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12/15/2011
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Welcome to the 6th AnnualWelcome to the 6 Annual Pancreatic Cancer Awareness Day
November 12, 2011
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Program AgendaWelcome from the Executive Director
John Chabot, MD
Mission and Goals from the Administrative Director
Francine Castillo, MS
Topics:
I. Surgical Options and Post‐operative Lifestyle Changes
Beth Schrope, MD, PhD (Surgery)
II. Genetics & Prevention
Harold Frucht, MD (Genetics & Prevention)
III. Pancreatic Cysts
John Allendorf, MD (Surgery)f, ( g y)
IV. The W’s and H’s of Drug Therapy in Pancreatic Cancer: How Can We Move Forward?
Wasif Saif, MD (Medical Director, The Pancreas Center)
V. Epidemiology of Pancreatic Cancer: What We Know About Risk and Prevention
Jeanine Genkinger, PhD, MHS (Epidemiology)
Q & A Session
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Mission
To decrease the societal and individual burden of pancreatic disease by establishing and maintaining a center of excellence dedicated to providing outstanding research and medical care to patients with pancreatic disease
100 Day Plan (Feb 1, 2008)Clinical Research
Imminent Changes:• Receptionist 2/4
• Dr Fine outpt practice 2/18•Obesity Center final operational
flow agreement
ImplementTissue Banking
Continue and ExpandResearchMeetings
Imminent Changes:•Clinical Research Manager
Victoria Serrano 3/14Develop standards & ensure compliance for all researchinitiatives Liaison to HICCC
Fundraising/Marketing
Lustgarten Site VisitFeb 14
Mirzaand Dean visit
Data Collection&
Analysis
Continue to collectvolume numbers
and revenues acrossall departments
Have RN/NP help developsmooth patient flow process:
Temp RNs thru July 08Catherine & Rishikka
Break into three centers lead
Research MeetingsDr Fine Dr Su
Dr FruchtPromote investigator
driven studies
Continue to recruit forHigh Risk Prevention
Protocols:1: S‐MRCP vs S‐EUS
for pancreatic cancer screening inhigh‐risk individuals
2: Utilizing S‐MRCP & arginine Testing to compare exocrine/endocrine function following
Surgical resection for pancreatic
Fulfill staffing needs in 3 areas:• Secretarial
• Precerting and Credentialing• Financial Counseling
initiatives. Liaison to HICCC
Continue collaborationw/ other researchers
Dr. Wendy ChungDr.RotterdamDr. Lucas Dr. Verna
and ean visitFeb 28
Preliminary Proof of new comprehensiveMulitdept website
Comprehensive fundraising folder
High Risk program brochure
Develop patientsatisfaction survey, pinpoint areas in
need of improvement
Scanning HHQs & other clinicaldata directly into database
by mid level managers:Endocrine/Thyroid/Mesothel.
PancreasObesity
Design and developHigh Risk Prevention Room/
Patient resource room
Surgical resection for pancreatic adenocarcinoma
3: Comparing S‐MRCP with e‐PFT in patients w/abdominal pain or
symptoms of pancreatic insufficiency following surgical
resection for pancreaticadenocarcinoma
4: Studying the frequency ofdistal/multifocal PanIN lesions in locally‐recurrent pancreatic cancer5: Determining the frequency of
BRCA genetic mutations in Ashkenazi
Jewish pancreatic cancer patients
EMR Implementation• In compliance
with university guidelines
GI Research FellowDr Caroline HwangJuly 2008 – July 2009
The Pancreas Centercomprehensive
booklet
Purchase equipmentFor uniform study #s
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Long Term Goals
Marketing NetworkingClinical NYPH/HICCC
Research
Develop pancreas center affiliations
in suburbanhospitals
Fundraising forcharities
Encourage new donors
Develop true multi‐disciplinary practice with
open schedulingacross all depts.
Increase space on IP 8Develop a
robust clinicaltrial organization
Hire Pathologist Solely for Pancreas Center
Have largesttumor bank in
countryRollout GI MED and MED ONC on EMR
Participate inindustry trials
Develop financial model depictingNYP growth
Work with survivors/
family membersin the community to
organize local
Participate inspeaking
engagements
MED ONC on EMR NYP growth from PC activities
fundraising eventsand “walks”
GetNIH grants
Long(er) Term Goals!
Clinical Research Awareness
Continue to improve patient access/patient satisfaction
Auto‐islet Transplant
Grow CYST Program
Dedicated psychosocial support outpatient program on site
Pre‐surgical diabetes teaching video
SPORE grant!
