Preparing a child for surgery; detecting and treating pancreatic cancer: Upstate Medical University’s HealthLink on Air for Sunday, Dec. 26, 2021
Pediatric surgeon Michaela "Mikki" Kollisch, MD, advises how best to prepare your child for surgery. And pancreatic surgeon Thomas Vandermeer, MD, discusses how pancreatic cancer is often discovered and diagnosed, and how advances in treatment are offering new hope.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air": A pediatric surgeon gives advice about the best way to prepare a child for surgery: :.
Mikki Kollisch, MD: They usually imagine things way worse than they actually are, so I think that really having good communication with them, especially school age, if they're understanding it, and young teens, if they feel like they're a part of the decision making, can be useful.
Host Amber Smith: And a pancreatic surgeon discusses how pancreatic cancer is often discovered and diagnosed and how advances in treatment are offering hope: .
Thomas Vandermeer, MD: One of the reasons that, often, pancreatic cancer presents after it's metastasized, is that it will grow without really causing any symptoms.
Host Amber Smith: All that, plus the outlook for someone with multiple sclerosis and a visit from The Healing Muse, coming up right after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, pancreatic surgeon thomas Vandermeer gives an overview of pancreatic cancer, but first, pediatric surgeon Michaela "Mikki" Kollisch advises how to get your child ready for surgery.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." If a child in your life has an illness or injury that requires surgery, no matter how minor the procedure, it's a big deal to the child and to his or her caregivers. Here to talk with me about how to prepare a young person for surgery is pediatric surgeon Dr. Mikki Kollisch. Welcome to "HealthLink on Air," Dr. Kollisch.
Mikki Kollisch, MD: Thank you, Amber. Thank you so much for having me. I'm excited to be part of this.
Host Amber Smith: So what percentage of your surgeries are for scheduled things, and what percent are for emergencies?
Mikki Kollisch, MD: Yeah, unfortunately right now with COVID, we're not able to schedule elective cases. So the majority of our procedures right now are urgent or emergent surgeries. I would say about in the usual times, I would say about 30 to 40% are acute, non-scheduled cases. And the remaining are more elective, scheduled cases that we plan out in clinic.
Host Amber Smith: So as a pediatric surgeon, I imagine you take care of a variety of illnesses or injuries, but do you, yourself have a specialization?
Mikki Kollisch, MD: One of the great aspects of being a pediatric surgeon is that we're trained to take care of a variety of illnesses, whether it be trauma, critical care or diseases of the chest and belly. My special interest lies in critical care, which is in parallel with my research interests, and minimally invasive surgery, where we use a camera and long instruments to perform surgery.
Host Amber Smith: What's the smallest child that you've operated on?
Mikki Kollisch, MD: It was probably around 450 grams, which is roughly a pound. The baby was born early, at 22 weeks gestation, instead of the usual 40 weeks. So all of the organ systems are pretty fragile at that age. And this baby had a hole in his intestine that required an operation.
Host Amber Smith: And you're able to do that with, like you mentioned, the instruments, the long instruments?
Mikki Kollisch, MD: Great question. This is a case where you'd not be able to do minimally invasive surgery with the long instruments. This ends up being a laparotomy, or a bigger incision, which in a baby, you can actually do a relatively small incision and still get to the part that you need to.
Host Amber Smith: But they're so small. I mean, I just am trying to visualize this. Your hands are probably bigger than the baby.
Mikki Kollisch, MD: Usually they can kind of fit into the palm of your hand. But we use special glasses that have magnifying glasses on them, so we can see everything a little bit better than smaller things.
Host Amber Smith: All right, now, what is the oldest or the largest child that you would operate on as a pediatric surgeon?
Mikki Kollisch, MD: The general cutoff for pediatric surgery is over 18 years of age for general surgery. And for trauma, it's over 15 years of age. And the reason for this is that many of the surgical issues at those ages transition from being neonatal and congenital pediatric pathology to more adult type issues.
Host Amber Smith: What would you say are the advantages of having a child's surgery performed at a children's hospital -- because you're part of Upstate Golisano Children's Hospital -- versus elsewhere?
Mikki Kollisch, MD: Yes, exactly. So, because our surgeries are performed at Upstate, which as you said, is a children's hospital, we have the benefits of having all of the resources that a children's hospital has in our operating room. And so this includes specialty-trained pediatric anesthesiologists and subspecialists, and it also means we have nurses that have specific pediatric training and child life specialists who can help to make sure that both the parent and the child are comfortable and with age-appropriate interactions.
Host Amber Smith: And then, if they end up staying in the hospital during recovery, that's in the children's hospital, obviously.
