Scott Webb (Host): Pancreatic cancer is a deadly diagnosis for most, but there's reason for optimism in light of a potential blood test that would improve chances for earlier diagnosis. And surgeon Mark Healy is here today to tell us more about the pancreas, treatment advances for pancreatic cancer, and how the multidisciplinary team of cancer experts and surgeons at Salinas Valley Health can help.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb.

Doctor, it's so nice to have you here today. We're going to talk about pancreatic cancer, risk factors, symptoms, treatment, you know, the whole nine yards. So let's just start there for me and perhaps anyone else who's just not exactly sure, a little fuzzy on the pancreas. What is the role of the pancreas and where is it located?

Mark Healy, MD, MSc: Most people don't think much about their pancreas as long as things are working well, but the pancreas in general has two main functions in our everyday lives. First, and the one most people are familiar with, is that it produces insulin, which is a hormone that is secreted directly into our bloodstream. And it allows for a regulation of your blood glucose levels and ultimately helps your body to absorb glucose. Because of this, which is a hormonal function being directly secreted into the blood, as well as a few other hormones that the pancreas creates, the pancreas is considered an endocrine organ.

However, there is also a second, separate function of the pancreas, which is to secrete enzymes directly into our intestines that help us to digest the food that we eat. These enzymes, they'll break down carbohydrates and proteins in our food so that our body can use these. And that function, by definition, makes the pancreas an exocrine organ as well.

So it's both an endocrine and exocrine organ. The location of the pancreas, it's very deep in the upper part of your belly or abdomen. It sits right in front of your spine in the upper abdomen, deep behind the stomach and next to the spleen. With regard to how it looks, if you ever see a picture of a pancreas or a drawing, we often say the pancreas looks like a fish.

It has a head and a tail, which we sometimes divide further the tail and call the more middle portion the body and the distal portion the tail. But that's what it looks like and it sits really far kind of in the back of your upper abdomen.

Host: Yeah, you're so right. The pancreas is one of those things that has important functions, dual functions, as you say, but it's not something we think about until we have to think about it, and certainly, pancreatic cancer would be a time when folks get to know and learn a lot about their pancreas, of course.

So, how does pancreatic cancer begin?

Mark Healy, MD, MSc: Yeah, that's a great question, Scott, and it's the subject of a lot of study even now. I do have some answers that we can talk about at this point, but just for the sake of simplicity, to be clear, when I say pancreatic cancer from this point on, I'm referring to the much more common type which is about 95 percent of all pancreatic cancers, which is an exocrine pancreatic cancer or cancer of the cells that secrete the digestive enzymes into the intestinal tract. You can get cancers of the neuroendocrine cells of the pancreas as well, and that can be deadly. And it's actually much more rare. So, we'll have to have that discussion on a different episode, but moving forward, when I say pancreas cancer, I am talking about exocrine cancers of the pancreas, which unfortunately, pancreatic cancer is one of the most deadly cancers in the world.

In fact, the third leading cause of cancer deaths in the U.S. even though it's not even in the top 10 in terms of new diagnoses per year. And the reason for this level of severity and death is metastasis. This means, when I say metastasis, that the cancer starts in your pancreas, but then it becomes deadly when it spreads to other organs or other parts of the body.

So, half of all pancreas cancer patients currently, that present, come in at what we would consider stage 4, which is where the cancer is already in other organs of the body. And then that remaining half that comes in, only about 1 in 5 will actually have a cancer that can be surgically removed at the time of presentation.

Those remaining 4 or 5 patients there, and they're kind of in a gray zone between where they don't clearly have spread of the cancer to other parts of the body, but the tumor needs to shrink down before we can remove it. Now, going back to the question about the start of pancreatic cancer. So for a long time, we didn't know whether this high rate of distance spread at presentation was due to late diagnosis or was it just that these are really bad cancers that spread very rapidly as soon as they start.

 And we actually got a very important piece of information from a study that came out in Nature, actually back in 2010 that shed some light on this issue. In that study, the investigators found that there's at least a decade between the initiating mutation that causes pancreatic cancer and the cancer itself forming.

Then after that decade, there's at least five more years for the tumor to develop metastatic ability, meaning can go to the other organs, as we discussed, and patients on average died about two years after that. So you're talking about, potentially about a 17 year time period between the beginning of this and when patients are dying from it, but we're really just catching it kind of at the end of that tail right now.

But knowing that and knowing how much time there is, gives me a lot of hope as far as early detection as a possibility in the future at a much more treatable stage. Unfortunately, we're still working on getting to that point with new tests, however.

