3RD ANNUAL Patient and Family Centered Care for PANCREATIC ... · 10/19/2019 · Georgiann Ziegler (Board Member, NPF Michigan Chapter) 10. Research: Pancreatic Enzyme Failure 24-27

FREE EVENT

3RD ANNUAL

Patient and Family Centered Care forPANCREATIC DISEASESSATURDAY, OCTOBER 19, 201911:30 am - 2:30 pmThe Inn at St. John’s, Plymouth, Michigan

PROGRAM11:30 am Registration & Light Refreshments

11:45 Welcome Matthew DiMagno, MD - Course Director

11:50 NPF and Michigan Chapter Updates Derrick Winke, EA; Robin Winke, LMSW

12:00 pm Clinical Problem – Maldigestion Erik-Jan Wamsteker, MD

12:05 Patient Testimony - Georgiann Ziegler

12:15 Research: Pancreatic Enzyme Failure Allen Lee, MD

12:20 Keynote Presentation: Dietary Management Amanda Dixon, RD

12:35 Panel Discussion

12:55 Break

1:10 NPF Patient Passport Matthew Alsante, CEO of NPF

1:25 Pancreatic Cancer Richard Kwon, MD, MS

1:30 Patient Testimony - Lance Judd

1:40 Research: Personalizing Treatment Eileen Carpenter, MD, PhD

1:45 Keynote Presentation: Cancer SurgeryHari Nathan, MD, PhD

2:00 Panel Discussion

2:20 Questions / Answers

2:30 Adjourn

Pre-registration is required by October 1, 2019To register, visit: http://bit.ly/MichiganPatientEd2019To donate, visit: http://bit.ly/MichDonation

3rd Annual Patient and Family Centered Care for Pancreatic Diseases National Pancreas Foundation (NPF) Michigan Chapter

Saturday, October 19, 2019, 11:30 AM – 2:30 PM

Table of Contents Pages 1. Flyer for 3rd Annual Patient and Family Centered Care for Pancreatic Diseases 1

2. Table of contents 2

3. Abbreviations 3

4. Weblinks – NPF and Michigan Medicine (NPF center) clinical pages 4

5. True / false questions: reinforce key points from each speaker 5-66. Introduction – 3rd Annual Patient and Family Centered Care for Pancreatic Diseases 7-10

Matthew DiMagno, MD - Course Director (Medical Director, NPF Michigan Chapter)7. National Pancreas Foundation (NPF) and Michigan Chapter Updates 11-17

Derrick Winke, EA (Board Member, NPF Michigan Chapter)Robin Winke, LMSW (Chair, NPF Michigan Chapter)

Part I. Maldigestion 8. Clinical Problem – Maldigestion 18-21

Erik-Jan Wamsteker, MD (Board Member, NPF Michigan Chapter)

9. Patient Testimony 22-23Georgiann Ziegler (Board Member, NPF Michigan Chapter)

10. Research: Pancreatic Enzyme Failure 24-27Allen Lee, MD

11. Keynote Presentation: Dietary Management 28-36Amanda Dixon, RD

12. National Pancreas Foundation (NPF) Patient Passport 37Matthew Alsante, CEO of NPF.

Part II. Pancreatic Cancer 13. Pancreatic Cancer and Michigan Medicine 38-45

Richard Kwon, MD, MS (Board Member, NPF Michigan Chapter)

14. Patient Testimony 46-48Lance Judd (Board Member, NPF Michigan Chapter)

15. Research: Personalizing Treatment 49-51Eileen Carpenter, MD, PhD

16. Keynote Presentation: Surgery on the Pancreas 52-59Hari Nathan, MD, PhD

Part III. About NPF Michigan Chapter and Events 17. NPF Michigan Chapter Poster 60

NPF Michigan Board

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Definitions

CEA, carcinoembryonic antigen

CF, cystic fibrosis

CME, continuing medical education

CT, computed tomography (CAT scan)

DEXA, dual-energy x-ray absorptiometry (bone densitometry)

DM, diabetes mellitus

EPI, exocrine pancreatic insufficiency

FACS, Fellow, American College of Surgeons GI, gastrointestinal

IBD, inflammatory bowel disease

LMSW, Licensed Master Social Worker NPF, National Pancreas Foundation

NRF2, Nuclear factor erythroid 2-related factor 2

MCT, medium chain triglycerides

MD, Doctor of Medicine

MRI, magnetic resonance imaging

MS, Master of Science

PA, physician assistant

PhD, Doctor of Philosophy

PERT, pancreatic enzyme replacement therapy

REE, resting energy expenditure

SIBO, small intestinal bacterial overgrowth

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Weblinks

National Pancreas Foundation (NPF) Home page

• https://pancreasfoundation.org/NPF Centers of Excellence

• https://pancreasfoundation.org/npf-centers-info/State chapters

• https://pancreasfoundation.org/state-chapters/About the pancreas

• https://pancreasfoundation.org/patient-information/about-the-pancreas/

Animated pancreas patient• https://pancreasfoundation.org/patient-information/animated-pancreas-patient/

