Pancreatic Cancer Awareness Day

12/15/2011
Welcome to the 6th Annual
Pancreatic Cancer Awareness Day
November 12, 2011
1
12/15/2011
Program Agenda
Welcome from the Executive Director
John Chabot, MD
Mission and Goals from the Administrative Director
Francine Castillo, MS
Topics: I. Surgical Options and Post‐operative Lifestyle Changes
Beth Schrope, MD, PhD (Surgery)
II. Genetics & Prevention Harold Frucht, MD (Genetics & Prevention)
III. Pancreatic Cysts f,
( g y)
John Allendorf, MD (Surgery)
IV. The W’s and H’s of Drug Therapy in Pancreatic Cancer: How Can We Move Forward?
Wasif Saif, MD (Medical Director, The Pancreas Center)
V. Epidemiology of Pancreatic Cancer: What We Know About Risk and Prevention
Jeanine Genkinger, PhD, MHS (Epidemiology)
Q & A Session
2
12/15/2011
Mission
To decrease the societal and individual burden of pancreatic disease by establishing and maintaining a center of excellence dedicated to providing outstanding research and medical care to patients with pancreatic disease
100 Day Plan (Feb 1, 2008)
Clinical
Imminent Changes:
• Receptionist 2/4
• Dr Fine outpt practice 2/18
•Obesity Center final operational flow agreement
Fulfill staffing needs in 3 areas:
• Secretarial
• Precerting and Credentialing
• Financial Counseling
Have RN/NP help develop
smooth patient flow process:
Temp RNs thru July 08
Catherine & Rishikka
Break into three centers lead
by mid level managers:
Endocrine/Thyroid/Mesothel.
Pancreas
Obesity
Design and develop
High Risk Prevention Room/
Patient resource room
EMR Implementation
• In compliance
with university guidelines
Research
Imminent Changes:
Fundraising/
Marketing
Data Collection
&
Analysis
Continue to collect
volume numbers
and revenues across
all departments
•Clinical Research Manager
Implement
Tissue Banking
Lustgarten Site Visit
Feb 14
Victoria Serrano 3/14
Develop standards & ensure compliance for all research
initiatives Liaison to HICCC
initiatives. Liaison to HICCC
Continue and Expand
Research Meetings
Research Meetings
Mirza
and ean visit
and Dean visit
Feb 28
Scanning HHQs & other clinical
data directly into database
Continue to recruit for
High Risk Prevention
Protocols:
1: S‐MRCP vs S‐EUS for pancreatic cancer screening in
high‐risk individuals
2: Utilizing S‐MRCP & arginine Testing to compare exocrine/
endocrine function following Surgical resection for pancreatic
Surgical resection for pancreatic adenocarcinoma
3: Comparing S‐MRCP with e‐PFT in patients w/abdominal pain or
symptoms of pancreatic insufficiency following surgical
resection for pancreatic
adenocarcinoma
4: Studying the frequency of
distal/multifocal PanIN lesions in locally‐recurrent pancreatic cancer
5: Determining the frequency of
BRCA genetic mutations in Ashkenazi Jewish pancreatic cancer patients
Dr Fine Dr Su
Dr Frucht
Promote investigator driven studies
Preliminary Proof of new comprehensive
Mulitdept website
Continue collaboration
w/ other researchers
Comprehensive fundraising folder
Dr. Wendy Chung
Dr.Rotterdam
Dr. Lucas Dr. Verna
Develop patient
satisfaction survey, pinpoint areas in need of improvement
High Risk program brochure GI Research Fellow
Dr Caroline Hwang
July 2008 – July 2009
The Pancreas Center
comprehensive booklet
Purchase equipment
For uniform study #s
3
12/15/2011
Long Term Goals
Clinical
Marketing
Participate in
speaking
engagements
Increase space on IP 8
Develop true multi‐
disciplinary practice with
open scheduling
across all depts.
Fundraising for
charities
Encourage new donors
Rollout GI MED and MED ONC on EMR
MED ONC on EMR
Networking
Develop pancreas center affiliations
in suburban
hospitals
NYPH/
HICCC
Research
Develop a robust clinical
trial organization
Participate in
industry trials
Work with survivors/
family members
in the community to
organize local fundraising events
and “walks”
Develop financial model depicting
NYP growth
NYP growth from PC activities
Hire Pathologist Solely for Pancreas Center
Have largest
tumor bank in
country
Get
NIH grants
Long(er) Term Goals!
Clinical
Research
Awareness
Continue to improve patient access/patient satisfaction
SPORE grant!