Expand translational research to improve patient outcomes
Add to clinical trials/continue collaboration with other
institutions
Complete stool study
Build mainstream media outlets
PC Awareness outreach in minority communities
Build internet presence/blog
Pancreas Center Endowment!!!!
Expand referral physician base out of tri‐state area
Build international reputation
Create lost to follow up protocol
Collaboration for pain management
……………………….
Complete stool study
Funding for new lab equipment
Recruit up and coming basic science researchers dedicated to
the pancreas
……………………………
Develop psychosocial program for families
Collaborate with American Cancer Society
……………………………..
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570589600
700
Pancreas Center New Patient Volume
159
184
281
386
200
300
400
500
44
92
136159
0
100
2002 2003 2004 2005 2006 2007 2008 2009 2010
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Th P C t TThe Pancreas Center Team
The Pancreas Center
Vasudha Dhar, MD (Interventional Endoscopy)Tomas Gonda (Interventional Endoscopy)Claudia Kipp, PA (Interventional Endoscopy) Charles Lightdale, MD (Interventional Endoscopy)
John Allendorf, MD (Surgery)Laurie Budd, RN (Surgery)John Chabot, MD (Surgery)Nicole Goetz, DNP(Surgery)G b i l i (S )
Charles Lightdale, MD (Interventional Endoscopy)John Poneros, MD (Interventional Endoscopy) Amrita Sethi, MD (Interventional Endoscopy)Tim Wang, MD, PhD (GI/Basic Science Research)
Kyung Chu, NP (Medical Oncology)Robert Fine, MD (Medical Oncology)Wasif Saif, MD (Medical Oncology)William Sherman, MD (Medical Oncology)
Helen Remotti, MD (Pathology)Heidi Rotterdam, MD (Pathology)David Leung, MD (Nuclear Medicine)
( d l )
Gabriela Harrington (Surgery)James A. Lee, MD (Surgery)Beth Schrope, MD, PhD (Surgery)Yanghee Woo, MD (Surgery)
The Muzzi Mirza Pancreatic Cancer Prevention and Genetics Program
Harold Frucht, MD (Program Director )Wendy Chung, MD (Genetics)Fay Kastrinos, MD (Research)Michael Rasiej, MD (Radiology)Ashley Dikos (Administrative Manager)Jason Chu (Part Time Research Admin)Leonora Mui, MD (Radiology)
Jeffrey Newhouse, MD (Radiology)Martin Prince, MD (Radiology )
Mary Sciutto, MD (Dept of Psychiatry)
Jason Chu (Part Time Research Admin)Lauren Khanna, MD (Research)Elana Levinson, MS (Genetics Counselor)Aimee Lucas, MD (Research)Vilma Rosario (Part Time Research Admin)Eizabeth Verna, MD Research)
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The Pancreas CenterDivision of GI Endocrine Surgery Administrative
SupportFrancine Castillo, MS(Administrative Director/Division Administrator)Bonnie Badenchini (Administrative Manager)Maureen Benjamin (Billing Manager General Surgery)Sarah Cambria (New Patient Coordinator, NP Admin Asst)
Division of Hematology Oncology Administrative Support
Nancy Amalbert (Divisional Administrator)Jennifer Arroyo (Practice Manager)Kristina Howard (Admin Asst)Kindra Matthews (Admin Asst)
( )Colina Chapman Williams (Admin Asst)Kimone Crossley (Data Manager)Tyrina Jones (Medical Assistant)Alba Munoz (Financial Coordinator General Surgery)Priscilla Novas (New Patient Coordinator, NP Admin Asst)Ana Rosario (Admin Asst) Quanda Tarleton (Medical Assistant)Allison Villacis (Data Manager) Rodelyn Zapanta (Admin Asst)
Division of Digestive and Liver Diseases Administrative Support
Misc Administrative StaffBryan Dotson (NYP Public Relations Office)Jada Fabrizio (Office of External Affairs )Bradley Jobling (Pancreas Center/Surgery Social Networking)Kristen Mahood (Assistant VP of Development)Juan Mejia (Service Line Director, Digestive Diseases)Marilyn Mullins (Development Officer)Amy Pietzak (NYP Public Relations Office)Kathleen Propp (NYP Marketing)Christine Rein (Office of External Affairs Events Coord)Deb Schwartz (Director, Office of External Affairs)Stephanie Sheeler (Office of External Affairs Events Coord)
i Shi h ( b i l )pp
