Hello everybody and welcome back to the podcast. So it's cancer. It's a podcast dedicated to being a how to manual for cancer patients and their friends and families. Each month we'll work through different elements of the overall problem from from soup to nuts, as they say, beginning at the beginning, such as the basics of what cancer is, who may be at risk, who is involved in the treatments, why treatments differ so much from one cancer to another.

or even within the same type of cancer. The podcast works through the various possible outcomes and quality of life. We felt the need for a physician led podcast series that is patient centric. It helps to have a chat with your physician. Only that chat is usually short, emotional, hard to remember and often only a beginning. So welcome to the show. My name is Paul Roach. I'm a surgical oncologist. We've got with us Peter Schlagel, a medical oncologist, Michael Reardon.

Thank you.

graphic designer and we are really excited to present our special guest Dr. Eva Galca. Welcome Eva.

Thank you. Thank you for inviting me. I think you wanted a little bit of information about all of us. You've done that before.

Yeah. We've introduced Peter and Michael and myself, but we'd love to get to know, uh, let the audience get to know you a little bit better. Eva. Um, tell us, yeah. How did, uh, where did you grow up?

So I grew up in New Jersey. I'm an immigrant child. My parents are from Poland. And I went to school there and then went to engineering school in Rutgers in New Jersey and didn't really even think about medicine until I met my significant other who was in medical school.

In our long conversations, I recognized that what he was doing was way more cool than what I was doing. And so I said, well, I guess I could do that too. And decided to go to medical school. And then on the way, discovered surgery rather quickly as the type of specialty that I would go into. And then further along the way, discovered surgical oncology.

There you have it.

How did you pick surgery from the different specialties?

Well, my background has always been that of kind of, I guess, math, science, how do things work as well as using my hands. My father was a mechanical engineer. I didn't want to be a mechanical engineer, so I went into biomedical and material science. When I heard about medicine and...

thought about it, I thought, well, maybe I could use the background of engineering into and melding it with medicine. And so I thought initially about orthopedics and using biomaterials, but I kind of rather quickly decided that orthopedics wasn't the way to go. But really surgery. Thank you. But really just using my hands and

Yeah, good choice.

and coming up with solutions and then actually doing something about it. I don't want to disparage medicine, but more than just thinking about it, but actually being able to kind of use my hands to fix it and maybe a lack of delayed gratification skills. So, yeah.

Yeah.

They are way too long.

So that's where surgery came in. And then medical oncology was never even, like it wasn't even something I thought of. I thought of surgery first and then surgical oncology became something that I became aware of and that I could have a long-term relationship with a patient as well as help them through a very difficult diagnosis, help them figure out what's the...

what's the right order of things, and then obviously the ability to actually make a difference from a surgical standpoint in excising tumors. But really it's the journey that patients take and the long-term relationship that we form, not just the surgery itself. And so I think it's unique in the surgical specialties that we...

I will never say that I know all that the medical oncologists know, but I at least am aware of their options and their side effects of medicines. And I can help guide patients into the order of things and be part of a team. And I really like that.

Awesome, fantastic. And then we, you and I met back at, when you were interviewing for fellowship at University of Chicago, we managed to talk you into it, which I'm sure there were days where you're like, oh man, I could have been anywhere, but here we are.

That's right.

Yeah.

I'm so lucky to have met you, Paul.

All right, Michael, Peter, how have you guys been?

Good. No complaints here.

Yeah, I'm doing very well. It's refreshing to hear Dr. Dalke talk about surgical oncology and what brings her to the table here, what made her a surgical oncologist being part of the team fighting cancer, having an admission. I thoroughly enjoy all those things as well. It is a surgical oncology is definitely a high stress field with lots of rewards as medical oncologists and in fact everyone who treats cancer.

Yeah, totally. I mean, it's the more I interact with my medical oncology colleagues, I realize how much, how much I don't know about cancer, how much they're working with, how much stress there is. So anyway, get to get back to it. Let's get to the subject of today, which is pancreatic cancer. Dr. Galka, Eva, let's just,

What would be your average patient, let's say, or pick a case or just an average kind of presentation for a person with pancreatic cancer? And maybe if you would just walk us through.

