Melanie Cole, MS (Host): There are so many advancements in pancreatic cancer care, including clinical trials and high risk clinics. We're here today to highlight the Pancreatic Cancer Center of Excellence on AHN MedTalks, an informative resource for physicians across various specialties, as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole, and joining me today is Dr. Dulabh Monga. She's an Associate Professor of Medicine at Drexel University School of Medicine, the Allegheny Health Network Cancer Institute. Dr. Monga, thank you so much for joining us today. What does it mean to be a center of excellence in pancreatic disease? It's not something that many or all hospitals and medical centers can claim. When we think of pancreatic disease, we right away think of cancer, of course. But what is the primary mission and overarching goal of a pancreatic center of excellence?

Dulabh Monga, MD: Thank you very much for having me on studio today, and I am excited to showcase the Allegheny Health Network Cancer Institute Pancreatic Cancer Center of Excellence. What this means is it provides comprehensive care to patients diagnosed with pancreatic cancer, or patients who have conditions that predispose them to pancreatic cancer.

This involves multidisciplinary care. And what that means is that we have multiple disciplines who provide the best recommendations to improve overall survival and improve overall outcomes,quality of care and it is the best treatment for the patient.

So multi disciplinary care really means that we have disciplines such as gastroenterology where usually the patient starts off when they're first diagnosed with a pancreatic disorder. And then after that, these patients are then referred to a surgeon, medical oncologist, eventually sometimes a radiation oncologist, geneticists, and then as part of our team, we also have nutritionists, social workers, and nurse navigators.

So all these disciplines play a vital role in providing the best recommendation for a patient's case, whether it may be a pancreatic cancer, a high risk pancreatic cyst, conditions such as IPMN, which is intraductal papillary mucinous neoplasms, or if it's a patient who is at high risk of developing pancreas cancer and still does not have pancreatic cancer.

Host: Well, thank you for that. And it's such a comprehensive approach, as you say. What advancements in early diagnosis and screening have been really prioritized at the center of excellence, because I think that diagnoses comes late for some people. And that's where we're really headed is to try and get earlier and the screening. Tell us about that.

Dulabh Monga, MD: Yes, that's an excellent question. So unfortunately, most cases of pancreatic cancer are diagnosed at an advanced stage. That is 50 percent of the patients. So our goal is to try to identify at our high risk pancreatic cancer clinic, those patients who may be at high risk of developing pancreatic cancer or precancerous conditions.

So at this multidisciplinary high risk clinic, we have several experts who the patient will meet and we do several things. One is we do a risk assessment, and that's based on family history. So if a patient has a history of a first degree relative who was diagnosed with pancreatic cancer at age 45 or less or two family members with pancreatic cancer; they're considered high risk.

If you have a first degree relative with pancreas cancer and two additional family members who have other cancers, you are considered a patient who should be screened. If you have a genetic mutation that you're aware of because you got tested because of a parent who was diagnosed with a genetic mutation, such as important ones are BRCA1, BRCA2, PALB2, and several others, then again, you are considered eligible for high risk testing.

 Some conditions are like hereditary pancreatitis can predispose you and if someone is diagnosed with diabetes at a late stage in life, that's kind of unusual. And they should also be considered for a risk assessment. So, what the physicians do is, you know, we can order a CT scan, MRI, endoscopic ultrasound, we can do genetic counseling, we can do genetic testing, which can be done with a blood test or with saliva testing.

And then once we have all these results, the patient comes back, and then depending on what we find, we follow them in surveillance and very closely. And the goal is really to pick up any small pre cancerous lesion and either resect it or, you know, we investigate it further.

Host: What's exciting as far as treatment modalities in your field, Dr. Monga? Targeted therapies, immunotherapy, personalized medicine are all coming in to help change the landscape of pancreatic diseases. Tell us what's really exciting as far as treatments.

Dulabh Monga, MD: As you all know, pancreatic cancer is a devastating illness and it is the third leading cause of cancer death in the United States and soon to be the second leading cause of cancer death. So there are several treatment options for patients, especially those who are diagnosed at an advanced stage. We have three different drug regimens.

Immunotherapy is being tested right now in combination with other novel therapies. And the hope is that one day, a combination of all these therapies will be brought for patients and will help improve overall survival. However, one exciting clinical trial that's coming to AHN is a combination of chemotherapy with gemcitabine and Abraxane in combination with a drug called quemliclustat. Now, this quemliclustat drug is a novel drug that is an inhibitor of something called CD73. So it is a CD73 inhibitor, and what it is is it's an enzymatic productive chemical that inhibits something called adenosine. So what tumor cells like to do is create an immunosuppressive environment around them, and that's how they survive.

So this CD73 inhibitor inhibits adenosine, which then allows our immune system to go and attack the cancer cells. This strategy, in combination with existing chemotherapy that we already have, which is standard of care, we're hopeful that it'll improve the overall survival for patients with pancreatic cancer.

And, I'm hoping in the next couple of weeks, this will be open at Allegheny Health Network. And we are able to provide this treatment to our patients. So this treatment is going to be compared with the standard of care.

Host: What an exciting time as these advancements are coming to light in your field, Dr. Monga. How does the center help to support the families? Because as you said, this is devastating. These are devastating diagnoses. So how do you work with the families, whether it's financially, emotionally, psychosocially, to deal with these kinds of diagnoses?

