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“If the tumor is wrapped around those, and if we cannot remove all of the tumor – even if we leave a little bit behind – it’s the same as not doing the operation,” Merchant explained.
“In the past, these operations were considered high-risk,” Merchant said. But thanks to improvements in surgical techniques, “in high-volume cancer centers, the mortality for this procedure is less than 2 percent. We’re very aggressive here at Vanderbilt-Ingram when it comes to operating in tight spots.”
Dramatic improvements in imaging also help physicians identify the best candidates for surgery. “We are so much better now at taking the appropriate patients to surgery,” Merchant said. There is a lot of progress being made in terms of defining characteristics of which tumors are resectable, unresectable or borderline resectable based on the involvement of the surrounding blood vessels.”
The Lipscomb family knew how fortunate they were that David was a candidate for surgery, which provides the only hope for a cure.
“It was a three-centimeter tumor and honestly, had it been a centimeter either way and not on that bile duct, we wouldn’t be having this conversation,” Robi explained.
Still, David knew the surgery would be tough.
On Jan. 22, 2008, Merchant performed the Whipple procedure, removing one-third of Lipscomb’s pancreas, his gallbladder, a small piece of his liver, and part of his small intestines.
While the surgery went well, there were setbacks and Lipscomb spent nearly three weeks in the hospital. Over the next few months he underwent chemotherapy and then combination chemo-radiation therapy.
Lipscomb’s medical oncologist, Laura Williams Goff, M.D., prescribed a chemotherapy drug called gemcitabine.
“I always feel good about offering gemcitabine to patients with pancreas cancer because it was approved on the basis of improvement in clinical benefit, improvement in pain and
overall energy levels,” said Goff, an assistant professor of Medicine at Vanderbilt-Ingram. “Most people don’t lose their hair, and they have minimal nausea and vomiting. It’s a pretty well-tolerated regimen.”
While chemotherapy after surgery does improve survival, it is difficult to cure the disease. Some patients also receive radiation therapy, which may be helpful especially for high-risk tumors.
“There has been a lack of progress in clinical trials for adjuvant therapy after surgery,” said Merchant. “Based on all of the clinical trials so far, there is still a great deal of controversy regarding the role of radiation therapy. It’s unfortunate that we haven’t been able to come to a consensus because there are such limited options for our patients.”
Since 80 percent of patients are not eligible for surgery, cancer researchers are diligently trying to develop new drug treatments for pancreatic cancer. So far, the only targeted therapy approved by the Food and Drug Administration (FDA) is erlotinib, known commercially as Tarceva. While the drug normally extends life by a few weeks, the fact that it works at all is reason for hope in a disease that has proved difficult to understand and treat. Even when patients are successfully treated with surgery, chemotherapy, radiation or Tarceva, the chance of a recurrence is dramatic; the cancer returns in about 80 percent of patients.
Researchers are also starting to identify the genetic pathways that mark the progression of the disease.
“We have known for some time that the K-ras gene is mutated and overactive in pancreas cancer,” Goff explained. “It seems to happen early in the development of pancreas cancer, but figuring out how to turn it off or to target that abnormal K-ras has so far eluded us.”
Hal Moses, M.D., Director Emeritus of Vanderbilt-Ingram, and colleagues have developed a mouse model of pancreatic cancer – by coupling a K-ras mutation with another mutation – that closely resembles human disease. This model could provide new opportunities for studying the disease’s progression and for investigating potential therapies.
Goff hopes that it will be possible to individualize chemotherapy or targeted therapies for different types of pancreas cancer.
“There have been preliminary efforts to try to segment types of pancreas cancer by groups of genes – similar to what has been done for breast cancer or lung cancer – but that research is very early and is not ready for prime time,” she said.
The successes in treating and curing breast and colon cancer make the lack of success in pancreatic cancer even more frustrating for physicians and patients. And they all point to the same fact: the dramatic difference in levels of research funding. While pancreatic cancer is among the top five cancer killers, the disease constitutes less than 2 percent of the National Cancer Institute’s research budget – far less than funding for other major cancer types.
“For more than 30 years we have been talking about waging a war on cancer,” said Jordan Berlin, M.D., associate professor of Medicine and clinical director of Gastrointestinal Oncology at Vanderbilt-Ingram. “But when you look at the amount of money devoted to pancreatic cancer research, it’s more like a skirmish.”
“One of the reasons we have made so many inroads in
treating breast or colon cancer is because we have devoted so
many financial resources to basic and clinical research,” Berlin said. “With an aging population, we are going to see many more pancreatic cancer patients, and we need to start focusing our research dollars on this disease.”
David Lipscomb and family agree with that sentiment – and hope to help raise public awareness of this disease.
Nine months after surgery, Lipscomb had regained some of the weight he lost and was starting to exercise again. He had even managed to keep working during much of his recovery. But the battle is far from over.
“Even though the percentages are bleak, somebody always beats the percentages,” Lipscomb said. “Why not me? Somebody has to. How humbling to think only two out of 10 patients who get this can have surgery. I can’t help but feel hopeful because I’ve already beaten the odds.”
Editor’s note: As Momentum was going to press, David's cancer returned and progressed quickly. He passed away on Feb. 25. For those who would like to help patients like David, his family requests that donations be made to the Pancreatic Cancer Action Network (www.pancan.org ), an organization that sponsors research and advocates for more public awareness of this disease.