Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting achievements and advancements in the Digestive Health Institute Pancreas Program. Joining me is Dr. Rajesh Keswani. He's an Associate Professor of Medicine in the Division of Gastroenterology and Hepatology at Northwestern Medicine.

Dr. Keswani, thank you so much for joining us today. Northwestern Medicine has really built a nationally recognized Digestive Health Institute. Can you start by telling us a little bit about how the Pancreas Program fits into that broader vision? What are the most significant clinical research achievements in the pancreas program? And when you look at the evolution of this program over the past several years, what defining moments or milestones stand out to you the most?

Dr. Rajesh Keswani: Thanks. Thanks for the question and the opportunity to talk a little bit more about what we're doing in the area of the pancreas at the Digestive Health Institute. What I think about the pancreas, I think it's very helpful to divide it up into two separate areas so that we can really understand what is being worked upon.

There is the area of pancreatitis or pancreas inflammation, which there is quite a bit of work being done as well as precancerous lesions of the pancreas and cancer itself. And so, as I think about what we're doing and the achievements, I like to think about first in terms of pancreatitis, what is happening in Northwestern Medicine that is both unique and truly helpful for our patients.

First of all, we've really worked hard to standardize the care of pancreatitis patients throughout our system. So, our goal in the Digestive Health Institute is if you show up at any of our hospitals in the system, you get standardized high quality, evidence-based care. And we've worked very hard to make sure that that point of care is equivalent throughout the system. Patients get care that is evidence-based. And it is easy for the clinician to implement.

Beyond that, we like to be involved in all the major international trials on how to both prevent pancreatitis and improve the outcomes of pancreatitis. So, examples of that would be a trial that we completed a couple years ago that was recently published on how to reduce the risk of pancreatitis after patients have an ERCP. This was called the stent versus indomethacin trial, and was an important trial that showed that in patients getting an ERCP, placing a pancreas stent in addition to administrative medicine called recto-indomethacin actually reduce the severity and development of pancreatitis.

We also recently completed a trial called the SHARP trial on how patients with pancreas divisum, whether or not they benefit from an ERCP or not. And that study was just published actually just this past week in JAMA. So, another international trial that we've participated in at Northwestern.

And then, finally, we're also participating in trials around the development of diabetes in patients with pancreatitis. That's called the DREAM trial. So, that's a lot of stuff around the area of pancreatitis itself. And then, we also are doing a quite a bit of work around pancreas neoplasia or precancerous pancreas cysts, as well as pancreas cancer.

Similar to what we discussed in pancreatitis, we have worked very hard to standardize the management of patients who have pancreas cysts throughout the system. That helps us identify these cysts at an early stage and identify what is the most appropriate surveillance protocol for them. We found a lot of variance. And to reduce that variance, we developed a consensus guideline from all of our clinicians. And we've implemented it at the point of care in our radiology testing. We've also standardized our high-risk pancreas cancer screening program, which is now at over 450 patients to make sure that people who are at high-risk for developing pancreas cancer have consistent guidance on what they should be doing to both prevent pancreas cancer development and make sure they're getting the appropriate screening for their condition, which is a combination generally of endoscopy and MRI.

And we're also increasing our research program around the outcomes and use of artificial intelligence in both pancreas cysts and patients at high-risk for pancreas cancer. So really, we're very proud of the fact that we aren't just focused on one area. We want to develop a more comprehensive approach to improving the care of pancreas disease.

Melanie Cole, MS: Well, you certainly have. And what an exciting time in your field, Dr. Keswani. So, how is the program addressing challenges such as early detection of pancreatic cancer or complex pancreatitis cases? The progress that the program has made, I know that that's one of the unmet challenges, is early detection and surveillance. So, speak a little bit about what the program does in that regard.

Dr. Rajesh Keswani: Yeah. That's the biggest challenge that our field of the pancreas has is the real fear that our patients have for developing pancreas cancer. As you may know, pancreas cancer is increasing in incidence. And that there are certain people who are at higher risk for developing pancreas cancer.

