Pancreatic Cancer will afflict over 55,000 people a year in the US. Often referred to as a silent disease because most people do not experience symptoms until its later stages, pancreatic cancer is annually the second most mortal cancer. The 5-year survival rate is just 8% for all patients with the diagnosis, but improves to around 25% if surgery can be performed.
Penn Surgery has one of the strongest, most expert, pancreatic surgical specialty units in the country. Penn Medicine’s group of five surgeons, directed by Dr. Vollmer, performs nearly 200 major operations – including Whipple resections - a year. They provide state-of-the-art surgical expertise which integrates with the other strengths of Penn Medicine including Medical and Radiation Oncology, and associations with basic and translational scientists in the medical school. They also offer the region’s only dedicated multidisciplinary program for pre-malignant pancreatic cysts.
Charles M. Vollmer, MD discusses The Pancreatic Cancer Surgery Center and The Whipple Procedure Program at Penn Medicine.
Penn Medicine: The Future of Pancreatic Cancer Surgery
Featuring:
He is active in multiple international, national and regional surgical societies where he has served in various leadership positions. After serving in the capacities of Membership Chairman, Program Chairman, and Treasurer, he currently serves as President-Elect of the Americas Hepato-Pancreato-Biliary Association (AHPBA) – the leading society of HPB surgeons in the world.
Dr. Vollmer received his medical degree in 1994 from Jefferson Medical College in his hometown of Philadelphia. From there he received general surgical training at the Barnes-Jewish Hospital program at the Washington University of St. Louis. Dr. Vollmer became the Director of Pancreatic Surgery at the University of Pennsylvania in 2011 after initiating his career at the Beth Israel Deaconess Medical Center in Boston where he served as an Assistant Professor of Surgery at Harvard Medical School.
Charles Vollmer, MD
Charles Vollmer, MD specializes in Pancreaticobiliary and other complex gastrointestinal surgery with a research focus in clinical outcomes assessment in high-acuity surgery. His practice at Penn Medicine encompasses both malignant and benign conditions of the pancreas and biliary system with a strong emphasis in care of pancreatic cancer and pancreatitis. As Co-Director of the Penn Pancreatic Cyst Program – a coordinated multidisciplinary center for managing patients who have pancreatic cysts - he provides comprehensive care for patients with pancreatic cystic lesions (including IPMN), and also provides education and screening for patients who are at high risk for developing pancreatic cancer.He is active in multiple international, national and regional surgical societies where he has served in various leadership positions. After serving in the capacities of Membership Chairman, Program Chairman, and Treasurer, he currently serves as President-Elect of the Americas Hepato-Pancreato-Biliary Association (AHPBA) – the leading society of HPB surgeons in the world.
Dr. Vollmer received his medical degree in 1994 from Jefferson Medical College in his hometown of Philadelphia. From there he received general surgical training at the Barnes-Jewish Hospital program at the Washington University of St. Louis. Dr. Vollmer became the Director of Pancreatic Surgery at the University of Pennsylvania in 2011 after initiating his career at the Beth Israel Deaconess Medical Center in Boston where he served as an Assistant Professor of Surgery at Harvard Medical School.
Transcription:
Melanie Cole (Host): Pancreatic cancer will afflict over 55,000 people a year in the US, often referred to as the silent disease, because most people do not experience symptoms until it’s later stages.
Dr. Charles Vollmer is a professor of surgery at the Perelman School of Medicine at the University of Pennsylvania. He is a nationally and internationally respected researcher and thought leader in the field and the immediate past president of the AHPBA, the world’s preeminent society of surgeons performing pancreatic surgery. His research focuses on improving pancreatic surgical outcomes especially in the most impactful problem, pancreatic leaks. Today, we are talking about the Pancreatic Cancer Surgery Center and the Whipple Procedure Program at Penn Medicine.
Welcome. Dr. Vollmer I’m so glad to have you on with us today. Why is pancreatic cancer commonly caught so late and why is it so hard to treat?
Charles Vollmer, MD (Guest): Well basically, the problem is that it’s caught in the Netherlands of the abdomen. And what I mean by that is it’s not obvious externally through palpation or visualization as other cancers of the body often are like melanomas or breast cancers and the like. And the second thing is that the only real sign that comes about for most people that is obvious is the onset of jaundice and that’s when the tumor is situated near the common bile duct and gets to the point of blocking that. However, it can take a long time for a tumor from it’s genesis to get to that point.
So, it’s oftentimes that the tumors are found quite late because they are silent basically.
Host: So, Dr. Vollmer, tell us about the Whipple procedure and Penn’s expertise. How does someone go about choosing a surgeon or a program that performs it and what would you like other providers to know about referring?
Dr. Vollmer: The Whipple procedure is, the largest elective surgery that there is in terms of the scope of the procedure. It’s what we call high acuity surgery.