National Pancreas Foundation, Michigan Chapter Home page – board, educational events, support group meeting

• https://pancreasfoundation.org/state-chapters/michigan/

To donate• http://bit.ly/MichDonation

Michigan Medicine, Comprehensive Pancreas Program – Gastroenterology • https://medicine.umich.edu/dept/intmed/divisions/gastroenterology-

hepatology/programs/comprehensive-pancreas-program• Appointments: 888-229-7408 (www.UofMHealth.org/gi)

Michigan Medicine, Pancreatic Cancer Clinic – Cancer Center • https://www.rogelcancercenter.org/pancreatic-cancer/clinic• https://pancreas.med.umich.edu/

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https://pancreasfoundation.org/https://pancreasfoundation.org/npf-centers-info/https://pancreasfoundation.org/state-chapters/https://pancreasfoundation.org/patient-information/about-the-pancreas/https://pancreasfoundation.org/patient-information/animated-pancreas-patient/https://pancreasfoundation.org/state-chapters/michigan/http://bit.ly/MichDonationhttp://bit.ly/MichDonationhttps://medicine.umich.edu/dept/intmed/divisions/gastroenterology-hepatology/programs/comprehensive-pancreas-programhttps://medicine.umich.edu/dept/intmed/divisions/gastroenterology-hepatology/programs/comprehensive-pancreas-programhttp://www.uofmhealth.org/gihttps://www.rogelcancercenter.org/pancreatic-cancer/clinichttps://pancreas.med.umich.edu/



THANK YOU!!

Pre-test questions for Patient & Family Centered Care for Pancreatic Diseases Event

• Please answer all questions before the educational event begins• You will be asked similar questions at the end of the session to measure how much you learned

Please circle the correct answer.

1. The NPF Michigan chapter has support group meetings on one Saturday morning per month in Ann Arbor.(Winke) True False

2. The animated pancreas patient on the NPF website will teach anyone seeking information about pancreatitis,pancreatic cancer, clinical trials, pancreatic surgeries and pancreatic endoscopy.(Winke) True False

3. Severe pancreatic maldigestion (insufficiency) is treated with pancreatic enzymes.(Wamsteker) True False

4. Complications of pancreatic maldigestion include weight loss, muscle wasting, osteoporosis and neuropathy.(Wamsteker) True False

5. Small intestinal bacterial overgrowth (SIBO) is an uncommon cause of persistent maldigestion despite use ofpancreatic enzymes in patients with chronic pancreatitis.(Lee) True False

6. Recommended amounts of dietary fat are 30 % of total calories for patients with pancreatic maldigestion.(Dixon) True False

7. Vitamin E is the least common vitamin deficiency in patients with pancreatic maldigestion.(Dixon) True False

8. Pancreatic cancer is the 3rd most common cause of cancer death in the United States.(Kwon) True False

9. A cutting edge upcoming approach to pancreatic cancer treatment involves taking a tissue biopsy to grow andrecreate a cancer model outside the body to test the effectiveness of therapies before offering to patients.(Carpenter) True False

10. Pancreaticoduodenectomy (Whipple) is an uncommon pancreas surgery for patients with pancreatic cancer.(Nathan) True False

PLEASE COMPLETE BACK SIDE AFTER HEARING EACH PRESENTATION

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THANK YOU!!

Post-test questions for Patient & Family Centered Care for Pancreatic Diseases Education Event • Please answer all questions & the evaluation before leaving the educational event.• We will compare your answers to your original answers to measure how much you learned.

Please circle the correct answer.

1. The NPF Michigan chapter has support group meetings on one Saturday morning per month in Ann Arbor.(Winke) True False

2. The animated pancreas patient on the NPF website will teach anyone seeking information about pancreatitis,pancreatic cancer, clinical trials, pancreatic surgeries and pancreatic endoscopy.(Winke) True False

3. Severe pancreatic maldigestion (insufficiency) is treated with pancreatic enzymes.(Wamsteker) True False

4. Complications of pancreatic maldigestion include weight loss, muscle wasting, osteoporosis and neuropathy.(Wamsteker) True False

5. Small intestinal bacterial overgrowth (SIBO) is an uncommon cause of persistent maldigestion despite use ofpancreatic enzymes in patients with chronic pancreatitis.(Lee) True False

6. Recommended amounts of dietary fat are 30 % of total calories for patients with pancreatic maldigestion.(Dixon) True False

7. Vitamin E is the least common vitamin deficiency in patients with pancreatic maldigestion.(Dixon) True False

8. Pancreatic cancer is the 3rd most common cause of cancer death in the United States.(Kwon) True False

9. A cutting edge upcoming approach to pancreatic cancer treatment involves taking a tissue biopsy to grow andrecreate a cancer model outside the body to test the effectiveness of therapies before offering to patients.(Carpenter) True False

10. Pancreaticoduodenectomy (Whipple) is an uncommon pancreas surgery for patients with pancreatic cancer.(Nathan) True False

Evaluation of Patient & Family Centered Care for Pancreatic Diseases Education Event

