Episode Transcript
Speaker 1 00:00:16 And good evening. Thank you for joining disability and progress, where we bring you insights into ideas about and discussions on disability topics. My name is Sam I'm the host of this show. Charlene doll is my research woman. Good evening, Charlene. Good evening everybody. Tonight we have Dr. Emo Lou, Dr. Lou is, we'll be discussing the topic of pancreatic cancer. Dr. Lou is a PhD, uh, gastrointestinal oncology and assistant professor of medicine in the division of hematology, oncology and transplantation at the university of Minnesota medical school and Masonic cancer center. Did I get all that Dr. Lewis?
Speaker 2 00:00:57 Absolutely. Right. Thank you so much for having me on
Speaker 1 00:01:04 Hats off to you. Thank you so much for sharing your time tonight. We appreciate that on this important topic. Um, I want to start out by, uh, tell us a little bit about your path to medicine and why you chose this particular field.
Speaker 2 00:01:22 Sure. Um, and, uh, and, and hello to all your listeners as well. Joining us on talking about this important topic. So just to give you a little bit of background for myself, I'm both a physician and scientist. I went to medical school and also graduate school and completed a program to do for a career path that sometimes it's called physician dash scientist or Hyson, uh, or clinician investigator. And so what this does is allow me, or provided me the background to both investigate, uh, at the cellular and molecular level. And in this particular type of career, uh, cancer is very specifically the biology of it all the way to being a medical physician trained in oncology to, in order to treat patients with cancer. My specific area of focus is gastrointestinal oncology and pancreatic cancer is one of the more common types of cancer. Um, at, uh, the time that I was in high school and early part of college, my best friend's mother was diagnosed with pancreas cancer.
Speaker 2 00:02:19 And that was probably my, my earliest exposures, um, to pancreas cancer and the devastation that it can cause on a personal level. Um, she passed away at the end of our first year of college when we just come back after the completion of our first year of college. And matter of fact, to me a lot. And then over the years, I think just like, like many Americans, you either, if you're not affected by cancer yourself personally, then it might be, uh, someone close to you, family, friend, neighbor, or someone that you know of as one in two American men. And one in three American women are diagnosed with cancer. Um, pancreatic cancer is, is on the rise in the last few years in this country.
Speaker 1 00:03:00 So can you, um, start out by giving us, um, a definition of what pancreatic cancer is and how does it work?
Speaker 2 00:03:10 Sure. So the pancreas is an organ in the body that produces hormones and other, um, enzymes are things that help us suggest food. So as we know, we eat food to our mouth and it goes through a long type called our tunnel called the esophagus that leads into the stomach. And then our, as our food begins digestion in the stomach, it'll pass through all the rest of the digestive tract, including what we know of the small intestines and colon, and somewhere more in the middle of our body, in the, in the abdomen or our midsection, that organ called the pancreas. It's a kind of a long, rather relatively slender organ sitting across our body horizontally. And it feeds into that digestive system when it produces enzymes, for example, a digest foods, pretty commonly. We don't really think anything of it if it's functioning. Normally we think a lot about it when it's not functioning.
Speaker 2 00:03:59 Normally other types of hormones pretty commonly are hormones that help us to, to regulate the blood sugar that, that we have that, uh, when we ingest food or our liver makes blood sugar, that's normally sits at a, at a baseline level that sugar normally would function to, to feed our, our organs, like our brain and our heart. And it keeps them going. And when cancer develops in the pancreas, then it's basically developed a tumor. A tumor is basically a, an abnormal mass that should not be there. And pancreas cancers are almost always malignant or are actually cancerous that tumor, that growth that shouldn't be there interferes with the normal function of what this, this and this organ called the pancreas does. And so that's just the, at the beginning of the problems that pancreas cancer poses.
Speaker 1 00:04:49 Okay. Um, is it, it seems like it may be, it's not an equal opportunity that it hits more of one gender than the next,
Speaker 2 00:05:01 Um, in general. Yeah. It's a, it's a cancer that's overall was not considered to be one of the more common cancers, but, uh, for many reasons we still don't know in general as an oncology community, it's, it's on the rise in America. And I, I think I brought as well. Um, overall there might be a, oh, go ahead.
Speaker 1 00:05:19 I was just going to say, do you see it more in males or females?
Speaker 2 00:05:23 Um, I think it's, it's about more or less the same, maybe slightly more in males and females. Um, but, uh, the reasons for that are not really clear yet as are most of the potential causes of pancreas cancer.
Speaker 1 00:05:36 Do you see any elevation of as far as like, is it more in Caucasian or in other races? Is there a race?
Speaker 2 00:05:46 Yeah. Yeah. Um, I think, um, more so in, in general, I mean the studies that are out there, um, they port the results of a general population, but they would study, but in general, um, it's a higher in the Caucasian population, but, uh, and some studies have indicated that it may be, uh, African Americans may be at higher risk as well. Um, some of the potential known causes are just like many, many other cancers tobacco use or smoking cigarettes over a prolonged period of time, years or decades, um, can increase the risk of developing of pancreas cancer, at least two fold higher. So in other words, someone would have a two times higher risk by being a smoker long-term than never having smoked cigarettes. Other potential causes.
Speaker 1 00:06:34 Is there, like I know in a mess kind of is higher in the Midwest. Um, for some strange reasons. Does pancreatic cancer have a region where it's generally higher or is it just kind of all across the board anywhere?