Build mainstream media outlets
Expand translational research to improve patient outcomes PC Awareness outreach in minority communities
Add to clinical trials/continue collaboration with other institutions
Build internet presence/blog
Auto‐islet Transplant
Grow CYST Program
Dedicated psychosocial support outpatient program on site
Pre‐surgical diabetes teaching video
Expand referral physician base out of tri‐state area
Complete stool study
Complete stool study
Funding for new lab equipment
Build international reputation
Create lost to follow up protocol
Collaboration for pain management
……………………….
Recruit up and coming basic science researchers dedicated to the pancreas
Pancreas Center Endowment!!!!
Develop psychosocial program for families
Collaborate with American Cancer Society
……………………………..
……………………………
4
12/15/2011
Pancreas Center New Patient Volume
700
589
600
570
500
386
400
300
281
184
200
159
136
92
100
44
0
2002
2003
2004
2005
2006
2007
2008
2009
2010
5
12/15/2011
Th P
The Pancreas Center Team C t T
The Pancreas Center
Vasudha Dhar, MD (Interventional Endoscopy)
Tomas Gonda (Interventional Endoscopy)
Claudia Kipp, PA (Interventional Endoscopy) Charles Lightdale, MD (Interventional Endoscopy)
Charles Lightdale, MD (Interventional Endoscopy)
John Poneros, MD (Interventional Endoscopy) Amrita Sethi, MD (Interventional Endoscopy)
Tim Wang, MD, PhD (GI/Basic Science Research)
John Allendorf, MD (Surgery)
Laurie Budd, RN (Surgery)
John Chabot, MD (Surgery)
Nicole Goetz, DNP(Surgery)
G bi l
Gabriela Harrington (Surgery)
i
(S
)
James A. Lee, MD (Surgery)
Beth Schrope, MD, PhD (Surgery)
Yanghee Woo, MD (Surgery)
Kyung Chu, NP (Medical Oncology)
Robert Fine, MD (Medical Oncology)
Wasif Saif, MD (Medical Oncology)
William Sherman, MD (Medical Oncology)
The Muzzi Mirza Pancreatic Cancer Prevention and Genetics Program
Helen Remotti, MD (Pathology)
Heidi Rotterdam, MD (Pathology)
David Leung, MD (Nuclear Medicine)
Leonora Mui, MD (Radiology)
( d l )
Jeffrey Newhouse, MD (Radiology)
Martin Prince, MD (Radiology ) Mary Sciutto, MD (Dept of Psychiatry)
Harold Frucht, MD (Program Director )
Wendy Chung, MD (Genetics)
Fay Kastrinos, MD (Research)
Michael Rasiej, MD (Radiology)
Ashley Dikos (Administrative Manager)
Jason Chu (Part Time Research Admin)
Jason Chu (Part Time Research Admin)
Lauren Khanna, MD (Research)
Elana Levinson, MS (Genetics Counselor)
Aimee Lucas, MD (Research)
Vilma Rosario (Part Time Research Admin)
Eizabeth Verna, MD Research)
6
12/15/2011
The Pancreas Center
Division of GI Endocrine Surgery Administrative Support
Division of Hematology Oncology Administrative Support
Francine Castillo, MS
(Administrative Director/Division Administrator)
Bonnie Badenchini (Administrative Manager)
Maureen Benjamin (Billing Manager General Surgery)
Sarah Cambria (New Patient Coordinator, NP Admin Asst)
(
)
Colina Chapman Williams (Admin Asst)
Kimone Crossley (Data Manager)
Tyrina Jones (Medical Assistant)
Alba Munoz (Financial Coordinator General Surgery)
Priscilla Novas (New Patient Coordinator, NP Admin Asst)
Ana Rosario (Admin Asst) Quanda Tarleton (Medical Assistant)
Allison Villacis (Data Manager) Rodelyn Zapanta (Admin Asst) Nancy Amalbert (Divisional Administrator)
Jennifer Arroyo (Practice Manager)
Kristina Howard (Admin Asst)
Kindra Matthews (Admin Asst)
Division of Digestive and Liver Diseases pp
Administrative Support
Ana Ignat (Divisional Administrator)
Clarissa Alvino (MA)
Yandreily Arroyo (Admin Asst)
Carolyn Baldwin (Call Center)
George DeJesus (Admin Asst)
Jacqueline Infante (Practice Manager)
Evelyn Martinez‐Garcia (Admin Asst)
Camelia Salajeanu (Billing)
Yaniria Perez (Reception)
Beatriz Valladres (Call Center)
Connie Zapata (Practice Manager)
Misc Administrative Staff