Overall evaluation: Do you feel you increased your knowledge today? Y N How would you rate the venue? Excellent Good Fair Poor Would you attend another NPF patient education event? Y N What topics would be helpful or interesting? ________________________________________________ ___________________________________________________________________________________

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Introductory comments Matthew J. DiMagno, MD, AGAFAssociate Professor, Michigan MedicineMedical Director, NPF Michigan Chapter

3RD ANNUAL

Part I . Maldigestion Part I I . Pancreatic Cancer

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Introductory comments Matthew J. DiMagno, MD, AGAFAssociate Professor, Michigan MedicineMedical Director, NPF Michigan Chapter

3RD ANNUAL

BRIEF ANNOUNCEMENTS

• Free box lunch for those who pre-registered• Restrooms• Program at registration desk• Use index cards to write down questions• Handout

10 questions Suggest topics for future programs

• Please Visit Poster on display to learn more about usHOPE

Write down questions

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PROGRAM GOALS

• Review resources: National Pancreas Foundation, University of Michigan• Increase understanding of how pancreatitis and pancreatic surgery

decrease pancreatic function and impair nutrition• Discuss resources and treatments available to improve/maintain nutrition

15 min break• Introduce the National Pancreas Foundation patient passport• Highlight the Michigan Medicine approach to pancreatic cancer, including

research & treatment aims to personalize medical and surgical care

HOPE

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THANK YOU

Sponsors National Pancreas Foundation (NPF)• Matthew Alsante, Executive Director• Patrick Salami, National Chapter Manager

Michigan Medicine, Division of GastroenterologyAbvie

Planning Board, NPF Michigan Chapter (http://pancreasfoundation.org/state-chapters/michigan/)Michigan Medicine CME office

Attendees Thank you for attending!

HOPE

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3RD ANNUAL

National Pancreas Foundation (NPF) and Michigan Chapter UpdatesDerrick Winke, EA (Board Member, NPF Michigan)Robin Winke LMSW (Chair, NPF Michigan)


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National Pancreas FoundationPresented by

Derrick Winke, EARobin Winke LMSW.Michigan Chapter

NPF Mission

The National Pancreas Foundation provides hope for those suffering from pancreatitisand pancreatic cancer through funding cutting edge research, advocating fornew and better therapies, and providing support and education for patients,caregivers, and health care professionals

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NPF Programs

ResearchNPF is the only foundation that supports research in pancreatic cancer and acute pancreatitis, chronic pancreatitis and pediatric pancreatitis. • Awards for $50,000• Funded 122 research projects totaling over 4million dollars since 1997.

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Pancreas Education and ResourcesNPF seeks to provide education, information and resources to researchers and patients. Thru the website, Pancreas 101 app for IOS and Android, 29 state chapters, NPF Centers of Excellence in 27 states for Pancreatitis including Michigan Health and locally in Michigan monthly support groups.

Also todays event the 3rd Annual Patient and Family Centered Care for Pancreatic Diseases.

Fellows Symposium

The annual Fellows Symposium remains one of our most important programs. By engaging young physicians and researchers and teaming them up with world‐class mentors, we encourage them to enter and remain in the field of pancreatology. Bringing thebest young minds to this field will have long term impact on the lives of our patients.

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Advocate for Patients

• Participation annually with the DigestiveDisease National Coalition (DDNC)

• Executive Committee of DDNC• Public Policy Forum

NPF Michigan Chapter Support Group

We offer local support group monthy where individuals change share stories, experiences and receive support to deal with Pancreatitis and resulting effects on both patient, care givers and survivors. We also bring special speakers to educate on new treatments and provide useful hints on navigating insurance and medication issues.

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NPF Centers

The NPF has identified treatment centers for patient referrals based upon specific criteria. At an approved NPF Center, patients can expect excellent multidisciplinary care that focuses on the whole patient to include: experienced oncologists, gastroenterologists, surgeons, dietitians, pain specialists, psychosocial support and more.

http://www.uofmhealth.org/conditions‐treatments/digestive‐and‐liver‐health/pancreatitis

https://pancreasfoundation.org/npf‐centers‐info/

The University of Michigan is the Only National Pancreas Foundation center of excellence in Michigan

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Pancreas_Animation1_Loop.exe

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3RD ANNUAL

I. Maldigestion – Clinical ProblemErik-Jan Wamsteker, MD, Associate Professor, Michigan MedicineBoard Member, NPF Michigan Chapter, No COI


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3RD ANNUAL

I. Maldigestion – Clinical ProblemErik-Jan Wamsteker, MD, Associate Professor, Michigan MedicineBoard Member, NPF Michigan Chapter, No COI

Maldigestion - Definition

Maldigestion- Impaired digestion of food or nutrients in the intestine- Example: from pancreatic an enzyme deficiency

Malabsorption- Impaired mucosal absorption of nutrients- Can arise from maldigestion (above) or defects in absorption or transport .

