Pancreatic Cancer: The Latest Advancements to Treat a Deadly Disease

Back in 2014, Dr. Paul Silverstein had just finished up a surgical procedure, something he’s performed thousands of times during a six-decade career as a board-certified surgeon. But this day was different. His scrub nurse at INTEGRIS Health noticed his eyes were yellowed, which he knew could be a telltale sign of pancreatic cancer.

Pancreatic cancer is one of the deadliest forms of cancer. About 47,050 people will die this year from pancreatic cancer, according to the American Cancer Society. This includes Alex Trebek, the beloved "Jeopardy!" host, who died last Sunday, about 20 months after he announced he had been diagnosed with Stage 4 pancreatic cancer. Since July, Civil Rights icon Rep. John Lewis and U.S. Supreme Court Justice Ruth Bader Ginsburg have also died of pancreatic cancer. Other well-known people who have died of pancreatic cancer in the past include Patrick Swayze, Steve Jobs, Aretha Franklin, Joan Crawford, Luciano Pavarotti and astronaut Sally Ride.

Subsequent medical tests confirmed Dr. Silverstein’s fears. He had a type of pancreatic cancer known as adenocarcinoma that had spread to his lymph nodes. This type of cancer comes with a 12% five-year survival rate. To his credit, Dr. Silverstein continues to beat the odds as he’s on year six of his battle against the disease.

Since November is Pancreatic Cancer Awareness Month, we recently checked in with Dr. Silverstein, who is now retired, and Dr. Brian Geister, a board-certified oncologist and internal medicine doctor who treats Dr. Silverstein, to learn more about pancreatic cancer, why it’s so deadly and what the future holds.

Why is pancreatic cancer so deadly?

In short, pancreatic cancer is aggressive and it’s difficult to treat.

“Symptoms don’t typically occur until the disease is already more advanced and it tends to be more resistant to treatment than other cancers,” says Dr. Geister.

Unlike mammograms for breast cancer, colonoscopies for colon and rectal cancers or pap tests for cervical cancer, there isn’t a standardized screening for pancreatic cancer. Generally, you only become aware when symptoms appear and you have a reason to get blood work or imaging. By then, the cancer growth can be considerable and has possibly spread to another area, further complicating treatment.

The American Cancer Society relies on information from the SEER database, maintained by the National Cancer Institute, to provide survival statistics for different types of cancer.

The SEER database tracks 5-year relative survival rates for pancreatic cancer in the U.S., based on how far the cancer has spread. The SEER database groups cancers into localized, regional, and distant stages:

• Localized: There is no sign that the cancer has spread outside of the pancreas.
• Regional: The cancer has spread from the pancreas to nearby structures or lymph nodes.
• Distant: The cancer has spread to distant parts of the body such as the lungs, liver or bones.

There is a 9% five-year survival rate for all SEER stages combined. That figure jumps to 37% if it’s found early and contained to the pancreas. If it spreads to the lymph nodes or another nearby structure, there is a 12% five-year survival rate. The survival rate falls to just 3% if it metastasizes and spreads to a distant body part or organ, such as the liver or lungs. Liver failure is the cause of death for many metastatic cancer patients.

The 9% overall figure is the lowest survival rate among the most common types of cancers. By comparison, prostate cancer has a 98% five-year survival rate, stomach cancer has a 32% five-year survival rate and liver cancer has an 18% five-year survival rate.

Many people are unaware of how deadly pancreatic cancer can be. Even Dr. Silverstein learned something new after his diagnosis. Initially, he believed there was a cure for adenocarcinoma of the pancreas, which starts in the pancreatic ducts. While certain treatments can shrink and control the cancer, trace amounts will never leave your body.

“I also recently learned that pancreatic cancer is now the third-leading cause of cancer death in the United States,” says Dr. Silverstein, whose illustrious career at INTEGRIS Health includes being instrumental in creating the INTEGRIS Paul Silverstein Burn Center. “With it being the third-leading cause of cancer deaths, diagnosing is still coming too late.”

Early warning signs

Dr. Geister says that pancreatic cancer is projected to be the leading cause of cancer deaths by 2030, which makes it crucial to pay attention to early warning signs.

The pancreas acts as a factory of sorts, as it helps produce digestive juices to help break down food and creates important hormones to regulate your blood sugar. Exocrine cells produce the digestive juices, while endocrine cells produce the hormones, such as insulin.

Roughly 95% of pancreatic cancers start in exocrine cells, so many early symptoms involve digestive issues. For example, cancer in the pancreas can disrupt enzymes from getting to your intestines to process fats you consume, leading to greasy or light-colored stools. It can also affect how your body absorbs important nutrients, causing weight loss and fatigue. In the event the cancer starts in endocrine cells, you may begin to develop dark-colored urine.

The tricky part is many of these symptoms, such as nausea and vomiting, mirror everyday issues. A tumor growth pressing on your stomach or spine can cause abdominal or back pain. But, without knowing you have a tumor, your initial reaction may be to see a doctor for muscular pain.

Often, the location of your cancer can determine some symptoms, which could serve as a lifesaver. The pancreas resembles a flat pear, sectioned off into a head, body and tail. The head is closest to the liver, gallbladder and intestines. A growth in this area can affect your bile duct, leading to jaundice.

Sure enough, with Dr. Silverstein, the yellowed eyes his nurse noticed in 2014 turned out to be jaundice.

“That prompted me to do some testing. At the time, I felt perfectly healthy and wasn’t feeling sick at all,” he says. He scheduled a CT scan and had blood work done. His labs showed elevated liver functions, and the scan showed a 2.5 cm mass at the head of the pancreas.