Bryan Dotson (NYP Public Relations Office)
Jada Fabrizio (Office of External Affairs )
Bradley Jobling (Pancreas Center/Surgery Social Networking)
Kristen Mahood (Assistant VP of Development)
Juan Mejia (Service Line Director, Digestive Diseases)
Marilyn Mullins (Development Officer)
Amy Pietzak (NYP Public Relations Office)
Kathleen Propp (NYP Marketing)
Christine Rein (Office of External Affairs Events Coord)
Deb Schwartz (Director, Office of External Affairs)
Stephanie Sheeler (Office of External Affairs Events Coord)
Ju‐Mei Shieh (Pancreas Center Website Developer)
i Shi h (
bi
l
)
Jennifer Turvey (Office of External Affairs)
Herbert Irving Comprehensive Cancer Center Translational Research
Basic Science Research
Mary Ann Kral (Executive Director for Clinical Research) Mary Ann Kiernan (Regulatory Compliance Specialist) Frances Brogran (Research Nurse ‐ Dr. Wasif Saif) Kyung Chu, NP (Research Nurse ‐ Dr. William Sherman) Kelly Mowatt (Study Coordinator ‐ Dr Robert Fine) Dawn Tsushima, RN (Research Nurse ‐ Dr Robert Fine) Sarah Zelonis (Study Coordinator ‐ Dr Wasif Saif) Gloria Su, PhD Dario Garcia‐Carracedo, PhD Xiaojun Li Wanglong Qiu, MD, PhD Ken Olive, PhD Mike Badgley
Marina Furmanov
Jennifer Jongen
Paul Oberstein
Barbara Orelli, PhD
Carmine Palermo
Stephen Sastra
Dafydd Thomas, PhD
Yilong Hung Robert Fine, MD Richard Dinnen, PhD Yuehua Mao,MD Pancreas Center Research Staff
Joseph Dinorcia, MD (Research Fellow)
Irene Epelboym (Research) Jeanine Genkinger( Epidemiology)
Minna Lee (Research)
Qiongfen Li (Research – Autoislet) Megan Winner, MD (Research Fellow) NYP Ancillary Care Team
Anne Ammons, RD (Nutrition) Fran Hellar, LCSW (Inpt Social Work) Angela Lloyd, LCSW (Social Work) Tina Sapienza, LCSW (Social Work)
7
12/15/2011
Bob Brown
Bob Brown
Patient Speaker
Click to View Bob Brown's Story on Youtube
8
12/15/2011
SURGICAL OPTIONS &
POST‐OPERATIVE LIFESTYLE OS O
S
CHANGES
Beth Schrope, MD, PhD
Department of Surgery
Department of Surgery
Columbia University Medical Center/ New York‐
Presbyterian University
Pancreatic Surgery
Who gets surgery?
Types of procedures
Post‐operative lifestyle implications
9
12/15/2011
Who is Eligible for Surgery?
Localized disease
Localized disease
Assess with MRI, PET scan
Acceptable medical risk
Cardiovascular clearance
Preoperative chemo or radiation
For “locally advanced” disease
The Neighborhood
10
12/15/2011
Whipple Procedure
Removal of the head of the pancreas, duodenum, +/‐
portion of stomach, gallbladder
Typical hospital length of stay 7 – 14 days
Over 100 Whipples
performed at CUMC in 2010, 22% with vascular reconstruction
Distal Pancreatectomy
Removal of the body and tail of pancreas and possibly
tail of pancreas and possibly spleen
Option for laparoscopic procedure
Typical hospital length of stay 5 – 9 days
Requires certain Requires certain
vaccinations (for loss of spleen)
11
12/15/2011
Central Pancreatectomy
Removal of a portion of the body of pancreas
body of pancreas Reserved for benign and low grade malignant lesions (islet cell tumors)
Typical hospital length of stay 5 – 9 days
Goal to preserve as much Goal to preserve as much
pancreatic function as possible*
Total Pancreatectomy
Removal of entire pancreas, duodenum, gallbladder, +/‐
spleen
Typical hospital length of stay 10 – 14 days
All patients become insulin dependent diabetics*
Reserved for high cancer‐risk individuals
12
12/15/2011
Postoperative Expectations
Hospital length of stay
Pain
Resumption of diet / gastric ileus
Blood sugar monitoring / control
Bl d
it i /
t l
Pain Management
Immediate postoperative pain
l
d
PCA ‐> oral pain medications
Non‐narcotics – Toradol, Lyrica, Tramadol
Chronic pain
Oral pain medications –
Oral pain medications narcotic, NSAIDs, other
narcotic NSAIDs other
Narcotic patch