Host: Right. Yeah, which we'll talk about today. Just wondering what are some of the risk factors, especially something like secondhand smoke, like a spouse smoking, and how all of that would contribute to someone developing pancreatic cancer.

Mark Healy, MD, MSc: The vast majority of patients that come into my office with a new diagnosis of pancreatic cancer, they have no known cause. The best I can tell them at this point is it's bad luck. I mean, that's really what I do say to patients. There are some rare genetic syndromes that lead to increased risk of pancreatic cancer in certain families, but these are the minority of cases.

That being said, there are some clear risk factors where we can't necessarily say that this is the cause of an individual patient's cancer, but we know on a large scale that there is a relationship. And one, as you already pointed out and might expect, is smoking. If you are a smoker yourself, the relative risk for developing pancreatic cancer is 50 percent higher in smokers than non smokers. And that risk we see in data also increases with the amount of cigarettes consumed and it's highest in heavy smokers. So if you are a smoker, this is yet another reason to quit smoking.

Host: So many, so many good reasons to not be a smoker, right Doc?

Mark Healy, MD, MSc: Absolutely. Yeah. And, and even better news and to put an optimistic side to it, if you are able to quit smoking, the excess risk in smokers decreases with quitting smoking. So one study showed almost a 50 percent drop in pancreatic cancer risk if you can quit smoking for two years. And by the time you've quit for 10 to 15 years, you're pretty much back at the level of non smokers. Now, with regard to the secondhand smoke question, there is some evidence that secondhand smoke, or what is often referred to in the literature as passive smoking, is associated with pancreatic cancer.

The best data that we have is actually for those who are around it as young children or even neonates where a pregnant woman is around secondhand smoke and the risk in those patients down the road is actually higher for developing pancreatic cancer. As far as other risk factors, we do know diabetics are a little more than twice as likely to develop pancreatic cancer.

But as far as whether that's a chicken or egg kind of situation with the pancreas having some dysfunction because of cancer developing versus actually a risk factor is a little less clear. So we'll have to get back to you on that when there's more research available. And then another risk factor that's definitively been shown is obesity and physical inactivity.

So some studies have suggested that a BMI of 30 or greater is associated with a significantly increased risk of pancreatic cancer, especially when those same patients are physically inactive. So two things that you can do to lower your risk are to work to get down to a healthy body weight and at least participate in moderate physical activity and exercise.

Host: Yeah, and I was thinking about symptoms, right, listening to you there, and I'm wondering, I'm connecting dots that maybe I shouldn't connect, but that's why you're here, you're the expert. So you say there's this long, for lack of a better term, sort of gestation period from when pancreatic cancer could begin to develop, but to the point in which a patient's actually in the office with you. So it makes me wonder, are the symptoms just not that obvious?

Mark Healy, MD, MSc: Well, that's exactly right, Scott. So, you know, the most common symptoms when someone comes in and they end up being having pancreatic cancer are not very specific. They include things like generally feeling weak or fatigued more than usual, some unintentional weight loss, loss of appetite, pain in the upper abdomen or back, nausea and vomiting.

A couple more specific things that we do see include dark urine, and jaundice or yellowing of the skin and eyes. And more rarely, some people are able to feel a mass in their abdomen, and even more rarely, sometimes they'll notice a new protrusion of the abdomen with fluid, which we call ascites. But many of these symptoms are quite vague.

So, you know, if someone comes into the primary care doctor office or the emergency room or really any healthcare setting, with these symptoms of abdominal pain, back pain, nausea, and vomiting, more often than not, the cause is not going to be pancreatic cancer. It's going to be something else that causes these symptoms just by the odds.

And so, to identify this is a challenge. Jaundice is usually the telltale sign when someone develops jaundice, even without pain. Then they will be diagnosed more quickly after it develops, but many of these cancers don't present with jaundice, especially those of the body and tail of the pancreas, which are further away from the other organs that can lead to symptoms, and that's partially the reason for the delayed diagnosis as well.

Host: Yeah, you say delayed diagnosis there, and we know that early diagnosis is key. As you say, someone could have as many as 17 years in there where it could be diagnosed and could save their lives, of course. But what makes it so difficult to diagnose early? Is it just really that the symptoms are sort of non specific? Maybe people ignore the symptoms? They have no family history or genetics involved? Maybe you could take us through that. Why is it so hard to diagnose early?