Sure, absolutely. So patient that I just saw approximately a week ago, and I'll explain a little bit more about the different ways that people might come to us. But the first one was a patient who came to the emergency room because they were bright yellow.

You mean their eyes or their skin?

Eyes and skin, we call that jaundice and ichthyrus in the eyes and jaundice in the skin. But really their family members said, who hasn't seen them in a few days said, oh my gosh, you're bright yellow. And spoke to them and went to their primary care doctor who

clearly saw that they were jaundiced and ordered some lab tests. The lab tests showed that they had some liver enzyme abnormalities, specifically their belly ribbon was elevated. And the patient was not having pain at all. And the primary care doctor said, you should go right to the hospital. And so they went through the emergency room and were admitted to the hospital.

the hospital to the medicine service. And based on the lab results, CT scan was ordered and surgical oncology referral was ordered.

And so for patients who don't know what liver enzymes are, how would you describe that? Like how does a vial of blood tell the patient that, or the doctor that it's something in your liver and not somewhere else?

Yeah?

Sure. So in this case, the patient has something that just by looking at them is abnormal. Their skin and eyes are yellow in color as compared to everyone else around them. They might also describe that their urine has been very dark, almost orange in color, and their bowel movements might be regular, but they're very pale in color.

So they've lost their kind of brown coloring. By lap, so that would be the first thing that a patient's family member might see. It need not be too obvious, but sometimes someone who hasn't seen them in a while might say, oh, you just don't look right in color. And so that might prompt them to go see their primary care doctor. The blood work that we're checking would be

a simple blood test that everyone gets every once in a while where a sample of blood is taken and they're specifically looking at laboratory values that are looking at how their liver is functioning and in a normal person the AST, ALT, alkaline phosphatase,

thresholds which is what we would say within normal limits can be a little abnormal if you have some liver dysfunction or high cholesterol and those types of things but in this case two specific values would be high and higher than what is considered normal and sometimes really high and so that would be the alkaline phosphatase and total bilirubin

And those two specifically would trigger, well, this is something not liver-based, but outside of the liver, and maybe there is something causing an obstruction, or causing those to back up into the liver, and therefore back up into the bloodstream. And so...

Most physicians would recognize that those specifically could be from gallbladder disease. Many gallstones can cause it, but it can also be caused by a cancer. And that's our worry in most cases is that it's from a cancer. We need to make sure it's not some of the simple things that could be more easily treated.

Got it.

Would cancer of the liver trigger that same discoloration in the person or is that so?

Yeah, it's a really great question. So in general, no. So a cancer in the liver, most commonly would be a primary cancer of the liver. And they don't generally cause these abnormalities. They can when things get very severe and they're causing kind of blockage of that.

Thank you.

outflow of the liver, but if it's primarily in the liver, then there's so much other liver to take care of it that That doesn't really happen. Yeah, so this kind of guides us to the fact that it's Where the liver exits? So and it's a kind of a funny thing. So we think of the liver you know the liver clears our blood of toxins and makes proteins and

filters, does a bunch of things. And so that's blood flow going to the liver and then back to the heart. So the liver acts as a filter. But one of the functions of the liver is to actually make bile, which breaks down our foods. Well, it breaks down our fats, I should say, into smaller pieces. And it's kind of going in the opposite direction. It's heading towards the bowel as opposed to back towards the heart. And in that case, the...

Thank you.

bile is made in the liver and kind of changed a little, we call it conjugated, but it doesn't really matter, but changed in the liver a little bit. And then it's heading back to the bowel to help you break down your fatty foods. And if that part has a problem, then that's when the bilirubin elevates generally. Yeah, so it kind of gives us a little hint of what part...

Thank you.

I'm just...

is a problem.

Yeah, I'm just going to take a little step back here. We were talking about diagnosing somebody with pancreatic cancer and how is it, how does it present? How does someone know that they have pancreatic cancer? And from my point of view, it's often very dramatic. Someone has a lot of pain. It's progressive. They have weight loss. They have nausea. They can't sleep because of the pain. There's a lot of drama and pancreatic cancer is really different from the other more common cancers like

breast cancer where most likely it's from a mammogram. Sometimes it's a lump. Of course you can have more advanced than that, but more typically it's just something small, minor, that's really not in their face, if you will. Colon cancers, likewise you get a colon cancer, oh you got colon cancer, oh I didn't know that, and you go through the steps. Even for prostate cancer, you have a high PSA, but for pancreatic cancer it's often,

The presentation to the emergency room, something that's causing horrible pain, causes some dramatic changes like the yellowness, the jaundice. Someone has intractable nausea or vomiting. It's unfortunate, but it often presents in a very dramatic way.