Nerve blocks
13
12/15/2011
Post‐pancreatectomy Diet
Reduce the size of your meals
Restrict dietary fat
Consider dietary supplements
Have nourishing snacks within easy reach
Don't worry if you have days when you can't eat at all
Try to drink plenty of fluids
Pancreatic Digestive Insufficiency
Symptoms
Diarrhea
Bloating
Foul‐smelling stool
Hair loss, dry skin
Difficulty gaining weight
Difficulty gaining weight
14
12/15/2011
Digestive Medications
Pancreatic enzymes (take at each meal)
Creon
Zenpep
Pancrease
Promotility agents
Reglan (metoclopramide)
Erythromycin
Antiulcer agents
Constipation regimen
Diabetes
ALL surgical patients experience elevated blood p
sugar after surgery
Insulin drip after surgery improves healing
Long term risk of diabetes 10 p
– 12% in patients with normal blood sugar before surgery (after Whipple)
15
12/15/2011
Quality of Life
Questionnaires from patients who have undergone Whipple report good quality of life,
undergone Whipple report good quality of life, comparable scores to healthy controls (79 ‐ 81 vs. 83 ‐ 86)
Diabetes is not a ‘guarantee’ and is a controllable consequence
Digestive and nutritional issues are easily controlled with medications and food choices
GENETICS & PREVENTION
GENETICS & PREVENTION
Harold Frucht, MD
Director, The Muzzi Mirza Pancreatic Cancer Prevention & Director
The Muzzi Mirza Pancreatic Cancer Prevention &
Genetics Program
Associate Professor, Division of GI Medicine
Columbia University Medical Center/New York‐Presbyterian Hospital 16
12/15/2011
15% of patients with pancreatic cancer have a familial aggregation or an inherited predisposition
Number of FDRs Incidence Increased Risk (w/ Pancreatic Cancer)
(per 100,000 in the
US Population)
(by Number of FDR)
General U.S. (reference)
9
‐
1
41
4.6 x
2
58
6.4 x
3 or more
288
32.0 x
Source: Klein AP, et al., Cancer Research 2004; 64; 2634‐2638
Mutation
Relative Risk
BRCA1, BRCA2
10
P16
15‐65
STK11
130
HNPCC
MLH1, MSH2
2
H di
Hereditary pancreatitis
ii
T
Trypsinogen
i
50
APC
5
Breast cancer
FAMMM
Peutz‐Jeghers Syndrome
Familial Polyposis
17
12/15/2011
2 or more FDR with pancreatic cancer
1 FDR with pancreas cancer, ≤ 50 years old
2 or more second degree relatives with pancreatic cancer, one at an early age
History, physical exam, family history, genetic testing
Average Risk:
‐1 family member with PC at > 55 years old Basic blood tests, additional testing if symptoms
Moderate Risk High Risk ‐ ≥ 2 1st, 2nd or 3rd °with PC
1 1st °at
< 55 years old
‐ 1 1
at < 55 years old ‐ Not high risk
‐ ≥ 3 1st, 2nd or 3rd°with PC ‐ ≥ 2 1st° with PC ‐ ≥ 1 1st & 1 2nd° with PC, 1 at < 55 years old
MRI or EUS
EUS and MRI
Any abnormal testing: EUS (if not already done)
No malignant or pre‐malignant disease identified
Malignant or pre‐malignant disease diagnosed or suspected
Surveillance (based on further risk stratification)
Consider Surgery
Verna EC, et al, Pancreatic cancer screening in a prospective cohort of high‐risk patients: a comprehensive strategy of imaging and genetics. Clin Cancer Res. 2010 Oct 15;16(20):5028‐37
18
12/15/2011
Genetic Counseling / Testing
&
Screening / Prevention
History Suggestive of Inherited Pancreatic Cancer
Probable HNPCC/FAMMM
Genetic test of an
affected individual
affected
individual
Negative
Positive
Cancer screening as recommended for the general population
Genetic testing of family members
Negative
Continued high risk cancer screening of the individual and all family members
Positive
Negative
Positive
for cancer
Surgery
Calvert & Frucht, Ann Int Med, 2002:137;603‐613
19
12/15/2011
Genetic Testing
EUS
CA 19‐9, OGTT
MRI/MRCP
ERCP
Laparoscopic Distal Pancreatectomy
Total Pancreatectomy
Ongoing Research 20
12/15/2011
Potentially the same methodology for Colon & Pancreas cancer screening?
