What PCPs Need to Know About Pancreatic Cancer

Tremendous effort is underway to improve the dismal 5-year relative survival rate for pancreatic cancer in the United States, which is currently around 12%. But for many these therapeutic advancements will be too late. Right now, the best hope for patients is earlier detection.

“There isn’t a screening protocol or reliable test for pancreatic cancer, so it’s essential that we get patients referred as soon as the first potential signs of disease arise,” says Mayank Roy, MD, Surgical Director of the Pancreas Center at Cleveland Clinic Weston Hospital. “Primary care providers have an incredibly important role in helping identify earlier stage disease when it is more likely to be resectable.”

Four red flags

According to the American Cancer Society, more than 66,000 people will be diagnosed with pancreatic cancer this year. “More physicians will see these individuals in their offices as the incidence of pancreatic cancer continues to rise,” says Dr. Roy.

Unfortunately, symptoms associated with pancreatic cancer can be vague and often do not develop until the disease has begun impacting other organs. These include nausea, bloating and abdominal or back pain as well as weight loss and jaundice, among others.

Dr. Roy, however, points to four key red flags that should raise suspicion of pancreatic cancer:

• Painless jaundice.
• New onset diabetes in older adults.
• Uncontrolled diabetes after years of control.
• Initial presentation of adult pancreatitis with no obvious cause.

“If pancreatic cancer is suspected or even just one of a number of differential diagnoses, the patient should be referred to a specialist as quickly as possible,” says Dr. Roy, who specializes in the treatment of benign and malignant conditions of the liver, pancreas, gallbladder, and bile duct.

Multidisciplinary collaboration

National Comprehensive Cancer Network (NCCN) guidelines recommend that diagnostic management for pancreatic cancer involve a multidisciplinary consultation conducted at a high-volume center. Likewise, the American Society of Clinical Oncology (ASCO) guidelines call for multidisciplinary collaboration for treatment formulation and disease management.

The Pancreas Center at Cleveland Clinic Weston Hospital, for example, has a team of gastroenterologists, surgeons, oncologists, radiologists, nutritionists, and geneticists highly experienced in the diagnosis and treatment of pancreatic cancer. It is one of only four centers in Florida recognized by the National Pancreatic Foundation as a Center of Excellence for the treatment of both pancreatic cancer and pancreatitis.

“We have specialists from South Florida to the Treasure Coast who participate in our multidisciplinary Tumor Board meetings held every two weeks to review cases and develop treatment plans,” explains Dr. Roy. “It’s a critical part of making sure our patients receive the right care for the best possible outcome.”

He also credits this collaborative approach with ensuring patients undergo the necessary tests to determine disease staging and resectability. These may include multidetector computed tomography and MRI, endoscopic ultrasound (EUS) biopsy or endoscopic retrograde cholangiopancreatography (ERCP), and genetic screening, among others.

Surgical innovation

Because most patients with pancreatic cancer are diagnosed with advanced disease, only about 20% of cases are considered resectable. Generally, tumors are categorized as resectable or non-resectable based on vascular involvements and the presence of metastatic disease. “Surgery is the only curative treatment for pancreatic cancer, but too few patients qualify for surgery,” says Dr. Roy.

Pancreatic ductal adenocarcinoma (PDAC) is the most common and deadliest form of pancreatic cancer, accounting for about 90% of malignancies. About two-thirds of these tumors arise in the head of the pancreas and are treated with the Whipple procedure (pancreaticoduodenectomy), which entails removal of the bile duct and gallbladder and part of the pancreas, small intestine and stomach. The rest occur in the body and tail of the pancreas, typically requiring a distal pancreatectomy with splenecotmy.

Dr. Roy says there is some good news for patients with resectable disease. “Surgery for pancreatic cancer is safer today than ever before, with postoperative mortality below 2% in high volume centers, supporting the shift of patients to these hospitals per industry guidelines,” he reports.

Weston Hospital is a high-volume center that receives referrals from across southeast Florida including all surgical cases within Cleveland Clinic’s regional health system in Florida. “More than two-thirds of our pancreatic resections are for patients with cancers,” says Dr. Roy.

He also points to the increased use of minimally invasive surgical approaches for having reduced the morbidity and mortality associated with these highly complex surgeries.

“Nationally, about 25% to 30% of distal pancreatectomies are performed with a minimally invasive approach,” says Dr. Roy. “Here in Weston, we perform most of our pancreas surgeries laparoscopically or robotically.”

Neoadjuvant treatment

Surgery and chemotherapy are the current standard of care for resectable pancreatic cancers. For some patients with locally advanced disease, however, systemic therapy also may be a bridge to surgery.

“More and more neoadjuvant therapies are being used to downstage cancer,” says Dr. Roy. One notable study demonstrated that about 60% of initially surgically untreatable disease was resectable following treatment with Folfirinox.

Other research is looking to determine if neoadjuvant therapy can improve overall survival in cases of resectable disease. Weston Hospital was an enrollment site for the phase III Alliance A021806 trial that was comparing perioperative chemotherapy, given before and after surgery, to adjuvant chemotherapy for the treatment of pancreatic cancer that can be removed by surgery.

“The timing and order of chemotherapy for pancreatic cancer remain an open question with no robust trial data or clear answer,” notes Dr. Roy. “Our hope is that future trials will help to provide better guidance and improve the process in our goal of prolonging patient survival.”

Future advancements

Trends suggest pancreatic cancer will be the second leading cause of cancer death in the United States by 2030. There is a clear need for innovative and effective pancreatic cancer treatment.

An analysis of the clinical trial landscape in pancreatic cancer published in 2020 identified 430 total active therapeutic interventional trials testing 590 interventions. According to the authors, there are a large number of novel therapeutic strategies under investigation but with few in late-stage testing.

“That means it will likely be many years yet before we have a major treatment advancement to offer patients,” laments Dr. Roy. “Our best hope in the short term is to improve early detection and find more resectable disease.”

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