I, um, I was researching, uh, for today. Uh, I pulled down a little thing on the clinical presentation. I pulled down a little thing on the clinical presentation and, uh, the most common presenting symptoms of people with pancreatic cancer pain and jaundice, which is that yellowish that he was talking about and weight loss, um, uh,

Also just sort of, uh, energy loss, about 86% weight loss, 85% loss of appetite, 83% abdominal pain, 79% belly, uh, upper abdominal pain, 71% dark urine, 60% jaundice, 56% nausea, 50% back pain, 50% so forth. And so.

I think, yeah, what you're describing is people get really sick pretty fast. Don't you think?

Well, yeah, but I would disagree with actually, you Peter, more of the patients show up with no pain and jaundice that I see in a hospital setting, and they've been sent by their primary or a family member. There, I agree with you totally that those symptoms can occur, but many of the times the patient has had low grade discomfort.

low-grade nausea, weight loss that they didn't even notice was happening. And it's only until we kind of talk with them longer and I ask those questions that they say, yeah, I've been avoiding certain foods. And so there are different presentations, certainly. But I would say the majority of the patients I see don't actually have pain. They have jaundice.

They might even come with fever and chills and they have what we call cholangitis, which is an infection because they had obstruction of their biliary tree. But pain is not like often. Those are the folks that have pancreatitis that have or low grade pancreatitis. And there are certainly patients by the way that have had pain and

kind of nausea and vomiting, but it's been low grade and it's been going on for a very long time. And they didn't develop obstructive jaundice as we call it. But it's interesting. I mean, you know, like I guess it's, they do certainly come in waves and we have different presentations and different people. But most of the patients that I see, the pain is not the primary. It's, you know.

weight loss that's unexpected, but they just blow it off because they feel okay.

As I think most cancers, it sneaks up on people, whether it's roll in or.

Yeah, right, it's really terrible when they have the nausea, the vomiting, the abdominal pain and the jaundice. Then we're really in trouble.

What's the difference between pancreatitis and then pancreatic cancer? Like what either would send me to a doctor, right? If I'm having symptoms, but is there anything that I might kind of watch out for?

Yeah, so pancreatitis is a very severe pain due to inflammation of the pancreas. And what's really happening is that the pancreas, whose one of its primary goals is or functions is to make juice to break down your food. So I tell people the pancreas has three functions.

three main functions. The first is to break down your food with a juice, which is like liquid dreino. It dissolves your food into different smaller products. The second is to make bicarbonate to neutralize the acid of your stomach. And the third, and it's a totally separate function with separate cells, but they live in the pancreas, is to make insulin and other hormones, but insulin is the primary hormone.

to help us absorb our glucose. And those first two functions are actually juices that the pancreas makes, that it passes through little passageways and empties into the bowel. And so, pancreatitis is really a dysfunction that allows that juice to break down the pancreas. And so, it's like auto-digesting itself.

if you will, and it's very, very painful. And you can have pancreatitis from stones in the gallbladder or from excessive alcohol use or even autoimmune causes, but also because a cancer has obstructed the passageway and then the pancreas juice just kind of starts auto digesting and causes pain. So you know, as we talked about, we were going to talk about like...

Thank you.

how do patients show up in my office? One is that the patient came to the emergency room, like I said, they were yellow, they were having significant pain, as Peter mentioned, or they weren't having any pain at all, but they just weren't the right color. And then just by labs, you see that they have these enzyme abnormalities that kind of point you to an obstruction, and then you have to do imaging to go searching for it.

make sure it's not the gallbladder, oh, there's a mass in the pancreas. Okay, now we're worried about pancreas cancer. We're not worried about gallstones. But the other patient may be someone who's had multiple episodes of pancreatitis. And they, I mean, in my area, they show up in multiple hospitals having abdominal pain. They might drink occasionally, but.