Exfoliated cells 
ducts  bowel  stool
Extract crude DNA from
stool samples
Analysis for
abnormalities
Our Study Results
21
12/15/2011
TO MAKE AN APPOINTMENT
PLEASE CALL:
212--305
212
305--9337
PANCREATIC CYSTS
PANCREATIC CYSTS
John Allendorf, MD Assistant Professor of Surgery
Director of Endocrine Surgery Fellowship
Columbia University Medical Center/ New York‐Presbyterian Hospital 22
12/15/2011
23
12/15/2011
24
12/15/2011
Differential Diagnosis
Inflammatory ‐‐ Pseudocyst
Neoplastic
Serous cystadenoma
Mucinous lesions
Mucinous cystadenoma
IPMN
Side Branch IPMN
Main Duct IPMN
Main Duct IPMN
Cystic degeneration of endocrine neoplasms
Diagnostic Workup
History
Physical exam
Physical exam
Imaging
CT
MRI/MRCP
EUS
Fluid Analysis
Cytology
Biochemistry
CEA (192 ng/mL)
Amylase
Mutational analysis
25
12/15/2011
Pseudocyst
Inflammatory
Hi t
fP
titi
History of Pancreatitis
Fluid Inflammatory cells
Debris
High amylase
Low CEA
Serous Cystadenoma
Asymptomatic, may i
cause pain
Palpable mass
Central scar, calcification
Microcystic on EUS
Low amylase
Low amylase
Low CEA
Benign
26
12/15/2011
Mucinous Cystadenoma
Often asymptomatic
Young women
Usually located in tail
Unilocular or few septations
Low Amylase
High CEA
Ovarian type stroma
Ovarian type stroma
Malignant potential
Sidebranch IPMN
Asymptomatic or pancreatitis
Both genders
Not limited to the tail
Fluid analysis
High amylase
High CEA
High CEA
Malignant potential
27
12/15/2011
Main Duct IPMN
Pancreatitis
Fishmouth ampulla
Mucin
M cin
High amylase
High CEA Malignant potential
Management
28
12/15/2011
Pseudocyst
Natural history
Ob
ti
Observation
Drainage
External
Internal
Endoscopic Surgical Surgical
Endoscopic Internal Drainage
29
12/15/2011
Serous Cystadenoma
Observation
Resection
Symptoms
Size
Diagnostic uncertainty
Mucinous Cystadenoma
Resection
30
12/15/2011
Main Duct IPMN
Risk of malignancy (70%)
Resection
Affected portion of duct
Frozen section
May require total pancreatectomy
Observation
Poor surgical candidates
Poor surgical candidates
Advanced age
International consensus Guidelines (Sendai criteria)
Sidebranch IPMN
Risk of malignancy vs risk of morbidity
Resection
Symptomatic
>3cm
Mural nodules
Young age
Observation
Surveillance
Interval
Modality
? Practical
International consensus Guidelines (Tanaka, et al)
31
12/15/2011
Pancreatic Cyst Surveillance Program
500 patients in the registry
Program of active surveillance
Program of active surveillance
MRI
EUS
Natural history
Patient quality of life
Patient quality of life
Mutational analysis of cyst fluid
Summary
Systematic approach
History, imaging, fluid analysis
Distinguish inflammatory from neoplastic
Weigh the risks and benefits of intervention
Symptoms
Risk of malignant degeneration
Risk of surgical complications and diabetes
Risk of surgical complications and diabetes
Design an intervention tailored to the patient
32
12/15/2011
THE W’S AND H’S OF DRUG THERAPY IN PANCREATIC CANCER:
HOW CAN WE MOVE FORWARD?
Wasif Saif, MD
Professor of Clinical Medicine
Director of the Clinical Section GI Oncology Medical Director, Pancreas Center
Columbia University Medical Center/New York‐Presbyterian Hospital
Outline
Are there any different types of pancreatic cancer?
What are the known risk factors?
What are the known risk factors? What are the common symptoms and signs?
How do we diagnose pancreatic cancer?
How do we treat pancreatic cancer?
What is the prognosis? What Can I do to Improve my Odds?
Wh t C I d t I
Odd ?
What are the novel drugs offered @ CU Pancreas Center?
33
12/15/2011
Types of Pancreatic Cancer
There are two types of cells in the pancreas: exocrine cells and endocrine cells.
