Hear a Patient Power interview with Dr. Kimberly Kirkwood, a pancreatic and gastrointestinal surgeon, who discusses the warning signs of pancreatic cancer, technological advances for early diagnosis, and surgical treatments and follow-up care that are saving lives. Pancreatic cancer is the fourth leading cause of cancer-related death and one of the most difficult cancers to treat.
Pancreatic cancer can be a terrifying diagnosis, and often it's preceded by just vague symptoms, but there are advances being made in diagnosis and in surgical approaches that can really make a difference. You'll hear from a leading pancreatic cancer surgical specialist from UCSF Medical Center next on Patient Power.
Hello and welcome to Patient Power, sponsored by UCSF Medical Center. This is where we connect you with a leading UCSF medical expert talking about significant health conditions, and one of the scariest diagnoses is pancreatic cancer. Unfortunately it is usually discovered late, but there are ways to diagnose it earlier, and that can make a huge difference. We'll hear about that as we continue our discussion now with Dr. Kimberly Kirkwood.
Dr. Kirkwood of course is a pancreatic cancer specialist. She's a gastrointestinal surgeon, and she's the surgical director of the Pancreas Cancer Center at the UCSF Helen Diller Family Comprehensive Cancer Center and a professor of surgery at UCSF.
Dr. Kirkwood, let's talk about the vague symptoms. Unfortunately there are people who have some problems, and maybe you can help us understand what they are, and they don't seek care or it's not recognized, and if only it were it could have maybe saved their life. What are some of the symptoms that may be vague early on for pancreatic cancer?
So, Andrew, many patients will tell us that they've been having vague discomfort in their upper abdomen for some number of months. Often, this was thought to be some dyspepsia or ulcer disease, and they were given an antacid, but the symptoms persisted and in fact were not improved by the antacid, which should be a clue to both the patient and the primary care doctor.
The other finding we almost always see is weight loss, and this will be a diet that has never worked in the past and all of sudden is really working great now, which should be a hint, or it will be unintentional weight loss that is unexplained.
These two symptoms in our view should prompt an investigation for pancreatic cancer because weight loss almost always means something bad; and particularly in older patients who are not usually trying to lose weight, weight loss in our view should prompt an evaluation, which typically would include imaging.
You're a major NCI Comprehensive Cancer Center at UCSF. What do you do there as far as taking a closer look to try to see what's going on and catch it early, which I know can make all the difference?
It does make all the difference. What we do is a combination of blood tests for tumor markers and specifically the CA 19-9 is the marker we use most commonly, and we get a pancreas tumor protocol CT scan. This is a CT scan, an X-ray, that is done with the specific question in mind of looking with a fine-toothed comb for pancreatic tumors.
Now I understand there are some new uses of PET scanning as well in combination to try to help you understand what you're dealing with too.
PET scanning has really helped us to understand the extent of disease. If a CT scan that is done, say, at a community hospital identifies a lesion in the pancreas, one of the first things we'll do when we see that patient is to do a PET scan combined with a very high-quality fine-cut CT scan on a special scanner. That gives us an idea of both the extent of the tumor and whether or not it's spread to other organs.
This process of determining the extent of spread is called "staging" and it helps us to determine the proper sequence of treatments.
Dr. Kirkwood, let's say that something is seen in and around the pancreas that's nonmalignant. Does that mean it's not of concern? What's the correlation between these nonmalignant masses and something that could be cancer later on?
We know a lot more about these nonmalignant lesions now than we ever have in the past. Cysts are not normal findings in the pancreas. Often something that appears to be a cyst is actually a cystic tumor and something that can become a malignancy down the road. These cystic tumors are often overlooked or dismissed as unimportant, but actually they represent one of the easiest ways to detect early pancreatic cancers. If we remove these premalignant lesions then we can prevent the development of cancer for a patient, which is always our goal.
We're going to talk about surgical approaches in just a minute, but the truth is maybe the mortality from pancreatic cancer is so great because it's discovered later and for whatever reason, many people are not offered surgery. They're just told to basically put their affairs in order and often don't live very long.
Is there any new data about what's going on there or how often that's the case, and then we'll talk about what you can do that makes a difference at UCSF.
Andrew, I think this has been a surprising finding. We now know that the majority of patients in the country who have localized tumors, that is tumors that are within the pancreas and have not spread, are actually not being seen by surgeons who have the expertise to remove them. Recent research studies tell us that many, many patients are being denied potentially curative therapy. These patients are seen by physicians who are well-meaning but not up to date on the latest advances in diagnosis and treatment options.
Pancreatic cancer has a very bad reputation so patients may be told the situation is hopeless, even when they have curable disease. We regularly remove pancreatic tumors from patients who were told they had six months to live. Those hugs we share in my office years later are the most rewarding aspect of my job! Patients with pancreatic tumors and cysts must have access to NCI-designated cancer centers where these tumors can be properly evaluated and potentially cured.
What is the rate at UCSF versus the national finding?
Among patients who have localized tumors, 80 percent of those patients will have their tumors removed when they're seen at UCSF as compared to only 30 percent nationally. Among the patients who have their tumors removed, we have a 40 percent cure rate as compared to only 20 percent nationally. So it really argues in favor of getting yourself to an NCI-designated cancer center where these therapies are available.
I know so often people seek cancer care close to home, family, and friends, but the pancreatic cancer diagnosis may well be the battle of their life, and it seems like even if need be they should go the extra mile.
