It takes a team

How physician subspecialists come together to tackle a dangerous, deadly cancer

Location, location, location. That's the primary reason pancreatic cancer is so difficult to treat. Nestled beneath the liver, next door to the gallbladder, kidneys, and spleen, with easy access to the blood stream and lymph system--in most cases, pancreatic cancer spreads to its neighbors before it is even detected. Tackling this ticking time bomb takes a team of doctors.

Focus article photo

Thomas A. Colacchio, MD, Surgical Oncologist.

It was an impressive sight: a lineup of five physicians—each representing a different subspecialty—medical oncology, gastroenterology, radiation oncology, surgical oncology, and radiology.  The group was fielding questions from the audience at DHMC's 2nd Annual Pancreas Education Day.

In response to one question, Timothy Gardner, MD, Gastroenterology, said "I wish someone from pathology was here." 

Audience members then realized: this wasn't the full roster of the doctors on the all-star pancreatic cancer team.  Dr. Ira Byock, a palliative care specialist, and Jeannine Mills, a clinical dietitian at the Norris Cotton Cancer Center, sat in the wings waiting to speak. In addition to pathologists, nurses, social workers and genetic counselors are also members of the team that meets weekly to formulate an aggressive treatment strategy for every patient.

"I am overwhelmed that you are all standing here in front of me," said one participant who had raised her hand to ask a question, "and blown away that you all come together and talk so frequently."

Pancreatic cancer treatment managed by a team of doctors

Physicians call this all-star team a "tumor board." Every week more than 13 different tumor boards meet at Norris Cotton Cancer Center, each with more than a half dozen different medical subspecialists at the table.

As physician after physician stood up to discuss his role in the team, it became clear how and why they  work so closely together. 

  • The radiologist does the medical imaging and provides a comprehensive map of where the tumor is and what organs, blood vessels, or nerves it has invaded.
  • A medical oncologist delivers chemotherapy to shrink the tumor.
  • A radiation oncologist uses x-ray breams to zap the tumor from all directions so they cancer cells die when they try to divide or grow.
Pancreatic tumors targeted with novel approach at DHMC

The physicians call this approach neoadjuvant treatment. It refers to care that occurs before surgery. This approach has been studied and developed here at DHMC, proving to be more successful in treating pancreatic cancer. Since pancreatic tumors can wrap themselves around blood vessels and organs, the strategy is to pull the tumor away from these vital systems with chemotherapy and radiation before operating.

Pancreatic surgery: a complicated but promising treatment

Thomas A. Colacchio, MD, Surgical Oncologist.

"Removing all the cancer surgically is the only cure for pancreatic cancer," said Thomas Colacchio, MD, surgical oncologist. "But it is a big surgery with long recovery and lots of complications. It's a place that is hard to get to and the pancreas can't be lifted and mobilized in surgery like other organs."

Colacchio reinforced the need for neoadjuvant treatment. "When I am operating tumor cells break off and spread in the body. Neoadjuvant treatment is killing 60, 80, 90 or 100 percent of cancer cells before surgery minimizing any dissemination."

Not all pancreatic cancer patients are suitable for surgery. Age and health are two factors. Where and how the cancer has spread also determines if it is operable. But Colacchio says neoadjuvant therapy helps more people become candidates for surgery, even those in later life.

Complications for pancreatic cancer surgery are about 30-40%, but decreasing in severity over the last few decades. Only 1-3% of patients who undergo the procedure die from the complications. Common complications are anastomotic leak, pancreatic fistula, or delayed gastric emptying.

Given the complexity of the pancreatic cancer surgery and the risk of complications, Colacchio recommends "it be performed at institutions with adequate experience and it should be combined with adjuvant chemo-radiation, ideally in the setting of a clinical trial."  

One way he said patients can judge an institution's experience is to ask how many pancreatic cancer resections they do in a year. "You want to find a place that does 20-25 of them safely a year. At DHMC, we do 75-100 per year," said Colacchio.

Risk factors for pancreatic cancer

Donna Solura, Palliative Care, Continuing Care Manager and Jeannine Mills, MS, RD, LD Oncology Dietitian with patient.

There aren't any screening tests for pancreatic cancer. Risk factors for the disease include:

  • cigarette smoking
  • long-standing diabetes
  • pancreatitis
  • over 50 years of age
  • and potentially the Hepatitis B virus

The tendency toward developing pancreatic cancer can also be inherited. Those with a family history should talk to their doctor about their risk or visit the familial cancer clinic at Norris Cotton Cancer Center.  

Warming signs of pancreatic cancer

The signs and symptoms of pancreatic cancer include:

  • pain
  • jaundice
  • light colored stool
  • dark colored urine
  • loss of appetite, weight loss
  • blood clots, bleeding

Unfortunately, most of those diagnosed with the disease have had pancreatic cancer for six months before it was detected.

March 25, 2013