Subtle distinction between terms- Maldigestion is one cause of malabsorption- Terms often used interchangeably

HOPE

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Pancreatic Maldigestion - Symptoms

- Diarrhea- Weight loss- Flatulence- Abdominal bloating- Cramps and abdominal pain

Symptoms are not specific to pancreatic maldigestionHOPE

Pancreatic Maldigestion - Causes

• Exocrine Pancreatic Insufficiency• Maldigestion occurs with loss of >90% of exocrine function• Examples: Chronic pancreatitis

Pancreatic surgical resectionCystic fibrosis

• Certain liver diseases• Small intestinal bacterial overgrowth• Enzyme deficiencies in small intestine (ie. Lactase def.)

HOPE

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Pancreatic Maldigestion - Complications

• Weight loss

• Muscle wasting

• Osteoporosis

• Visual disturbances

• Neuropathy

HOPE

Pancreatic Maldigestion - Treatment

• Treatment directed at underlying disorder• Replacement of a deficient enzyme(s)• Pancreatic digestive enzyme replacement (PERT) during meals/snacks

(90,000 lipase units/meal; ½ dose for snacks)

• In at risk patients, screening for and treating maldigestion mayreduce symptoms and reduce long term complications

HOPE

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3RD ANNUAL

I. Maldigestion – Patient TestimonyGeorgiann ZieglerBoard Member, NPF Michigan Chapter


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Georgiann Ziegler Maldigestion – Patient Testimony

DIAGNOSIS: Idiopathic chronic pancreatitis

FUN FACT: I am a brand new grandmother

DIAGNOSIS: In 2004 I was diagnosed with Idiopathic Chronic Pancreatitis. Never knew where or what the pancreas did but I sure realized how painful and angry the pancreas can be. After a 65-day hospital stay in 2004, I continue to have multiple hospital stays per year. Fortunately, when not in a pancreas flare my days are good.

SUPPORT SYSTEM: Faith, family and friends are my greatest support team, along with my medical team. For me, I could not do this journey alone. The challenging part of all this is that most of my family and friends knew very little about the pancreas so we all learned together. I can say we are all still learning.

LIFESTYLE CHANGES YOU’VE MADE: I had to disability retire from a great job with the UAW in 2010. This was not only hard emotionally but financially as well. I always thought I would work to “retirement age”, have the going away lunch and walk away fulfilled. I felt cheated that my illness determined by timeline for retirement.

WHAT THE DISEASE TAUGHT YOU ABOUT YOURSELF: I feel that my attitude and strength is greater than I ever could have imagine. I run with my good days and try not to worry if a flare is around the corner. If asked to go somewhere or participate in something I generally say yes with the hope that I will be well enough to go. I take my diagnosis seriously but I do not let it steal my joy!

WHERE ARE YOU NOW: I continue to have pancreas flares and hospital stays. Happy to say that the admits are getting farther apart. For me, my cup will always be half full and never half empty. Because of my pancreatitis I am a patient advisor at Michigan Medicine which allows me to be a voice for not only myself but many patients and families.

WHERE ARE YOU NOW: I continue to have pancreas flares and hospital stays. Happy to say that the admits are getting farther apart. For me, my cup will always be half full and never half empty. Because of my pancreatitis I am a patient advisor at Michigan Medicine which allows me to be a voice for not only myself but many patients and families.

HOW ARE YOU INVOLVED WITH NPF MICHIGAN: I was approached a year ago by an NPF Michigan board member. I was honored to be asked to join a very important group. I currently am the fundraising chair and am excited to not only raise funds for research but to build relationships with others that are on the same pancreas journey.

ADVICE FOR SOMEONE FACING A DIAGNOSIS: The greatest advice I would give to family and friends when dealing with someone with a chronic condition would be to love us, listen to us, and just be there. I understand how hard it is to watch me struggle but many times all I need to know is that you’re there. As for the new patient I would say it’s okay to be mad, angry and upset. You to you!

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3RD ANNUAL

I. Maldigestion – Causes of Pancreatic Enzyme FailureAllen A. Lee, MDClinical Lecturer, University of Michigan, Division of Gastroenterology


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Causes of Pancreatic Enzyme Failure

Allen A. Lee, MDClinical Lecturer

University of Michigan Division of Gastroenterology

• Inadequate Dose or Non-adherence

• Incorrect timing of medication (e.g. surgery, gastroparesis)

• Need for addition of acid blocking medication (aciddegradation of lipase)

• Small intestinal bacterial overgrowth (SIBO)

• Deconjugates bile salts decreased fat digestion/absorption

Possible Causes of Steatorrhea

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• Others reported a prevalence of SIBO in CP ranging 0-92%• Only known risk factor is prior gastrointestinal (GI) surgery

• Aims• Perform the largest study to date• Determine prevalence of SIBO in a well-defined cohort of

CP without prior GI surgery• Define risk-factors for SIBO in CP

SIBO is Common in Chronic Pancreatitis (CP)

Lee and Baker et al., American Journal of Gastroenterology, 2019

• 41% of CP patients had SIBO by glucose breath test• Five risk-factors for SIBO were identified:

• Use of opiates• Diabetes Mellitus (DM)• Markers of severe pancreatitis: total Mayo Score (Clinical symptoms,