Ana Ignat (Divisional Administrator)Clarissa Alvino (MA)Yandreily Arroyo (Admin Asst)Carolyn Baldwin (Call Center)George DeJesus (Admin Asst)Jacqueline Infante (Practice Manager)Evelyn Martinez‐Garcia (Admin Asst)Camelia Salajeanu (Billing)Yaniria Perez (Reception)Beatriz Valladres (Call Center)Connie Zapata (Practice Manager)
Ju‐Mei Shieh (Pancreas Center Website Developer)Jennifer Turvey (Office of External Affairs)
Herbert Irving Comprehensive Cancer Center Translational ResearchMary Ann Kral (Executive Director for Clinical Research) Mary Ann Kiernan (Regulatory Compliance Specialist) Frances Brogran (Research Nurse ‐ Dr. Wasif Saif) Kyung Chu, NP (Research Nurse ‐ Dr. William Sherman)
Basic Science ResearchGloria Su, PhD Dario Garcia‐Carracedo, PhD Xiaojun Li Wanglong Qiu, MD, PhD Ken Olive, PhD
Kelly Mowatt (Study Coordinator ‐ Dr Robert Fine) Dawn Tsushima, RN (Research Nurse ‐ Dr Robert Fine) Sarah Zelonis (Study Coordinator ‐ Dr Wasif Saif)
Pancreas Center Research StaffJoseph Dinorcia, MD (Research Fellow)Irene Epelboym (Research) Jeanine Genkinger( Epidemiology)Minna Lee (Research)Qiongfen Li (Research – Autoislet) Megan Winner, MD (Research Fellow)
Mike BadgleyMarina FurmanovJennifer JongenPaul ObersteinBarbara Orelli, PhDCarmine PalermoStephen SastraDafydd Thomas, PhDYilong Hung Robert Fine, MD Richard Dinnen, PhD Yuehua Mao,MD
NYP Ancillary Care TeamAnne Ammons, RD (Nutrition) Fran Hellar, LCSW (Inpt Social Work) Angela Lloyd, LCSW (Social Work) Tina Sapienza, LCSW (Social Work)
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Bob BrownBob BrownPatient Speaker
Click to View Bob Brown's Story on Youtube
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SURGICAL OPTIONS &OS O SPOST‐OPERATIVE LIFESTYLE
CHANGES
Beth Schrope, MD, PhDDepartment of SurgeryDepartment of Surgery
Columbia University Medical Center/ New York‐Presbyterian University
Pancreatic Surgery
Who gets surgery?
Types of procedures
Post‐operative lifestyle implications
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Who is Eligible for Surgery?
Localized diseaseLocalized diseaseAssess with MRI, PET scan
Acceptable medical riskCardiovascular clearance
Preoperative chemo or radiationFor “locally advanced” disease
The Neighborhood
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Whipple Procedure
Removal of the head of the pancreas, duodenum, +/‐portion of stomach, gallbladder
Typical hospital length of stay 7 – 14 days
Over 100 Whipplesperformed at CUMC in 2010, 22% with vascular reconstruction
Distal Pancreatectomy
Removal of the body and tail of pancreas and possiblytail of pancreas and possibly spleen
Option for laparoscopic procedure
Typical hospital length of stay 5 – 9 days
Requires certainRequires certain vaccinations (for loss of spleen)
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Central Pancreatectomy
Removal of a portion of the body of pancreasbody of pancreas
Reserved for benign and low grade malignant lesions (islet cell tumors)
Typical hospital length of stay 5 – 9 days
Goal to preserve as muchGoal to preserve as much pancreatic function as possible*
Total Pancreatectomy
Removal of entire pancreas, duodenum, gallbladder, +/‐spleen
Typical hospital length of stay 10 – 14 days
All patients become insulin dependent diabetics*
Reserved for high cancer‐risk individuals
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Postoperative Expectations
Hospital length of stay
Pain
Resumption of diet / gastric ileus
Bl d it i / t lBlood sugar monitoring / control
Pain Management
Immediate postoperative pain
l dPCA ‐> oral pain medications
Non‐narcotics – Toradol, Lyrica, Tramadol
Chronic pain
Oral pain medications narcotic NSAIDs otherOral pain medications – narcotic, NSAIDs, other
Narcotic patch
Nerve blocks
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Post‐pancreatectomy Diet
Reduce the size of your meals
Restrict dietary fat
Consider dietary supplements
Have nourishing snacks within easy reach
Don't worry if you have days when you can't eat at all