Thank you.

someone heard the word alcohol and they say, oh, this is because of alcohol. And they don't really look into, well, their drinking isn't excessive. They don't have stones in their gallbladder. Should we look a little more closely at their pancreas? Is there a mass there? And that actually happens, you know, probably 20% of the time for me. Or they have a cyst in their pancreas.

not all of which are cancer and not all of which are even pre cancers, but they have a cyst at the wrong time, meaning they have a cyst the minute they had pancreatitis, which that's not normal. That's not a result of the pancreatitis. That's perhaps a cause. And someone hasn't put it together and then the patient's just discharged, comes back again.

They didn't like the response they got from one hospital, so they go to another hospital, and eventually they come to mine. And I say, gosh, you've had three episodes of pancreatitis within a year. Well, how much do you really drink? And they say I drink a little bit, but not excessive. And I say, well, I don't believe that this is due to alcohol, and we kind of continue that workup. So that's another way that patients might show up.

I have a couple of questions on that, you know, not being a doctor, but having watched House, you know, where exactly I feel like I've had medical training.

Well then you're halfway there. If you add the 17 seasons of Grey's Anatomy, then that's like two thirds.

Ah, yes!

Ha ha.

right but you know when they say they say I only drink a little house would say and how much do you lie like people don't seem to want to have the doctor think poorly of them so they don't necessarily tell you the truth on that so I imagine that that's like something that you have to sort of discern

Ha ha.

I usually double whatever the patient says, by the way. But honestly, I mean, you know, I sit there with a patient and I say, I'm not being judgmental. I just want to get a real sense because I'm trying to figure out what's the cause here, by the way. And you know, I've gotten called after the patient's been doing this at different hospitals for several times, or even our same old hospital.

Hahaha

my same hospital, but just multiple times, if you know what I mean. And nobody's really sat down with them and it's just been assumed. And I think that's one of the judgments in medicine is that people take what someone else said and just assumes that it's true without re-verification. So what's a lot of alcohol? Well, frankly, there are people that drink every day excessively and they don't have pancreatitis. But then there are people

who say, yeah, I have a couple drinks a week and then they get pink rotitis and people are, you know, like physicians are really quick to say, oh, well it's due to alcohol when many times it's not. So it's hard, yeah.

Yeah. And now for patients, for patients, uh, they, they won't know people listening won't have a sense of the anatomic relationship between the liver and the pancreas and, and what is the biliary tree exactly? And so I don't know if there's a way to describe it without drawing it, but

How would we kind of explain to people why those two are so closely related and how a problem in one can affect the other?

Sure. Go ahead.

I think the important thing in the context of pancreatic cancer is that at some point the patient will cross the line from being a spot or some other problem to say, hey, pancreatic cancer is a possibility here. And that leads to a number of procedures, tests to make sure that we know exactly what we're dealing with. So the first question is, do we have a diagnosis? And often if we're talking about the first patient who came in Yellow Jaundice, we're

Usually the next step is to do advanced imaging. CT scans are great, MRIs are probably a step up in general. We have gastroenterologists who do fancy MRCPs. It's basically like doing an EGD, looking into someone's stomach with a scope, but been able to track it up the biliary tree into the pancreas, into the liver itself. Very high tech stuff. But that's in terms of trying to make, number one, a diagnosis. And then number two,

is where is the cancer? Is it localized? Is it something that a surgeon can realistically take out or is it something that's more advanced? I think that's really the genesis of why Dr. Zolka said, well, most of my patients don't have pain and as a medical oncologist where I'm more of an expertise in advanced cancer, I usually see the latter where it's... But anyway, the important thing is that when they're bouncing from the ER to the primary care,

somebody's going to make a notice to say, hey, this is something concerning. This could be pancreatic cancer. What are, what are things that are typically going to happen at that junction? And it's my experience and knowledge that usually it starts with a CT scan, MRIs, MRCPs are what they're called, the frequent go on and then advanced endoscopic ultrasound and scopes called the ERCP.