Calcifications, Histology, Abnormal imaging, Exocrine function, DM)• Markers of nutritional deficiency:

• Low albumin and zinc levels

• ~ 80% of CP patients with SIBO responded to antibiotics

SIBO is Associated with Diabetes, CP Severity, Low Zinc, and Opiate Use

Lee and Baker et al., American Journal of Gastroenterology, 2019

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• SIBO is common• ~40% of CP patients without upper GI surgery

• Consider SIBO when• Persistent steatorrhea or weight loss despite PERT

• Markers of more severe CP are present- Low Zinc level - Diabetes Mellitus- Increased Mayo Score - Opiate Use

Conclusions

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3RD ANNUAL

I. Maldigestion - Dietary ManagementAmanda Dixon, RDWUniversity of Michigan, Division of Gastroenterology


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Dietary ManagementAmanda Dixon, RDN

• Malabsorption• Micronutrient deficiencies• Nutrient recommendations• Dietary fat intake• Dietary modifications• Diabetes in chronic pancreatitis• Challenges with PERT• Role of Dietitian

Overview

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• Annual blood tests: Vitamins A, D, E, K• Annual diabetes screen: hemoglobin A1C• Stool testing every 1-2 years if pancreatic function has not

declined• Bone densitometry (DEXA) every 5 years• Documentation of weight changes/ body mass index• Fat malabsorption is usually most common

Screening tests in Chronic Pancreatitis patients with actual or suspected maldigestion

Rasmussen, 2019Mandalia, MD and DiMagno, MD

• All chronic pancreatitis patients should be monitored• Fat soluble vitamins are more likely to be deficient• Vitamin E

- Most common deficiency• Vitamin A• Vitamin D• Vitamin B12• Zinc and Copper

Nutrient Deficiencies

Duggan et al.,2010Irspen.ie, 2019

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Clinical clues to micronutrient deficiencies

Mandaila, MD and DiMagno, MD

Micronutrient Clinical manifestations of deficiency

Vitamin A Xerophthalmia Night blindness Bitot’s spots Follicular hyperkeratosis Immune dysfunction

Vitamin D Rickets Bowed legs Osteomalacia

Vitamin E Peripheral neuropathy Spinocerebellar ataxia Skeletal Muscle atrophy Retinopathy Anemia

Vitamin K Elevated prothrombin time Coagulopathy Decreased bone health

Zinc Dermatitis Alopecia Diarrhea Weight loss Infection Hypogonadism

Copper Neutropenia Impaired bone calcification Myelopathy Neuropathy Anemia

Clinical manifestation of fat soluble vitamin and select mineral deficiencies

• High calorie intake- Up to 30-50% higher REE

• High protein intake

Nutrition Recommendations

Irspen.ie, 2019Owira PM, Winter TA 2008

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• 30% of total calories (divided between meals)• Concerns with very low fat diets

- May lead to malnutrition in already nutritionally at-risk individuals• Use of medium-chain triglycerides (MCT)

- Doesn’t require pancreatic lipase for digestion.- Recommended to increase slowly as it can cause side effectssuch as cramps, nausea, diarrhea.- Max of 50 g/d

Dietary Fat Recommendations

Irspen.ie, 2019

• Eat small, frequent meals (aim for 5-6 throughout the day)• Eat well balanced meals that include a protein source• Aim for 5 servings of fruits/vegetables per day• Eat healthy calorie dense foods (avocado, nuts, olive oil)• Separate liquid intake from solid intake• Eat slowly and chew thoroughly• Exercise• Avoid laying down for 2-3 hours after meals

Diet Modifications

Pancreatic Cancer Action Network

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• Avoid alcohol• Limit refined carbohydrates• Limit/avoid fried, greasy foods• Limit intake of red meat, organ meat, processed meats,

margarine/butter, full fat dairy, pastries, high sugar drinks andsnacks

Diet Modifications

Pancreatic Cancer Action NetworkClevelandclinic.org

• Increased risk with longer disease duration and worseningdamage

• Type 3c DM• Hypoglycemia• Alcohol abstinence• Scheduled well balanced meals• Pancreatic enzyme compliance

Diabetes in Chronic Pancreatitis

Gudipaty, L, Rickels, M. 2015

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• Patient understanding• Out of pocket costs• Patient assistance programs

• https://www.creon.com/creon-support-programs• https://www.abbvie.com/patients/patient-assistance.html• https://www.allergan.com/responsibility/patient-

resources/patient-assistance-programs/zenpep - Zenpep:Allergan USA INC. 1800 Waters Ridge Drive, Lewisville,Tx 75057 (800)377-7790

Challenges with PERT

DiMagno

• Screening and monitoring for malnutrition• Aid in dietary modifications• Aid in common GI symptoms

- Loss of appetite- Diarrhea- Abdominal pain- Bone health

• Customize individual meal plans

GI Dietitians role

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• Gather background information- Weight history- Nutrient labs/other biochemical data- Food and Beverage Recall- GI symptoms/non-GI symptoms

• Nutrition Intervention and counseling• Education• Monitor and evaluation

What would a nutrition appointment be like?

