Progress Continues in Pancreatic Cancer Treatment, But More Is Needed

Although new drugs are needed to improve outcomes for patients with pancreatic cancer, one expert noted that it is important to remember that researchers continue to make progress in this area.

Patients with pancreatic cancer are treated with a combination of modalities including chemotherapy and surgery, depending on the disease stage, but pancreatic cancer can be refractory, or nonresponsive, to treatment.

CURE® spoke with Dr. Nicholas N. Nissen, director of hepato-pancreato-biliary surgery and co-director of a multidisciplinary pancreatic cancer clinic at Cedars-Sinai Medical Center in Los Angeles, and scientific and medical advisory board member for Pancreatic Cancer Action Network to learn more about treatments for pancreatic cancer and where he sees the field going in the future.

What are the available treatment options for pancreatic cancer?

It depends a bit on the stage. For stage 4 patients, treatment is all focused on systemic therapy with chemotherapy. And there are a variety of treatment protocols now, clinical trials, different chemotherapy types, different patterns of chemotherapy that are given in stage 4.

But in the earlier stages — stage 1, 2 and 3 — the goal is cure, but it's also long-term disease control. We know that for stage 1 and 2, we're really still trying to get the person to a curative operation. In other words, the goal is still surgery. The timing of surgery, though, has become something that's debated. Should we operate right at the beginning, or should we give chemotherapy first and operate later? And that's still being debated, but your goal for early-stage pancreas cancer is ultimately surgery to remove it. But surgery is always combined with chemotherapy either before or after surgery. For later stages, your goal is chemotherapy with disease control, trying to both have longer term remissions and also longer life.

What unmet needs persist in this area?

Well, we do not have enough drugs available. Pancreas cancer tends to be fairly refractory to many types of chemotherapy; we really only have a few forms of chemotherapy that have been shown to work.

The so-called targeted therapies that are available for a lot of other cancers, in most cases, are not beneficial in pancreas cancer. There are a few cases where they're beneficial, so everybody should have a tumor profile to see if they're a candidate for targeted therapy. But as a general rule, the odds that a pancreatic cancer case is amenable to targeted therapy is pretty low.

So we have our standard chemotherapy options, which we don't have a lot of, but we have a few. If you're lucky, we can find a targeted therapy option for you. We of course have clinical trials trying to look at everything from immunotherapy to amino acid additives to other combinations of chemotherapy. But those are still in trial form.

But we need new drugs. That's the unmet need, new types of chemotherapy, new cancer approaches. And we're still waiting for that groundbreaking approach that's going to really change the landscape, and we haven't found it yet for pancreas cancer.

When do you think that groundbreaking approach will come into the field?

Dr. Nicholas N. Nissen said that the field is still waiting for the "groundbreaking approach" that will change the field of pancreatic cancer.

It's hard to speculate on any groundbreaking treatment in the cancer world. Immunotherapy was very exciting across a lot of tumor types; it just hasn't really shown itself to be beneficial in this disease. But maybe there's a way to potentiate these treatments to really make them more beneficial.

I'm an eternal optimist. So yes, I'm optimistic that with all the energy and all the funding —well, it's not enough funding, by the way — but with so many committed programs and people, I'm confident we're going to keep making progress. It just feels like we're making progress not really at a snail's pace but at a pretty slow pace. But we are making progress. We are. There’s no question.

What is the recurrence risk in patients with pancreatic cancer?

The risk of recurrence very much depends on stage, on lymph nodes and even on some of your early parameters. For example, whether we thought you might have had micrometastatic disease, other things.

The risk of recurrence after complete treatment, meaning chemotherapy and surgery, plus or minus radiation. By the way, we haven't really talked about radiation because there's a lot of debate on that. But complete treatment would be considered, you got it removed and you had a full course of chemotherapy either before, during or after your surgery. When that's done, your risk of recurrence does depend on stage, and it depends probably mostly on the stage at presentation. But believe it or not, it may also depend on the stage at tumor removal. And that's this concept of trying to downstage a tumor, trying to take it from a more advanced stage, use chemotherapy, convert it to an earlier stage and then when it's removed, hopefully you follow a different path. You now follow the recurrence risk of an earlier-stage case. But across the board, early stage, 1, 2 and 3, they all have a high risk of recurrence after successful surgery. The risk of recurrence can be as low as 50% and as high as 80%. But these are staggering numbers here. You could be in the best prognostic group and still be facing a 40% to 60% risk of recurrence. That's how difficult this disease is.

What advice would you give to patients who have been recently diagnosed with pancreatic cancer?

I think that the first advice is to make sure you've found a team that is well-versed, skilled and meets your needs. Sometimes, if you're remote from a major medical center, your team can be the local cancer center, but you still need a team that knows how to treat the disease. It's so important. We found there's probably no other cancer that needs teamsmanship and teamwork as much as this one does, from nutrition, to oncology, to surgery, radiation, pain control, supportive medicine, everything. So find a good team. Even if you have to drive a bit, somehow find a team. That’s No. 1.

No. 2 is rally your network. You need help with transportation, with staying focused and positive, with nutrition, you need help with everything. This is a time to, rather than hide the disease, rally your network, and people will surprise you. They'll help you in so many different ways possible.

No. 3, remember that we are making progress, and we're making progress even month by month. We are. It feels slow, but we are making progress. And therefore, that progress may benefit you, a person with a new diagnosis.

Be careful about your information sources. Go to well reputed information sources and stay away from sources that you're not sure about, because you're going to get really bad misinformation. So be careful about your information sources.

Yes, educate yourself. But again, just be careful about your information, educate yourself so you can talk to doctors in a useful way. So you can get second opinions and don't be afraid of second opinions.

And then finally, remember, there are a surprising number of success stories out there that sometimes don't make the internet, a surprising number of what we call outliers who surprised everybody. We're actually studying those patients. We're trying to figure out what's the secret to the patients who weren't supposed to live very long and yet, we're still seeing them years later. I remember there's a lot of outliers out there. And our goal is to make more and more of our patients into outliers who far outlive the published survival curves. Outliers are real. Remember, you can be an outlier.

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