Expert Analysis Highlights:

• Radiation and surgery components of treatment for pancreatic cancer are highly complex
• Data indicate that rates of postoperative mortality are directly related to the surgical volume of the treatment team and medical facility
• It is my recommendation that patients with pancreatic cancer seek out major institutions of excellence for their treatment
• Here is a comprehensive list of all cancer treatment centers in your state from  our companion site patientresource.net

Pancreatic cancer remains one of the most difficult to treat and deadliest forms of cancer. This blog highlights the value of an aggressive approach that combines preoperative proton radiation with chemotherapy followed by an aggressive resection known as a “Whipple” procedure. For selected patients who present with the disease still localized within the pancreas, this approach represents the best chance for cure.

The radiation and surgery components of treatment for pancreatic cancer are highly complex. The video describes using a highly specialized form of radiation called proton therapy. Proton radiation differs from conventional X-ray radiation in the way the radiation dose is deposited. With proton radiation, the dose increases to a peak and then rapidly falls off. The goal of the protocol study described is to uses these physical properties of protons to limit the dose to the very sensitive normal structures just adjacent to pancreatic tumors. These structures include the liver, stomach, and small intestine.

The surgery for localized pancreatic cancer is equally complex. Studies have clearly indicated that these types of complex operations are best handled by experienced surgeons. Data indicate that rates of postoperative mortality are directly related to the surgical volume of the treatment team and medical facility. Therefore, it is my recommendation that patients with pancreatic cancer seek out major institutions of excellence for their treatment.

Expert Analysis Highlights:

• Day before surgery can be an intimidating and confusing time
• Patients who do well the day before surgery describe being active with others
• Contrary to popular opinion, the days before surgery should be an active time with good hearty meals
• Exercising beforehand can set back atrophy by not allowing it to get a head start
• Remember the details of your instructions before surgery

The day before surgery can be an intimidating and confusing time. Anxiety about the outcome of the operation and long-term survival can be alleviated by knowing facts about surgery and tips patients have found useful in preparing.

First, stay active and eat well right up until the night before surgery. Unless you’re having colon surgery which often requires a bowel prep and an extra day of a restricted diet before surgery, go ahead and beef up! Contrary to popular opinion, the days before surgery should be an active time with good hearty meals. I tell many patients to treat themselves to a delicious meal in the days leading up to surgery and, depending on the operation, even the night before surgery. You won’t be eating much after the operation for a couple days at least, so to minimize the period of going without nutrition, its good to get some good calories in the system. Nutrition is also known to strengthen your immune system, which sometimes needs to work well during your recovery.

Along the same lines, stay fit. Go ahead and go to the gym and get some good exercise before surgery. The days after surgery are like being an astronaut in that your muscles get weak from lack of use (called atrophy). Exercising beforehand can set back atrophy by not allowing it to get a head start.

Here are some more facts that are good to ease fears. The data on surgery demonstrate that the operation itself is very standardized. In my field of pancreas surgery for example, nearly every experienced pancreas surgeon in the world performs essentially the same operation with minimal variation. Many patients are also worried about general anesthesia, perhaps based on scary movies or public legends of the olden days, but general anesthesia today has a major complication rate of only about 1 in 100,000. Anesthesia is very safe in the modern era, and its safety profile in medicine is among the best of any medical intervention.

Patients who do well the day before surgery describe being active with others. As a general note on patients that I see who are depressed and anxious, the more someone has a community, the less likely they are to experience depression or anxiety. Movies, performances, getting together with friends, and family gatherings are some of the activities patients find helpful in making the day before surgery a pleasant experience. Often times patients describe a great experience surrounding themselves with positive friends—people who are optimistic and enjoy life.

Finally, remember the details of your instructions before surgery: Nothing to eat or drink by mouth 8 hours before your scheduled surgery time, and bring your most recent CAT scan with you if your surgeon does not already have it.



Expert Analysis Highlights:

• Advances in technology and instrumentation has allowed surgeons to approach tumors previously thought to be impossible to remove with laparoscopy
• The reason why only a few patients get the superior operation is that only a few doctors in the country know how to do it
• Ask your local doctor for a surgeon in your area who has a lot of experience with minimally-invasive pancreas surgery, and don’t be afraid to call an expert for a phone consultation

Minimally-invasive Surgery has advanced so quickly in the last 2 years, that the largest operations of the body can now be completed through minimally-invasive techniques. Advances in technology and instrumentation has allowed surgeons to approach tumors previously thought to be impossible to remove with laparoscopy.   Determining laparoscopic candidacy requires good judgment by a surgeon who has experience with both the laparoscopic and traditional large open operations.

Many operations of the pancreas can now be done with these techniques.  These options include:

Laparoscopic Whipple Procedures

Laparoscopic Distal Pancreatectomy

Laparoscopic Central Pancreas Removal

Laparoscopic Pancreas Tumor Enucleation

Consider a highly-standardized surgical problem like a 2 cm mass in the tail of the pancreas.  95% of these are removed through a large open operation, even though a minimally-invasive approach results in less pain, fewer wound infections, fewer hernias, and an earlier return to work.  So who gets the laparoscopic operation?  The motivated patient!

The reason why only a few patients get the superior operation is that only a few doctors in the country know how to do it.  Ask your local doctor for a surgeon in your area who has a lot of experience with minimally-invasive pancreas surgery, and don’t be afraid to call an expert for a phone consultation.

