February 2009

Extending the Lives of Pancreatic Cancer Patients

Kimberly S. Kirkwood, M.D.
Pancreatic and Gastrointestinal Surgeon
UCSF Division of Surgery and UCSF Helen Diller Family Comprehensive Cancer Center

Eric K. Nakakura, M.D.
Cancer Surgeon
UCSF Division of Surgery and UCSF Helen Diller Family Comprehensive Cancer Center

Surgery is the only curative therapy for pancreatic cancer, the fourth leading cause of cancer-related death. Although many patients have metastases at the time of diagnosis, surgical removal is possible for most patients who present with tumors confined to the pancreas. Recent data suggest that the long-term survival rate after resection for localized disease is approaching 30 percent. Significant advances in preoperative evaluation, surgical techniques and postoperative care over the last two decades have reduced the mortality following pancreatic resection from 25 percent in the 1960s to less than 3 percent today in some high-volume centers.

Despite these improvements in the survival rates of patients with stage I pancreatic adenocarcinoma who undergo curative resection, a recent study found that more than half the patients with potentially resectable tumors failed to undergo surgery. Among the 9,559 patients, 6.4 percent were excluded due to comorbidities and 4.2 percent refused. In most cases, however, surgery was not offered for unclear reasons.

Patients treated at comprehensive care hospitals designated by National Cancer Institute (NCI) were more likely to undergo surgery than those treated at community hospitals. The striking underuse of curative resection may have been due to factors such as nihilistic attitudes by physicians toward pancreatic cancer, the reliance on outdated survival data and lack of awareness of advanced diagnostic and surgical techniques, including minimally invasive surgery. These factors may have led to the failure to refer patients for prompt surgical evaluation.

Surgical Evaluation

Primary care physicians play a critical role in the treatment and survival of pancreatic cancer patients. All patients with a pancreatic mass should be referred to a surgeon for evaluation.

Diagnostic techniques, such as multidetector CT scans, MRI and endoscopic ultrasound available at comprehensive cancer centers, allow surgeons to detect pancreatic tumors at an earlier stage when they can still be removed and, in some cases, before they become cancer. Early surgical evaluation ensures accurate and timely diagnosis and optimal care, and avoids wasted resources and unnecessary diagnostic interventions.

Masses in the pancreas are often assumed to be cancerous, but not all are malignant. Many pre-malignant or benign masses have a 100 percent cure rate following surgery.

Duodenal cancer, which has a long-term survival rate similar to colon cancer after surgery, is sometimes misdiagnosed as pancreatic cancer when it occurs near the pancreatic head. Patients often endure unnecessary surgical interventions or biopsies that could have been avoided if they had seen a surgeon initially. By the time some patients are referred to a surgeon, their cancer has advanced and is no longer suitable for resection.

Patients should be referred to high-volume, National Comprehensive Cancer Network (NCCN) and NCI institutions that have documented lower morbidity and mortality rates and access to the latest diagnostic and surgical approaches. Surgeons at comprehensive cancer centers have the multidisciplinary support and resources to best coordinate a patient's individualized diagnosis, treatment, family support and follow-up care.

Minimally Invasive Surgery

Minimally invasive or laparoscopic surgery, available at the UCSF Helen Diller Family Comprehensive Cancer Center, can be used in the diagnosis, staging and palliation of pancreatic cancer symptoms, and in the removal of benign or pre-malignant tumors.

Through very small incisions, surgeons at UCSF laparoscopically remove suitable benign or pre-malignant tumors. Intraoperative ultrasound techniques allow surgeons to precisely localize the tumor and examine its relationship to surrounding blood vessels. Laser and electrocautery are used to coagulate small blood vessels. Patients who undergo laparoscopic surgery typically experience minimal bleeding, less discomfort, quicker recovery and shorter hospital stays compared to those who have traditional open surgery.

High-Volume Center

UCSF Medical Center is a high-volume center, performing more than 100 pancreatic surgeries each year. We see the highest volume of patients with pancreatic neoplasms in Northern California and offer advanced diagnostic and surgical approaches available at only a few centers nationwide. Each patient receives individualized, multidisciplinary care from a team of experts — many of them leaders in the field, including surgeons specializing in gastrointestinal and pancreatic cancer, oncologists, radiation cancer specialists, gastroenterologists, pathologists and gastrointestinal radiologists.

As dedicated clinicians, we are keen observers of the course of disease in our patients. One problem commonly faced by our patients is malnutrition. We are studying the causes of poor appetite and food intolerance and have developed a multilayered approach to preventing and treating malnutrition among patients recovering from major pancreatic surgery.

UCSF is also home to one of the few pancreatic cancer research programs in the country. Our multidisciplinary team includes physicians and basic scientists specializing in endocrinology, epidemiology, gastroenterology, medical oncology, radiation oncology and surgical oncology. We have discovered the importance of new receptors in the regulation of pancreatic inflammation and pain, which may participate in cancer cell growth and may be important targets for future pancreatic cancer therapies.

For more information, contact the Physician Referral Service at UCSF Medical Center:

Phone (888) 689-UCSF or (888) 689-8273
Email referral.center@ucsfmedctr.org

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