Try to drink plenty of fluids
Pancreatic Digestive InsufficiencySymptoms
Diarrhea
Bloating
Foul‐smelling stool
Hair loss, dry skin
Difficulty gaining weightDifficulty gaining weight
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Digestive Medications
Pancreatic enzymes (take at each meal)Creon
Zenpep
Pancrease
Promotility agentsReglan (metoclopramide)
ErythromycinErythromycin
Antiulcer agents
Constipation regimen
Diabetes
ALL surgical patients experience elevated blood psugar after surgery
Insulin drip after surgery improves healing
Long term risk of diabetes 10 – 12% in patients with pnormal blood sugar before surgery (after Whipple)
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Quality of Life
Questionnaires from patients who have undergone Whipple report good quality of life,undergone Whipple report good quality of life, comparable scores to healthy controls (79 ‐ 81 vs. 83 ‐ 86)
Diabetes is not a ‘guarantee’ and is a controllable consequence
Digestive and nutritional issues are easily controlled with medications and food choices
GENETICS & PREVENTIONGENETICS & PREVENTION
Harold Frucht, MDDirector The Muzzi Mirza Pancreatic Cancer Prevention &Director, The Muzzi Mirza Pancreatic Cancer Prevention &
Genetics Program
Associate Professor, Division of GI MedicineColumbia University Medical Center/New York‐Presbyterian Hospital
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15% of patients with pancreatic cancer have a familial aggregation or an inherited predisposition15% of patients with pancreatic cancer have a familial aggregation or an inherited predisposition
Number of FDRs (w/ Pancreatic Cancer)
Incidence (per 100,000 in theUS Population)
Increased Risk (by Number of FDR)
General U.S. (reference) 9 ‐
1 41 4.6 x
2 58 6.4 x
3 or more 288 32.0 xSource: Klein AP, et al., Cancer Research 2004; 64; 2634‐2638
Mutation Relative Risk
Breast cancer BRCA1, BRCA2 10
FAMMM P16 15‐65
Peutz‐Jeghers Syndrome STK11 130
HNPCC MLH1, MSH2 2
H di i i T i 50Hereditary pancreatitis Trypsinogen 50
Familial Polyposis APC 5
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2 or more FDR with pancreatic cancer
1 FDR with pancreas cancer, ≤ 50 years old
2 or more second degree relatives with pancreatic
cancer, one at an early age
History, physical exam, family history, genetic testing
Average Risk:
‐1 family member with PC at > 55 years old
Moderate Risk
‐ ≥ 2 1st, 2nd or 3rd °with PC‐ 1 1st °at < 55 years old
High Risk
‐ ≥ 3 1st, 2nd or 3rd°with PC
Basic blood tests, additional testing if symptoms
‐ 1 1 at < 55 years old ‐ Not high risk
MRI or EUS
Any abnormal testing: EUS (if not already done)
‐ ≥ 2 1st° with PC
‐ ≥ 1 1st & 1 2nd° with PC, 1 at < 55 years old
EUS and MRI
Verna EC, et al, Pancreatic cancer screening in a prospective cohort of high‐risk patients: a comprehensive strategy of imaging and genetics. Clin Cancer Res. 2010 Oct 15;16(20):5028‐37
No malignant or pre‐malignant disease identified
Surveillance (based on further risk stratification)
Malignant or pre‐malignant disease diagnosed or suspected
Consider Surgery
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Genetic Counseling / TestingGenetic Counseling / Testing&&
Screening / PreventionScreening / Prevention
Probable HNPCC/FAMMM
History Suggestive of Inherited Pancreatic Cancer
Genetic test of anaffected individualaffected individual
Positive Negative
Genetic testing of family members
Continued high risk cancer screening of the individual and all
family members
Cancer screening as recommended for
the general population
PositiveNegative
Positivefor cancer
Surgery
Negative
Calvert & Frucht, Ann Int Med, 2002:137;603‐613
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Genetic Testing
EUS
CA 19‐9, OGTT
MRI/MRCP
ERCP
Laparoscopic Distal Pancreatectomy
Total Pancreatectomy
Ongoing Research Ongoing Research
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Potentially the same methodology for Colon & Pancreas cancer screening?