Speaker 2 00:06:49 It's a unfortunately all across America, uh, regardless of race, creed, background, ethnicity, and gender, it seems to be, um, where it is when it is, when it is diagnosed, it's going to be prevalent across the board, um, including region of the country.
Speaker 1 00:07:05 So how has it diagnosed and are there some things Go ahead, how is it diagnosed and are there symptoms,
Speaker 2 00:07:18 Right? Um, it's one of the most challenging types of cancers. And the way I generally tell patients is by comparison some of the few cancers for which we have CA affective and validated screening tests, for example, for women getting mammographies to screen for, to try and catch breast cancer early, or for both men and women, a recommendation to obtain colonoscopies or, or newer type of tests with the intention of finding colon and rectal cancer earlier. Unfortunately no yet that we don't yet have such screening tests that are effective and proven to work for screening for pancreas cancer to detect it early. For that reason, there's a particular talent in that most cases are found at a more advanced stage. And unfortunately those advanced stages of the tumors, and if they've already spread can cause symptoms that often lead to the diagnosis. So there are approximately 45,000 cases expected to be diagnosed in the United States this year.
Speaker 2 00:08:17 Approximately half of them will already be stage four at the time of diagnosis. And that could mean that the cancer can go and spread way outside of the confines of where it started, like the liver or the lungs or the bone, approximately a third or considered tumors that are particularly invasive and maybe surrounding major structures, like other organs around there or major blood vessels that would make it unsafe for any surgeon to try and take it out, um, successfully, but only about 10 or 15% are so small enough that you might consider at the time of diagnosis with their surgically removable. So overall, some of the symptoms that patients might present with would be more vague symptoms like abdominal pain, or, um, just general discomfort, what we call Malaysia, just feeling queasy, things that are not necessarily specific to pancreas cancer. And that can also make the diagnosis complicated because it can be Nast or mimic other types of symptoms for things that have nothing to do with cancer. Right.
Speaker 1 00:09:13 I want to ask about, are there different types of pancreatic cancer or is it just all one lump thing?
Speaker 2 00:09:23 Right. Um, so I'm speaking as a biologist, as well as an oncologist physician who treats the patient's eye. Um, in one sense, you globally, if you go on internet search and search pancreas cancer, it comes across as if it's just one disease, but in many ways I think of it as many multiple forums. Um, and here's what I mean by that overall of those 45,000 cases expected 2019, but I mentioned the vast majority of them up to 90% or more, slightly more, or what are called adenocarcinoma. So I mentioned earlier, the pancreas is a hormone producing Oregon, and we're producing enzymes and other things other come from glands that compose the pancreas, but those glands become cancerous. That's called under the microscope adenocarcinoma. And that's what we generally think of when we think of someone's been diagnosed with pancreas cancer, approximately five to 10% are called neuroendocrine tumors that at the cellular level are completely different and they behave relatively differently.
Speaker 2 00:10:23 Although both types of cancer can spread, but the prognosis could be quite a bit different. And the behavior of the cells in that tumors could be quite different depending on the diagnosis within pancreas carcinoma in general, they might look the same under the microscope, but I also, in my clinical practice I've seen, and in my training that that a patient may suffer differently or have different symptoms. If the cancer predominantly goes to the liver as compared to if, if the predominant site that it moves through the lungs, they can be clinically impacted differently. So in some ways, although at the same cancer and it started from the same place and it's under the microscope looks identical, it could have a different impact. In that sense, I might call it a different type of cancer the way it behaves based on the characteristics at any individual patient.
Speaker 1 00:11:11 So let's talk, I, I think you're hearing more and more about pancreatic cancer, especially in the media. And, and there was somebody fairly famous, not too long ago, who's diagnosed with it. Um, how does it look as far as is it always terminal?
Speaker 2 00:11:33 It's a, that's a tough question. It's, uh, th the, the great goal of research and clinical trials and lab based research that I do at the university of Minnesota and many others do across the world is to make what's a very difficult to treat disease and turn it into a, um, at the very least, that's a definitely a long-term ideal goal at the very least. We're trying to take something that 20 to 30 years ago was pretty much considered a death sentence and turn it into at least the disease that we can manage chronically, and they can put, call it chronic disease. Then the answer to the question of whether or not it's terminal, um, might depend on how you define terminal or we'll consider each case if terminal means that someone will ultimately die of the disease. And that, that is unfortunately majority of cases, uh, the vast majority of cases with pancreas carcinoma, um, if the patient can have is in that minority of patients whose tumor for whatever reason was found early enough, and surgery can be performed, that would be done.
Speaker 2 00:12:41 The surgery would be done with an intent to cure was considered a high risk cancer, but there's a chance. And there's definitely a better chance of, uh, rendering someone. Cancer-free, there's also components of chemotherapy. And in certain cases, radiation as well, if someone is diagnosed with stage four form of pancreatic adenocarcinoma, that's half the cases are at time of diagnosis. Then the goal of chemotherapy that we would give would be palliative and intent. In other words, the chemotherapy, our current technology does not have the capability of eliminating, uh, getting rid of, or curing. However you want to say it, that kind of cancer, but if we can turn it into a chronic disease that would improve the quality of life of the patient, and that would be the ultimate goal in that setting.
Speaker 1 00:13:27 So theoretically, if someone was caught early enough and the tumor could be removed, presumably that would be a tumor on the pancreas. Yes.