Host: Who is this procedure indicated for and what are some of the clinical contraindications for performing the procedure?
Dr. Vollmer: So, in general, the Whipple procedure means removing the head of the pancreas, the duodenum and the gallbladder. And its what’s used on the front end of the pancreas when the pathology is situated there. Pancreatic resections also happen on the other side of the gland, that’s called a distal pancreatectomy and you can even take the whole pancreas out in certain circumstances.
About 50-60% of our reasons for pancreatectomy are for malignancy of some sort dominated by adenocarcinoma of the pancreas. So, we have a lot of different reasons why someone would come in with a need for a pancreatectomy. The big picture story is at this point in time there aren’t a lot of daunting contraindications to us in terms of physiology. We are able to perform this operation on people who are very, very sick in terms of comorbidity and there are very few things from a cardiac or pulmonary standpoint that would stop us from proceeding. Age is quite commonly thought of as a problem let’s say for going to operation. It really has nothing to do with the patient’s numerical age but more about their physiologic age and their state of wellness basically and fitness. So, age by itself is not a contraindication.
One of the biggest things that is a real contraindication for us is metastatic disease. It realistically is something that should not be considered in this day and time as a reason to go forth with the operation. On the other hand, we have resectable disease which is clearly evident that the tumor can come out physically through the operative setting but what’s been fascinating for us in this current era is the locally advanced or borderline pancreatic tumors. And we are actually in a field where that term borderline means we are not sure if it can come out or not completely with a clean margin.
About 30% of the patients who present with this disease have that scenario and it’s become a very, very challenging field for us because we are working with our peers in medical and radiation oncology to try and downstage tumors to make them resectable. And one of the concepts for that is neoadjuvant therapy. The idea is to downsize tumors to get them to the point where we can technically attack them at this point.
Host: Well you certainly did segue into my next question on neoadjuvant therapies and also, I’d like you Dr. Vollmer to speak about follow up.
Dr. Vollmer: Yes, so I’ll talk about neoadjuvant at first and then follow up with follow up. So, the word adjuvant means additive therapy. That’s the base of it. And generally, historically, for most cancers, chemotherapy would come after a curative resection of the tumor. There have been other tumors of the body where the paradigm has been shifted and the chemotherapy and radiation approach would be given preoperatively in a manner to either get tumors to be more amenable for surgery or even improve their survivability thereafter and the outcome oncologically.
We in the pancreas have sort of lagged behind with this but there have been certain centers in the country that for about 25 years now have tried to push this concept of giving the therapy ahead of time.
What it does is it provides us an ability to actually see the biology of the cancer in real time. So, we can treat it in a way, in a form, but we can also find out how aggressive it is in terms of its behavior. If it’s going to go on and become very aggressive and spread to metastatic disease; we’d like to know that such that it doesn’t – so that we don’t do an unnecessary operation that has little value.
So, it’s been used more and more frequently, We use the neoadjuvant approach to figure out if those patients are going to be able to get the surgery and who among them will do the best. It is still in its basic infancy in terms of results and knowledge base about it. But virtually every major center dealing with pancreatic cancer is converting to doing more and more neoadjuvant therapy because it has worked in other places.
Now the other question I believe was about follow up and I think you are talking about thereafter.
In terms of follow up thereafter, we basically need to get the patient through the initial storm of the operation. And this operation takes a wallop on a patient and I tell people it takes about three months to get over the operation to be to the fitness and the feeling of perfectness that you were before the operation. I used to tell people that was six months back when I was training and when we had patients in the hospital for about three weeks at a time. Now we have patients in the hospital for about a week and the recovery is about 70 to 80% there when they leave the hospital. And then it’s going to take about another three month period to get to the point of full wellness with that.
And then at that point on, usually about a month after the operation or so is when we get involved with the medical oncology doctors for cancers and sort of pass the baton of the cancer care to them to take on the next phases of the multidisciplinary care. I personally see a patient at one month after the operation, four months after the operation and then a year and basically checking up on the anatomical and surgical implications of the operation but in that whole period of time; there’s a transition to the oncology expertise that goes on thereafter.
Host: Dr. Vollmer what is current research indicate for future developments in treatment? Give us a little blueprint for future research.
Dr. Vollmer: Okay, so the research elements are – I will tell you. The real future of this is going to be in the genetics of the disease and what I mean genetics, is not inherited genetics as much as the gene elements that make cancer start and flourish. So, that’s really the future and what we need more than anything else to win with this disease better than we do now is a good strong chemotherapy that’s effective. Right now we have things that work, but it’s really on a sort of haphazard hit or miss basis whether a patient is going to – whether their tumor is going to respond very well to those therapies.