Exfoliated cells ducts bowel stool
Extract crude DNA from stool samples
Analysis for abnormalities
Our Study Results
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TO MAKE AN APPOINTMENTTO MAKE AN APPOINTMENTPLEASE CALL:PLEASE CALL:
212212 305305 9337 9337 212212--305305--9337 9337
PANCREATIC CYSTSPANCREATIC CYSTS
John Allendorf, MD
Assistant Professor of Surgery
Director of Endocrine Surgery Fellowship
Columbia University Medical Center/ New York‐Presbyterian Hospital
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Differential Diagnosis
Inflammatory ‐‐ Pseudocyst
NeoplasticSerous cystadenoma
Mucinous lesionsMucinous cystadenoma
IPMNSide Branch IPMN
Main Duct IPMNMain Duct IPMN
Cystic degeneration of endocrine neoplasms
Diagnostic Workup
History
Physical exam
Fluid AnalysisCytologyPhysical exam
Imaging
CT
MRI/MRCP
EUS
BiochemistryCEA (192 ng/mL)Amylase
Mutational analysis
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Pseudocyst
Inflammatory
Hi t f P titiHistory of Pancreatitis
Fluid
Inflammatory cells
Debris
High amylase
Low CEA
Serous Cystadenoma
Asymptomatic, may icause pain
Palpable mass
Central scar, calcification
Microcystic on EUS
Low amylaseLow amylase
Low CEA
Benign
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Mucinous Cystadenoma
Often asymptomatic
YYoung women
Usually located in tail
Unilocular or few septations
Low Amylase
High CEA
Ovarian type stromaOvarian type stroma
Malignant potential
Sidebranch IPMN
Asymptomatic or pancreatitis
Both genders
Not limited to the tail
Fluid analysis
High amylase
High CEAHigh CEA
Malignant potential
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Main Duct IPMN
Pancreatitis
Fishmouth ampulla
M cinMucin
High amylase
High CEA
Malignant potential
Management
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Pseudocyst
Natural history
Ob tiObservation
Drainage
External
InternalEndoscopic
SurgicalSurgical
Endoscopic Internal Drainage
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Serous Cystadenoma
Observation
Resection
Symptoms
Size
Diagnostic uncertainty
Mucinous Cystadenoma
Resection
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Main Duct IPMN
Risk of malignancy (70%)
ResectionAffected portion of duct
Frozen section
May require total pancreatectomy
ObservationPoor surgical candidatesPoor surgical candidates
Advanced age
International consensus Guidelines (Sendai criteria)
Sidebranch IPMN
Risk of malignancy vs risk of morbidity
ResectionSymptomatic
>3cm
Mural nodules
Young age
ObservationSurveillance
Interval
Modality
? Practical
International consensus Guidelines (Tanaka, et al)
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Pancreatic Cyst Surveillance Program
500 patients in the registry
Program of active surveillanceProgram of active surveillance
MRI
EUS
Natural history
Patient quality of lifePatient quality of life
Mutational analysis of cyst fluid
Summary
Systematic approach
History, imaging, fluid analysis
Distinguish inflammatory from neoplastic
Weigh the risks and benefits of intervention
Symptoms
Risk of malignant degeneration
Risk of surgical complications and diabetesRisk of surgical complications and diabetes
Design an intervention tailored to the patient
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THE W’S AND H’S OF DRUG THERAPY IN PANCREATIC CANCER:
HOW CAN WE MOVE FORWARD?
Wasif Saif, MD
Professor of Clinical Medicine
Director of the Clinical Section GI Oncology
Medical Director, Pancreas Center
Columbia University Medical Center/New York‐Presbyterian Hospital
Outline
Are there any different types of pancreatic cancer?
What are the known risk factors?What are the known risk factors?
What are the common symptoms and signs?
How do we diagnose pancreatic cancer?
How do we treat pancreatic cancer?
What is the prognosis?
Wh t C I d t I Odd ?What Can I do to Improve my Odds?
What are the novel drugs offered @ CU Pancreas Center?
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Types of Pancreatic Cancer
There are two types of cells in the pancreas: exocrine cells and endocrine cells.
Th ll l h diff f i
EXOCRINE95% of pancreatic cancers are classified as
exocrine tumors because they begin in the
exocrine cells that produce enzymes to aid
in digestion.
ENDOCRINE5% are endocrine tumors, also called
neuroendocrine or islet cell tumors.
Islet cells of the pancreas produce hormones
including insulin, glucagon and
These cells also have different functions.
somatostatin.
Endocrine tumors may be benign or
malignant and tend to be slower growing
than exocrine tumors.