Yeah. The way that plays out typically is let's say a person comes into the hospital, whether it's outpatient or it's the ER, and they have some symptoms, any of those lists that we've been talking about and people are putting two and two together and they're trying to figure out, Oh, look, this is, you know, more likely to be gallstones or this is more likely to be alcohol induced or whatever, but, uh, they might first get an ultrasound to rule out the most common thing, which is the gallstone that gives you a sense.

that it might be gallstone, maybe not. You didn't see any stones in the gallbladder. So you get a CAT scan. The CAT scan shows, gets you a little bit closer and they call Dr. Galka and she says, I would like a triple phase pancreas protocol CAT scan, or she'll say, I want an MRI or something. So you get even a little bit more. And then she calls her friend, the gastroenterologist and says, hey, can you see this person for me and put a...

endoscope down and they take a scope and they may look at it with an ultrasound probe at the tip of the scope. So they're right next to the organ because it's deep in the center of your body. And then they get even more definition, maybe even a little tissue sample. And then after all of that, because this, this pancreas is in the center of your body, it's really hard to reach. You have to go through all of those steps in order to be able to come back to Dr.

Yes, your intuition was correct. This is pancreatic cancer. Does that help, Michael?

Sure. But what I'm not hearing is I'm at my primary care physician for my annual checkup and they draw blood and they say, oh, you have an elevated enzyme or chemistry of some sort. I'm not hearing that. Like, does that mean that pancreatic cancer is one of these things that's not got an early detection sort of system about it? And I'm in trouble by the time I go to see Dr. Galka.

I think you're astute.

Very, you're right. There is not a way to pre-screen for pancreas cancer with the very few exception of individuals who have a high family risk. Yeah, family.

hit them in medical history.

So patients who have a single or two parents with pancreas cancer or multiple siblings who may have because of that high risk been put onto a protocol where they get imaged, lab work really isn't good enough. Then there are the few patients who have breast cancer or breast cancer related syndromes, in which case they have

known BRCA mutations, which is a mutation that has been found in breast cancer in families and in those there's also a high risk of pink risk cancers. So they might be put on surveillance from that standpoint.

And lastly, another very common syndrome would be one that I actually see often also because I take care of melanoma, our patients with melanoma and a family history of pancreas cancer which has another kind of known associated syndrome, in which case once we catch those, they would be put into a hereditary kind of, you know, program. Aside from that.

There really are not ways to assess this ahead of time. I guess the last patient population I would say that does get some surveillance are those patients who in general just by virtue of getting a CT scan or an image for something else were found to have a pink wrist cyst. And then because it's a cyst, the person ordering it says,

What do I do with this? And so thankfully in many cases they're sent to either myself or GI, so either to surgery or GI to kind of comment and follow pancreas cysts. Gastroenterology, sorry. Yep. So sometimes those patients, you know, from a primary care doctor or someone else who ordered a CT scan or chest scan or something where all of a sudden...

GI, help me out.

The radiologist notes assist in the pancreas and then those patients either might be sent to a gastroenterologist or they might be sent to, in my case, a surgical oncologist and we follow those based on certain guidelines. So when we see assist in the pancreas, it's not a cancer but it may have a risk for that and so we follow those. So aside from those folks where we know

is high risk, unfortunately, you have to have a symptom to come to find us, if you will. And I guess certainly there are patients that have lots of symptoms, as mentioned, the nausea and vomiting, perhaps, abdominal pain, weight loss. But those are obvious.

Those patients should be seen, right? They should be, something should be evaluated. It's the patient that doesn't have any of those symptoms, the gen just turns yellow, that those are the ones that are, I would say probably worst case. I mean, I don't wanna say worst case, but that's worrisome, right? Because they had no symptoms to prompt anyone to do evaluation.

And just to take a step back so people can visualize what we're talking about is. Um, you got it. All right, go for it.

I think I could do it. I think I could do it. I do it all the time. Yeah. So I do draw this for every patient. But yeah, but I've tried to learn how to explain it without. So if everyone can imagine when you swallow food, it goes into your esophagus and then it goes into the stomach, which is a pretty large organ. And then the next location is the small bowel.

Me too.

Specifically what we call the duodenum, the first part of the small bowel. And just behind the stomach is this organ that is like the size of a tube of toothpaste. And it's lying sideways, right behind everything, right on top of the spine. And that's the pancreas. And just like a tube of toothpaste, it empties on one side, and that's where it's emptying the juice, onto the right side.

the juice to help you break down your foods. The liver is on the right side of the abdomen and as mentioned before the liver is meagy.