Resources

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• Pancreatic Cancer Action Networkhttps://www.pancan.org/

• The National Pancreas Foundationhttps://pancreasfoundation.org/

Resources

http://www.animatedpancreaspatient.com/en‐pancreas/view/m501‐a12‐understanding‐nutrition‐and‐the‐role‐and‐benefits‐of‐pert‐animation

Thank you

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3RD ANNUAL

National Pancreas Foundation (NPF) Patient PassportMatthew AlsanteChief Executive Officer (CEO), NPF


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3RD ANNUAL

II. Pancreatic Cancer – and Michigan MedicineRichard Kwon, MD, MSBoard Member, NPF Michigan Chapter, No COI


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Pancreatic cancer and Michigan Medicine

Richard Kwon, MD,MSOctober 19, 2019

Division of Gastroenterology & Hepatology

Pancreatic adenocarcinoma

• ~ 50,000 Cases Annually• 3rd most common cause of cancer‐related deaths• Likely top by 2030

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How do these patients present?Symptoms

Sx Freq (%)Asthenia 86Weight loss 85Anorexia 83Abd Pain 79Dark Urine 59Jaundice 56Nausea 51Back Pain 49

SignsSx Freq (%)Jaundice 56Hepatomegaly 39Abd mass 10‐15Cachexia 13Ascites 5


Risk factors for Pancreatic CancerDefinite

• Smoking• Age > 50 years• Family History• Hereditary Pancreatitis• Chronic Pancreatitis• IPMN• Obesity• Diabetes• Blood Group

Risk Increase Lifetime RiskSmoking 1.74x 2‐3%

ETOH >6 drinks/day 1.46x 1‐2%

Obesity BMI>35 1.5x 1‐2%

Type 2 Diabetes 1.8x 2%

Family HistoryAny with PCa 2.4x 4%

3 or more relatives 6.8x 12‐20%

Genetic Syndromes 2‐132x 4‐50%

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Hereditary Cancer Syndromes Associated with Risk for Pancreatic Cancer

Syndrome Gene (s) Lifetime Risk PDACHereditary Breast Ovarian Cancer BRCA1

BRCA2PALB2

5‐10%

Lynch Syndrome MLH1MSH2MSH6PMS2

4‐10%

Familial Melanoma (FAMMM) CDKN2A 10‐30%Peutz Jeghers Syndrome STK11 10‐30%Familial Adenomatous Polyposis APC 1‐5%Li Fraumeni Syndrome TP53Ataxia Telangiectasia ATM 1‐5%Hereditary Pancreatitis PRSS1 50%


Other pancreatic conditions• Cystic neoplasms• Neuroendocrine tumors• Peripancreatic tumors

• Ampulla• Duodenum• Distal bile duct

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Multidisciplinary, patient‐centered approach

• Gastroenterology• Radiologists• Medical oncologists + PAs• Pancreatic surgeons• Radiation oncologists• Medical genetics + counselors

• Intake coordinator• Clinical carecoordinators


Team approach

• Multidisciplinary Tumor Board• Benign Pancreas Conference

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Patient journey• Intake coordinator• Clinical care coordinator• Patient navigator• Patient Assistance Center• PsychOncology Program• Complementary Therapies Program• Support groups• Grief and Loss Program

Das A, et al. Gastrointest Endosc 2009


Pushing for progress• 11 cancer clinical trials

• Chemo +/‐ Radiation• Pancreatic enzyme replacement therapy

• Personalized care• Tumor genetic sequencing• Research: cancer organoids

• Early detection in high risk patients• Clinical trial

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Pushing for progress‐ research

• Tumor immunology• Tumor metabolomics• Tumor imaging• Surgical outcomes• Biomarkers


Resources

• https://www.rogelcancercenter.org/pancreatic‐cancer/clinic

• https://medicine.umich.edu/dept/intmed/divisions/gastroenterology‐hepatology/programs/comprehensive‐pancreas‐program

• https://pancreas.med.umich.edu/

• https://pancreasfoundation.org/

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Summary• Pancreatic cancer is a battle.• Michigan Medicine offers world class andpersonalized multidisciplinary care forpatients with pancreatic diseases.

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3RD ANNUAL

II. Pancreatic Cancer – Patient TestimonyLance JuddBoard Member, NPF Michigan Chapter


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Lance Judd Pancreatic Cancer: Patient Testimony

I am a 25-year survivor of Pancreatic Cancer!

At the time of my diagnosis I had been a Stock Broker for approximately 12 years. I was 41 and had never had any significant medical problems that couldn’t be cured with Anti-biotics and/or Chicken Soup.

It was November of 1994. My wife Lori and I had just finished building our first home, in the Union Lake area, and we were preparing for guests at our house warming party that night. While going to the bathroom I was shocked that my urine had turned the color of Coffee. It was all that was on my mind that night. The following Monday, after arriving at work, three different co-workers told me I was yellow. Needless to say that spooked me pretty good and I went to the Doctor that night.