Speaker 2 00:13:39 Right. That had not yet
Speaker 1 00:13:40 Spread. So why not? Why would they consider just removing the pancreas grant? It would leave them diabetic, but Hey, I could think of worse things.
Speaker 2 00:13:50 Right, right. Yeah. So, so in that case, um, uh, in that 10 to 15% of cases, I was mentioning earlier, uh, surgery is done with intent to cure and the extent of the surgery. And I certainly depended on my surgical expert colleagues on this could depend on the, the location, the tumors so much like our bodies, uh, the pancreas that the data is having different parts. So there's the head what's called the head of the pancreas is a part that's more towards the right side of our body. And looking at close to the liver and at the tumor established in that area, then someone might have a extensive, not trivial surgery, something that's called a Whipple surgery or Whipple procedure. In that case, an expert surgeon would take out the head of the pancreas, but not the entire pancreas. They leave the remaining pancreas intact.
Speaker 2 00:14:40 And then they might take out parts of the small intestine, the surrounding area to try and get as much as they could if the cancer is only at the tail, which is on the left side of the body, part of the pancreas and away from the rest, maybe the surgeon can get away with taking out the entire tumor, but preserving the rest of the pancreas. But, uh, on occasion, if the tumor is pretty extensive, there are cases, uh, that, uh, a surgeon may need to take out much more. And, uh, you're, you're exactly right. Uh, a patient may get diabetes as a result of the tumor. Sometimes interestingly enough, to diabetes heralds the diagnosis of pancreas cancer some months in advance. And there's no explanation, but it's only in hindsight when pancreas cancer is diagnosed later, that one realizes if the tumor interfered with the normal function of the pancreas, that's why the patient got the diabetes. Um, it's, it's not a reliable marker. It's not the case that everybody gets diabetes has pancreas cancer, but there are cases and we've pulled the belt diabetes. And only later do we, do we understand once the diagnosis has been made that in hindsight, it was caused by that,
Speaker 3 00:15:41 Um, what exact test diagnostic test is used to actually determine that the location of the tumor?
Speaker 2 00:15:51 That's an excellent question. So initially, um, the, the usual course of, of symptoms, what usually lead one to go to, if someone has a primary care provider, whether it be physician assistant or family, doctor, or internal medicine doctor with symptoms, and often better description of symptoms that might lead to a CT scan, or what's commonly called a cat scan, uh, occasionally at different types of scandals, MRI might be called upon as it might have high resolution and clarify, but usually, um, either one of those tasks, including a CT scan, which is more common, might show a mass on the pancreas that a radiologist would point out to the doctor, maybe with a call and say, there's a mass on the pancreas that should not be there. And at that point it would be cancer unless it would be suspected to be cancer until proven otherwise. And so the critical step to make the diagnosis would be an actual biopsy. And that's often done by an experienced gastroenterologist who would do procedures. He or she would do, what's called an endoscopy or endoscopic ultrasound more specifically than they go down the throat. And they had a camera and a probe, and which they can take biopsy specimen, specimens, or samples that they would give to a pathologist who looks in the microscope and confirms, yes, this is cancerous. And the type of cancer is adenocarcinoma. Remember McQueen.
Speaker 1 00:17:09 I knew of somebody, an acquaintance who his father died of pancreatic cancer. His brother was diagnosed, um, a year later. And I think there was another person in his family who was diagnosed. Does it run in families or can it,
Speaker 2 00:17:31 Uh, it can. And it's a, it's a, it's a very common question because one of the things that we're trained to do in medical school and especially in the cancer field is to really ask not just about the patient and as we're treating them, but to ask, is anyone else in the family, has anyone in the family been affected by cancer biologic relatives? And is there some kind of pattern, um, I was saying earlier that things like smoking, or, um, maybe alcohol use or other things that cause chronic inflammation or pancreas or strong most strongly linked or being risk factors, interestingly only approximately five to 10% of pancreas and other similar cancers might be considered hereditary, but it's definitely not trivial. If, if someone is in that five to 10% category, right, there are, there are genes that we know about, uh, and are being linked to pancreas cancer and increased risk.
Speaker 2 00:18:22 And I have, I have no doubt there are genes yet to be discovered that someday will enlighten us a little bit more. And that five, 10% number might actually rise in the future with discovery of other genes. Um, there are some clusters of family syndromes or genetic syndromes that we know of that perhaps might be, for example, linked to skin cancers, that skin cancer called melanoma. And at that gene might increase the risk of melanoma. It might also increase the risk of pancreas cancer. Um, a common one that's been in the news more recently, even just in the last month is a gene more associated with breast cancer. Um, some people have heard of or sometimes it's called BRACA. Um, there are different forms of BRACA and there's one form called BRACA two that although it's only seen in a small minority of pancreas cancer patients under 5%, it's definitely present. And sometimes I've had patients under my care who, who tell me stories when they're first diagnosed that other people in their families have pancreas cancer, but also breast cancer and maybe bile, duct cancer, maybe some other cancers. And that sets off, um, some bells in my head that there might be a genetic syndrome and we might have a cancer genetics team expert meet with the patient to try and delve further into that and use available testing to find that out that would have implication and, and whether other family members might need to get tested.
Speaker 1 00:19:43 Yeah. So I'd like to just stick on this path just for a minute and say, so let's say you had two or three people in the family that did have pancreatic cancer, presumably you'd test to see if are they the same. Yes. You would make sure they're the same, um, pancreatic cancers. Cause it could be different from each other. Right.