Mikki Kollisch, MD: That's correct. The children's hospital tends to be on the 11th or 12th floor. Most of our post-surgical patients go to the 11th floor, and each room is equipped with an individual bathroom and a pullout sofa to try to make the stay as pleasant as possible. And similarly, our hospital has the same pediatric-trained nurses and support staff. And again, child life is always available.
Host Amber Smith: Well, I know it must vary depending on the child's age, but I wanted to talk to you about how you prepare a child for surgery, say, a toddler.
Mikki Kollisch, MD: Yeah. I find that I tend to prepare each child a little bit differently, like you said, depending on their age, but also the sense that I get from them. Some kids are a little more nervous and want all the details. Some are not as interested and would rather not know as much. So I first try to gauge the child when I meet them. Toddlers tend to be pretty easy because they're not yet at the point where they necessarily comprehend what a surgery is. The one thing that I think makes a difference for a toddler is not being able to eat before surgery. That's usually the thing that impacts them the most. They don't understand why they can't, and they're more comfortable when they can. So we do try to maximize their eating time. So for instance, they can have clear liquids up to two hours before their surgery, breast milk up to four hours before, formula six hours before, solids eight hours before, etc., just to try to make it a little bit easier for them.
Host Amber Smith: So, what are some of the fears and concerns that you've heard from some of your patients before surgery?
Mikki Kollisch, MD: The biggest fear is of course not only the anesthesia itself, but the surgery. And most children do better when we take away that unknown because they usually imagine things way worse than they actually are, so I think that really having a good communication with them, especially school age, if they're understanding it, and young teens, if they feel like they're a part of the decision making, can be useful. This is another time that our child life team becomes really important. We have an incredible team who are always available, not only in the hospital and in the operating room, but they can even do preoperative phone calls and tours to help make the experience more comfortable. Right now, they're actually working on a virtual option because obviously we're not able to do in-person tours at the moment. And so there is a video on the center for children's surgery website that shows kids what a typical day looks like when they come in for surgery. So even if you're not able to come into the hospital beforehand, you can watch that, but you can also talk to child life, and they can talk to both the parent as well as the child about what to expect, what to bring and some of those common fears and misconceptions.
Host Amber Smith: So that they know what to put in their bag, what to pack in their bag and what to wear.
Mikki Kollisch, MD: That's exactly right.
Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, and I'm talking with pediatric surgeon Dr. Mikki Kollisch about preparing your child for surgery. And we've talked a little about how you address the child. How do you prepare the parents? Because I imagine there's a range of anxiety levels with some parents?
Mikki Kollisch, MD: Absolutely, absolutely. The one thing we really try hard to do is to go through the whole procedure when we meet in clinic and discuss everything, including the risks and benefits then. And this allows parents to think about things, so that they can develop questions. And then we can rediscuss the day of the procedure. This helps them so that they're not overwhelmed with information right before surgery. And it should help to take out some of the unknowns of the day.
Host Amber Smith: Are there things that you can advise parents to do at home in the days ahead of surgery that will kind of help you prepare for the day of?
Mikki Kollisch, MD: Yeah, absolutely. I find that kids are pretty intuitive, even if they're not yet speaking. And so I think that being honest with kids is probably the most important thing. And I would try to caution parents to not talk about the surgery or to avoid and talk around the surgery. The other thing is that routines are comforting. And so I suggest that you try to stick to usual routines, when you have dinner, when you go to bed, because if the child senses things are off or that mom or dad are nervous, then it can sometimes feed into their own anxiety. And then for older kids, it's good to encourage them to talk about the procedures and to ask questions because if they feel like Mom and Dad are reluctant to talk about it again, it may, it might make the child themselves a little more nervous.
Host Amber Smith: So with the surgery, at what point are the parents separated from their child? Do they bring the child into the operating room?
Mikki Kollisch, MD: Unfortunately parents can't come to the operating room with their child. And this is really just to ensure that the operating rooms maintain their sterility. The parent stays with their child through the whole preoperative preparation, and that allows them an opportunity to meet all of the providers who will be taking care of their child. But then once it's time to go back to surgery, that's when they say their goodbyes. And then after surgery, we let the child wake up just a little bit. And as soon as they're awake enough to recognize their parent is there, we'll either bring the parent to them to see them or vice versa.
Host Amber Smith: So they're with somebody from the time they leave their parent. They're with somebody until they're back in their parents' arms?
Mikki Kollisch, MD: It's usually one of the same nurses that they've met, so it's someone that the child has already seen.
