Scott Webb (Host): There have been many advances in the diagnosis and treatment of pancreatic cancer, and my guest is here today to tell us about the signs, symptoms, and reason for optimism when it comes to pancreatic cancer. I'm joined today for our 200th episode of the podcast by Dr. Joshua Kays. He's a Board Certified Surgeon in Surgical Oncology and Hepatobiliary Surgery with Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb.

Dr. Kays, it's nice to have you back. Last time we talked about liver cancer. Today we're talking about pancreatic cancer. So let's start there. The most obvious one, what is the pancreas? Like what are the primary functions of the pancreas?

Joshua Kays, MD: The pancreas is an organ that is critical for digestion of food and regulation of blood sugar. So it's kind of a interesting organ is that has two functions and we refer to it, in that way as having endocrine functions, creating hormones like insulin that everybody's very aware of and help control blood sugar, also creates some other hormones that are important for digestion.

But the other part is the exocrine function, which creates the digestive enzymes that break food down into something that we can actually absorb and then use those nutrients.

Host: Sure. Yeah. So it's one of those organs in our body that wears many hats, if you will. And you know, as I prefaced there, we're talking about pancreatic cancer. So how prevalent is pancreatic cancer?

Joshua Kays, MD: So there'll be about 60 to 70,000 cases of pancreatic cancer in the United States this year. That seems to be pretty steady, maybe slightly rising over the last few years, but it's been pretty steady in that 60 to 70,000 range.

Host: Which for me, when you think about the population of the United States, doesn't seem like a lot, unless of course, you're one of those people who's, you know, stricken by it and the family's affected by it. So let's talk about the risk factors associated with pancreatic cancer.

Joshua Kays, MD: As with every cancer, you know, smoking is the number one risk factor. Just causes a lot of damage to cells throughout our entire body. There are some other risk factors including, you know, alcohol abuse, genetics actually plays a fairly big role. There are several genetic mutations that predispose people, and then unfortunately, or fortunately, however you want to look at it, most cases aren't really associated with anything but just kind of those bad luck cases.

Host: Right. And there are some things, as you say, that are within our control, like lifestyle factors, diet, smoking. Family history, genetics, unfortunately we can't outrun that. So a multitude of risk factors. Is gender, age, any of those things also a factor?

Joshua Kays, MD: Yeah, as with most cancers, it's typically a disease of, you know, people as we get older. We typically don't see it very often under 60 years old. So 60 and above is a risk factor. And then we do tend to see it more often in males, but it's not a huge difference between males and females. Maybe just slightly more often in males than females.

Host: Okay, so let's then talk about the symptoms of pancreatic cancer. Like some of the things that folks can get, there are symptoms, sometimes there aren't. Sometimes the symptoms are confusing and we really need experts. But in general, are there any, let's say, common symptoms of pancreatic cancer and how might we distinguish them from other things?

Joshua Kays, MD: Yeah, so the classic big symptom is jaundice. You turn yellow, your urine gets dark, you know your skin and eyes turn yellow. That's the big, big red flag that everybody associates with pancreatic cancer. But more commonly, I probably see vague symptoms like just kind of vague abdominal discomfort.

Weight loss is another big one. Unintentional weight loss. And then other things that we see commonly are decreased appetite, changes in bowel habits, and even new onset diabetes can be a sign of pancreatic cancer.

Host: Okay. You know, I'm wondering, it seems like, uh, this is anecdotal at best of course, but seems like pancreatic cancer is often diagnosed in the later stages. Why is that?

Joshua Kays, MD: Yeah, you're exactly right. About 80% of patients that get diagnosed are going to have advanced stage pancreatic cancer. Part of the reason is going back to those vague symptoms. When you get back into, how common is that? It's about the eighth most common cancer in the United States. So, you know, we think of a lot of other things when someone comes in and sees us and they're like, I just haven't been eating as much.

You know, I have had this discomfort in my belly. There's a list of about 40 things that are much more common than pancreatic cancer. So those obviously are going to get worked up first. And part of that is the fact that the pancreas is an organ that sits way back almost by our spine, and it just doesn't have a lot of symptoms that we can look and say, oh, that's definitely pancreas. So it's often a confusing picture. And so we have to start looking for the things that are more common. So sometimes it gets caught, you know, after a workup's already been initiated.