Speaker 2 00:20:07 Right. So to clarify you mean, um, whether the person or the persons actually diagnosed with a cancer will be tested or
Speaker 1 00:20:15 You would make sure that the people who had, let's say three people in a family had pancreatic cancer, you might compare like, are these pancreatic cancers the same? And then what would you do with the leftover family members? Would there be any early tests or what would you do
Speaker 2 00:20:32 Sure. Um, to address the first part of that question, uh, you sometimes we're limited because especially from bygone era, somebody might say just the older patients that their parents would either be very elderly or no longer alive, maybe come from an era where the technology was not as good. And maybe the cancer was diagnosed too late, or the, uh, there was less information. And frankly also cancer was more, um, in some cultures not allowed to be talked about and among families. So sometimes patients will suspect that someone had pancreas cancer, or if it's from the seventies or eighties or nineties beds is not either someone not alive or not much information is known. Uh, so that's sometimes of a hindrance. If somebody, for example, might have contemporaries like in their family, siblings or cousins who in recent years were diagnosed, then there might be an opportunity to do testing on both or multiple individuals.
Speaker 2 00:21:26 It's a little harder right now, uh, to, to say what exactly can be done for people who are family members, not yet diagnosed, but they're there they're a family member or a biological relative has been diagnosed with pancreas cancer. What exactly to do? I think that I definitely very, very strongly encourage those individuals. If they're tested and found to have potential gene, to have very in-depth conversations with their, their own physicians and determine the best course we don't because we still don't have effective pancreas cancer screening tests. There isn't an exact screen test. Like if a family member had colorectal cancer and then someone had the gene, you would tell them, go get your colonoscopy sooner. Don't wait until the age of 50 or even 45. Maybe you need to do it sooner in your young adulthood too, because you will be at high risk because there still is no effective pancreas cancer screening test. That's a little harder, but it's certainly is worth consideration about potentially considering, uh, ways to, to screen for it. And those individuals who are at higher risk,
Speaker 1 00:22:25 Is there a general age that this is diagnosed, that
Speaker 2 00:22:31 It's, uh, you know, the, the average age surprisingly would be older than I would think, uh, based on what I see in my clinic, Dave, the average or the median age is, is generally in the 55 to 65 range nationwide, but I've had patients who are in their early to mid twenties diagnosed and all the way till early nineties and treated or been a physician for, um, those patients. And then in any age in between, um, exactly why it, it, it still remains a mystery in the medical community, especially as we're seeing a higher risk of many types of cancers, not just pancreas, but colon and rectal and others in what we consider the young adult population. And that's overall on the rise in the last few decades compared to the last half of the 20th century,
Speaker 1 00:23:22 It makes you wonder what environmentally, what environmental thing has gone on that is producing this or, or causing maybe higher cancer. Uh, is there, I don't know. I think I've heard about studies Dr. Lewin involving vitamin D. And can you talk a little bit about that and does that affect things? If so, how and what are you guys doing with that?
Speaker 2 00:23:55 Right. Yeah, it's, it's, um, it's, I, I bundle that with a, B, C vitamins and many other things, and even further, uh, supplements of that. So I guess one aspect of that would be due does deficiency of certain vitamins, especially vitamin D lead to increase risk of cancer. And there has been some evidence to support that, um, in some respects for every study that comes back and says, that definitely is there might be an equal and opposite research study from legitimate researchers and institutions to say the opposite show. So I think, uh, it's important to keep that in mind, vitamin D is, is an interesting, uh, vitamin a in particular, because it's something that we ingest in our food it's milk is often four to five vitamin D, especially for children. And then it's activated when we are the exposure to sunlight and, and, and some, uh, research studies, the efficiency of it will increase broadly our risk of cancer, uh, when someone is diagnosed with cancer that typically have in our clinic, people will ask questions that what can I do for myself?
Speaker 2 00:25:00 So, uh, and I often say, well, if you're a smoker, stop smoking, limit your alcohol intake. But also, um, I think I've common question as well. If I take vitamin D or certain other vitamins, would that help combat or treat my cancer today? There really isn't any firm evidence to state that it would, but I, I think so many Americans, especially in Minnesota here where that exposure is limited many months of the year, or we tend to be vitamin D deficient. We spend much of our time indoors, uh, whether at desks or not. Um, so in general, for overall health it's, uh, the risk to benefit aspect is no harm and then taking the vitamin D supplement. But in general, I would more focus on dietary intake having a balanced diet of proteins and carbohydrates, and also exercise, I think is something that's, that's all too overlooked, but it's very crucial. In fact, over vitamin levels and actual nutrition diet type of concerns, I'd say that's probably the most amount of data supporting the role of exercise in cancer, survivorship, and the ability of patients to better tolerate the chemotherapy treatments that they undergo. Um, but the, the vitamin question is still an outstanding question that, uh, there's, it's somewhat controversial in the field of cancer, but a lot of research being done there.
Speaker 1 00:26:27 Do you, let's talk about treatments, um, talk a little bit about what the treatment is and how it works.