So for the average person walking down the street, the lifetime risk of pancreas cancer is 1.6%. But if you have a family history of pancreas cancer, or you have a genetic predisposition to pancreas cancer, that risk goes up. At a certain threshold, patients are at a high enough risk that they are able to get screened for pancreas cancer through a series of longitudinal tests, again, including endoscopy, MRI, and blood work. And we're very proud of the fact that we are able to develop this sort of comprehensive program that both focuses on counseling patients on what they can do personally to try to prevent pancreas cancer, but also ensuring that patients get the highest quality care and screening tests.

And despite this, we know that there are limitations. We know that this is a very challenging thing to just basically hope that patients won't develop pancreas cancer the best we can, and hope that our tests will identify at an early stage. And we know from other work that has been done in this space that, despite adherence to this testing, things can be missed. And that's why we're really excited about the idea of artificial intelligence, using computers to look at these scans and identify things at an earlier stage than even the human eye can see as a radiologist, because we know that there may be features or signs on scans that a human eye can't see, that artificial intelligence can see, which might identify patients at the earliest stage of disease when the chance of cure is the highest.

So, there's really a lot of work around this area, but it all starts with just developing a really collaborative program between radiology and our researchers as well as cancer genetics on how we can really serve these patients best.

Melanie Cole, MS: Well, that segues beautifully into my next question for you, Dr. Keswani. Many institutions talk about that multidisciplinary and interdisciplinary care, but Northwestern is well-known for using it. So, how does that collaboration actually work day to day in the pancreas program? Gastroenterology, hepatobilliary, surgery, medical oncology, you've got all of these different specialties working together and aligning around complex decision-making. So, speak a little bit about those collaborations and how they've been key to driving that innovation in pancreatic care.

Dr. Rajesh Keswani: I think it's really important to develop a team early on anytime you're trying to tackle a complex diseases. And that's what we do, right? We early on identify key stakeholders who have an interest in a space. And that may be an in-person or virtual media initially and multiple meetings.

But longitudinally, what tends to happen is you have a virtual working group of questions that develop and who to reach out to, right? So if cancer genetics has a question on a patient of, do they qualify for screening for pancreas cancer? Or if the radiologist identifies a lesion that they're worried about, we know who to speak to, right? We don't have to all meet every week to talk about these cases. We have a real-time discussion of, "Okay, I'm worried about this. And let's refer this patient onto this surgeon or get a second opinion from this radiologist, or have this gastroenterologist do an endoscopy."

And that's how think that Northwestern really excels. We have interested clinicians that, when you ask them for their help or their opinion, it's not if it's, how soon does it need to be done. You know, does it need to be done tomorrow, then we'll get the patient in tomorrow. "Do you need me to look at this right now? I'm happy to do so." And that's really where we excel as an institution. Everyone is on board to work as a team. But everyone understands that, when you're dealing with things like the pancreas, time is of the essence and they're happy to help at a moment's notice.

Melanie Cole, MS: Dr. Keswani, you mentioned AI a few times. I'd like you to expand on that because that is really exciting. It's fascinating actually. So, how is it being integrated into pancreatic cancer diagnosis and treatment at Northwestern Medicine? And how have you seen these kinds of exciting advancements improve patient outcomes, care, delivery, and the program in general?

Dr. Rajesh Keswani: AI is obviously the buzzword for everything. And in the pancreas, it's not just a buzzword. It is a true innovation in where we're headed in terms of managing patients with pancreas disease. And the best example in Northwestern medicine is we have a world-class team of researchers that we and the Digestive Health Institute collaborate with. These are researchers that truly are groundbreaking in terms of how they're using AI to risk stratify patients with precancerous lesions of the pancreas.

And what do I mean by that? We know that, for example, pancreas cysts, which are very common, probably 20-30% of the population, depending on the age, will have some sort of precancerous cyst in the pancreas. We know that based on the algorithms developed by team of researchers at Northwestern, artificial intelligence can better risk stratify which patients are more likely to have cancer within those cysts, compared to just the expert radiologist.