So, we really need to be bringing in the work of our basic scientists to then be testing new drugs for this. Immunotherapy is a situation. We have a lot of that going on here at Penn in terms of the scientific intrigue for it. It’s got a lot of promise. It’s not quite there for prime time in terms of patient care at this point in time.
I think the last thing to size up for you in terms of referral and who should be seeing the patients. I would always say that I think the surgeon in general is sort of the fulcrum point of the decision making on pancreatic cancer. And we would love to see patients earlier in the process. In general, many of our patients come to us between four to six weeks after an initial onset of symptoms and diagnostic maneuvers come about and we often see them about three to four doctors into the line of fire. What we’d like to say is that the real thing about winning with pancreatic cancer is you need a surgery to remove the tumor to be able to survive. And so that very, very important node in the thought process is that you’ve got to be able to determine if someone is surgically resectable or not.
The four surgeons who do pancreatic surgery here have done over 1500 resections in our careers and we’re doing about 200 resections on a yearly basis between the four of us.
So, we would very much relish to see these patients and we are very available to see them early and fast. It takes just a few days to be seen by us rather than weeks. So, we’re very keen to help patients with this and see your patients to help us get the efficiencies of their care going faster.
Host: Thank you Dr. Vollmer so much for sharing your expertise and coming on with us today and explaining this very complex procedure and what is available for patients and when it’s important to refer. You’ve given us some really great information also about the future for pancreatic cancer and the like. So, thank you again for that.
That wraps up this episode with the experts at Penn Medicine. To refer a patient please visit www.pennmedicine.org/refer or you can call 877-937-PENN. If you found this podcast informative, please share with other providers, share on your social media and be sure to check out all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.
Melanie Cole (Host): Pancreatic cancer will afflict over 55,000 people a year in the US, often referred to as the silent disease, because most people do not experience symptoms until it’s later stages.
Dr. Charles Vollmer is a professor of surgery at the Perelman School of Medicine at the University of Pennsylvania. He is a nationally and internationally respected researcher and thought leader in the field and the immediate past president of the AHPBA, the world’s preeminent society of surgeons performing pancreatic surgery. His research focuses on improving pancreatic surgical outcomes especially in the most impactful problem, pancreatic leaks. Today, we are talking about the Pancreatic Cancer Surgery Center and the Whipple Procedure Program at Penn Medicine.
Welcome. Dr. Vollmer I’m so glad to have you on with us today. Why is pancreatic cancer commonly caught so late and why is it so hard to treat?
Charles Vollmer, MD (Guest): Well basically, the problem is that it’s caught in the Netherlands of the abdomen. And what I mean by that is it’s not obvious externally through palpation or visualization as other cancers of the body often are like melanomas or breast cancers and the like. And the second thing is that the only real sign that comes about for most people that is obvious is the onset of jaundice and that’s when the tumor is situated near the common bile duct and gets to the point of blocking that. However, it can take a long time for a tumor from it’s genesis to get to that point.
So, it’s oftentimes that the tumors are found quite late because they are silent basically.
Host: So, Dr. Vollmer, tell us about the Whipple procedure and Penn’s expertise. How does someone go about choosing a surgeon or a program that performs it and what would you like other providers to know about referring?
Dr. Vollmer: The Whipple procedure is, the largest elective surgery that there is in terms of the scope of the procedure. It’s what we call high acuity surgery.
Host: Who is this procedure indicated for and what are some of the clinical contraindications for performing the procedure?
Dr. Vollmer: So, in general, the Whipple procedure means removing the head of the pancreas, the duodenum and the gallbladder. And its what’s used on the front end of the pancreas when the pathology is situated there. Pancreatic resections also happen on the other side of the gland, that’s called a distal pancreatectomy and you can even take the whole pancreas out in certain circumstances.
About 50-60% of our reasons for pancreatectomy are for malignancy of some sort dominated by adenocarcinoma of the pancreas. So, we have a lot of different reasons why someone would come in with a need for a pancreatectomy. The big picture story is at this point in time there aren’t a lot of daunting contraindications to us in terms of physiology. We are able to perform this operation on people who are very, very sick in terms of comorbidity and there are very few things from a cardiac or pulmonary standpoint that would stop us from proceeding. Age is quite commonly thought of as a problem let’s say for going to operation. It really has nothing to do with the patient’s numerical age but more about their physiologic age and their state of wellness basically and fitness. So, age by itself is not a contraindication.
One of the biggest things that is a real contraindication for us is metastatic disease. It realistically is something that should not be considered in this day and time as a reason to go forth with the operation. On the other hand, we have resectable disease which is clearly evident that the tumor can come out physically through the operative setting but what’s been fascinating for us in this current era is the locally advanced or borderline pancreatic tumors. And we are actually in a field where that term borderline means we are not sure if it can come out or not completely with a clean margin.