That's interesting. You use a tube of toothpaste as your example. I always tell everyone it's like a long slender fish. I think I'll stick with toothpaste better.

It makes the juices seem like they'd be minty.

Yeah.

Does it actually look like a Nike swoosh? I've heard it radiographically, it sometimes looks like a Nike swoosh, but I don't know when you're actually in there.

Like an upside down Nike Swish. Yeah. That's good.

Heheheheheheh!

Awesome. That is great. I love it.

Well, this explains to me as a layperson why a doctor might be asking for a urine sample, a stool sample. I mean, even if they're going to run the chemistry on it, they can just look at it and determine certain things about it immediately.

Right. Okay. And so, you know, we've discussed how it might present with all the different symptoms and signs and what we would do to diagnose it. Um, the next step, once we know that this is a cancer and we do this for every cancer is called staging. Um, and so Eva or Dr.

are what it is and why it matters.

Thank you.

Yeah, absolutely. But it did leave me with a question about some of the other cancers that we've talked about. You can take out partial pieces and bits of other organs or bone or whatever. But I remember there was one that we couldn't, I think it might have been maybe the gallbladder where the whole thing has to come out. I could be wrong, I can't remember which one it was. What about the pancreas? Do you have to take out the entire pancreas or can you like cut half a pancreas and still get functionality on it?

Yeah.

I'd like to.

I would, I'd like to jump in and just add some, some numbers. Okay, so in the United States, and with our listening audience, I would guess it's about half the United States and half is really all around the world. We've got listeners in Australia and Sub-Saharan Africa and Singapore and Northern Europe and Western Europe. So it's been pretty great.

But anyway, in the US, because this is where we're talking from, there's 64,000 patients diagnosed with cancer of the pancreas, the type we're talking about, which is about 85% of all pancreas cancer. It's about 85% of all pancreas cancer. So it's about 64,000 of them in the US a year, and it's the fourth leading cause of cancer-related death in the US. Worldwide,

It's the seventh leading cause of cancer-related death in both men and women, according to the World Health Organization. It seems to be a bit higher incidence in the more industrialized economies, and the highest incidences in North America, the high-income areas of the Asia Pacific and Western and Central Europe.

It's rare to happen before the age of 45. It does once in a while, but so for anyone listening, if you're 40 and you've got abdominal pain, it's still more likely to be something else. It can happen before 45, but it's rare. And it's mostly between ages 65 and 69 for men. That's the peak incidence. And a little later for women, 75 to 79. It varies a little bit by sex and race and...

socioeconomic status and things like that. The majority of pancreatic cases are advanced local regionally, meaning.

Um, meaning that it, it isn't something that a surgeon can resect, uh, probably, uh, 80 to 85% of patients are going to go straight to Dr. Schlegel instead of to Dr. Galka or myself, because either it's already metastatic or it's just, its characteristics are such that a surgeon can't resect them because it's involving key structures.

Uh, the stages, as we said, we talked about the size of the tumor and the lymph nodes, and we break it into four stages, roughly one, two, three, and four. And the best category to be in is called stage one a, and with all the imaging and whatnot in Western societies, we're getting a greater, um, incidents of finding people early enough that they're still one a and, and importantly over the past, uh, 20 years or so.

compared to, you know, with the surgeon, we're like, let's just cut this thing out. And then we leave the hard work to you to deal with the medications.

Dr. Golka made a good point about the reception of pancreatic cancer, if it is respectable. And those are really the only people that are curable. The converse of that, the opposite, is that if it's unrespectable, it's advanced. And unfortunately, it's usually the vast majority of times a terminal illness. And so there is no cure. And nobody likes to hear that, that it's not a cure. But we have to be realistic.

in terms of going forward. And what does it mean to have advanced metastatic pancreatic cancer? Well, you're not gonna be cured, but there are a lot of things we can do to slow it down to improve quality of life and to extend survivorship. And so we wanna do that. But really it is a sad moment to say, you've crossed the line and this cancer from all these fancy studies that we've done doesn't look like we can take that out. I think when...

patients are going through the journey with pancreatic cancer, and they have had all their studies and then the surgeon, surgical oncologist, medical oncologist is going to sit down with them and say, we just discussed your case in tumor board. We looked at all this information, the pathology, the images, we talked with the radiation doctor, all this and that. And we've determined what the best course of action is. We always want to be able to be as optimistic as we can. And if there's a potential for a cure, we want to go down that route.

