Amitabh Chak, MD, Professor of Medicine at University Hospitals Cleveland Medical Center, talks about how his study is trying to identify the causes for pancreatic cancer so that it can be detected earlier on.
Now, I thought this was really surprising – that pancreatic cancer is surpassing several other cancers.
Chak: In terms of death rate or…
Diagnosis.
Chak: Diagnosis and incidence rate, yeah. A number of other cancers actually have been going down. We made an impact on colon cancer, which is gastrointestinal cancer – the rates are going down. Breast cancer. But pancreatic cancer, for some reason, the rates are going up and it remains one of the cancers where we really have not made much of a difference in terms of impact.
Do you know why there’s such a big increase?
Chak: There’s a number of theories as to why pancreatic cancer might be on the increase. We know one of the major risk factors for pancreatic cancer is obesity, and there is an epidemic of obesity, which is increasing. Probably has something to do with change in environment. We know that there are environmental agents that cause cancer. So whether it’s a change in our diet, whether it’s a change in the microbiome or bacteria that are around us, whether it’s additives in foods we eat – we don’t know exactly what, but probably is some environmental change that’s causing the increase. But a lot of it is a mystery.
And smoking, too. I had no idea.
Chak: Yeah, smoking is a risk factor. On the other hand, smoking rates in the country haven’t gone up to the extent that they would explain why pancreatic cancer is going up, but smoking is definitely a major risk factor for pancreatic cancer.
Now, are the incidents of death also going up?
Chak: As the numbers go up, the incidents of death have also gone up. Pancreatic cancer is one of the deadliest cancers that we know. Certainly for solid cancers – it’s what we call in cancer research lingo a refractory cancer – or one of those cancers where we have not made any difference in terms of survival. Five-year survival remains less than 10% – a dismal rate.
Why is that?
Chak: It’s always been a deadly cancer. Don’t know why. Part of it may have to do with the fact that the pancreas is not surrounded by a capsule, so the cancer tends to spread much more rapidly. Part of it is also that it’s asymptomatic for a long period of time. We don’t know when it develops. We do know, by the time that symptoms develop, that the cancer is generally advanced, and we can’t remove it very easily when it develops.
Would you say, by the time you see a patient that are with symptoms, they’re stage three – stage four?
Chak: Most of the patients that present with pain or even jaundice is advanced stage – generally, stage three, and often would spread to the liver or stage four cancers. When it’s that advanced, even with surgery and chemotherapy, you don’t cure the cancer. It’s rare to cure pancreatic cancer. We have not made a major difference in pancreatic cancer chemotherapies. Some other cancers – even with metastatic disease, we’re able to control and even cure, but not with pancreatic cancer.
What’s the treatment currently?
Chak: If you catch it early enough, surgery is still the favorite treatment. If it’s advanced beyond where it can be operated, then we try to palliate it with chemotherapy and radiation as appropriate.
Now, UH is taking part in a study. Tell me about the study.
Chak: Yeah. We’re part of a national multi-center group that the National Institutes of Health is funding, and the goal of that study is to identify people who are at high risk for developing pancreatic cancer, and image them every year to try to detect the cancer before it becomes symptomatic.
How early will you start?
Chak: We keep changing our standards for who should be in the study every few years based on information and research that is done. We typically will start it at about age 50 in people who are at high risk for developing pancreatic cancer. Now, the first part of research was to identify who is at higher risk than the regular population, and much of this has come from genetic studies and studies about epidemiology. We’re looking at patients whose family members have had pancreatic cancer. If an individual has two or more members with familial pancreatic cancer, those individuals are at a higher risk for pancreatic cancer. You can further determine what the risk is if they have a known genetic condition. There are some genetic conditions that have a very high risk of pancreatic cancer.
Are those things we would know?
Chak: They’re unusual conditions. There is a syndrome called familial atypical malignant melanoma syndrome, which is rare, but it is associated with a high risk of pancreatic cancer. There’s a syndrome called Peutz-Jeghers syndrome. Again, these are unusual, but those are rare conditions, but they can be tested for now with blood tests and genetic tests.
Is pancreatic cancer like, let’s say, breast cancer? I’m just going to make this up, but if your grandmother on your mother’s side had breast cancer, then you’re more at risk. Is there something like that with pancreatic cancer?
Chak: It’s not one side of the family or the other. It’s not like the father or mother confers greater risk, but yes. In fact, some of the breast cancer genes BRCA2 families that have pancreatic cancer in the family are at higher risk for getting pancreatic cancer. Not as high a risk as familial atypical melanoma or Peutz-Jeghers. There’s a gene called CDKN2A. Mutations in that gene that – produce the syndrome of – can lead to a much higher risk of pancreatic cancer than mutations in BRCA2. But mutations in BRCA2 with a family history of pancreatic cancer is at higher risk for developing pancreatic cancer than the regular population.
I think this is the biggest debate in the whole wide world. Is it BRCA? Is it BRCA? Is it BRCA? That would be the biggest debate in the world, really.
Chak: It’s any or all of the above, as long as you’re aware of it.
Okay, good. We have this debate every time we see a story that we do, so at least we have this on there. Now, let’s talk about Bob Adelman. Can you tell me a little bit about him?
Chak: If you take a look at families that have two or three members with pancreatic cancer, in very few of them will we find a known genetic mutation. Then, we’re left with just a family history of multiple members having pancreatic cancer. Even in those families, we still do annual imaging, and that’s what we’re doing with Bob and his family.
So far so good?
Chak: So far so good.
How long have you been doing this?
Chak: We started doing selective screening probably about 10 years ago in certain families. I think we started, as part of this multi-center group, about four or five years ago.
Have you been able to find early stage pancreatic cancer?
Chak: We have found a few cases of early stage pancreatic cancer. As a physician, you’re always concerned giving someone the news of having pancreatic cancer, but those individuals have been incredibly grateful because, if you do catch it early, they’re able to see their family member go through pancreatic cancer. Unfortunately, the survival is very poor and a lot of it is just helping support them and manage their symptoms and you’re trying to improve their quality of life as best as you can. I’m a gastroenterologist, so I often am involved making the diagnosis. That care is often done by my oncology colleagues.
END OF INTERVIEW
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