Th
ll l h
diff
f
i
These cells also have different functions. EXOCRINE
95% of pancreatic cancers are classified as
exocrine tumors because they begin in the
exocrine cells that produce enzymes to aid
in digestion. ENDOCRINE
5% are endocrine tumors, also called
neuroendocrine or islet cell tumors. Islet cells of the pancreas produce hormones
including insulin, glucagon and
somatostatin. Endocrine tumors may be benign or
malignant and tend to be slower growing
than exocrine tumors. Signs and Symptoms of Pancreatic Cancer
There aren’t any noticeable signs or symptoms in the early stages of PC Signs of PC, when present, are like the signs of many other illnesses
Pain : 80%
Mid epigastric
Mid epigastric
43%
Upper abdominal 23%
Lower abdominal 18% Left upper quadrant 13% Jaundice : 47%
Weight loss: 60%
New onset of D. mellitus
Para‐neoplastic Syndromes
Weight loss
Trousseau’s syndrome
Depressive Symptoms
Courvoisier’s sign
34
12/15/2011
Causes of Pancreatic Cancer
Sporadic
Sporadic ~65 ‐ 80%
Familial pancreatic cancer
~10% or more
Known genetic syndromes ~5%
Hereditary Pancreatitis, HNPCC Lynch II Variant, BRCA2, FAMMM, Peutz‐Jeghers Syndrome
How Do We Diagnose Pancreatic Cancer?
Blood Tests
Serum chemistries, CBC, LFTs
Serum CA19‐9 and in some cases CEA
Other tests, such as fecal fat, stool trypsin, trypsinogen, amylase, and lipase may be evaluated to determine pancreas function and need for pancreatic enzyme supplementation.
Diagnostic Imaging
Diagnostic Imaging
CT scan of chest, abdomen, and pelvis
EUS
ERCP/MRCP
PET scan in certain cases
35
12/15/2011
How Do We Treat Pancreatic Cancer?
Inoperable PC
Resectable PC
Stages I‐IIB
15‐20%
Surgery
Adjuvant Chemoradiotherapy
j
py
Adjuvant Chemotherapy
Locally Advanced
Stage III 30‐40%
Metastatic
Stage IV
40‐50%
Chemoradiation
Ch
Chemotherapy
th
Novel Therapeutics
Chemotherapy
Novel Therapeutics
N
l Th
ti
Supportive Care
After Surgery: Adjuvant Therapy For Pancreatic Cancer
Adj
Adjuvant therapy is treatment after surgery to try and prevent disease relapse
t th
i t t
t ft
t t
d
t di
l
As most patients after surgery will have the disease relapse in other places, the cancer must have spread prior to surgery
Tumors smaller than 10 million cells cannot be seen, so we cannot detect “micrometastatic” disease
Standards of care vary depending on which side of the Atlantic you’re on:
North America (GITSG, RTOG): chemo‐radiation followed by chemotherapy
Europe (ESPAC‐1, CONKO, ESPAC‐3): chemotherapy alone
The critical thing is that SOMETHING is better than NOTHING
36
12/15/2011
Neoadjuvant Therapy
Goals:
Increase the resectability rate
Increase the resectability rate
See who needs radiation therapy
Determine why therapy fails
Increase the survival and cure rate of pancreatic cancer patients
LA Pancreatic Cancer
OPTIONS:
Chemo‐XRT XRT (radiation therapy)
Chemotherapy followed by Chemo‐XRT
37
12/15/2011
Treatment For Patients With Advanced Pancreatic Cancer
A Timeline For Slow Progress
Pre‐1996
Many drugs tested, nothing worked
y
g
,
g
1996
Gemcitabine FDA approved
1996‐2005
Many drugs tested, no drug or drug combination is better than Gemcitabine
2005
Tarceva FDA approved
2005
Capecitabine + Gemcitabine better than Gemcitabine
2006
G
Gemcitabine + Oxaliplatin and FDR Gemcitabine not better than i bi
O li l i
d FDR G
i bi
b
h
Gemcitabine
2006
Gemcitabine + Bevacizumab not better than Gemcitabine
2007
Gemcitabine + Cetuximab not better than Gemcitabine
2010
FOLFORINOX better than Gemcitabine
Li J, Saif MW. JOP. 2009 Mar 9;10(2):109‐17
Prognosis
Estimated new cases and deaths from pancreatic cancer in the United States in 2010:
New cases: 43,140
Deaths: 36,800
4th leading cause of cancer mortality (6%)
Functional Stage
Description
Median Survival (m)
Resectable
Tumor confined to 15‐19 pancreas or extends beyond pancreas but without involvement of CA or SMA + Regional LAD
LA
Tumor involves CA or SMA 6‐10 Met/Adv
Distant Mets
3‐6 Staley CA, Pancreas 1996
38
12/15/2011
When Would Chemotherapy Not Be Appropriate?
If you are staying in bed greater than 50% of the time after you wake up
This may be a sign that your cancer is so advanced that chemotherapy will likely do more harm than good
Hospice care and relief of symptoms should be the primary focus of your care
What Can I Do To Improve My Odds?