And so for the stage two and three, the locally advanced, borderline, respectable, I think that's the scientific term used, borderline, respectable, we go through a whole bunch of different steps to say, can we shrink it? But really, the object is that if we can respect you, you can be cured. People can go live normal lives. On the other hand, if it is not respectable, if it's metastasized, it is in a terminal situation.

Our goal is palliative to slow it down, improve quality of life, but not secure.

It sounds like the position of your tumor really sort of determines your viability. Like if it's around those blood vessels, your chances of having a surgical removal are slim to none. And if it's, but if it's in an area off to the left, I guess, in the tail of the tube of toothpaste, then...

It's, it's, it's a really nuanced thing because if it's right on the vessels, then it's a problem because it's on these major vessels. Um, and that's what Dr. Galko is talking about locally advanced. Maybe we can hit it with chemotherapy and radiation and shrink it such that we can then go after and peel it away from the vessels. If it's just to the side of the vessels and involving the, the end of the common bile duct.

Mm-hmm.

but not the vessels, then you're going to turn yellow. Everyone's going to see it. They call us and we can take it out. If it's in the tail, it sounds like that would be a better deal. But the problem is it tends to grow and grow without anyone ever noticing. It doesn't.

Oh.

Yeah, yeah.

When someone's determined to have stage one resectable pancreatic cancer, then they're taken to surgery. If they have advanced metastatic disease, then they generally go through a whole body treatment, chemotherapy at least, that's what's recommended. There are some molecular based therapies, immunotherapies used in some cases, but that's the minority of people. So that's why we have clinical trials to come up with better systemic therapies. When people have the locally advanced, we say, well, should we cut it out?

there is a big risk to benefit ratio in terms of doing the Whipple procedure. And I think that would be important for our surgeon to comment on that. If you have pancreatic cancer, say, well, I've got nothing to lose. You know, if this is resected and can cut out, I can be cured. And if it can't, well, you know, so be it. But the problem is that the surgery is one of the most labor intensive and difficult surgeries there are from a medical oncologist's point of view.

So I just want to really impress that it's not, well, you don't have any other options just to do it, but there are some major costs. So Dr. Golka, if you could just talk about what happens with the pancreatic surgery and how long it takes you in the OR and how long to recover it. Just basic.

That's not, that's an excellent summary, Eva. Thank you very much. And it's a great segue into the, uh, the last part of the show, which is, you know, when we touch base on.

just blanked out.

where we show what's coming around the corner in the treatment of pancreatic cancer, such as a paper that you and I had talked about, which was the subject of, if I have a pancreatic cancer, should I have surgery first or chemotherapy first?

Well, I think the important thing is to know that micro metastases or seeds, in most cases of pancreatic cancer, even if respectable, even if slow, a small, do exist. And the chemotherapy does kill some of these seeds before they germinate and take root. We've known these principles with breast cancer for about 30 years, colorectal cancer 20 years. So it's the same idea that the microscopic seeds have left before the surgeon even gets to the operation.

Having said that, the chemotherapy can be effective and kill the cancer, not just shrink it if it's in a microscopic amount. So we really encourage that. There's a question about does the chemo work better in the front or afterwards? And I think we know for a fact that for all these borderline people that were not stage one, they're not stage four, where are they at?

There's a glimmer of hope. We use chemotherapy when we shrink it. In many cases, it shrinks, and then it does make the cancer respectable. I think that's the important thing. The trials are still out there in terms of determining what's the best course, but I think the bottom line is that people who've been diagnosed with pancreatic adeno-carcinoma do need chemotherapy, and it is real chemotherapy. There's a lot of toxicity side effects. It does take a lot out of people for several months, and the recovery also.

several months, but it does show very good evidence of working to prolong people's survivorship and to increase the number of people that are cured.

It sounds like there's no pure radiological or chemotherapy that you can address pancreatic cancer with, is there? It sounds like it's both.