Host Amber Smith: Well, let me ask you how COVID has changed the procedures or the preparations for surgery. You talked about the video that people are able to do to sort of familiarize themselves with what to expect. Are there other things that COVID has impacted?
Mikki Kollisch, MD: Yes. Yes. Now of course, Upstate follows the CDC (Centers for Disease Control and Prevention) guidelines in terms of patient protection and screening. So when the parents and children first come in, they're provided screening questions as well as a temperature check at the entrance, in addition to a fresh mask. We have all of our children get a COVID test within five days of the procedure. This is important not only to protect the hospital staff, but it's especially meant to protect the patient because if they have COVID and they're undergoing an elective procedure, that's not the right time to be putting them under anesthesia. The other thing we do is, instead of having the parents wait in a communal waiting room, we have them wait, instead, in their individual preoperative rooms. The major unfortunate, but obviously understandable, condition with COVID is that only one parent can accompany the child to surgery. And also even if they're admitted.
Host Amber Smith: Well, we've talked a lot about preparing for surgery and the day of, but then after surgery comes recovery. So what are the concerns that you're always on the lookout for, in children as they recover from surgery?
Mikki Kollisch, MD: The main thing initially is making sure they wake up well after the anesthesia because of the medications that we use to make them sleepy. We need to make sure they're breathing well after the breathing tube is removed. This is super important for the younger infants, but especially those who are born early, preterm. After the anesthesia recovery period, the main things we look out for that's kind of universal to every surgery are pain control and infection. And then, of course, each surgery has its own unique set of associated risks that we also look out for.
Host Amber Smith: How do you handle pain control, particularly in a baby, who can't talk and tell you that they're in pain? How do you decide how much pain medicine they need?
Mikki Kollisch, MD: That can be challenging. Now all of our nurses and support team are trained to work with infants and children. And so they're trained to recognize signs that might suggest they're in pain. So for instance, if a baby is particularly fussy, this could be an indication of pain. But this is going to be challenging in babies who aren't able to eat because obviously that fussing could be attributable to the baby being hungry. So we look for some other more objective things like changes in their vital signs, like their heart rate, which would increase if they're in pain. In most procedures we use local anesthesia or numbing medicine to help with pain control. And then for most same-day procedures, kids often don't need anything more than Tylenol or Motrin. If they're old enough for pain control, we seldom need to use narcotics in kids.
Host Amber Smith: Do you think that kids typically heal better and faster than adults after surgery?
Mikki Kollisch, MD: Kids are amazing. Yes, they do seem to heal faster. And the incisions are usually less noticeable. They heal just so well. So after surgery, I often don't really restrict their activity too much. And especially in toddlers, it's pretty tough to restrict their activity anyway, but I find that kids tend to self-limit what they do just based on what they're feeling up for.
Host Amber Smith: So they may be more apt to want to get out of bed, whereas an adult may want to rest a little bit more?
Mikki Kollisch, MD: Yes. So true. Yes.
Host Amber Smith: In adult surgery, I know minimally invasive techniques are being developed for more and more different types of procedures. Is that true with children?
Mikki Kollisch, MD: It is true. It is true for general surgery, minimally invasive techniques started really with appendectomies, which is one of the most common procedures we do. And then we got pretty good at that, so we started doing gallbladders, and then we started doing bowel surgery and lung work and so on. And in the same way, we've continued to push the envelope in children to make sure that we're getting the same surgeries accomplished with smaller incisions, less pain, and ideally a shorter hospital stay. So in kids, we similarly started out with appendectomies and gallbladders, and we've continued to expand our repertoire. So now we do hernias, repair pyloric stenosis, and remove extra parts of bowel called Meckel's.
Host Amber Smith: Can you talk about the benefits of a minimally invasive technique in a child?
Mikki Kollisch, MD: The main benefit is really the smaller incisions. So with those smaller incisions, you not only have less pain after surgery, but then you also have a better cosmetic outcome. And then from a surgeon's perspective, it can often give us greater reach through the abdomen and also through the lung cavity, as well as better visibility.
Host Amber Smith: Great. And now I'm imagining these tools have to be smaller for smaller people than they are for the adult, for the robotic tools, right?
Mikki Kollisch, MD: That's true. So we do both laparoscopy and robotic techniques, and they're kind of the flip side of the same coin. With laparoscopic surgeries, we'll use smaller ports and smaller instruments. So for instance, in adults, we'll use kind of 5 millimeter ports, and then with kids we'll even use something to as small as a 3 millimeter port, which is the access point to the belly that we use to put the instruments in. In the robot, pediatric surgeons have started dabbling in robotic surgery, but the problem that we have is that the port sites are still larger than those we use in laparoscopic surgery. And so that can make a big difference in a small child, because then you lose the advantage of the smaller incisions.