Participate in a CLINICAL TRIAL
Select the option that you feel is the best in conjunction with your doctors
When you require highly specialized care of a multi‐disciplinary nature, seek care in an institution where these teams are in place and i i i
h
h
i l
d
functioning to work together on a daily basis
39
12/15/2011
CUMC PC Research
Treatment Options At The Pancreas Center
Resected
* HyperAcute Vaccine
* GTX
LA , Borderline Advanced disease
2nd‐line  GTX
 GTX + Xeloda‐XRT
1st‐line • CO 1.01
• MM398 vs.
vs
5FU/LV
•
•
•
•
Gemcitabine ± IPI-926
Gemcitabine ± GS6624
GTX
GTX vs. Gem-Erlotinib
3rd‐line
line
Pipeline
• NUC1031
• NV-196
40
12/15/2011
EPIDEMIOLOGY OF PANCREATIC CANCER: WHAT WE KNOW ABOUT RISK AND PREVENTION?
Jeanine Genkinger, PhD, MHS
Department of Epidemiology
Columbia University
Mailman School of Public Health
2011 Estimated US Cancer Cases*
Men Women
822,300 774,370
Prostate
29%
30%
Lung & bronchus
Lung & bronchus
14%
14%
g
Lung & bronchus
Colon & rectum
9%
9%
Colon & rectum
Urinary bladder
6%
6%
Uterine corpus
Melanoma of skin
5%
5%
Thyroid 5%
4%
Non‐Hodgkin
lymphoma
4%
Melanoma
of skin
Kidney Non‐Hodgkin Breast
lymphoma
lymphoma 4%
Oral Cavity
3%
3% Kidney Leukemia
3%
3%
Ovary
Pancreas
3%
3%
Pancreas
All Other Sites
19%
19%
All Other Sites
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2011.
41
12/15/2011
2011 Estimated US Cancer Deaths*
Men
Women
300,430 271,520
Lung & bronchus
28%
26%
Lung & bronchus
Prostate 11%
15%
Breast
Colon & rectum 8%
9%
Colon & rectum
Pancreas
6%
7%
Pancreas
6%
Ovary Leukemia
4%
4%
Non‐hodgkin lymphoma Esophagus
4%
3%
Leukemia
Urinary Bladder 4%
3%
2%
Uterine corpus
Liver & intrahepatic bile duct
Brain & other nervous system
Liver & Intrahepatic bile 4%
Non‐hodgkin lymphoma 3%
Kidney & renal pelvis
3%
2%
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.
Source: American Cancer Society, 2011.
Lifetime Risk
1.41% of men and women born today will be diagnosed with cancer of the pancreas at some time during their lifetime. OR
1 in 71 men and women will be diagnosed with cancer of the pancreas during 1
in 71 men and women will be diagnosed with cancer of the pancreas during
their lifetime. Comparison: BREAST CANCER: 12.15% of women born today will be diagnosed at some time during their lifetime.
1 in 8 women will be diagnosed with cancer of the breast during their lifetime.
g
g
COLORECTAL CANCER:
5.12% of men and women born today will be diagnosed with cancer of the colon and rectum at some time during their lifetime. 1 in 20 men and women will be diagnosed with cancer of the colon and rectum during their lifetime.
42
12/15/2011
Risk Factors for Pancreatic Cancer
Non‐modifiable Factors
Age (60‐80 yrs of age)
Race Sex
Family History/Genetics
(Lowenfels AB, J Cell Biochem 2005)
Incidence Rates by Race/Ethnicity and Gender
Race/Ethnicity
Male
Female
All Races
55.0 per 100,000 men
41.0 per 100,000 women
White
54.4 per 100,000 men
40.2 per 100,000 women
Black
67.7 per 100,000 men
51.2 per 100,000 women
Asian/Pacific Islander 45.4 per 100,000 men
34.6 per 100,000 women
American Indian/Alaska
American Indian/Alaska Native a
42.7 per 100,000 men
40.0 per 100,000 women
Hispanic b
39.9 per 100,000 men
28.4 per 100,000 women
43
12/15/2011
Risk or Preventive Factors for Pancreatic Cancer
Modifiable Factors:
Smoking Alcohol
Obesity – BMI Physical Inactivity?
Dietary Factors?