Oh, there's definitely chemo therapy. It just doesn't work as well as we want. We want it to work 99% of the time and only have 1% side effects. It doesn't work like that. We have it work maybe flip of the coin, maybe a little bit better in terms of side effects. Likewise, it's a flip of the coin. So the clinical trials are looking for that balance that's way in favor of the efficacy rather than the side effects or toxicity.

And the radiation therapy can be important, but for this, this type of cancer, it's usually, uh, playing the role of it's, it's a, an additional type of treatment, it's not the primary treatment for this cancer.

The biggest question that I have, Dr. Eva, is after you've taken out all of these additional parts like gallbladder and spleen, does that mean that if I'm this patient, I'm going to be on a chemical regimen for a long time in terms of drugs that are going to help me duplicate whatever you took out, did?

Peter, I know you have an interest in things like tumor vaccines and so forth. Is there anything coming down the pike that you're following, that you're tracking, such as that...

Yeah, there was a recent paper that used K-RAS, which is a tumor antigen that's expressed on a lot of cancer cells, particularly pancreatic cancer, and we're using that as a target for a vaccine. And it's in early stage trials has been pretty effective in terms of combating the pancreatic cancer that has a specific sign, molecular signature, if you will.

And tumor vaccines are something of a Holy grail for cancer treatment. It always seems like something that should work. And, and the NIH has invested, I think, well over a billion dollars into trying to find something that works, but it's always been elusive. Uh, but like this KRAS one that you were talking about, I was looking at the paper that you sent me. It looks pretty interesting that, you know, it's early on in the process, but they are in

encouraged in their phase one trial that maybe this time they might be onto something that will work. Can you describe what the mechanism is of a tumor vaccine?

Well, I think you're training your immune system to see something as for and then to get rid of it, use your immune system. And in fact, we're using what we call checkpoint inhibitors for a number of cancers that promote the immune system for fighting the cancer with really remarkable results. Melanoma has been treated very successfully with immunotherapy. It's now standard care, non-small cell lung cancer has been successfully treated with immunotherapy.

But turning to Paul's question about the vaccinations, is they, how do we find this target only on cancer cells and not everything else? What is special about this particular cancer cell? But I think for one thing that we're just learning more and more about the cancer cell, what makes it unique? How can we target it? So that's really where clinical trials are heading in. Yes, we haven't been as successful as we'd like, but we're moving forward.

And we just got to keep at the research and it's going to pay off dividends. For lung cancer, for most of my career, we just had phenol and it was pretty, a very sad situation. But then the checkpoint inhibitors came and just really changed it. Malignant melanoma, you wouldn't believe how different of a world that is with having immunotherapy for people with advanced melanoma. I will also say that some of the cancer vaccination trials went on for some of the COVID.

vaccination, some of the technology we would use. So I don't know what your feelings are with COVID, but COVID vaccinations. But I think the scientific is, yeah, they're good. They're not great. They have side effects. But the research was taken directly from cancer research in terms of manufacturing these vaccinations in such a rapid fashion.

If I have an inoperable, I can't remember the word you guys used, nonsectable, there we go, non-resectable tumor and it seems like maybe it's more advanced. How do I get into a study so that I might benefit from one of those vaccinations? Where might I go?

Non-resectable, yeah.

find out how to get into a study, if it's even possible.

Generally, the tertiary care centers, I'm more of a local clinic, a community level. So we do run some clinical trial, but not the big academic trials. If you're in the major cities, they always have cancer centers, and most oncologists have access to some sort of registry or regional experts they can contact and state who's interested in and what kind of cancer, what some of the specifics.

So your doctor will recommend that.

but I think it's part.

Well, any doctor that is like an associate professor or assistant professor or whatever, anyone who's involved with teaching is frequently. Involved with, with trials. Was that fair to say?

What if my doctor is not though? How do I get it?

I'll, I'll put the links to, I'll put the links to both of those in the show notes. So people can just go to the show notes and find the link and, and access it.

at PanCan.com.

Yeah, yeah, yeah. Well, all right, well, Dr. Galka, Eva, my dear friend, thank you very much for joining us. I think, speak for Michael and Peter and myself, it's been a delight. And we will invite you back anytime you want. And hopefully if patients have any questions, they can reach out directly. The email is letters at Paul Brian Roach.

P-A- You can send me a letter directly and we can answer your questions. Thanks everybody.

Thank you.

Thanks for coming.