My Doctor sent me to have bloodwork done. He also said if anything was out-of-the-ordinary he would call me. The next morning at 10 am I got a call. He said I needed to have a scope done. Basically, this involved passing a tube with a tiny camera through my mouth and down my throat to look around, maybe do a biopsy, and report back with the results.

On Saturday my Doctor came in and said I had a Cancerous tumor at the head of the Pancreas and I needed to see a Surgeon.

Luckily, I had a wonderful cousin who worked at Harper Hospital who knew a Surgeon by the name Dr. Don Weaver. Dr. Weaver had performed over 500 hundred pancreatic surgeries known as the “Whipple” surgery, and also came to be, later on, the personal surgeon of the Michael Ilitch of the Red Wings and Little Caesar’s pizza. I was extremely fortunate to have Dr. Weaver play a part in my case. After reviewing my FILMS and PICTURES of the pancreas he confirmed that I had Pancreatic Cancer and recommended the Whipple surgery. It was Monday mind you and he said he could do it the next day Tuesday or Thursday. I took Thursday.

By a second stroke of luck, I was interviewed after the Surgery by some students at the University of Michigan. They were looking for patient volunteers who were interested in participating in an ongoing clinical trial focused on patients with a recent diagnosis of Pancreatic Cancer. The study was directed by a renowned Michigan Oncologist known as Dr. V. Dr. V. headed up the Study that was investigating a new regimen/treatment of Chemotherapy and Radiation. I agreed to enroll in the study and Dr. V became my Oncologist.

In my first few weeks of the study and treatment I lost 51 pounds.

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My wife and I had been married a little shy of 2 years at the time. This certainly wasn’t how we had planned our first 2 years! Lori worked tirelessly keeping up with the countless appointments and the back and forth to the treatments at Harper.

Chemotherapy was very DIFFICULT. They ran it into me through a line in my chest and heart, running 24 hours a day, 7 days a week and they changed the pack every 7 days from mid-January through the beginning of June. They only paused the treatment occasionally to let my immune system recover. I remember reeking of the smell of the Chemo, my body was so saturated with the stuff.

During the last 6 weeks of the treatment, I began radiation, I did not stop the Chemotherapy, which was offered Monday through Friday for 28 days. They really couldn’t have continued the radiation much longer because my bowels were shutting down.

Over the next 7 years I began to embark on the new me…which also involved weathering two notable complications. First becoming a diabetic and Second losing a lot of blood due to an ulcer that developed at the site where two of my organs, my pancreas and intestine, were surgically connected. I got through this and for the next 12 years, and life was pretty uneventful until my liver function declined due to scar tissue from the original Whipple surgery. Because of this a SECOND Whipple surgery would be required. I’m very happy to say this Whipple was successful as well. For those of us that have undergone such a major alteration in our bodies all I can say is I’ve tried to keep a sense of humor about it so as not to worry those around me but there are times when you can’t laugh off the kind of symptoms that require you to call an ambulance!

In closing I want to thank my Wonderful Steadfast Wife and family. I want to thank the professionals, Doctors, Nurses and general staff that I have worked with over the 25 years at Harper and Karmanos! In an ODD WAY they have become part of my extended family as I’m sure so many other survivors have had similar feelings about their Medical professionals! I attempt every few years to track them down and thank them again letting them know how much I appreciate them!!

Thanks for this opportunity to spend some time with you tonight!

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3RD ANNUAL

II. Pancreatic Cancer - Research: Personalizing TreatmentEileen Carpenter, MD, PhDFellow, Gastroenterology and Hepatology, Michigan Medicine


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3RD ANNUAL

II. Pancreatic Cancer - Research: Personalizing TreatmentEileen Carpenter, MD, PhDFellow, Gastroenterology and Hepatology, Michigan Medicine

Personalizing Treatment of Pancreatic Cancer

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Eileen Carpenter, MD, PhD Research: Personalizing Treatment of Pancreatic Cancer

Thank you for that introduction. I would like to thank Dr. Matt DiMagno and all the organizers for the opportunity to share with you all today. I’m a gastroenterology fellow in the research phase of my training at the University of Michigan, and my interest is in uncovering the mechanisms that make pancreas cancer such a deadly disease.

My first experience with this disease was when my own mother was diagnosed with it when I was 15. By the time we figured out what was going on, the disease was already in its advanced stages, which is the case in with most patients. When she passed away a few months later, I made the decision to devote my life to understanding the mechanisms that drive pancreatic cancer to ultimately improve outcomes for patients. In the years that followed, I obtained a combined MD and PhD degree in NY to receive the best possible training for cancer research, and moved to Michigan for my residency and fellowship training, given the excellent clinical and research opportunities that Ann Arbor has to offer. Now, as I enter my time as an investigator in pancreatic cancer, 2 decades after my mother passed away, the 5-year survival rate for pancreatic cancer is still in the single digits.