Pain : 80%
Mid epigastric 43%
Signs and Symptoms of Pancreatic CancerThere aren’t any noticeable signs or symptoms in the early stages of PC Signs of PC, when present, are like the signs of many other illnesses
Mid epigastric 43%
Upper abdominal 23%
Lower abdominal 18%
Left upper quadrant 13%
Jaundice : 47%
Weight loss: 60%
New onset of D. mellitus
Para‐neoplastic Syndromes
Weight loss
Trousseau’s syndrome
Depressive Symptoms
Courvoisier’s sign
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Causes of Pancreatic Cancer
SporadicSporadic ~65 ‐ 80%
Known genetic syndromes ~5%Hereditary Pancreatitis, HNPCC Lynch II Variant, BRCA2, FAMMM, Peutz‐Jeghers Syndrome
Familial pancreatic cancer~10% or more
How Do We Diagnose Pancreatic Cancer?
Blood TestsSerum chemistries, CBC, LFTs
Serum CA19‐9 and in some cases CEA
Other tests, such as fecal fat, stool trypsin, trypsinogen, amylase, and lipase may be evaluated to determine pancreas function and need for pancreatic enzyme supplementation.
Diagnostic ImagingDiagnostic ImagingCT scan of chest, abdomen, and pelvis
EUS
ERCP/MRCP
PET scan in certain cases
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How Do We Treat Pancreatic Cancer?
Resectable PC
Stages I‐IIB15‐20%
SurgeryAdjuvant Chemoradiotherapy
Inoperable PC
Locally AdvancedStage III 30‐40%
MetastaticStage IV40‐50%
ChemoradiationCh th
ChemotherapyN l Th ti
Inoperable PC
Locally AdvancedStage III 30‐40%
MetastaticStage IV40‐50%
j pyAdjuvant Chemotherapy
ChemotherapyNovel Therapeutics
Novel TherapeuticsSupportive Care
Adj t th i t t t ft t t d t di l
After Surgery: Adjuvant Therapy For Pancreatic Cancer
Adjuvant therapy is treatment after surgery to try and prevent disease relapse
As most patients after surgery will have the disease relapse in other places, the
cancer must have spread prior to surgery
Tumors smaller than 10 million cells cannot be seen, so we cannot detect
“micrometastatic” disease
Standards of care vary depending on which side of the Atlantic you’re on:
North America (GITSG, RTOG): chemo‐radiation followed by
chemotherapy
Europe (ESPAC‐1, CONKO, ESPAC‐3): chemotherapy alone
The critical thing is that SOMETHING is better than NOTHING
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Neoadjuvant Therapy
Goals:Increase the resectability rateIncrease the resectability rateSee who needs radiation therapyDetermine why therapy failsIncrease the survival and cure rate of pancreatic cancer patients
LA Pancreatic Cancer
OPTIONS:Chemo‐XRT XRT (radiation therapy)Chemotherapy followed by Chemo‐XRT
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Treatment For Patients With Advanced Pancreatic Cancer
A Timeline For Slow Progress
Pre‐1996 Many drugs tested, nothing workedy g , g
1996 Gemcitabine FDA approved
1996‐2005 Many drugs tested, no drug or drug combination is better than Gemcitabine
2005 Tarceva FDA approved
2005 Capecitabine + Gemcitabine better than Gemcitabine
2006 G i bi O li l i d FDR G i bi b h2006 Gemcitabine + Oxaliplatin and FDR Gemcitabine not better than Gemcitabine
2006 Gemcitabine + Bevacizumab not better than Gemcitabine
2007 Gemcitabine + Cetuximab not better than Gemcitabine
2010 FOLFORINOX better than Gemcitabine
Li J, Saif MW. JOP. 2009 Mar 9;10(2):109‐17
PrognosisEstimated new cases and deaths from pancreatic cancer in the United States in 2010:
New cases: 43,140Deaths: 36,800
Functional Stage Description Median Survival (m)
Resectable Tumor confined to pancreas or extends beyond pancreas but without involvement of
15‐19
4th leading cause of cancer mortality (6%)
CA or SMA + Regional LAD
LA Tumor involves CA or SMA 6‐10
Met/Adv Distant Mets 3‐6
Staley CA, Pancreas 1996
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When Would Chemotherapy Not Be Appropriate?
If you are staying in bed greater than 50% of the time after you wake up
This may be a sign that your cancer is so advanced that chemotherapy will likely do more harm than good
Hospice care and relief of symptoms should be the primary focus of your care
What Can I Do To Improve My Odds?