Host Amber Smith: I see. Well, before we wrap up, can you tell us about the research you've been involved with lung diseases in critical care?
Mikki Kollisch, MD: Yes. I've been interested in lung injury and critical care since I was a surgery resident. I did a research fellowship in the Upstate critical care lab under professor Gary Nieman. Lungs can get injured for a variety of reasons, like infections and inhalation injury, or trauma, where you get bruises and rib fractures. And the lungs can even get inflamed just when the body is really ill and fighting off some other process. So my research has been focused on how and why the lung gets secondarily injured, as well as understanding how mechanical ventilation or the breathing tube impacts the sub-units of the lung. And so now that I've rejoined the lab at Upstate, I'll be focusing some of our research a little bit more toward the neonatal and pediatric realms.
Host Amber Smith: Oh, very interesting. I want to thank you for your time. Thank you to Dr. Mikki Kollisch. She's a pediatric surgeon at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
An overview of pancreatic cancer, next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Pancreatic cancer accounts for about 3% of all cancers in the United States, but accounts for 7% of all cancer deaths. And it's the fourth leading cause of death from cancer. Advances in the treatment of pancreatic cancer are offering hope, and today I'm speaking with an expert about this disease. Dr. Thomas Vandermeer is a professor of surgery at Upstate. He serves as chief of surgical oncology, and he's the interim director of the Upstate Cancer Center. And as a pancreatic surgeon, he's had extensive experience in the care of patients with pancreatic cancer. Welcome to "HealthLink on Air," Dr. Vandermeer.
Thomas Vandermeer, MD: Thank you for having me, Amber.
Host Amber Smith: "Jeopardy!" host Alex Trebek was diagnosed with pancreatic cancer when it was at stage four. And I understand most pancreatic cancer patients are diagnosed at stage four. Can you explain the stages and why most people don't find out about it at an earlier stage?
Thomas Vandermeer, MD: There are four stages in cancer. Stage four is unfortunately what Alex Trebek had. And, that's when the cancer has traveled to some distance site beyond the pancreas, and most commonly that's in the liver. It can be into the lungs and into the abdominal cavity as well.
Host Amber Smith: So let me stop you, if I can, and interrupt. You say it travels, the cancer. Does it go through the bloodstream, or how does it get from the pancreas to other places?
Thomas Vandermeer, MD: Commonly it goes through the bloodstream, and then the blood from the pancreas drains into the liver. And so that's one of the main reasons for the propensity of pancreatic cancer to implant in the liver. It also gets into the lymphatics, which are fluid tubes that drain fluid around the body. And so it can get into the system through the lymph nodes that surround the pancreas as well.
Host Amber Smith: Well, do we know why cancer starts in the pancreas?
Thomas Vandermeer, MD: Cancer can start in, really, any cell because the basic mechanism by which cancer forms is through the dysregulation of the growth of the cell. Usually through some series of genetic changes that cause cancer to keep growing when normal cells would grow, divide, and then the original cells die back as the normal method of replenishment of the body, cancer cells just continue to grow, and have progressive changes that then cause them to spread into other places in the body.
Host Amber Smith: Do we have any way to predict who is likely to develop pancreatic cancer?
Thomas Vandermeer, MD: We're starting to get some information about a few of the predispositions, although the vast majority of pancreatic cancers are what we call sporadic, meaning that there really isn't any identifiable predisposition to them. We are increasingly identifying genes that can be present at the time of birth that cause increased likelihood of pancreatic cancer. But most of the genetic changes in pancreatic cancers are acquired during the lifetime.
Host Amber Smith: So are there risk factors that we can do something about that would help reduce our risk?
Thomas Vandermeer, MD: The main behavioral risk factors are smoking and obesity. There are some environmental exposures, people who work with chemicals and things like that. But by far the most common risk factor is smoking, and obesity.
Host Amber Smith: Wow, smoking again. Even though you think of smoking with lungs, but it can affect, I guess, cancer anywhere.
Thomas Vandermeer, MD: Yeah. Because obviously the lungs are exposed to smoke primarily, but the changes, the chemicals that are introduced into the body as a result of smoking can really cause mutations in genes in many different places in the body. So, smoking in general is just a risk factor for many different kinds of cancer.
Host Amber Smith: Well, getting back to the idea that at stage four, it's usually progressed before people discover it. Do you think there's ever going to be a way to screen for pancreatic cancer so that it could be caught earlier?
