Pancreatic cancer isn’t as common as some other cancers, but it is somewhat renowned for being difficult to treat. Symptoms usually don’t show up until the cancer has grown to an advanced stage, but now, more than ever, patients with pancreatic cancer have good reason to be optimistic about their futures due to advances researchers have made.
In this podcast, we’re joined by Brian M. Wolpin, MD, MPH, director of the Gastrointestinal Cancer Treatment Center at Dana-Farber/Brigham and Women’s Cancer Center, who answers some common questions about this disease, including:
- What is the #1 cause of pancreatic cancer?
- What are the early warning signs of pancreatic cancer?
- Why is pancreatic cancer called “the silent killer”? Is that an accurate way of putting it, or is that too simplistic or even not true?
- Is anxiety a symptom of pancreatic cancer?
- Does pancreatic cancer show up in blood tests?
- Can pancreatic cancer be treated with immunotherapy?
- How else are researchers making progress in pancreatic cancer?
MEGAN RIESZ (DANA-FARBER COMMUNICATIONS): So, to get started, what do we know about the #1 cause of pancreatic cancer? What is it?
WOLPIN: There really isn’t one single cause of pancreatic cancer. There are a number of different risk factors. These including things like smoking, obesity, diabetes, and then family history of cancer.
RIESZ: What are the early warning signs of pancreatic cancer, if any?
WOLPIN: One of the problems with pancreatic cancer is that there are not really very many early warning signs. The signs that people do get are often quite nonspecific and could be due to many different things, not just pancreatic cancer. Those symptoms tend to be abdominal discomfort that sometimes radiates backwards, towards the back. People will lose weight in some instances and often feel not as hungry as they normally do. However, many of these symptoms can be caused by other things and so are not very specific for pancreatic cancer.
RIESZ: We hear a lot that pancreatic cancer is called ‘the silent killer.’ Is that an accurate way of putting it? Is that too simplistic or not even true? What would you say about that?
WOLPIN: Well, I think there are two components to that: the ‘silent’ part and then the ‘killer’ part. I would say, from the second perspective, pancreatic cancer is a difficult cancer, and many of the patients who get this kind of cancer do die from it. So, in that way, yes, it is a difficult one, and it’s actually the third leading cause of cancer death in the United States.
In terms of the silent part, I think it goes back to the symptoms that we were talking about, which is that many patients don’t have early symptoms, so by the time people do have symptoms, the tumor has often progressed, and even often metastasized. So, yes, I think it’s a reasonably accurate term, although, obviously, not one we would use in the clinic, per se.
RIESZ: A common question we get is whether anxiety or depression are symptoms of pancreatic cancer. Can you speak to that as well?
WOLPIN: Once the tumor has been diagnosed, certainly, patients feel some anxiety about that because it’s a difficult cancer to treat. And reasonably so, that can make people feel anxious. There’s been some work to try to identify whether depression symptoms or anxiety symptoms occur before diagnosis. There is some data to suggest that may be true, but, really, further studies are needed to show whether that’s really present before the diagnosis.
RIESZ: Does pancreatic cancer show up in blood tests?
WOLPIN: Most of the time, pancreatic cancer does not show up in blood tests. The blood tests that you would normally do at your primary care doctor’s office test relatively nonspecific things, including, say, liver tests.
Pancreatic cancer can cause some abnormalities in people’s liver tests or liver function tests. This can occur because the tumor has metastasized to the liver or, in some cases, because it blocks the bile duct, which drains the bile from the liver. However, many, many things cause those abnormalities, and most of the time, that doesn’t indicate pancreatic cancer as present.
We have a lot of studies ongoing looking for more specific blood tests that would show an early pancreatic cancer is present, and that’s a very large area of research going on at Dana-Farber right now.
RIESZ: Immunotherapy is, obviously, a big area of research and treatment. Can pancreatic cancer be treated with immunotherapy?
WOLPIN: It has been very exciting to see the advances in immunotherapy and how that’s been effective to treat a host of different cancer types. Unfortunately, for pancreatic cancer, that has not generally been a very effective treatment thus far. Most of the immunotherapies that we use now are related to antibodies that bind to specific checkpoint inhibitors, as they’re sometimes called.
There is a small sliver, a small percentage of patients — it’s about 1% of patients with pancreatic cancer — who are responsive to these medicines. These are patients that have what are called microsatellite instable (or MSI-high) tumors. Again, that’s present in about 1% of patients with pancreatic cancer. We screen all patients at Dana-Farber for that abnormality, and if it’s present, then we will use some of these newer immunotherapies that have been brought to the clinic.
However, for the 99% of patients who don’t have this abnormality, really, immunotherapy has not shown to be effective thus far. That being said, we have many, many clinical trials going on now, trying to test new ways to get the immune system to attack the tumor, and our absolute hope is that some of these newer or different ways to get the immune system to attack the tumor will work in pancreatic cancer, where the others have not so far.
RIESZ: Anything else you want to say about how we are making progress in pancreatic cancer, generally?
WOLPIN: I think there have been a number of areas where we’ve made progress for patients with pancreatic cancer, really, in the past five or 10 years. I think this has been true in many aspects of the disease. Surgery has gotten better and safer, so when we take out the tumor, we’re more likely to get the full tumor out, and patients recover better from the surgery.
Radiation has been improving, the ability to really target the tumor more directly, and we’re very excited about some new technology that just came to Dana-Farber/Brigham and Women’s Hospital, which is MRI-guided radiation. We really think this has the potential to target the tumor more accurately and spare the tissues around the tumor. This is an advance we hope to see in radiation, really, in the coming several years.
Chemotherapy has also gotten better. The chemotherapies we use now are substantially better than the ones we used ten years ago, and now patients are living longer because of that, we’re actually able to cure more patients than we were before because the chemotherapy can be helpful after surgery.
Then I also think we are starting to get smarter with our therapies. The first targeted therapy for pancreas cancer was just approved in December of 2019. This takes advantage of a vulnerability in the tumor, which is related to people who have a BRCA-1 or BRCA-2 mutation that they inherit. That can be anywhere from 5% to 7% of our patients, and now, for the first time, we have a therapy specific for those patients.
I think that’s really the future for where we see things going. It’s being able to define what the abnormality in a particular person’s tumor is and then give them a drug that matches to that. It’s very nice to see this finally starting to come true with the first drug approved to do that, and Dana-Farber had a lot to do with that. We did a bunch of these initial research around this idea that ultimately led to the approval. I think, really, there’s a lot of reason for optimism. Things have improved over the past ten years, and I think, over the next ten years, things will improve significantly more.
Learn more about pancreatic cancer from the Gastrointestinal Cancer Treatment Center at Dana-Farber/Brigham and Women’s Cancer Center.
About the Medical Reviewer
Dr. Wolpin received his medical degree from Harvard Medical School in 2001. He subsequently completed his residency in Internal Medicine at Brigham and Women's Hospital, and his fellowship in Medical Oncology at the Dana-Farber Cancer Institute. He joined the staff of DFCI and Brigham and Women's Hospital in 2007, where he is a medical oncologist and clinical investigator in the Center for Gastrointestinal Oncology. His research focuses on biomarkers and novel therapeutics in gastrointestinal malignancies, and mechanisms by which lifestyle factors interact with malignant risk and progression.