Participate in a CLINICAL TRIAL
Select the option that you feel is the best in conjunction with your doctors
When you require highly specialized care of a multi‐disciplinary nature, seek care in an i i i h h i l dinstitution where these teams are in place and functioning to work together on a daily basis
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CUMC PC Research
Treatment Options At The Pancreas Center
Resected LA , Borderline Advanced disease
* HyperAcute Vaccine* GTX
1st‐line
2nd‐line
3rd‐line• CO 1.01• MM398 vs
GTX GTX + Xeloda‐XRT
3 line
• Gemcitabine ± IPI-926• Gemcitabine ± GS6624• GTX• GTX vs. Gem-Erlotinib
• MM398 vs. 5FU/LV
Pipeline• NUC1031• NV-196
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EPIDEMIOLOGY OF PANCREATIC CANCER: WHAT WE KNOW ABOUT
RISK AND PREVENTION?
Jeanine Genkinger, PhD, MHS
Department of Epidemiology
Columbia University
Mailman School of Public Health
2011 Estimated US Cancer Cases*
30% Breast
14% Lung & bronchus
Men822,300
Women774,370
Prostate 29%
Lung & bronchus 14% g
9% Colon & rectum
6% Uterine corpus
5% Thyroid
4% Non‐Hodgkinlymphoma
4% Melanomaof skin
Lung & bronchus 14%
Colon & rectum 9%
Urinary bladder 6%
Melanoma of skin 5%
Kidney 5%
Non‐Hodgkin
lymphoma 4%
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2011.
3% Kidney
3% Ovary
3% Pancreas
19% All Other Sites
lymphoma 4%
Oral Cavity 3%
Leukemia 3%
Pancreas 3%
All Other Sites 19%
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2011 Estimated US Cancer Deaths*
26% Lung & bronchus
15% Breast
Men300,430
Women271,520
Lung & bronchus 28%
Prostate 11%
9% Colon & rectum
7% Pancreas
6% Ovary
4% Non‐hodgkin lymphoma
3% Leukemia
3% Uterine corpus
Colon & rectum 8%
Pancreas 6%
Liver & Intrahepatic bile 4%
Leukemia 4%
Esophagus 4%
Urinary Bladder 4%
*Excludes basal and squamous cell skin cancers and in situ carcinomas except urinary bladder.Source: American Cancer Society, 2011.
2% Liver & intrahepatic bile duct
2% Brain & other nervous system
Non‐hodgkin lymphoma 3%
Kidney & renal pelvis 3%
Lifetime Risk1.41% of men and women born today will be diagnosed with cancer of the pancreas at some time during their lifetime.
OR
1 in 71 men and women will be diagnosed with cancer of the pancreas during1 in 71 men and women will be diagnosed with cancer of the pancreas during their lifetime.
Comparison:
BREAST CANCER: 12.15% of women born today will be diagnosed at some time during their lifetime.
1 in 8 women will be diagnosed with cancer of the breast during their lifetime.g g
COLORECTAL CANCER:5.12% of men and women born today will be diagnosed with cancer of the colon and rectum at some time during their lifetime.
1 in 20 men and women will be diagnosed with cancer of the colon and rectum during their lifetime.
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Risk Factors for Pancreatic Cancer
Non‐modifiable Factors
Age (60‐80 yrs of age)
Race
Sex
Family History/Genetics
(Lowenfels AB, J Cell Biochem 2005)
Incidence Rates by Race/Ethnicity and Gender
Race/Ethnicity Male Female
All Races 55.0 per 100,000 men 41.0 per 100,000 women
White 54.4 per 100,000 men 40.2 per 100,000 women
Black 67.7 per 100,000 men 51.2 per 100,000 women
Asian/Pacific Islander 45.4 per 100,000 men 34.6 per 100,000 women
American Indian/AlaskaAmerican Indian/Alaska Native a
42.7 per 100,000 men 40.0 per 100,000 women
Hispanic b 39.9 per 100,000 men 28.4 per 100,000 women
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Risk or Preventive Factors for Pancreatic Cancer
Modifiable Factors:Smoking
Alcohol
Obesity – BMI
Physical Inactivity?