Speaker 2 00:26:39 So the treatment that going from the category of patients whose tumors localized and containment to the pancreas, the standard of care for more than dozen years has been the attempt at surgery, wherever the cancer might be located and often followed by approximately or up to six months of chemotherapy. In that situation, the role of chemotherapy would be to try and, and get rid of, and quash or eradicate and kill off any microscopic cells that are inevitably left behind in order to decrease the risk that would come back and hopefully to have patients live longer. And hopefully cancer-free the foundation of that approach would be the surgery. But I think definitely the experience compared to prior to the 20th century was a surgery alone and not the unacceptably high number of cases would come back. Unfortunately, the vast majority of cases are not that it's 80% or more where the tumor is either wrapped around major structures that do not allow us to have surgery performed fund or half of all cases where the cancer has not only escaped the pancreas, the gut into the bloodstream and spread to other sites.
Speaker 2 00:27:47 That's been the cancer terminology with the called metastasis, meaning spread far away from where it started. That's equivalent to saying stage four, in which those types of cancers of Pinterest carcinoma not curable, but the purpose of chemotherapy is palliative and intentional. In other words, to make someone feel better to improve their quality of life as compared to not doing the chemotherapy, that the actual drugs that are used, most of which go through the vein are pretty similar. Whether it's the scenario where it's being given after a surgery or a surgery cannot be performed for any reason, the drugs themselves are pretty similar and a pancreatic cancer community worldwide has made a lot of progress based on clinical trials, just in the last decade and increasing the number of options. We have to treat patients with new combinations and actual new drugs for pancreas cancer that work effectively.
Speaker 1 00:28:38 I was going to say, I've kind of been told that, um, there's not, if you look at breast cancer, there's a lot of chemotherapies. There are choices of that combinations of stuff to use on that, where I've kind of been told that pancreatic cancer, there's not nearly as many, is this true? And why would that be
Speaker 2 00:29:02 Right? Uh, I think relatively too, for example, compared to breast cancer, you're absolutely correct. Um, I think some of the unique biologic features I'll use both breast cancer and even, um, the more common, a common form of lung cancer called non-small cell lung cancer. Uh, when I was in training at Memorial Sloan Kettering cancer center in New York city, more than decade ago, entering that period, we just thought of someone being diagnosed with lung cancer. And if you want to be more specific it's non-small cell lung cancer, or someone was diagnosed with breast cancer, who has breast cancer, what do you do for breast cancer? And the evolution of the field of cancer treatment has been rather remarkable in the last decade, decade and a half where it's not just, it's only the beginning of the categorization. So we end up splitting based on the properties of the cell under the microscope, but also advanced techniques to find out what genes might be driving, uh, what proteins might be deriving from those genes, and then how those cancers actually present different subtypes.
Speaker 2 00:30:02 That way it's important to oncologists like myself, making a treatment decision is we have more options for treatment that actually targets specific subtypes. So to give you an example from lung cancer, approximately 5% of that category called non-small cell lung cancer are driven by a gene that's similar to a type of leukemia it's called ALK or out for short there in recent years, there was a drug that can be taken to target that, to go against that target and work quite effectively to treat that form of cancer. And if that target is seen in other types of cancers, that may also work effectively, but it should not, it would not work effectively or not expected to work effectively and the other 95%. So that, that is a 5% sounds small, but it's very important to that. 5% of patients who have pancreas cancer has presented much more of a biological dilemma, which many, many researchers are still trying to overcome.
Speaker 2 00:30:57 Um, we have not yet identified various specific subsets at the genomic or cellular level with pancreas cancer. Like we have with breast cancer and lung cancer. As I specified that's limited the type of treatment options that can be given. We're also familiar with whether people seeing advertisements on the internet, reading about types of cancers, like what are called targeted therapy or molecular therapy or immunotherapy. And it's pretty common question. People will come in saying, well, I know somebody who has cancer, they're getting no name, a type of therapy, and I'll, I'll ask further, what kind of cancer are they getting treated for him? I have a pretty similar discussion that I have now, the type of chemotherapies that are given for pancreas cancer, are there things that have been around for decades, but maybe new, is it new you, the new combinations or new reformulations of drugs, or actually new drugs altogether that have been perhaps used in other types of cancers, or perhaps use a new combination that I've gone through years long clinical trials that are shown to be better than what previously existed at standard of care. And it entered the repertoire, but what we can use, but you're absolutely right. The, the, the actual number of actual trucks that we're using for Memphis cancer, it's much higher than it was a decade ago. But, um, compared to some other types of cancers, we have a long way to go.
Speaker 1 00:32:21 Could you talk a little bit about, and I'm sure I'll explain this incorrectly. So my apologies, but there's something to do with how, when, when there is pancreatic cancers, how the cancer is that actually part of your body forms around it, part of your cells form around it. And, and it makes almost a shell around it and it's hard and it makes it difficult for other, um, thing, drugs and stuff to, to permeate it, or to tell that it's to break it down so it's, they can get to the cancer. It's like your body's almost fighting against it because it's protecting that cancer. Am I saying that right? How do you
Speaker 2 00:33:00 You're I think you gave an excellent, excellent description of the, of that conundrum. Um, so the, the important thing, um, to view tumors, and I'm kind of putting on my biologist hat, and it's also a great reminder for even doctors and other oncologists and or students of medicine to understand is that when we, we, we were often referred to these entities called tumor clones, but they're actually very heterogeneous. They're made of so many different types of cells. So one who has a cancerous tumor, it's not the case at a hundred percent of it is just cancer cells. It's some composition, it could be half or less than half even of cancer cells, but then all these other things that are either like structural scaffolds or maybe help to feed the cancer cells or maybe blood vessels that the cancer cells will form to nourish themselves all become part of this.