Mark Healy, MD, MSc: Yeah, and I think one of the biggest issues, and just to be clear, that 17 year period, the beginning of that is actually just the mutations leading up to the cancer, so that decade, you're not going to have symptoms during that time. And in fact, we would actually be removing a pre cancer at that time.

But I think, catching a pancreatic cancer early is, is really kind of the holy grail in our line of work. And, you want to be able to treat it before it spreads, but as we discussed already, you know, more than half of patients are presenting after this. And, there's not a test like in someone who turns 45 and is able to go in and get a colonoscopy and screen for colon cancer or a mammography.

We don't have that right now for pancreatic cancer, but there's a tremendous amount of work being put into understanding ways to do that. The most promising thing that is in the works right now is blood tests that look for cancer DNA circulating in the blood. Unfortunately for now, none of these techniques are really ready for prime time. We haven't gotten it to an exact science yet, but I can guarantee once the science is improved, that will be an incredibly useful way to do this. But, that's kind of in the future.

Host: Yeah, I was just thinking there, you know, those of us who have our yearly physical exams and get blood panels done, it'd be so great if there was just a test, right, that would just tell our primaries, there's something floating around in there and it might be pancreatic cancer, right?

Mark Healy, MD, MSc: Exactly, exactly. And, you know, for now, I think the patients that I'm able to help the most often present with an incidental finding of a cystic lesion in the pancreas, which often happens after a CT scan for some other reason, like they were in a car accident or they had kidney stones. And a mass in the pancreas is picked up in this way.

If that happens, we can study it to determine the chances of it ever turning into a cancer. That usually involves getting a special type of MRI called an MRCP. And depending on the results of this, we can send patients for further testing, including an upper endoscopy, which is basically like a colonoscopy, but it goes through your mouth rather than from below.

And with that test, we can actually do an ultrasound and biopsies of these incidental masses. Once we know if there's any cancer potential in these masses, then we can provide specific guidance on how to proceed. In some cases, the risk is so high that we recommend doing surgery just to remove the cyst. In other times, it can be a case of a monitoring situation where I'll have patients come back once a year or on a different schedule to get repeat scans or ultrasound. That's a tremendous opportunity when those patients come in because we can catch some cancers before they form. But we have to be careful not to put patients through surgery if there's no potential for a cancer.

And all of these scans that people get, are for other good reasons, but we wouldn't want to routinely scan everyone in the population with CTs and things like that that can give them radiation and lead to these unnecessary things. So we really are waiting for some sort of blood test or other easier screening option to become available.

Host: Yeah, I was just sort of thinking about diagnosis, right, a definitive diagnosis. And I'm thinking, all right, so could be, as you say, bad luck, family history, genetics, some folks may have symptoms like jaundice, things like that, that would really stand out. So you're getting the patient history.

You see that they have jaundice, you know, you starting to connect the dots there, how do you definitively diagnose pancreatic cancer? And then I think the 64,000 question, Doctor, is then what treatment options are available right now?

Mark Healy, MD, MSc: I tell patients when they come to see me, we have with all cancers, three main steps. Number one is to name it. Number two is to stage it, and then number three is to treat it. So, typically, patients will present with one or more of the symptoms that we talked about, abdominal pain, unexpected weight loss, jaundice, etc.

And this will prompt additional testing, usually a CT scan, and then once you see a mass in the pancreas on CT, then patients typically will undergo a biopsy of that mass. We say tissue is the issue when it comes to diagnosing cancers. So we really need to get these masses biopsied. And this is usually done with an endoscopic ultrasound, which is that procedure I mentioned, and a biopsy but occasionally you can do a biopsy under image guidance as well.

 But once the biopsy results show pancreatic cancer, then that's step one, that's naming it. So we know you have pancreatic cancer. We've seen this mass, we've biopsied it, looked at the tissue under a microscope, and it tells us that you have pancreatic cancer. Step two is to stage it. So this usually involves a CT scan of the chest, abdomen, and pelvis.

Mostly, we're looking for evidence of cancer outside of the pancreas, in other organs like the lung or the liver, which would make the cancer a stage 4. If lymph nodes around the pancreas have cancer, that's sort of a tricky middle area, so this is either stage 2b, if it's 1 to 3 lymph nodes that are involved, or it's stage 3 with four or more lymph nodes that we can see sometimes on a scan as well, but usually it's best to look with that endoscopic ultrasound test.

And then finally, the more definitive answer on the lymph nodes comes after surgery when we look at these lymph nodes under a microscope after we've removed them to see if there's any cancer inside. And then lastly, the best stages are stage 1 and stage 2a. which are based on the size of the main tumor.