To talk briefly about the research efforts on pancreatic cancer at the University of Michigan, when I came here as a physician scientist in training, my goal was to develop a translational research project that was unique to my background in basic science research and my clinical training in gastroenterology. As a key to my success, I met Dr. Michelle Anderson, the clinical chief of endoscopy at the University of Michigan, who promoted collaboration with Drs. Marina Pasca Di Magliano and Howard Crawford, both experts in the molecular biology of cancer. We developed an exciting project focused on patients with new suspected pancreatic cancer who are referred to Michigan Medicine for diagnostic biopsy. The tissue from their biopsy not only helps to establish a clinical diagnosis of pancreatic cancer, but is also useful for cutting edge translational research to help individualize treatment of cancer for each patient. Specifically, we use these small bits of tissue to culture patient tumor cells in a 3 dimensional culture system called organoids, which allow us to recreate the cancer outside the body for study. This cancer model can be used to determine the most effective chemotherapy and understand why pancreatic cancer behavior varies so greatly between patient to patient. In the future, we hope to build a precision medicine platform using a simple, minimally invasive endoscopic biopsy, to match patients to appropriate clinical trials that their specific disease has the best chance of responding to. Equally as important, we are working on a process that can benefit all pancreatic cancer patients, both in early and advanced stages of the disease.

I believe that we are on the precipice of change. At the University of Michigan and other tertiary academic centers across the country, patients with pancreatic cancer are treated in a multidisciplinary approach, with careful discussions between oncologists, surgeons, radiologists, and gastroenterologists. We are hearing more and more of stories of patients living years with pancreatic cancer, not months. Research for pancreas cancer is growing, as people realize the need to understand the biology of this disease. Ultimately, our goal is to work together with each other and with you to put an end to this terrible disease. Thank you.

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3RD ANNUAL

II. Pancreatic Cancer – Surgery on the PancreasHari Nathan, MD, PhD, Surgical DirectorMultidisciplinary Pancreatic Cancer Clinic, University of Michigan


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@DrHariNathan

Cancer Surgery on the PancreasHari Nathan, MD, PhD

Assistant Professor of SurgerySurgical Director, Multidisciplinary Pancreatic Cancer Clinic

University of Michigan

@DrHariNathan

Pancreatic cancer (85%)

Duodenal cancer (5%)

Ampullary cancerBile duct cancer(cholangiocarcinoma)

Peri‐Ampullary Cancers

@DrHariNathan

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@DrHariNathan

Pancreatic cancer

57,000 cases/year

46,000 deaths/year

5‐year survival 9%

Surgery 5‐year survival 20‐30%

@DrHariNathan

Staging pancreatic cancer

• High‐quality CT or MRI scanof abdomen

• CT scan of chest

• Labs• CA19‐9• CEA

• Diagnostic laparoscopy

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@DrHariNathan

Multidisciplinary treatment is key

@DrHariNathan

Distal pancreatectomy

• Pancreatic body/tail (left side)• Usually spleen• Maybe other organs

• Pancreatic leak in 30%• 15% ”significant”

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@DrHariNathan

Pancreaticoduodenectomy(Whipple operation)• Pancreatic head (right side)• Duodenum• Bottom of stomach• First part of jejunum• Gallbladder• Part of bile duct

@DrHariNathan

Whipple steps

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@DrHariNathan

Whipple outcomes

Complications• Pancreatic leak (10%)• Bile leak (

@DrHariNathan

Typical Whipple recovery

• About 7 days in hospital

• Discharge to home, walking and eating

• 90% recovery by 4 weeks

• Full recovery by 8 weeks

Invasion of blood vessels

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@DrHariNathan

Summary

• Pancreatic surgery can be done safely when done in high‐volumecenters by experienced teams (especially Whipple)

• Tumors that we used to consider unresectable are now beingremoved

• As other treatments improve (e.g., chemotherapy), we will likelybecome more surgically aggressive in pancreatic cancer

pancreasfoundation.organimatedpancreaspatient.com

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@DrHariNathan

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1.0 Annual U-M Pancreas Patient Program 9-2019 (final)1.0 Table Contents Definitions Weblinks 20191.1 True_False_Questions(2019)-version 21.2 DiMagno_Intro Page 11.3 DiMagno_Intro all slides2.1 Winke Page 12.2 Winke all slides3.1 Wamsteker Maldigestion page 13.2 Wamsteker Maldigestion all slides4.1 Georgiann Patient Slide 14.2 Georgiann - Text5.1 Lee SIBO Page 15.2 Lee SIBO in CP(3) all slides6.1 Dixon Slide 16.2 Dixon all slides7. Matt Alsante cover slide8.1 Kwon Slide 18.2 Kwon All slides9.1 Lance cover slide9.2 Lance Judd pancreatic cancer10.1 Carpenter slide 110.2 Carpenter all slides10.3 Carpenter 4 min umich panc talk11.1 Nathan slide 111.2 Nathan all slides12. Poster

Documents

3RD ANNUAL Patient and Family Centered Care for PANCREATIC ... · 10/19/2019 · Georgiann Ziegler (Board Member, NPF Michigan Chapter) 10. Research: Pancreatic Enzyme Failure 24-27