Speaker 2 00:33:52 We call the tumor micro environment and pancreas cancer, because this is true across many types of cancers, but it's particularly challenging in pancreas carcinoma because tankers cancer really knows how to do this very, very well. Uh, I think the, the word you'd use to describe a shell brings to mind something that's really hard and, uh, almost cloaking like a fortress. And that's exactly right. That's exactly what a pancreas cancer does. It's a very insidious disease. Uh, it, it it's ahead of the game before we can even diagnose it. It's already laid for itself, um, a very fertile environment, and that can take the shape where the cancer cells settle themselves in a very hard and like a physically hard environment that might also make it hard for the surgeon to take it out effectively. But it also is great fertile soil for the cancer to grow uninterrupted.
Speaker 2 00:34:45 In other words, our immune system might not be able to recognize it early enough, and even if it were to attack it, wouldn't be able to penetrate that shell. We're having a lot of difficulty in some cases, more than others. And we're not yet sophisticated enough to be able to predict this ahead of time, but we're making progress that sometimes you give chemotherapy. And it's very clear on subsequent CT scans that it's getting into the tumor very well. Maybe the tumor shrinks and other times, uh, chemotherapy or drugs have a hard time getting in by Patrick Michelle. And we speculate that if only it could make it into the actual core of the tumor inside the cancer would probably hopefully work effectively, but it's, it's reaching a barrier that it can't pass. And that's why the drug doesn't work effectively. There have been recent approaches. And again, trying different strategies that are, maybe are not commonly used for breast or lung cancer. The other examples I gave earlier where targeted therapies are effective, but, um, some drugs designed not to attack the actual cancer cells, but to attack that shell and try and break it down. And he wrote that shell that would then allow the other chemotherapy drugs to infiltrate much better and work more effectively.
Speaker 1 00:35:55 So theoretically, immunotherapy probably wouldn't work in this case because
Speaker 2 00:36:01 At the current time I'd have to say, yeah, it's, uh, I know they did. It would be extreme minority, especially compared to other types of cancers. That immunotherapy is the way we're thinking about immunotherapy. The last few years is working exceptionally, exceptionally well, such as melanoma, skin cancer, or some forms of lung cancer, but not yet seeing that success, but there are, um, many types of clinical trials and, and lab based research, trying to cover that question about how can we manipulate pancreas cancer by treating it with something else to make it more susceptible to immunotherapy. That's very active and exciting and hopefully a reverse search as well.
Speaker 1 00:36:40 What is the, the length of time when is generally given when they've been diagnosed?
Speaker 2 00:36:53 It could be, I think the, the, uh, ability to perform surgery, if the tumor is localized, would certainly affect prognosis and the prognosis generally, uh, on average, and I'll qualify that with an asterisk in a moment on average, it would be better for those patients whose tumor is caught earlier localized at the time of diagnosis and able to have surgery performed. Um, if patients have widespread cancer and it could depend on where it's spread the purpose of chemotherapy and the ability of chemotherapy is readily limited because I said, I can't take it away. And, and prognosis might not be expected to be as good, but I, in my own practice, I I've learned never to. Um, when I first meet someone to, unless they want to know statistics. And I tell them, even if they do that, these clinical trials produce statistics, talking that calculate an average of hundreds and maybe even thousands of patients, but no individual person has a statistic.
Speaker 2 00:37:50 And so I've, I've been very pleasantly surprised by patients with stage four metastatic pancreas cancer living for years. Uh, and I, I wish I could scientifically discover what exactly was unique and different about their pancreas cancer compared to those who unfortunately do not live more than a few months after diagnosis, but, uh, that's also provided a lot of hope. And so, um, I, I'm doing that discussion with patients. I make it a personal discussion and, and try to provide the extent of information that they want to hear. And if they do wish for statistics, which I provide, I, I qualify by saying you're not assisted. Maybe you can beat the odds. Ah,
Speaker 1 00:38:33 So when one comes in and is it diagnosed? What, what are the steps you do? What do you, how, how are the family worked with what, what should happen? And, uh, when one comes in and they're diagnosed?
Speaker 2 00:38:50 Sure, well, uh, I, um, one of my greater fears is if someone does not have family or friends or other type of support, it could be a logistically more challenging, uh, both from a physical and emotional and mental standpoint, um, in terms of undergoing treatment and being able to do well through it. Uh, I'm actually thrilled when patients come in, majority of tend to do with either a spouse or significant other, uh, children, family members, or friends or neighbors, or I've had many people bring their, their, their, uh, people from church or other religious faith organizations, someone to help them and to be their eyes and ears, and to help them absorb what's a very impactful and a very emotionally fraught. Um, so I think first and foremost, we try and find a lot of reassurance more than just medical details, which can always be shared.
Speaker 2 00:39:44 I visited just trying to provide some hope that by the end of the visit, by the time I leave, if they leave the smile or the idea that I heard, the diagnosis of pancreas cancer, this is devastating. Um, is there hope for me? And I hope that they leave with more hope than they came in with. And I think logistically and sending up plans and just trying to show that, uh, we've, we've done our homework are usually trying to know as many of the details and, uh, request whatever tests are needed before I meet a patient that way, by the time they leave, we have a hundred percent of a plan that we could set in place if they choose to go forward with us as their care team. And so we have a great team at the university of Minnesota and our inner may Sonic cancer clinic.