Thomas Vandermeer, MD: We're looking into all kinds of different ways of screening people who are at increased risk. And we do know now that there are some genetic mutations, you know, most commonly what we call the BRCA mutation, which is present in a lot of patients with breast cancer and ovarian cancer. And so we do screen them. Currently what we're doing to screen people is based on doing tests like CTs or MRIs. There's a test called an endoscopic ultrasound where there's an ultrasound probe placed into the stomach and it can really give us detailed views on the pancreas and can pick up on tumors when they're very small. We also are looking into how we can look at genetic changes in the juice of the pancreas, so we can go down into the intestine with a scope and aspirate some of the fluid and look at genetic changes and changes in the proteins that are present in the pancreatic juice. So that's a very active area of investigation. That hasn't been really elucidated yet, nor have the populations that would be at sufficient risk to undergo intensive screening, but it's something that we're working on quite a bit.
Host Amber Smith: This is Upstate's "HealthLink on Air." I'm your host, Amber Smith, and I'm talking with Dr. Thomas Vandermeer. He's the chief of surgical oncology and interim director of the Upstate Cancer Center. We're talking about pancreatic cancer. Now, I've heard there's two main kinds of pancreatic cancer. Can you tell us about them?
Thomas Vandermeer, MD: The types of cancer tend to be divided into the type of cell from which they originate. And so the most common type is what we call a ductal adenocarcinoma. And that's a cancer that arises from the the cells that line the ducts that transport the fluid that is made by the pancreas down into the intestine. And that's the most common type. That's the most dangerous type.
By far and away the less common type is called a neuroendocrine tumor. And those are generated from the cells that produce hormones like insulin and some other hormones that regulate bodily functions. Those are much, much less aggressive and spread much less commonly. But even when they do spread, patients survive a long, long period of years, and years, and years, even with metastatic disease -- if it's originating from neuroendocrine carcinomas of the pancreas. Those patients also often have symptoms of hormonal excess so that the hormone that's made by those cells can cause things like increased production of insulin or increased production of other hormones that have other effects on the GI (gastrointestinal) tract. But the prognosis from that, from those tumors, is much, much better.
Host Amber Smith: So the really bad one, I think you call it adenocarcinoma?
Thomas Vandermeer, MD: Ductal adenocarcinoma.
Host Amber Smith: So that's the kind that Alex Trebek had?
Thomas Vandermeer, MD: Yeah. When people talk about pancreatic cancer, that's by and large what they're talking about.
Host Amber Smith: So, how do people typically find out that they have this? Do they just, at a regular annual physical, is the doctor able to find something unusual? Or, how is it usually discovered?
Thomas Vandermeer, MD: It's not something that can be discovered on physical examination because the pancreas sits deep inside the body, really on top of the spine. And so one of the reasons that, often pancreatic cancer presents after it's metastasized is that it will grow without really causing any symptoms. The main symptom that people identify is jaundice, because the duct that drains bile from the liver into the intestine runs through the pancreas. And if a tumor develops in that site, it will block the bile duct causing jaundice, even when it's very small. So when people get jaundiced, that's frequently in a way that would detect these early on. The other way is that, you know, having CAT scans is much more common than it used to be, and so we're identifying a lot of these incidentally when CAT scans are done for other reasons. And so we're picking up a lot of small, incurable pancreatic cancers at this point.
Host Amber Smith: So if someone has something discovered when they go in for a CT scan for something else, or if they have severe jaundice, how do you go about making sure and diagnosing it as pancreatic cancer?
Thomas Vandermeer, MD: We always try to get a biopsy, and that's most often done with this endoscopic ultrasound test that I mentioned a while back. And that's where an ultrasound probe is on the end of the scope that's placed in the stomach, and a thin needle can be advanced through the stomach, right into the tumor, and the diagnosis can be confirmed that way.
Host Amber Smith: So, how do you decide what stage it's at after you do the biopsy? Does that tell you the stage?
Thomas Vandermeer, MD: No. The stage is determined, definitively, after the tumor is removed, if it's operable. Stage one is a very early cancer that has not spread to lymph nodes. Stage two is basically when it has spread to lymph nodes. Stage three is when it's either inoperable or its lymph node spread is extensive, but it hasn't spread to a different organ like the liver or the lungs.
Host Amber Smith: Well, what can you tell us about the organ, the pancreas, the organ in terms of, does it matter where the cancer shows up in this organ, as to what you're going to be able to potentially treat for the patient?
Thomas Vandermeer, MD: To some extent it does, because if the cancer is in the area where it causes jaundice, and that's a visible sign that draws attention to the cancer, those tend to be smaller. And when we do cure pancreatic cancer, it's when we do catch it early, and we're able to give chemotherapy, as well as surgery, to address the tumor.
