Know Your Options When It Comes to Pancreatic Cancer

CURECURE® Winter 2021

On behalf of the National Pancreas Foundation, Dr. Andrew M. Lowy offers background on treatments and outcomes for pancreatic cancer.

As with many cancers, the sooner pancreatic cancer is diagnosed, the better. In particular, this may affect at what point chemotherapy is introduced as a therapeutic option.

And thanks to promising new treatments in the pipeline, patients with the disease will soon have more options besides surgery and chemotherapy. “The only way we can advance in this mission is to study the new treatments that we are developing,” said Dr. Andrew M. Lowy in an interview with CURE®.

Lowy, professor of surgery, chief of the Division of Surgical Oncology and clinical director for cancer surgery at the Moores Cancer Center at University of California San Diego Health, spoke about current standards of care for pancreatic cancer, as well as options being evaluated for the future.

Q: CURE®: How does early detection play a role in treatment?

A: Lowy: Early detection is critical for achieving the best outcomes in pancreatic cancer, as it is in really all cancers. One of the big problems and challenges we face in pancreatic cancer is still our inability to diagnose most patients at an early stage. But when we do diagnose patients with, for instance, stage 1 pancreatic cancer, we can cure more than half of them.

Q: Why is there a need to consider treatment at a high-volume cancer center?

A: Well, pancreatic cancer is a complex disease, for many reasons. ... Patients (with pancreatic cancer) face a number of issues that range from managing their therapy, whether it be chemotherapy, radiation therapy or surgery, to managing these other medical aspects. Multiple providers are involved, and you really need a team approach ... so they’re familiar with all the issues that patients with pancreatic cancer face.

Q: Can you explain what neoadjuvant therapy is and how it improves outcomes?

A: Neoadjuvant means getting your treatment, usually chemotherapy, before you have an operation. So for patients whose tumors are operable, the traditional means of caring for them has been to remove the tumor and then give them therapy afterward. While that’s the traditional approach, it’s become clear that that approach has a lot of disadvantages, as compared to giving chemotherapy upfront.

The thing to understand is that pancreas surgery is very complex. Despite the fact that we’ve gotten better at it, it is associated with a high complication rate. (It can take patients time) to recover from the operation to be able to get their chemotherapy. We know that the best outcomes are achieved when people get chemotherapy in addition to surgery. And so, by giving chemotherapy before the operation, when people are still in good shape before they have to undergo a surgical recovery, it ensures that we get that chemotherapy delivered.

The next thing that’s important is by giving the therapy when the cancer is present, we can get an assessment of whether the treatment is actually working, and that can allow us to continue therapy if it’s being effective or to consider changing therapies before or after surgery to something that may be more effective.

The last part that I’ll talk about is that, unfortunately, a certain percentage of patients, when they present, have disease ... somewhere else in their body, most often the liver. (In this instance), we don’t want to (operate) on those patients because those operations are not helpful.... We don’t want to do surgery on people unless we think the operation is really going to help. So by giving chemotherapy ahead of time, we are selecting out those folks who have a better chance of benefiting from the operation because in the time we’re giving treatment, some of those people who have disease in their liver, it will show up as we rescan them, and then we know they’re not a good candidate to have their operation.

Q: What are the standards of care for pancreatic cancer right now?

A: Like all cancers, the treatment selection is based on stage. However, what’s different about pancreatic cancer is, because it’s such an aggressive disease, every patient essentially will get chemotherapy at some point in their care.

We just talked about the earlier-stage patients who have operable disease, (for whom) we often will give chemotherapy before their operation. Patients who have tumors that are metastatic — meaning (the cancer has) spread to another organ or it’s inoperable because it’s involved in critical blood vessels, for instance — will get treated with chemotherapy. Two main standard regimens are used most often for this disease. One is called FOLFIRINOX (folinic acid, fluorouracil, irinotecan and oxaliplatin) and the other regimen consists of two drugs, gemcitabine and nab-paclitaxel (Abraxane).

Q: What kind of treatments are on the horizon for pancreatic cancer?

A: The exciting thing is that more drugs are being tested for pancreatic cancer than in any time in history. And the drugs span a variety of different classes. The one big area of intense investigation is immunotherapy. ... So far, we haven’t had success with most current immunotherapies for (patients with pancreatic cancer). And there are a lot of reasons for that, which are fairly complicated. In short, what we’re trying to understand is how we can make the immune system recognize pancreatic cancer by using combinations of immuno-modulating drugs. There’s a whole bunch of them that work on different parts of the immune system that are in clinical trials.

Another interesting area is tumor metabolism. Cancer cells have a different way of getting energy than do our normal cells. And there are drugs being developed that are trying to block the pathways that pancreatic cancer cells use to acquire and use their energy. Some of those drugs are even in very late-stage trials. And if we’re lucky, and they show efficacy, they could be approved as soon as next year.

And then finally, there are targeted therapies, which are drugs designed to target specific alterations or vulnerabilities in cancer cells that are often identified by (studying the tumor of an individual patient), rather than being broadly applicable like chemotherapy.

Q: What is your biggest piece of advice for patients considering their treatment options?

A: First of all, I think that being at a high-volume center is always a good idea, or at least to get an opinion from a center if that’s available to you. It’s never a bad idea to get multiple opinions to make sure that you’re comfortable with the treatment plan that’s being presented to you. And organizations like the National Pancreas Foundation (NPF) provide information to patients, which can help educate them about the disease and answer questions. (It’s also important for patients to realize): You’re not alone. NPF and other organizations are available to support you, help you through the journey and make it as easy as possible for you to deal with this difficult disease.

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