Speaker 2 00:40:27 It's I often tell folks that I'm the oncologist, I'm probably the least important person on the team. We have fantastic nurses and basically an army of physician assistants and nurse practitioners who patients see on a very routine regular basis. Uh, prior to the chemotherapy treatments, we have social workers, um, tomorrow who are super at our cancer. The next team, we have a palliative care team. These are board certified physicians and experts who are there for anything and everything that's, that's bothersome to the patient. And that might be physical symptoms like pain or trouble, their nutrition, but it can also be emotional or mental things. And so the role of the family I see is, is integral more than their medical specialty I can think of is that the family will, or I'll include in that friends or trust members of whomever. A patient would identify as our strongest source of support then to be a presence and to be a strength of that. I don't see that as being any different than the chemotherapy treatment or anything else that we do in the clinic. It's, it's integral and it's vital to the, for success and the patient will have,
Speaker 1 00:41:36 Can you talk about studies? What is it talk about how they work and how does somebody get involved?
Speaker 2 00:41:44 Sure. Uh, so they're often referred to by different names. Um, most commonly you might hear the term clinical trials, clinical research, clinical studies and, and the terms, all of which I mentioned can also be very imposing because it somehow implies that someone is being experimented on. So it's, it's very important to, as a foundation of understanding that it's something that, um, what we call informed consent that someone has to not just acknowledge or be aware, but, uh, ensure that something might be offered to them, but no one should ever feel an obligation to enroll them in these. But for, for cancers that are still remained very challenging to treat, we don't have broad sweeping potential cures. Uh, clinical trials are especially, uh, critical and vital to moving the field forward and to improving patient outcomes, including very much so in pancreas cancer. And I include some other cancers.
Speaker 2 00:42:38 I treat in that basket as well, but because we're just trying to find something better than what we already have. I mentioned in the very first part of our conversation, that when I was growing up in New York, my mom's best friend was getting treated with pancreas cancer. And she would fly down to the national institutes of health in Bethesda, Maryland, every few weeks for a drug that at the time was experimental on a clinical trial, but has now been around and prevalent for the last 20 years as very routine standard of care and remains one of the treatment options, the treatment options. I mentioned also throughout the conference conversation that even when I, when I began practice were not valid treatment options, all became so were approved by the United States FDA because they went through clinical trials where patients were volunteers and volunteer to get one drug treatment or another.
Speaker 2 00:43:27 And then once those results were assessed that there were found that yes, this combination is better than what previously existed. This is entering the options as a new standard of care. Overall, the United States for cancer clinical trials, as, as oncologists and cancer centers, we need to do much better job of educating the public of what trials are and bringing clinical trials to our centers and the Masonic Kansas clinic, Mayo clinic at the university. And so to stand out among many people's minds, but also many of the regional partnerships among the community oncology practices have access to community, uh, clinical trials that are nationwide brought here to the regions, not just in the metropolitan Minneapolis St Paul area, but throughout the state of Minnesota, including for the Minnesota clinic trials network to make us more accessible, because it's important because we want to provide the best treatment possible after cancers like pancreas cancer. We want to see, uh, at least offer the option that patients can have to have something more than just the standard of care. This is what moves the needle forward to, to get better treatment.
Speaker 1 00:44:28 My friend who had pancreatic cancer used to look for clinical trials and she would fly to places to be in them or to be assessed if she was able to be in them. It seems to me that that would, that could weigh very heavy on the family financially and otherwise. Is there anything that helps, helps pay that or, or support that?
Speaker 2 00:44:59 That's a, that's a great point. It's, it's something of increasing, um, increasingly being recognized, um, among the medical community, as it really should be. There's actually a term that's developed, uh, over time and use more commonly. Now, when we call it, it's called financial toxicity, because we often think of that, the toll that pancreas and other types of cancers take on the body and also the mind and the spirit, but, but, uh, the toll that is takes on, on the patient and family and how much it costs, because we're not waiting to my thing minutes a minute that the patient is, has a three-hour chemotherapy infusion. And how much does it cost for parking or the gas to come here, whether someone's coming from a few miles away, or sometimes my patients will come from several hours away, every, on a very routine basis to get chemotherapy treatment or other forms of treatment, or just for routine checkups.
Speaker 2 00:45:51 Um, the goal of any facility providing clinical trials is by clinical trials that fit the population of, uh, of the patients that they treat. Some of the challenges of clinical trials is that there are different types of clinical trials. And, uh, there's often a long list of a checklist that's designed to ensure above all safety. So if someone had the type of cancer and the combo trial enrolls patients with that cancer, does it make one automatically eligible from a biologic standpoint in may, for example, some trials are reserved for patients who have exhausted all available standard of care options that are already available by any oncology team. And then, and only then can someone enrolled in a certain sense of trial. Um, some other clinical trials are for patients who are newly diagnosed, but if someone gets a different form of treatment and then comes for example, to me and I had a trial, unfortunately I would not be able to offer that.