Sugar‐sweetened beverages
Red and processed meats Vitamin D
Fruits and Vegetables
Relative Risk (95% CI
Pooled Multivariate Adjusted Relative Risks (95% CI) for Pancreatic Cancer According to BMI at Baseline
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
1.16
(0.96-1.40)
0
1
<21
1.00
(REF)
2
21-22.9
1.07
(0.92-1.25)
3
23-24.9
1.18
(1.03-1.36)
1.47
(1.23-1.75)
overweight
obese
4
25-29.9
5
> 30
6
Categories of Body Mass Index
BMI is calculated from your height and weight. BMI is an estimate of body fat
Genkinger et al, CEBP
44
12/15/2011
Multivariate Adjusted Pooled Relative Risks (RR) and 95% Confidence Intervals (CI) for Pancreatic Cancer According to Alcohol Intake
1.40
1.20
R
Relative Risks
1.00
Females
0.80
Males
0.60
0 40
0.40
1.00
(REF)
1.02
(0 91 1 14)
(0.91-1.14)
0.91
(0 9 1 04)
(0.79-1.04)
0.96
(0 82 1 14)
(0.82-1.14)
1 drink/
day
0.20
1.22
(1 03 1 4 )
(1.03-1.45)
Total
>2 drinks/
day
0.00
0
1-4.9
5-14.9
15-29.9
>30
Alcohol Intake (g/day)
Genkinger et al, CEBP, 2009
Risk or Preventive Factors for Pancreatic Cancer
Modifiable Factors:
Smoking Alcohol
Obesity – BMI Physical Inactivity?
Dietary Factors?
Sugar‐sweetened beverages
Sugar sweetened beverages
Red and processed meats Vitamin D
Fruits and Vegetables
45
12/15/2011
Risk Factors for Pancreatic Cancer
Health History Factors
Health History Factors
Chronic pancreatitis
Diabetes
Periodontal Disease?
Allergies/Asthma?
(Lowenfels AB, J Cell Biochem 2005)
Recommendations
46
12/15/2011
World Cancer Research Fund/ American Institute for Cancer Research Recommendations
Be as lean as possible without becoming underweight.
h
ll
f
l
d
Be physically active for at least 30 minutes every day.
Limit consumption of energy‐dense foods (foods high in fats and/or added sugars and/or low in fiber) and avoid sugary drinks.
Eat more of a variety of vegetables, fruits, whole grains, and pulses (beans).
Limit consumption of red meats (such as beef, pork and lamb) and avoid processed meats (such as sausage, bacon).
If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a day.
Limit consumption of salty foods and foods processed with salt (sodium).
Don’t use supplements to protect against cancer.
http://www.wcrf.org/cancer_research/expert_report/recommendations.php
American Cancer Society
Recommendations
Stay away from tobacco.
Stay at a healthy weight.
Get moving with regular physical activity.
Eat healthy with plenty of fruits and vegetables.
Limit how much alcohol you drink (if you drink at all).
Protect your skin.
Know yourself, your family history, and your risks.
Have regular check‐ups and cancer screening tests.
47
12/15/2011
Screening Guidelines No current recommended screening guidelines for p
pancreatic cancer
USPTF recommends
Biennial screening mammography for women aged 50 to 74 years. Pap smear/HPV screening for cervical cancer in women who have been sexually active and have a cervix.
Fecal occult blood testing, sigmoidoscopy, or colonoscopy, for colorectal cancer in adults, beginning at age 50 years and continuing until age 75 years.
48
12/15/2011
American Heart Association Recommendations
Learn how many calories you are eating and drinking
Increase amount and intensity of physical activity (at least 30 mins/day)
Eat a variety of nutritious foods from all the food groups.
E t t i t i h f d (f it
Eat nutrient rich foods (fruits, vegetables, unrefined whole‐grain foods)
t bl
fi d h l
i f d)
Eat fish at least twice a week
Eat less of the nutrient‐poor foods. Reduce consumption of high calorie and low nutrient foods and beverages
Cut back on beverages and foods with added sugars.
Choose lean meats/poultry without skin and prepare them without saturated/trans fat.
Cut back on foods containing partially hydrogenated vegetable oils to reduce trans fat
Cut back on foods high in dietary cholesterol. Eat less than 300 mg of cholesterol/day Choose and prepare foods with little or no salt. Eat less than1,500 mg of sodium/day
Select fat‐free, 1 percent fat, and low‐fat dairy products.
Alcohol : If you drink alcohol, drink in moderation. Smoking: Don’t smoke tobacco — and stay away from tobacco smoke.
Online Resources
American Cancer Society: http://www.cancer.org/
National Cancer Institute: http://www cancer gov/
National Cancer Institute: http://www.cancer.gov/
Pancreatic Cancer Action Network: http://www.pancan.org/
Lustgarten Foundation: http://www.lustgarten.org/
Live Strong Foundation: http://www.livestrong.org/
Your Disease Risk: http://www.yourdiseaserisk.wustl.edu/english/index.htm
49
12/15/2011
Question & Answer Session
Thank You For Attending!
212.305.9467
www.pancreascenter.com
www.nyp.org
50