About 30% of the patients who present with this disease have that scenario and it’s become a very, very challenging field for us because we are working with our peers in medical and radiation oncology to try and downstage tumors to make them resectable. And one of the concepts for that is neoadjuvant therapy. The idea is to downsize tumors to get them to the point where we can technically attack them at this point.
Host: Well you certainly did segue into my next question on neoadjuvant therapies and also, I’d like you Dr. Vollmer to speak about follow up.
Dr. Vollmer: Yes, so I’ll talk about neoadjuvant at first and then follow up with follow up. So, the word adjuvant means additive therapy. That’s the base of it. And generally, historically, for most cancers, chemotherapy would come after a curative resection of the tumor. There have been other tumors of the body where the paradigm has been shifted and the chemotherapy and radiation approach would be given preoperatively in a manner to either get tumors to be more amenable for surgery or even improve their survivability thereafter and the outcome oncologically.
We in the pancreas have sort of lagged behind with this but there have been certain centers in the country that for about 25 years now have tried to push this concept of giving the therapy ahead of time.
What it does is it provides us an ability to actually see the biology of the cancer in real time. So, we can treat it in a way, in a form, but we can also find out how aggressive it is in terms of its behavior. If it’s going to go on and become very aggressive and spread to metastatic disease; we’d like to know that such that it doesn’t – so that we don’t do an unnecessary operation that has little value.
So, it’s been used more and more frequently, We use the neoadjuvant approach to figure out if those patients are going to be able to get the surgery and who among them will do the best. It is still in its basic infancy in terms of results and knowledge base about it. But virtually every major center dealing with pancreatic cancer is converting to doing more and more neoadjuvant therapy because it has worked in other places.
Now the other question I believe was about follow up and I think you are talking about thereafter.
In terms of follow up thereafter, we basically need to get the patient through the initial storm of the operation. And this operation takes a wallop on a patient and I tell people it takes about three months to get over the operation to be to the fitness and the feeling of perfectness that you were before the operation. I used to tell people that was six months back when I was training and when we had patients in the hospital for about three weeks at a time. Now we have patients in the hospital for about a week and the recovery is about 70 to 80% there when they leave the hospital. And then it’s going to take about another three month period to get to the point of full wellness with that.
And then at that point on, usually about a month after the operation or so is when we get involved with the medical oncology doctors for cancers and sort of pass the baton of the cancer care to them to take on the next phases of the multidisciplinary care. I personally see a patient at one month after the operation, four months after the operation and then a year and basically checking up on the anatomical and surgical implications of the operation but in that whole period of time; there’s a transition to the oncology expertise that goes on thereafter.
Host: Dr. Vollmer what is current research indicate for future developments in treatment? Give us a little blueprint for future research.
Dr. Vollmer: Okay, so the research elements are – I will tell you. The real future of this is going to be in the genetics of the disease and what I mean genetics, is not inherited genetics as much as the gene elements that make cancer start and flourish. So, that’s really the future and what we need more than anything else to win with this disease better than we do now is a good strong chemotherapy that’s effective. Right now we have things that work, but it’s really on a sort of haphazard hit or miss basis whether a patient is going to – whether their tumor is going to respond very well to those therapies.
So, we really need to be bringing in the work of our basic scientists to then be testing new drugs for this. Immunotherapy is a situation. We have a lot of that going on here at Penn in terms of the scientific intrigue for it. It’s got a lot of promise. It’s not quite there for prime time in terms of patient care at this point in time.
I think the last thing to size up for you in terms of referral and who should be seeing the patients. I would always say that I think the surgeon in general is sort of the fulcrum point of the decision making on pancreatic cancer. And we would love to see patients earlier in the process. In general, many of our patients come to us between four to six weeks after an initial onset of symptoms and diagnostic maneuvers come about and we often see them about three to four doctors into the line of fire. What we’d like to say is that the real thing about winning with pancreatic cancer is you need a surgery to remove the tumor to be able to survive. And so that very, very important node in the thought process is that you’ve got to be able to determine if someone is surgically resectable or not.
The four surgeons who do pancreatic surgery here have done over 1500 resections in our careers and we’re doing about 200 resections on a yearly basis between the four of us.
So, we would very much relish to see these patients and we are very available to see them early and fast. It takes just a few days to be seen by us rather than weeks. So, we’re very keen to help patients with this and see your patients to help us get the efficiencies of their care going faster.
Host: Thank you Dr. Vollmer so much for sharing your expertise and coming on with us today and explaining this very complex procedure and what is available for patients and when it’s important to refer. You’ve given us some really great information also about the future for pancreatic cancer and the like. So, thank you again for that.
That wraps up this episode with the experts at Penn Medicine. To refer a patient please visit www.pennmedicine.org/refer or you can call 877-937-PENN. If you found this podcast informative, please share with other providers, share on your social media and be sure to check out all the other fascinating podcasts in our library. Until next time, I’m Melanie Cole.