Speaker 2 00:46:46 So those are just some examples of eligibility. Um, and, uh, and yes, I, I think it's, it's very challenging if someone has a clinical trial, that's, it needs a clinical trial, but the trial is not available in every geographic area. It, it can, it can take a physical toll and as well as a financial toll to fly to another city, another state to seek that clinical trial clinical trial has also provided very close oversight and often the visits and the testing is often more frequent than it would be the standard of care. And that that can increase the, all of those types of toxicity that I mentioned financial and other ones. So they all presents challenges. But our, certainly our goal here is to have as many clinical trials as possible for the patients that we treat the, some of the logistics of clinical trials, because they're expensive to run of that.
Speaker 2 00:47:33 There's a preset number of patients that we can enroll. And sometimes logistically there have to be, uh, some amount of time after enrolling any given number of patients before we can enroll anymore, mostly out of safety evaluations to ensure that no one's being harmed, but anything that we're doing. And so one of the other challenges is patients come to our center, are many others seeking a clinical trial, and they're in need that week or within a couple of weeks of a trial, but perhaps we have a trial or another center may have had a trial, but not at that, not a spot to offer that week. And that's, that's really hard where we, if we can't offer it when it's needed all the time,
Speaker 1 00:48:11 Like a very tricky part of the, we want you for clinical trials, but fill in the blank.
Speaker 2 00:48:21 Absolutely, absolutely. I, uh, I it's, uh, it's, it's, uh, certainly a tremendous logistical operation and, and they're, they're certainly very expensive to operate. So, um, they're often funded by either grants or partnerships with pharmaceutical industries that these drugs are being provided and the sponsor of the clinical trials, but also it's always a constant, very intensive assessment of safety to ensure that the patients were enrolled. The mantra of medicine in general, globally is first do no harm. And so the greatest fear that I think that any oncologist would have, or any care member team of a team would have is to ensure that we're not doing harm by doing the clinical trial for any given patient.
Speaker 1 00:49:08 How do people find out about these clinical trials?
Speaker 2 00:49:12 So in the certainly, uh, if someone's already a cancer patient and asking your oncologist, um, the, uh, there's a, there are a number of different internet sites, uh, for pancreas cancer in particular, there are some excellent advocacy organizations nationwide. There's a pancreatic cancer action network, which is a fantastic acting network. That's been around for a couple of decades. Uh, and the local chapter here in Minneapolis St. Paul area is tremendously active and supportive of all pancreatic cancer patients and families. Um, the short version acronym of that organization is Penn can, or Penn can.org. They, um, they have a hotline where patients can call up or families call up for more information and to be steered towards clinical trials. Then national Institute of health has an official website successful to all clinical trials.gov it's Punka trials, as compact as one word.gov, and one can search by state type of cancer, the type of cancer center and whatnot.
Speaker 2 00:50:08 But, uh, all of this is because there's a lot of medical jargon involved. It can be very complicated and overwhelming for patients to navigate, um, many centers, including ours, have patient navigators who are support the patient, not for my, um, chemotherapy drug or, or physical exam type of standpoint, but really to help them navigate the medical system, which in of itself can be overwhelming. And that includes helping to steer patients towards physicians like myself, who might be able to offer clinical trials. But certainly if someone were to come and is under the care of a physician in the region, or even as we get many patients from not just the parts of Minnesota, but also in North Dakota, South Dakota, Northern Iowa, or Western Wisconsin, or even farther, they might come. And if they're, if it's come to our attention, they'd look into clinical trials where they tell us that they would try and turn over every stone that we can, especially if we have a clinical trial to offer at our center. But if it's elsewhere, we can help point in the right direction as well.
Speaker 1 00:51:05 So I wonder, um, you talked about how, at least in the last decade, there's been some great progress with treatments for pancreatic cancer. Uh, sometimes it feels like movement in the, you know, forward in the treatment area can be so slow for some cancers. Um, obviously they might be harder to treat, but is there a sense of like how much money gets put toward that particular cancer? And I'll take, for example, breast cancer, where a lot of money is put towards that. And, you know, I wouldn't begrudge that, um, obviously, but there might be some other cancers out there where, I mean, how, how does that break down funding for,
Speaker 2 00:51:56 Um, there even going even further you're right. And the breast cancer is one of the more common cancers, but certainly it has, I think a super good example of, um, very, um, high-level organized advocates, organizations that are very active in raising money. The pancreatic cancer action network that I mentioned earlier is just one of many locally, regionally, or nationally who also raised a lot of money stand up to cancer from the Hollywood community. Also raised a lot of money, including for pancreatic cancer specific research. There are different stages of research. Some people, including people who work for me in my lab, looking under the microscope it's cells that are not immediate in the horizon for altering new drugs for patients when I go to clinic. And the other end of the spectrum is actually funding clinical trials. Um, it's a tremendously research in general is a tremendously expensive enterprise.
Speaker 2 00:52:48 And, uh, I, I say many of my research colleagues would agree that a lot of our time is spent trying to raise the money. And, uh, for example, putting proposals together to get grants, to, to fund the research that takes sometimes most of our time away from actually doing the research or the clinical trials that we hope to do. Um, so because resources are precious, we have to be a little more cautious and think you're absolutely right. Science is slow. And, uh, even the aspect of clinical trials can be slow. Some of the clinical trials when we go to as oncologists to major oncology organization conferences, and he was also released, and sometimes it's, it's made public in, uh, in a nationwide news and press releases. I always keep in mind, or I tell trainees that sometimes the, the idea for that clinical trial we're hearing the end result, but the idea probably ruminated in someone's mind's eye 10 or 12 years ago. And by the time they got funding and were able to go from.