Dulabh Monga, MD: Absolutely. That's a great question. So we all realize that when a patient is diagnosed with pancreatic cancer, it is not only the patient who is embarking on this very difficult journey, but their loved ones, their family members who come with them to clinic are also very heavily impacted. So at the time of diagnosis, we have several disciplines interact with the patient.

But the first person to interact is not only the oncologist, but the nurse navigator. So our nurse navigators are vital to our program. They are there to provide the family all the resources they need when they're on this journey. So we have social worker contacts, we have transportation facilities, we have a transportation fund for people who don't have the means to be able to come to their appointments or for their chemotherapy appointments. We also have behavioral therapy. So the nurse navigator is fantastic because the nurse navigators accompany the patient to every appointment that they have. So as you can imagine, these patients have multiple appointments and physicians are in different parts of the building and it's overwhelming for them.

And so the nurse navigator facilitates all these appointments, helps with making scan appointments, helps with making follow up appointments. And even if the patients have other questions, they're there to guide them. And this extra layer of support is just vital for the patients and they really appreciate it.

We've received positive feedback and our nurse navigators are just very compassionate and really, really help these patients.

Host: What a wonderful addition to such a comprehensive program. I'm sure that helps the patients and their families to feel taken care of and supported as you said. So now tell us a little bit about the high risk pancreas clinic. How does it work to bring families in for screening and education about genetic diseases? As you mentioned, all of the genetic you know, heritable traits that come with pancreatic cancer. How does the high risk clinic work to bring those families in for screening?

Dulabh Monga, MD: Yes, that's an excellent question. So, if we have a patient who has a diagnosis of pancreatic cancer, then, you know, their family members could be at risk, especially if they have several family members. So, when we see our patients, we get a comprehensive family history, and we then advise those patients to bring their family members in.

The other way to get patients in is from the gastroenterology clinics. If the GI doctor sees a patient with a pancreas cyst or a patient who's had recurrent episodes of pancreatitis, then they are identified that way. Or for example, if a patient has a family member who was diagnosed with breast cancer and has a BRCA1 or BRCA2 gene mutation, then those patients are also at risk for developing pancreatic cancer, and then their family members, again, are counseled on obtaining an appointment with our high risk pancreas cancer clinic.

Host: I'd like you to expand, Dr. Monga. You mentioned the multidisciplinary approach at the beginning of our show today. So I'd like you to expand a little bit because it is such a big team and it is so comprehensive and so important, as you mentioned, whether it's GI, radiation, oncology, nurse navigator. Tell us a little bit about your team and how important that approach is.

Dulabh Monga, MD: Studies have been performed to look at whether a multidisciplinary clinic does improve overall outcomes. And actually, those studies have been published and have definitely shown that if a patient is presented at a multidisciplinary tumor board, their outcomes are much better than those who are not presented at the tumor board.

So we strive to encourage all our community oncology partners to present difficult cases at our tumor board so that we can come up with a great plan. We meet every week at 7am on a Wednesday morning to discuss these pancreatic cancer patients.

And all disciplines are present during this tumor board. The cases are presented. The radiologist will show us the CT scans, MRIs. The GI doctor will discuss the endoscopic ultrasound results. The pathologist will discuss what they saw under the microscope and come up with a diagnosis, whether it is a pancreatic adenocarcinoma, whether it's a pancreatic neuroendocrine tumor. It could be just a simple pancreas cyst that the patient is undergoing surveillance. It could be anything high risk pancreas. And so after we review all these studies, then the medical oncologists, surgeons, radiation oncologists, all come up with a treatment plan that is then conveyed to the patient.

The patient is then scheduled to see all the specialists in the clinic. We strive to see the patient on the same day as the surgeon and as the radiation oncologist so that the patient does not have to visit the clinic multiple times. And the nurse navigator truly helps with that aspect, you know scheduling the appointments. On the day of the visit, the patient also gets to see the dietician so that at the time of starting treatment, we are addressing their nutritional needs, trying to keep their weight up, appetite up, so they are also part of our team.

Host: Thank you for that. As we wrap up, where do you see the future of pancreatic care evolving? Tell us a little bit about a blueprint. You mentioned a few clinical trials and some exciting therapies that are on the way. Where do you see this going? What would you like to see happen in the world of pancreatic cancer?

Dulabh Monga, MD: Yes, that's a great question. One day we hope that we are able to cure these patients. We hope that they have a prolonged survival. We hope to improve the quality of life of these patients who are going through this long journey of cancer treatment. .

We hope to bring innovative, more innovative clinical trials to our clinics and provide access to care at our community sites as well, which we are doing right now, but even improve that further. So I think that overall, we're doing a fantastic job at our Cancer Institute, but as we learn more about this disease and the molecular underpinnings of this cancer and novel treatments are being developed; I think that we will be able to provide even more access to clinical trials as the years go by.

Host: Thank you so much, Dr. Monga, for joining us today and sharing your incredible expertise. To learn more or to refer a patient, you can call 844-MD REFER or you can visit ahn.org. Thank you so much for joining us on this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole. Thanks so much for joining us today.