. And a lot of people think of BRCA mutations being associated with gynecologic cancers like breast cancer and uterine cancer. However, there is a pretty significant risk of developing pancreatic cancer as well. So much in fact, the most updated guidelines recommend that anybody with a BRCA mutation should undergo pancreatic cancer screening. The previous guidelines had mentioned that only BRCA patients with a family history of pancreatic cancer should undergo screening. However, what studies have shown is that there's up to 8% lifetime risk with BRCA mutation alone, regardless of family history; and therefore, the guidelines have been updated.

Host: Gotcha. How about lifestyle-wise? Anything that certain people should be aware of that if they're doing means they perhaps should go for screening?

Dr. Constantine Melitas: There's nothing lifestyle wise that would qualify somebody just for pancreatic cancer screening alone. But risk factors for developing pancreatic cancer in the general population are smoking, heavy alcohol use, sedentary lifestyle, obesity, to name a few.

Host: So, you're saying that if you fall into any of those categories, it still doesn't necessarily mean you need to go for screening.

Dr. Constantine Melitas: Correct. The general population, at this point, there hasn't been any guidelines to recommend screening for the general population because it is a fairly rare cancer.

Host: Now, this disease also spreads very quickly. And so, how long does it usually take, for instance, to go from stage I to stage IV?

Dr. Constantine Melitas: It can vary to be honest. But what studies have shown based on animal models is that typically the stages can change in about a year, which is why when somebody is enrolled in a pancreatic cancer screening program, there has to be at least annual evaluation of their pancreas.

Now, pancreatic cancer screening, we have to remember does not prevent pancreatic cancer from forming. It's just a procedure or an imaging study to look for specifically a pancreatic abnormality that can raise our suspicion earlier, have it diagnosed earlier so that we have a better chance at curing it or improving survival.

Host: Understood. And so, you led me beautifully there, doc, into my next question, which is at Marian Regional Medical Center and Mission Hope Cancer Center, you're the one spearheading this new pancreatic cancer screening program, which is clearly one way of at least trying to avoid an advanced stage of the disease, right?

Dr. Constantine Melitas: Correct. Correct. It's similar to other cancer screening protocols where being proactive is always better, similar to mammograms and pap smears. The point of these studies is to detect cancer at a earlier stage. And so, hopefully by doing this, patients who meet criteria for pancreatic cancer screening program can get screened early and hopefully cure such a detrimental and lethal condition.

Host: And so under the care of you and yours, what can patients typically expect during one of these screenings? For instance, how long does it take? And is it invasive or painful?

Dr. Constantine Melitas: So, there's two modalities actually, which have been recommended for pancreatic cancer screening. One of those is something called endoscopic ultrasound, which requires an upper endoscope with an ultrasound probe at the end to be passed down the esophagus into the stomach. And with that ultrasound, we see through the stomach to get the most detailed picture and all of medicine of the pancreas. And the benefit of that procedure is that we also can biopsy an irregular-appearing portion of the pancreas if we need to right then and there. That is a little bit more invasive than the other modality. The other modality is MRI. And so, what a lot of places do is they alternate endoscopic ultrasound with MRI on an annual basis.

Host: And doctor, when we talk about these two modalities you mentioned, what's the main difference people should be aware of between the two?

Dr. Constantine Melitas: So, MRI is excellent. It's getting much better over the years, but it still has not caught up to endoscopic ultrasound. Endoscopic ultrasound is a little bit more detailed, and as I mentioned, we do have the capability of biopsying an abnormal appearing region of the pancreas. Now, patients don't always have to do these invasive procedures and can alternate on a yearly basis. But it's always best to start with endoscopic ultrasound because it is a little bit more detailed. And what studies have shown, there's been a couple studies that looked at endoscopic ultrasound versus MRI head to head, and endoscopic ultrasound was the modality that found the very small, very early pancreatic cancers under a centimeter, more so than MRI.

Host: So, you've mentioned needing to go for one of these screenings annually. Is there ever an instance for whatever reason that someone needs to go more?

Dr. Constantine Melitas: There is, in fact, there are some higher risk findings. There are patients who have abnormalities of the pancreas that may need to be evaluated a little bit more often, as you said. There are a lot of lesions in the pancreas, some of which are very benign for the significant majority of of us. But for patients who have a higher risk of pancreatic cancer, it may indicate that something more worrisome is to come in the future. And so for those patients, we like to keep a closer eye on them.

Host: Okay. A couple of other things. So, how would a patient go about getting a pancreatic cancer screening at one of your facilities?

Dr. Constantine Melitas: There's a lot of different ways. Luckily, especially now that we have this pancreatic cancer screening program in place. First, they can contact us directly and we can facilitate them and screen them to see if they're somebody who would meet criteria for pancreatic cancer screening. However, we luckily have an algorithm through a lot of primary care offices, through oncologists and other general gastroenterologists who can help us filter and find these patients who may find this of benefit.

Host: And then in summary, doc, I wanted to close by getting your further thoughts on something that you pointed out early on, which is it's a relatively small number of people that get pancreatic cancer. And yet, as you also mentioned, there can be a grim prognosis if it's caught too late. So, it's kind of a Catch-22 for people like you fighting against this, isn't it? Because I would imagine due to the fact that more people don't get pancreatic cancer, more people don't heed the kind of warning that you're trying to deliver right here today, right?

Dr. Constantine Melitas: Yeah. That's exactly right. But it is a cancer that is on the rise. it's responsible still for a lot of deaths. I mean, 1.6% percent of our large population in this country is still a lot of people. And if we can pinpoint some of the people who are at higher risk and try to minimize the disease progression, then I think that we can make such a huge impact. And luckily, here at Mission Hope and at Marian Regional Medical Center, we're super fortunate to have the amazing staff and support and resources to make such a significant impact on the community by developing only the second official pancreatic cancer screening program in the state. We offer both EUS and MRI to screen our patients. And luckily, as I mentioned, we have the support from multiple different specialties in order to give our patients the best possible care.

Host: Indeed. And as with so many other things in the medical world nowadays, the bottom line is simply put, early detection is the key. Well, folks, we trust you're now more familiar with pancreatic cancer screenings. Dr. Constantine Melitas, thanks so much again.

Dr. Constantine Melitas: Thank you guys. Thank you for having me.

Host: Absolutely. And for more information about Dr. Melitas, please visit dignityhealth.org/phc, and then click on services and then on Gastroenterology Advanced Endoscopy. In fact, there's a video posted there in which Dr. Melitas talks more about what he and his colleagues do. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks again for listening to Hello Healthy, a Dignity Health Podcast.