That is such an important statement. People feel comfortable closer to home, and they're concerned about traveling, and they're concerned about everything, including the parking in San Francisco! We've really tried to look at that in the past year to improve the patient's access to our medical center. Most of the beds in our surgical floor for example are in private rooms so patients and families can stay together. We partner with the local oncologists so that the patient may come for their surgery at UCSF but can still receive their oncology care locally, and I think that we're trying very hard now to break down some of these barriers to access to UCSF.
All good points. Now let's just talk for a minute about changes in surgical approach. If you're lucky enough to discover these lesions earlier on, can you do a more simple procedure than often what's done later where it can go nine or ten hours, and it's one of the most extensive abdominal surgeries there is?
Fortunately, we are now able to remove many of these tumors laparoscopically, which is how many patients have their gallbladder removed. This is a particularly good option for premalignant tumors. We're able to work through very small incisions and use specialized techniques that promote "bloodless surgery" to allow us to remove the portion of the pancreas containing the tumor using a minimally invasive approach. The patient typically recovers within a couple of days and often goes home two to three days later.
I think this has really advanced the quality of life for patients with benign or premalignant tumors and may be appropriate for some cancers.
Dr. Kirkwood, now I alluded to the major surgery that's traditionally been done, the so-called Whipple procedure, and I've interviewed people who are alive today because of it. So it would seem that a center such as yours, and you specifically as a surgeon, have a lot more experience with that than might be at outlying hospitals.
Pancreas tumors are rare, but we see patients with them every week. So we do more than 70 resections per year here at UCSF, and the average general surgeon in the community will only do one or two pancreas resections in their career. There are a lot of data, as you know Andrew, that show the survival following pancreatic resection is much improved at centers that do a lot of them, so-called "high volume" centers.
Interestingly, we now know that the long-term cure rate is better at centers such as UCSF where we do a lot of pancreatic surgery. We think that may be related to the fact that we get more lymph nodes to assist in staging and that we're more likely to get the entire tumor out rather than leaving behind a positive margin, so some of these factors may actually be improving long-term cure rates as well.
When we talk about pancreatic cancer we touch on a lot of specialties. So you are a subspecialist in pancreatic surgery. I'm sure that there are pathologists and radiologists that come into play very much along with you and also medical oncologists. That's a whole team approach you have to really a complex disease, right?
The team approach, I think, is one of our keys to success. We're fortunate here to have specialists who are actually "micro-specialists", if you will, in pancreatic disease who work with us from all those disciplines. In addition to all those you mentioned, we also partner with anesthesiologists who treat both surgical and chronic pancreatic pain, and gastroenterologists who specialize in pancreatic imaging techniques. Micro-specialists with this depth of expertise are simply not available in the community.
Then you can add specially trained nurses and nurse practioners, dieticians, physical therapists, and social workers. These people are so important in terms of helping us get a patient back to their high functioning lifestyle, because the recovery period can be so long.
Dr. Kirkwood, research goes on trying to better understand pancreatic cancer, and UCSF is a research institution as well. Is there anything promising or at least encouraging in better understanding this disease?
We have a very exciting new initiative using the Institute of Molecular Medicine here to partner with us to help us try to evaluate a particular patient's tumor and determine whether that tumor is more likely to respond to chemotherapy regimen A, B, C, or D. One of the problems we have right now in pancreatic cancer is that we don't know which chemotherapy agent is best for your particular tumor, so one of our new research initiatives takes advantage of the fact that UCSF is internationally known in molecular research. Our aim is to be able to characterize, or "profile" if you will, a particular patient's tumor and determine which regimen is most likely to be effective for that patient. We're very excited about that particular initiative because we think we can then offer individualized therapies.
We also have a new collaboration with the Osher Center for Integrative Medicine to evaluate the relationship between the level of optimism a patient has and their outcomes, which is based on promising research showing such a correlation among patients with other life-threatening diseases.
We also have research projects currently focusing on the causes of pancreatic cancer, nutrition, pain pathways, diagnostic tools, postoperative quality of life, and the process by which patients best learn about surgical options. From molecular pathways to patient attitudes, we are involved in a multi-pronged approach to curing this disease.
Dr. Kirkwood, as we mentioned it's not a common cancer, but people could be diagnosed anywhere and maybe far outside the city of San Francisco or somewhere else in the country. You encourage people to come to your center for even a second opinion don't you?
Absolutely, and sometimes all we do is reinforce the original treating surgeon's or treating oncologist's opinion, but we often provide that depth of expertise and that breadth of expertise that helps them to understand where they are in the whole scheme of pancreatic cancer patients and what's down the road. Often there are so many unanswered questions. Because we see so much pancreatic cancer, we can give them a much more complete understanding of where they are and what they can expect.
It doesn't sound even with such a serious diagnosis though that you're down about it. I mean we have to look at the reality, but it sounds like you are making progress.
I think the next 10 years is going to be a new era for pancreatic cancer. We've learned a lot from the advances in breast cancer and colon cancer therapy in the last decade, and I think this will be the decade in which we apply that knowledge to pancreatic cancer. I expect that our cure rates will improve dramatically in the next decade.
Dr. Kimberly Kirkwood that is encouraging news. I want to thank you for being with us today on Patient Power.
Thank you Andrew. It was a pleasure to be with you.
Dr. Kimberly Kirkwood is a pancreatic cancer surgical specialist and gastrointestinal surgeon, and she is the Surgical Director at the Pancreas Cancer Center at UCSF.
If you'd like more information you can just call 1 (888) 689-UCSF (8273).
Recorded May 2009
Reviewed by health care specialists at UCSF Medical Center.
This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.
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