So if the main tumor in the pancreas is less than or equal to four centimeters, and all the lymph nodes are negative, then that's stage 1, which is the best stage in terms of prognosis. So you, you do the staging. You've already done step one, which is naming it with a biopsy. Step two, staging it with these scans.

Then step three, as you were asking, is to treat it. So one thing I want to make clear is this is a bad cancer and everyone with pancreatic cancer does end up needing chemotherapy. Even though I'm a surgeon, chemotherapy is a critical part of treatment for pancreatic cancer. And it's really the only way to get long term survival currently.

With new chemotherapy, the survival has improved substantially with these treatments. And so the best, if you look at everyone that has had pancreatic cancer and the longest term survivors. The absolute best survival outcomes are in patients with non metastatic disease, who undergo both chemotherapy and surgery to remove the cancer.

And, with few exceptions, we actually typically prefer to do it in that order. By doing chemo first and then doing surgery, it tends to increase the likelihood of receiving complete treatment. If you had a complication from your surgery or there's some other issue to prevent you from getting chemo, it's not as much of an issue if you've already had it prior to the surgery.

I won't go too far into the weeds with this, but just know that the best treatment for most of these is to undergo chemotherapy, typically for a few months, and then surgery to remove the cancer. After that, depending on what we find in the surgical specimen and how much chemo you've received up front, you may be done with treatment after surgery, and then other times additional chemotherapy is needed.

Radiation is rarely needed, but it can be useful in select cases. But the bottom line is to be treated by a multidisciplinary group of physicians who work together in planning and sequencing the care, and that's the type of care that we provide at Salinas Valley Health.

Host: Of course. Yeah. Is it a thing, Doctor? Is it possible, you know, like there are things that I speak with experts and they offer suggestions, expert you know, advice on how to keep certain things healthy or healthier. Is it a thing to keep our pancreas healthy? Is that possible to live a healthy pancreatic life, if you get my meaning?

Mark Healy, MD, MSc: I think it is. I, I answer this question, I think the best things that we can do really relate to those risk factors that you had asked about before; avoiding smoking and being around people who smoke at home. If you do smoke, it's not too late to quit and get a reduction in risk.

And, I think from a dietary standpoint, there's no one thing, but if you eat a diverse diet of unprocessed foods with more vegetables and whole fruits and less highly processed or cured meats and saturated fats, that's very helpful. And as we've seen with research on obesity, avoiding obesity as much as possible by eating healthy and maintaining a habit of at least moderate regular exercise can reduce your risk as well.

And these are things, obviously, we hear about and in relation to a number of health problems, but with pancreatic cancer, there's no exception. These things can help.

Host: Right. Absolutely. It's been good stuff today. Educational, informational, and really just understanding that the importance of knowing your risk factors, identifying symptoms, early diagnosis, this much sought after blood test, which would really help all of us, providers, patients, everybody, just give you a chance here at the end, Doctor. Final thoughts, takeaways through the lens here of pancreatic cancer, what would be your best advice?

Mark Healy, MD, MSc: Yeah, I think in general, as we've discussed here, pancreatic cancer is a very deadly cancer, much more so than how often it is diagnosed, and it's something that we have evolved in treatment for quite a bit over even the past 10 to 20 years. Surgical techniques have improved the morbidity and mortality of surgery for this is much better now than it was but it's still a very,very deadly disease.

And so anytime you get a diagnosis of this, you want to make sure that you're seen by a multidisciplinary group of people, including surgeons, including medical oncologists and others who can help to kind of bring all the information together about your disease and make a informed recommendation to you.

Ultimately as the patient, you're the decision maker as to how to treat the cancer that you have. But I think you need the best information possible and that is a somewhat time sensitive thing. So trying to get in to see someone like myself or like one of our medical oncology colleagues and, and then hopefully down the road we will have better chances to treat this at an earlier point in the disease.

Host: Yeah. Well, they say, Doctor, that knowledge is power. And it certainly seems, especially when we talk about the pancreas and pancreatic cancer, that just knowing all this stuff, which hopefully now people do because they've listened to this great podcast. So I really appreciate that. Appreciate your time. Thank you so much.

Mark Healy, MD, MSc: Yeah. Thank you very much Scott. I appreciate you having me.

Host: And Dr. Mark Healy sees patients at Salinas Valley Health General Surgery. To schedule an appointment with Dr. Healy, please call 831-424-7389.

 And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.