Changing Course in Pancreatic Cancer

Small, yet significant, advances are reshaping pancreatic cancer treatment.

Unfortunately, there is a lack of established methods for early detection. While pancreatic cancer is diagnosed primarily through imaging, there is no consensus on when it should be used to detect the disease in its early stages. And unlike screening methods for other cancers, such as mammography or colonoscopy, there are also no reliable routine screening tests for pancreatic cancer.

Surgical Advances

Although surgery has been used to treat pancreatic cancer since the early 20th century, the first groundbreaking procedure wasn’t performed until 1935 when American surgeon Allen Whipple developed and later refined the procedure that still bears his name. After further modifications in the 1940s, the Whipple procedure became the standard operation for treating pancreatic cancer. This major surgery—which involves the pancreas, the duodenum, the gallbladder, the bile duct and a portion of the stomach— also comes with a historically high risk of complications and mortality. In fact, at more than 20 percent, the death rate was considered so high at one time that some surgeons suggested the operation no longer be performed. That has changed, thanks in part to advances in open operative techniques, improvement in operative and post-operative care, and the advent of minimally invasive surgery.

“The death rate has gone down to under 1 to 2 percent in major centers with open and laparoscopic surgery,” says Dilip Parekh, a professor of clinical surgery at the University of Southern California’s Keck School of Medicine. Minimally invasive or laparoscopic surgical techniques can sometimes be used in pancreatic surgery, enabling patients to recover in a shorter period of time.

The open procedure requires an incision that extends across the abdomen, explains Parekh, who helped pioneer the laparoscopic Whipple procedure. “A lot of the recovery from the surgery is related to recovery from the surgical incision,” he says. Because the recovery from open surgery tends to be lengthy, “many patients who require adjuvant therapy are not completely recovered by the time they start their chemotherapy or radiation therapy,” he adds.

“We are finding that recovery is much quicker with these patients,” Parekh says of patients who receive the laparoscopic procedure. “And generally, they are able to start chemotherapy earlier and have much better performance status when they begin adjuvant treatment.”

This is changing the treatment of pancreatic cancer in a big way, he adds. He expects the laparoscopic approach to soon become an available option for all patients.

A second major advance has been for patients whose cancer is “borderline resectable,” Parekh says.

“These are patients for whom the tumor is encroaching on, or partially obstructing, the superior mesenteric vein,” he says. “In the past, these patients were regarded as inoperable, but today, some of them will be candidates for a Whipple procedure and partially removing and reconstructing the vein. So we have extended the surgery to other patients.”

Laurie MacCaskill was just such a patient. At age 55, she was in terrific shape and was doing everything “right.” So how could she have cancer?

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