Host Amber Smith: I was going to ask in general what the treatment options are, but you just mentioned a couple of them, surgery and chemo. I'm imagining it's different for every patient in terms of whether you're able to do surgery, or if you do that before or after chemo. What is typical, if there is something typical?
Thomas Vandermeer, MD: That's a big question right now, when we see a pancreatic cancer that we think is operable. There is a large study going on right now to determine whether or not giving chemotherapy before the surgery improves survival. Or, if doing surgery first -- which has been the traditional way to do things -- is equivalent or even better. So that's a big unanswered question. But the reason it's come up is because there have been some small studies that have shown that if we give chemotherapy prior to surgery, there are some advantages. And one of those advantages is that it can "downstage" the tumor, it can make it smaller, and that makes the surgery more effective because it's less likely than that there would be some microscopic tumor left behind from the surgery. The other benefit is that then we can see, when we look at the surgical specimen, what the effect of the chemotherapy has been. So if we give some chemotherapy before surgery, and then on the specimen we see that there's been a really nice response, then we know that's an effective chemotherapy for that particular cancer, and that's what we would give after surgery.
Host Amber Smith: So can you actually, in the operating room, can you see the cancer in the organ, visually?
Thomas Vandermeer, MD: Frequently we can. We always try to divide the tissue well away from the tumor, as far as we can get away from it because cancer tends to be fairly infiltrative. So we really just get all of the tissue that we can off of the vital structures, leaving nothing behind.
Host Amber Smith: Upstate's "HealthLink on Air" will be right back with more about pancreatic cancer from Dr. Thomas Vandermeer.
Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith, and my guest is Dr. Thomas Vandermeer. He's the chief of surgical oncology at Upstate and the interim director of the Upstate Cancer Center. We've been talking about treatment options for stage four pancreatic cancer. Can you talk about the stroma and what's being done to get treatment through the stroma?
Thomas Vandermeer, MD: The stroma is a very interesting thing. So the stroma is really divided into three parts. What stroma is, is the area around the tumor, which in pancreatic cancer tends to be very thick. It generates a lot of scar tissue around it. And that's one of the things that makes it difficult to treat, because those thick scarlike proteins prevent the infiltration of chemotherapy into the tumor. So that's one aspect, is the scar tissue around it. That makes it very challenging.
The second part of this drama is the vasculature, the blood vessels. Cancer causes blood vessels to develop. It secretes hormones, and the blood vessels develop, and that's one of the pathways. Metastasis, like you mentioned earlier. So what the cancer will do is, it will generate the scar tissue that makes chemotherapy difficult to infiltrate, and then it generates a lot of blood vessels that give the cancer a route out of the primary site and into the bloodstream to other organs.
And then the third component of it are cells that create the stroma. And there's different types of cells. There's cells that kind of encourage tumor growth and cells that discourage tumor growth. So these are all, as you can imagine, active areas of investigation, because if we can say, for example, get the protein around the tumor to allow the chemotherapy to enter, then chemotherapy can be much more effective. The stroma also prevents infiltration of tumor-killing lymphocytes, which is really a big area of investigation success in a lot of other cancers that hasn't been as effective in pancreatic cancer, because there's this barrier to the body's own immune cells to get in, to attack the pancreatic cancer. And so there's a lot of work being done to look at how we can break down that stroma so that these cancer-killing cells that are in the body can do that.
Host Amber Smith: Now, what about molecular profiling? Are you using that?
Thomas Vandermeer, MD: Very, very much so. We're, as I mentioned, increasingly understanding the genetics of pancreatic cancer. And we're getting to the point now where we know that certain genetic profiles will predict a better response to treatment for different types of anti-cancer drugs. In other types of cancer, these immunotherapy drugs that are based on specific genetic profiles have been incredibly effective and actually really reduced mortality rates in things like lung cancer. We haven't gotten to that point in pancreatic cancer because these tumors tend to elude the immune system.
Host Amber Smith: So when do you recommend having relatives tested for hereditary pancreatic cancer? Does every pancreatic cancer patient need to have their family members tested?
Thomas Vandermeer, MD: No. As I mentioned, most pancreatic cancers are sporadic and not part of a familial syndrome. And so just having one first-degree relative have pancreatic cancer does increase the likelihood of a first degree relative having pancreatic cancer, but not to the degree that screening would be effective. And we also don't have really great screening mechanisms. So it's not currently recommended. Enhanced screening is recommended for patients who have BRCA2 mutations and other similar mutations. There are rare genes that predict familial pancreatic cancer and familial pancreatitis, which is an inflammatory condition of the pancreas. And so people with those specific genetic syndromes -- and there's about 10 or 12 of them that are uncommon, but if present do warrant screening.