Dietary Factors?Sugar‐sweetened beverages
Red and processed meats
Vitamin D
Fruits and Vegetables
Pooled Multivariate Adjusted Relative Risks (95% CI) for Pancreatic Cancer According to BMI at Baseline
00.2
0.40.6
0.81
1.21.4
1.61.8
2
Re
lati
ve
Ris
k (
95
% C
I
1.16(0.96-1.40)
1.47(1.23-1.75)
1.00(REF)
1.07(0.92-1.25)
1.18(1.03-1.36)
overweight obese0
0 1 2 3 4 5 6
Categories of Body Mass Index
Genkinger et al, CEBP
<21 21-22.9 23-24.9 25-29.9 > 30
BMI is calculated from your height and weight. BMI is an estimate of body fat
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Multivariate Adjusted Pooled Relative Risks (RR) and 95% Confidence Intervals (CI) for Pancreatic Cancer
According to Alcohol Intake
1.40
0 40
0.60
0.80
1.00
1.20
Relative Risks Females
Males
Total1.00(REF)
1.02(0 91 1 14)
0.91(0 9 1 04)
0.96(0 82 1 14)
1.22(1 03 1 4 )
0.00
0.20
0.40
Alcohol Intake (g/day)
R
0 1-4.9 15-29.95-14.9 >30
(REF) (0.91-1.14) (0.79-1.04) (0.82-1.14) (1.03-1.45)
Genkinger et al, CEBP, 2009
1 drink/day
>2 drinks/day
Risk or Preventive Factors for Pancreatic Cancer
Modifiable Factors:Smoking
Alcohol
Obesity – BMI
Physical Inactivity?
Dietary Factors?Sugar sweetened beveragesSugar‐sweetened beverages
Red and processed meats
Vitamin D
Fruits and Vegetables
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Risk Factors for Pancreatic Cancer
Health History FactorsHealth History Factors
Chronic pancreatitis
Diabetes
Periodontal Disease?
Allergies/Asthma?
(Lowenfels AB, J Cell Biochem 2005)
Recommendations
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World Cancer Research Fund/ American Institute for Cancer Research
RecommendationsBe as lean as possible without becoming underweight.
h ll f l dBe physically active for at least 30 minutes every day.
Limit consumption of energy‐dense foods (foods high in fats and/or
added sugars and/or low in fiber) and avoid sugary drinks.
Eat more of a variety of vegetables, fruits, whole grains, and pulses
(beans).
Limit consumption of red meats (such as beef, pork and lamb) and avoid
http://www.wcrf.org/cancer_research/expert_report/recommendations.php
processed meats (such as sausage, bacon).
If consumed at all, limit alcoholic drinks to 2 for men and 1 for women a
day.
Limit consumption of salty foods and foods processed with salt (sodium).
Don’t use supplements to protect against cancer.
American Cancer SocietyRecommendations
Stay away from tobacco.
Stay at a healthy weight.
Get moving with regular physical activity.
Eat healthy with plenty of fruits and vegetables.
Limit how much alcohol you drink (if you drink at all).
Protect your skin.
Know yourself, your family history, and your risks.
Have regular check‐ups and cancer screening tests.
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Screening Guidelines
No current recommended screening guidelines for pancreatic cancerp
USPTF recommends
Biennial screening mammography for women aged 50 to 74 years.
Pap smear/HPV screening for cervical cancer in women who have been sexually active and have a cervix.
Fecal occult blood testing, sigmoidoscopy, or colonoscopy, for colorectal cancer in adults, beginning at age 50 years and
continuing until age 75 years.
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American Heart Association Recommendations
Learn how many calories you are eating and drinkingIncrease amount and intensity of physical activity (at least 30 mins/day)Eat a variety of nutritious foods from all the food groups.
E t t i t i h f d (f it t bl fi d h l i f d )Eat nutrient rich foods (fruits, vegetables, unrefined whole‐grain foods)Eat fish at least twice a week
Eat less of the nutrient‐poor foods. Reduce consumption of high calorie and low nutrient foods and beverages
Cut back on beverages and foods with added sugars.Choose lean meats/poultry without skin and prepare them without saturated/trans fat.Cut back on foods containing partially hydrogenated vegetable oils to reduce trans fatCut back on foods high in dietary cholesterol. Eat less than 300 mg of cholesterol/day Choose and prepare foods with little or no salt. Eat less than1,500 mg of sodium/daySelect fat‐free, 1 percent fat, and low‐fat dairy products.
Alcohol : If you drink alcohol, drink in moderation. Smoking: Don’t smoke tobacco — and stay away from tobacco smoke.
Online Resources
American Cancer Society: http://www.cancer.org/
National Cancer Institute: http://www cancer gov/National Cancer Institute: http://www.cancer.gov/
Pancreatic Cancer Action Network: http://www.pancan.org/
Lustgarten Foundation: http://www.lustgarten.org/
Live Strong Foundation: http://www.livestrong.org/
Your Disease Risk: http://www.yourdiseaserisk.wustl.edu/english/index.htm
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Question & Answer Session
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