Host: Yeah. So what about the diagnostic tests and procedures? Like how do you detect pancreatic cancer? You're saying, you know, so you know, some things, you walk in the office and a patient tells you, gives you a patient history, and you go, okay, I know exactly what this is. And other times could be this could be that, but how do you narrow down pancreatic cancer?

Joshua Kays, MD: Yes. So you know, you're always going to start with some basic labs. You're going to look at your bilirubin levels. You can look at some tumor markers, but those are very non-specific. Ultimately, you're going to end up getting some kind of scan, whether it's a CT scan or an MRI of the abdomen, that will typically show a mass in the pancreas, but even that's not enough to diagnose pancreatic cancer.

Ultimately, we have to get a biopsy of it, and that's usually done with something called an endoscopic ultrasound, which is a very cool tool where the endoscope that we use to look inside the stomach actually has a little ultrasound machine on it, and the pancreas sits right behind the stomach. So using that ultrasound, we can visualize the pancreas and get a biopsy basically through the back wall of the stomach of whatever mass is in the pancreas.

Then we look at those cells under the microscope and determine are they cancerous or not?

Host: Yeah, it, it's very cool. I love hearing about these advances. It's great for patients, providers, everybody. And again, this is more of an anecdotal thing, but at least in my mind, Doctor, having known some folks that had pancreatic cancer and didn't survive, it seemed to me at one time that pancreatic cancer was unsurvivable, if you will.

Right. And it feels like things have changed. I'm hoping they have. So tell us how you treat pancreatic cancer? Can it be treated with surgery? What does that process entail?

Joshua Kays, MD: Yeah, so you're right. Even when I started my medical training, it didn't have a good prognosis, but we have made leaps and bounds with our treatments. So it's going to be a combination of surgery and chemotherapy in everybody who has pancreatic cancer. Now, whether you get chemotherapy first, then surgery or surgery and chemotherapy, you know, that's kind of getting in a little bit of the weeds that might be take a little longer than this podcast.

But those are going to be the two cornerstones of treatment. Sometimes we will add radiation, but that's kind of more on an individual basis. So you can pretty well count on chemotherapy and surgery in some manner, with maybe some radiation, depending on some very specific individual characteristics.

Host: Can you give us at least a sense of the survival rate or the success rate? It sounds like there's room for optimism, but how much?

Joshua Kays, MD: Yeah, so actually it's gotten again much better over the course of my career. For example, with the modern chemotherapies, if you have what we call resectable pancreatic cancer, meaning you were able to proceed, have surgery, have it taken out, median survival, or the time that it takes 50% of the people to die is about 40 months. So you're looking at three and a half years. Now that's doesn't sound like much, but that is much improved over about the 12 to 15 months that we would quote people back when I started, you know, my career. Even metastatic disease, we're pushing 20 to 24 months.

So these are people who, you know, the cancer has spread, they're not candidates for surgery. With the modern treatments, we're still getting almost two years of survival. Whereas again, go back to when I started, we'd tell them three to six months. So you know, we're not there yet. We are making great progress, but we still have a lot more to make. But it's also not hopeless either. We are making that progress.

Host: Yeah, for sure. And of course, folks diagnosed with pancreatic cancer, every day is precious. So every day you're saying we could live a longer, another day is a good thing. Let's finish up today and just talk about new or emerging treatments. You're saying there's room for optimism. So tell us about some of the clinical trials for pancreatic cancer.

Joshua Kays, MD: Yeah, so it goes to what we are learning about all cancers is they're not always equal. We're finding out specific mutations in each person's tumor, which might respond to different treatments better. This is allowing us to make what we call targeted therapies, which will attack those specific changes.

I think immunotherapy, it's the cutting edge for all cancers. We've had great success with colorectal cancers, melanomas, lung cancer, kidney cancer have been much improved by using these immunotherapies. I think it's only a matter of time before we kind of crack the code as to how pancreatic cancer, you know, we can use these to treat pancreatic cancer more effectively.

And then there's also some local therapies, different types of radiation, some ablation models, that you know, hold promise. They haven't been proven yet, but they hold promise.

Host: Right. Yeah. Well, it always brings a, at least a little bit of a smile to my face to hear that there's room for optimism. Nobody wants pancreatic cancer, of course. Patients, families, providers, but the survival rate, the length of time folks will be here is a good thing and lots of good things on the horizon. So thank you so much.

Joshua Kays, MD: You're welcome.

Host: And to learn more, visit franciscanhealth.org and search pancreatic cancer.

 And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.