And our goal is to take those research advances and make sure that they're implemented at the point of care. So, the expectation should be for the pancreas. And beyond that, can we take this research and bring it into the clinical space? And that's the work that is happening right now. We already know that the research is there, and that AI can read an MRI in conjunction with the radiologist better than the radiologist can do it alone. How do we make that point of care for the patient? That's the real focus right now with the implementation. But this is what we're going to see in all areas of AI research, right? We know that AI is an additive bonus for our clinicians. How do we bring it into practice? And we are thankfully beyond nearly all institutions that are working on this because of the really impressive science that's been done here, and our patients will benefit from that.

Melanie Cole, MS: I agree. And, Dr. Keswani, one thing we haven't mentioned yet is beyond the procedures, the protocols, the exciting advancements, how does the pancreas program address quality of life, nutrition, pain management, psychosocial support, because pancreas disorders can be quite taxing on the family, as you said, and they're quite terrifying. What feedback from patients and families has most influenced how care is delivered within the program, and how is all of this working together for the patients?

Dr. Rajesh Keswani: As you mentioned, even from both sides, the pancreatitis as well as the pancreas cancer, pancreas cysts, there is both physical symptoms that are challenging to manage unless you work in a truly multidisciplinary environment. And there's the psychological toll of the diseases and risk for disease.

So, let's think about pancreatitis, which is a very complex situation with both physical symptoms of pain, but also the stress of will another attack of pancreatitis occur, and how do I best manage my diet to prevent this from happening again? And we are so lucky in the Digestive Health Institute to work with just truly gifted, registered dieticians, clinical psychologists, other surgeons who potentially might have a solution that would be curative for these patients, gastroenterologists who can perform advanced procedures. So, it is a truly multidisciplinary approach.

The key is always for us to think about when to bring in all these other experts, for which cases, at what time, and how do we make sure that everyone has access to this? And some of it is one-time visit, right? You might just need to see a dietician to get some information on how to manage the diet in your diagnosis of chronic pancreatitis. Sometimes it's multiple visits with our behavioral medicine team to really think about what strategies a patient can use to manage their symptoms when they're having a flare up of their pancreatitis. And there's no one-size-fits-all. And that's what, I think, is very helpful for us. It's every patient has a different set of needs. But thankfully, we have all the resources available to us so we're able to develop that list of things that a patient needs and get them the appointments they need to have to help keep their symptoms and their quality of life under control.

Melanie Cole, MS: That's so important. And Dr. Keswani, this is really great information. As we wrap up, if we're having this conversation five years from now, what achievements would you hope to be celebrating in the Northwestern Pancreas Program? And what should referring physicians and healthcare leaders understand about the value of this comprehensive pancreas program like Northwestern's is today?

Dr. Rajesh Keswani: What I'm most proud of is that we run the gamut from the most basic to the complex research. And what I mean by that is sometimes doing the easiest things is the hardest in a large healthcare system. As a patient, you want to make sure that you're getting the highest quality care, no matter what door you enter into. And we spend a lot of time trying to reduce variance in care at Northwestern Medicine, making sure that every patient has the highest quality care for their conditions of pancreas cysts, pancreatitis, and high-risk pancreas cancer screening. That's the basics, but those are hard to do and we're doing that today.

We also are very proud of the fact that we are involved in all the important international pancreas research, and we are in many ways leading some components of this research. And so, I would hope in five years we see an expansion of that, that everyone can tell that we are now truly leaders in the space of high-risk pancreas cancer screening, and how artificial intelligence plays a role in that, as well as continuing to be important members of multi-center international trials in pancreas disease. And unfortunately, there's so much work to be done in pancreas disease, but that is an opportunity for us to continue to be leaders in that space.

Melanie Cole, MS: It certainly is. And thank you so much, Dr. Keswani, for joining us today and sharing your incredible expertise. For other providers to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/gastroenterology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.