The latest advancements in pancreatic cancer treatment

Early, aggressive treatments are just as important as early detection. Dr. Silverstein says pancreatic cancer patients should move swiftly, especially if they need surgery.

“Surgery is still the mainstay of therapy and surgical removal of the disease is the only realistic hope of cure,” Dr. Geister says. “You can also receive chemotherapy before surgery in an attempt to shrink the cancer to make surgery possible or after surgery to try to prevent the cancer from recurring.”

Dr. Geister says FOLFIRINOX is a very effective drug combination for chemotherapy treatment of pancreatic cancer. The powerful combination gets its name from the four medications that make it up — leucovorin calcium, leucovorin fluorouracil, irinotecan hydrochloride and oxaliplatin.

Eight days after Dr. Silverstein’s diagnosis, Dr. John P. Duffy, a hepatobiliary and abdominal transplant surgeon at the Nazih Zuhdi Transplant Institute, performed a Whipple procedure, a type of surgery that treats pancreatic cancer. Dr. Duffy removed the head of the pancreas, the duodenum, part of the stomach and other nearby tissues.

As part of his treatment, Dr. Silverstein received all-purpose chemotherapy drugs, such as gemcitabine and abraxane. He also received FOLFOX, a combination of drugs featuring leucovorin fluorouracil and oxaliplatin. While these medications are very important in chemotherapy treatment, they also attack your cells, both cancerous and healthy.

Immunotherapy

Beyond surgery and chemotherapy, immunotherapy in pancreatic cancer treatment is showing promise as a less toxic way to kill the cancer cells. Your immune system is a powerful defender against bacteria and viruses, but it can struggle to recognize and fight cancer cells. Immunotherapy uses drugs to boost your immune system so it’s better prepared to seek out and kill the cancer.

“The future for treating pancreatic cancer is immunogenetic treatment,” says Dr. Silverstein.

During his treatment, Dr. Silverstein enrolled in a clinical study that combined a PARP inhibitor with a checkpoint blockade agent. PARP enzymes help repair damaged cells. The PARP inhibitor blocks the enzymes and makes it harder for cancer cells to “repair” damaged cells and grow or spread.

Meanwhile, your immune system has protein checkpoints, which operate as on/off signals, to send alerts to cells to act on certain immune responses. Certain checkpoints keep cells turned off to prevent them from attacking your own cells. But some cancer cells have a similar composition that allows them to stay hidden, tricking your immune system into thinking the cancer cells are normal cells. The checkpoint inhibitors block these signals, allowing your immune system to better identity and attack cancer cells.

Genome testing

The relationship between the immune system and genetics starts with genome testing, which analyzes mutations in tumors. This process has many names, such as precision medicine molecular testing, DNA testing or personalized medicine.

Each cell has DNA, and the DNA contains genes that instruct your body on how to function. As the human body develops, cells divide and produce an exact gene copy. Sometimes, there’s an error in this process that causes genetic mutations. Not all mutations are harmful, but this is how cancer starts.

Many cancer drugs have a broad target, meaning their goal is to kill cancer cells regardless of the type or stage. But cancer cells vary for each individual since your genetic makeup may not be the same as someone else. For example, a cancer treatment that works on hundreds of people won’t have the same effect on you if your tumor is different.

This is where genome testing comes into play. Your doctor will take a biopsy that helps map out your tumor’s biology. By studying these tumors, oncologists can then put together a more strategic treatment plan to target specific genes and proteins.

“Every person with pancreatic cancer needs to get genomic mutation identifier testing so their oncologist can treat specific mutations,” says Dr. Silverstein.

In the future

Research for precision medicine continues, as does research on immunotherapy and targeted therapies.

“We still need better methods to screen for the pancreatic cancer and to diagnose it earlier, and we still need better treatments for advanced types of pancreatic cancer,” Dr. Geister says. “We have a long way to go, but this cancer has an active, growing research base committed to it.”

Dr. Silverstein’s advice to fellow cancer patients

Over the years, pancreatic cancer has become more mainstream as notable people have battled the disease. While it has received more press, the fact remains: Pancreatic cancer is an aggressive killer unless you find it early.

As Dr. Silverstein’s journey shows, good results are possible when you attack pancreatic cancer with multiple treatment methods. Currently, Dr. Silverstein is undergoing radiation therapy to treat metastatic lesions.

Aside from early detection and early intervention, he provides beneficial tips to anyone who is battling this type of cancer.

“I give the credit to God for the fact that I’ve survived for six years. I keep busy attending support groups and spending time with my family and friends,” he says. “It’s easy to become depressed with a pancreatic cancer diagnosis, and I still battle that today. It’s important to keep yourself engaged with work or a hobby.”

Dr. Silverstein’s support system comes from his wife of 30 years, Dr. Amalia Miranda, who is an ophthalmologist, as well as his four children and nine grandchildren. He also works out with a trainer, eats plenty of green vegetables and takes vitamins and supplements recommended by INTEGRIS Integrative Medicine Practitioner, Juli Johnson, APRN. He stresses the importance of eating natural foods to stimulate your immune system.

Above all else, he makes sure to relax and keep things in perspective.

“I take time to enjoy life and don’t go without a bit of Jack Daniels and a Cuban cigar each afternoon,” he says.

Contact an INTEGRIS primary care physician if you have any symptoms related to pancreatic cancer. If you’ve recently received a diagnosis or had treatment in the past and want a second opinion, contact the INTEGRIS Cancer Center to learn more about our therapeutic options and how an oncologist can help you today.