Expert Analysis Highlights:

• Pancreas cancer patients often have “the kitchen sink” thrown at them causing unnecessary delays before surgery
• Tests and studies that often don’t influence cancer management cause delays for a cancer known to grow especially fast
• Average time from discovery to treatment is 5.5 weeks
• If for example a 4 cm tumor were discovered on my pancreas, I would likely find myself a surgeon and get the cancer out within a few days

A work-up for cancer can be a stressful period.  What begins as an incidentally discovered “mass” found on the pancreas, can result in a long road of tests, studies, and psychological duress leading to an eventual treatment plan or surgery, chemo or neither. In the case of pancreas cancer, the average time from discovery to treatment is 5.5 weeks (which for the patient, often seems like 5.5 years).

In the case of pancreas cancer–one of the most aggressive cancers out there in terms of growth rate and time to metastasis (spreading)–many patients are overly worked-up.  Evaluations have been know to last for months, much of which is spent waiting for scheduled tests and studies, or appointments with specialists.  While some cases are complex and require multiple studies, tests, and procedures, VERY FEW actually require much more than a simple high-quality CT scan.

Despite the reality that most cancer are quickly evaluated enough to make a treatment plan, patients often have “the kitchen sink” thrown at them, including studies such as a PET scan which has never been proven to help in the evaluation of pancreas cancer like it has for lung, lymphoma and other cancers.  Pancreas specialists have long noted that patients who have clearly removable cancers have too many unnecessary delays before surgery, most of which are the result of non-specialists trying to do a “thorough” work-up before referral to a surgeon.   The result is patients are told they need to have biopsies, lab tests, or MRI’s.  But when the results of these many tests do not influence the management of the cancer, then they are unnecessary.  Furthermore, they delay treatment for a cancer known to grow especially fast.

Take a patient with a newly discovered pancreas tumor.  If the mass meets criteria for surgical removal, then it should be removed immediately.  Needle biopsies sample only a small piece of a mass and the biopsy can be negative even when there is a small focus of cancer within the tumor.  Consider that if the biopsy is negative and the recommendation would be to still have it removed, then the biopsy does not really influence the treatment/surgery plan and should not be done.  Futhermore, a simple CT is as good of a test as any in determining whether pancreas cancer has spread or not.  So the take home message is: Beware of too many delays for tests and studies which do not matter.

Pancreas cancer is one of the fastest growing cancers that exist within the universe of cancer.  Thus prompt surgical removal for appropriate cancer should be the goal and patients should ask with every intermediate step: “Will this change what we do?”  If I as a pancreas specialist has an incidentally found 4 cm tumor discovered on my pancreas on a routine CT scan done for another reason, I would likely find myself a surgeon and get it out within a few days.

Be sure to discuss these issues with your doctor.

For those who want to gain visual insights into minimally invasive surgery, this video segment shows a partial resection (removal) of a pancreas that has a cancer growing in it. The 2-minute segment shows only parts of the operation, but it does show representative steps in the partial surgical resection of the pancreas. The surgeon is from Santiago Chile.

This is an interview with Dr Richard Alexander, a prominent surgical oncologist at the University of Maryland Medical Center. He talks about pancreas cancer and shows an operating room video of cancerous segments of the pancreas being surgically removed.

A diagnosis of cancer can be scary, and understanding a treatment plan confusing. To gain more information, it is sometimes wise to seek a second opinion or advice from another qualified cancer specialist or group of specialists before or even after you begin treatment.

If you are asked to consider alternatives, such as surgery or radiation or chemotherapy or hormone therapy, you might want to hear from each type of oncologist who gives that treatment. It’s all right to look at all your options. A second opinion could save your life or better protect your quality of life.

Options for getting a second opinion:

- Talk to a cancer specialist in another specialty or medical group.

- Ask that your case be presented to a tumor board or tumor conference at your hospital.

- Ask to get a second opinion on your pathology reading, especially if there is any controversy in making a complete diagnosis.

- Seek the advice of a renowned cancer expert usually in a comprehensive cancer center especially if your situation is complicated or uncommon.

For more information, see our companion website: www.patientresource.net. Here’s some of the content from patientresource.net that you may find useful:

Getting a second opinion involves asking another cancer specialist or group of specialists to review your medical records and confirm your doctor’s diagnosis and treatment plan. Other specialists can confirm your pathology report and stage of cancer and might suggest changes or alternatives to the proposed treatment plan. They can also answer any additional questions you may have. There is often collective wisdom gained from the experience and opinions of different oncology specialists who are experts in your type of cancer.

There are lots of reasons for seeking a second opinion. Some doctors may favor one treatment approach, while others might suggest a different combination of treatments. Doctors in each oncology specialty bring different training and perspectives to cancer treatment planning. Another doctor’s opinion may change the diagnosis or reveal a treatment your first doctor was not aware of. You need to hear arguments for all of your treatment options. A second opinion is also a way to make sure your pathology diagnosis and staging are accurate, and that you are aware of clinical trials that you might want to consider.

If you are asked to consider alternatives, such as surgery, radiation, chemotherapy or hormone therapy, you might want to hear from each type of oncologist who provides that treatment. It’s all right to look at all your options; a second opinion could save your life or better protect your quality of life. Most doctors welcome another doctor’s opinion.

Second opinions are also valuable if you live in a small town or rural area where there may not be as many oncology specialists, especially if you have an uncommon type of cancer or might need a highly specialized or complicated type of care. If so, you may want to get an opinion from specialists at a larger medical center or comprehensive cancer center with particular expertise in treating your type of cancer.