Host Amber Smith: You mentioned BRCA. That's the breast cancer gene.
Thomas Vandermeer, MD: But only BRCA2. BRCA1 is the more common breast cancer gene.
Host Amber Smith: Now, what do you suggest in general for people who've been given a diagnosis of pancreatic cancer? Is it worth it, do they need to get a second opinion, to make sure?
Thomas Vandermeer, MD: I don't think routinely patients need to get a second opinion about the diagnosis, unless their treating physician thinks that there's a reason to doubt the diagnosis. It is a fairly straightforward diagnosis for a pathologist to make. But if there is discordance between the clinical impression and the pathologic impression, then by all means. I have seen occasionally where a biopsy will show a pancreatic cancer, but clinically we don't think that that's accurate. And so we do always send that out for a second opinion and sometimes a re-biopsy.
Host Amber Smith: Well, if someone's being treated for stage four pancreatic cancer, they know they have it. Does the pancreas still function and do what it's supposed to be doing, or does the cancer prevent the organ from working?
Thomas Vandermeer, MD: Cancer might prevent the organ from working properly. The pancreas has two main functions. One is to make hormones like insulin. And so, frequently in patients with pancreatic cancer, insulin production is compromised. And about two-thirds of patients who were diagnosed with pancreatic cancer will have new onset diabetes within the past year of diagnosis. Many of those patients do require control of their blood sugar. And then the second function is a digestive one. The pancreas makes the digestive juice that helps us break down the fat and protein in our diet, and if that transit of the pancreatic juice from the pancreas into the intestine is blocked by the tumor, then people have pancreatic insufficiency and fat malabsorption and weight loss just on that basis.
Host Amber Smith: Well, Alex Trebek was able to, or he appeared on "Jeopardy!" and did the recordings all through his treatment, up until a few days before he died. So it makes me wonder, are people not in pain when they're dealing with this? Are they able to go on about their lives, or was that unusual for him?
Thomas Vandermeer, MD: I think when people are at end stages of pancreatic cancer, like Alex Trebek was, they typically are not as healthy as he was. So I would not say that his experience is necessarily typical. But the symptoms don't tend to be related to pain so much as they do to fatigue and weight loss and just sort of a generalized, gradual failing. He was certainly remarkable, in many ways.
Host Amber Smith: You're listening to Upstate's "HealthLink on Air." I'm your host, Amber Smith. I'm talking with chief of surgical oncology and interim director of the Upstate Cancer Center, Dr. Thomas Vandermeer, about pancreatic cancer. So we've talked a lot about stage four, but what are the treatment options if the cancer's contained to the pancreas? Because I'm thinking surgery is maybe more of an option if it's caught earlier, right?
Thomas Vandermeer, MD: Yeah, certainly. So we always look to see if we can remove the tumor surgically. The reasons that we may not think that surgery would be helpful would be if it has spread to another organ or if it's not possible because the tumor is growing into arteries and veins that render it inoperable. In the second case, we will often try to convert that tumor into something that we can operate on. And with improvements in chemotherapy, we're seeing that happen much more often than we used to.
Host Amber Smith: Could someone ever seek a pancreas transplant? Is that ever used to treat pancreatic cancer?
Thomas Vandermeer, MD: No, the pancreas transplants are primarily used for patients with either severe Type 2 diabetes or patients who have had a severe obstruction of their pancreas from pancreatitis. And in that case they get a transplant of just the insulin-producing cells. During transplantation, immunosuppressive medications have to be given, and those actually encourage the growth of cancer.
Host Amber Smith: I see. So the surgery, potentially, you could remove just the tumor or tumors, maybe. Do you ever remove the whole organ or part of the organ?
Thomas Vandermeer, MD: Typically what we would do is one of two operations. If the cancer is present in one part of the pancreas, we remove that entire part of the pancreas. If it's present in what we call the head of the pancreas, and there's a lot of structures coming together in that area -- gallbladder, bile duct, and part of the intestine -- so we do remove portions of the pancreas in order to be able to get all the way around the tumor and have no microscopic tumor present at the edges.
Host Amber Smith: I was going to ask you to tell us about the Whipple procedure. I've heard that's a really challenging surgery. Is that what you just described?
Thomas Vandermeer, MD: Yeah. The Whipple procedure involves removing the head of the pancreas, first part of the intestine, the bile duct and the gallbladder. Then the reconstruction of that requires us to join three areas together. We sew the residual intestinal tract to the pancreas, the bile duct and the end of the stomach. And that's a challenging operation for people to get through mostly because of GI function. The stomach doesn't function normally at first, after that whole anatomic rearrangement. People do get back to eating normally, and the quality of life returns to normal after the Whipple procedure. Actually we did a study a number of years ago where we compared quality of life six months after the Whipple procedure to an open gallbladder operation, and quality of life had returned to baseline in both groups.
Host Amber Smith: So in surgery, whether it's the Whipple procedure or another technique for someone who it was maybe caught early in, does that remove the threat of pancreatic cancer coming back later?
Thomas Vandermeer, MD: No, unfortunately at this point it doesn't remove it entirely. We are seeing an increased rate of what we think are cures of pancreatic cancer. But unfortunately the way things stand now, the majority of the patients still do recur after surgery. But, surgery along with chemotherapy really does extend life quite a bit.
Host Amber Smith: So patients that have gone through surgery for this, are they followed regularly to make sure it doesn't come back? Or, who would be -- their primary doctor, or who would they see for that?
Thomas Vandermeer, MD: People are followed very, very closely every three months at first. And the way that we check on things is by getting CAT scans of the chest, the abdomen and the pelvis, because the cancer can recur in any of those areas. And then there's a blood test, too. There's a protein that we can measure in the blood that is produced by pancreatic cancer, and so we track that very carefully. In terms of who does it, it's usually the surgeon and the medical oncologist, the doctor that gives the chemotherapy, follows along with the patient together. And then it's also important to have a whole team put together of nutritionists. And increasingly we focus on what we call survivorship, which is how you manage things after you've come through your treatment and then you're cancer free, and you have this intense focus on "What am I going to do about this cancer?" And that goes on for months, and then you're done with all that. So, getting back to you living your normal life is obviously really important. And so we have a whole team of people who focus on those various other issues as well.
Host Amber Smith: Well, before we wrap up, I want to ask if you can tell us about the palliative surgical procedures you do for patients with pancreatic cancer?
Thomas Vandermeer, MD: Pancreatic cancer can block the drainage of the stomach, and so people can have trouble with nausea and vomiting. So sometimes we have to create a bypass so that food can get from the stomach down into the downstream gastrointestinal tract. So we will do another procedure to create an opening between those two areas so that patients can eat again.
And the same thing can happen n the bile duct. The tumor can block the bile duct, and sometimes surgery can be used to bypass the blockage as well. What's more common for the blockage in the bile duct is to have a stent put in with an endoscope. They can avoid surgery and keep the bile flowing up from the liver to the intestine.
Another symptom that's relatively common in pancreatic cancer is back pain because the tumor can infiltrate into nerves that cause back pain. And so nerve blocks can be very effective in controlling that, as can radiation. But most people do quite well with just a nerve block.
Host Amber Smith: This information about pancreatic cancer, its diagnosis and treatment considerations is from my guest, Dr. Thomas Vandermeer. He's the chief of surgical oncology, and he specializes in pancreatic cancer. He's also the interim director of the Upstate Cancer Center. I'm Amber Smith for Upstate's "HealthLink on Air. "
Here's some expert advice from Dr. Corey McGraw from Upstate Medical University.
What's the outlook for someone with multiple sclerosis?
Corey McGraw, MD: You know, the outlook for folks who are diagnosed with MS is very good. We live in an era of MS treatments in which we fully expect patients to have no disease activity.
So that means no additional attacks of neurological disability called relapses, no new scars on the MRIs; we call those lesions. No progression of disability. And this is our current goal in MS care for all of our patients.
Host Amber Smith: You've been listening to neurologist Corey McGraw from Upstate Medical University.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Harmony Button has had her work published in "Best American Notable Essays of 2015." She gifted us with a gorgeous short poem celebrating the birth of a new family. Here is "Rich":
King-size sheets on a queen-size bed.
Corn silk scalp and milky head.
Late night night light salt lamp glow.
Daytime naps and days of slow
walks and long talks and rich snacks
in bed: Honeycrisp apples and almond-
dappled crumbs of toast we offer the dog
as we count and log the minutes of sleep and
ounces of milk. This is how we show our
love from before and our love's new debut:
clean sheets, warm sleep, a precious few
moments of skin on skin with not baby -- him,
my new old body back to thin and fits
against his torso for so long as we can until
our mouths that clutch unlatch
from one and open to another
as if the world were made of milk
and we three were, all of us, afloat
and drowning in it.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. If you missed any of today's show or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org Upstate's "HealthLink on Air" is produced by Jim Howe with sound engineering by Stephen Shaw.
This is your host, Amber Smith, thanking you for listening.