Download Interview with an Expert: Surgery

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interview with
an Expert:
About
Sarah Thayer, M.D., Ph.D.
Sarah Thayer, M.D., Ph.D., is the Merle M. Musselman Centennial Professor of
Surgery and Chief of Surgical Oncology at the University of Nebraska Medical
Center. She also serves as associate director for clinical affairs and physician-inchief for the Fred & Pamela Buffett Cancer Center at UNMC.
Dr. Thayer began her new position in 2014 following a 13-year stint at Harvard
Medical School and its teaching hospital, Massachusetts General Hospital,
where she served as the W. Gerald Austen Scholar in Academic Surgery since
2002 and as director of the pancreatic cancer biology lab since 2008.
Dr. Thayer is an active surgeon with a clinical and research focus on pancreatic
cancer. Clinically, she specializes in cancers of the breast and gastrointestinal
system that include the stomach, duodenum, small bowel, bile duct, and colon.
As chief resident at Harvard, Dr. Thayer was honored for excellence in clinical
teaching in surgery. She was valedictorian of her medical school class at the
University of Virginia School of Medicine, and earned her Ph.D. in neuroscience
at Cornell University. She also holds degrees from Earlham (Ind.) College and
Georgetown University.
About The
Lustgarten Foundation
The Lustgarten Foundation is America’s largest private foundation dedicated to funding
pancreatic cancer research. Based in Bethpage, New York, the Foundation supports
research to find a cure for pancreatic cancer, facilitates dialogue within the medical and
scientific community, and educates the public about the disease through awareness
campaigns and fundraising events. The Foundation has provided millions of research dollars
and assembled the best scientific minds with the hope that one day, a cure can be found.
Cablevision Systems Corporation, a leading media and telecommunications company,
underwrites The Lustgarten Foundation's administrative costs, so 100 percent of every dollar
donated to the Foundation goes directly to pancreatic cancer research. Additional
information about The Lustgarten Foundation is available at www.lustgarten.org.
The "Interview with an Expert" series ("IWE") is not intended to provide medical advice and is
not a substitute for consulting with qualified health professionals familiar with your individual
medical needs. IWE should not take the place of any discussion with your physician, but should
be used to help guide you in discussions. All matters about your health should be under
professional medical supervision. The opinions expressed by IWE experts are not necessarily
those of The Lustgarten Foundation. Information contained in IWE cannot be guaranteed for
timeliness and accuracy. Sponsors of IWE do not control its content or the selection of experts.
Supported by educational grants from
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interview with
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an Expert:
1111 Stewart Avenue
Bethpage, NY 11714
516-803-2304
www.lustgarten.org
Glossary
Chemoradiation – radiation therapy used in
combination with chemotherapy.
Chemotherapy – use of drugs to kill cancer
cells.
Diabetes – a serious disease in which the
body cannot properly control the amount of
sugar in your blood because it does not have
enough insulin.
Distal pancreatectomy – surgical procedure
in which the tail and body of the pancreas are
removed, usually along with the entire
spleen; sometimes part of the body of the
pancreas can be preserved.
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Jaundice – condition in which the skin and
the whites of the eyes become yellow, urine
may become dark, and stool may become
clay-colored; occurs when the liver is not
working properly or a bile duct is blocked.
Laparoscopy – surgical procedure that uses a
small telescope-like instrument connected to
a video monitor.
Neoadjuvant therapy – a treatment given
before surgery.
Palliative care – healthcare that specializes in
the relief of suffering and improvement in
quality of life.
Sarah Thayer
Pancreatic lipase – an enzyme secreted from the
pancreas, that breaks down dietary fat molecules
in the human digestive system, converting
triglyceride substrates found in ingested oils to
monoglycerides and free fatty acids.
Lustgarten Foundation (LF): What role
does surgery play in the treatment of
pancreatic cancer?
Portal vein – a vein that collects blood from
one part of the body and distributes it in
another through capillaries; especially: a vein
carrying blood from the pancreas and spleen
to the liver.
Whipple procedure – surgical procedure in
patients with pancreatic cancer that removes
part of the stomach, the duodenum, the head
of the pancreas, part of the bile duct, the gallbladder, and lymph nodes in the area of the
pancreas.
Sarah Thayer (ST): The principle role of
surgery is to physically remove the
cancer from the body. There are two
different types of surgeries that depend
upon where the tumor is located in the
pancreas. The most common surgical
procedure is pancreaticoduodenectomy,
commonly referred to as the Whipple
procedure, which involves removing
the pancreatic head and associated
structures. A distal pancreatectomy is
performed when the tumor is located in
the body or tail of the pancreas. A total
pancreatectomy removes the entire
pancreas, but is rarely performed for
pancreatic adenocarcinoma.
Improved surgical techniques are
making it possible to increase the
number of patients who can have
surgery. For example, historically
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Interview
with an
Expert:
Surgery
pancreatic cancers located near or
wrapped around the portal vein (the
major vein leading to the pancreas)
were considered unresectable.
However, over the course of the last
few years, surgical techniques have
been developed that allow doctors to
safely remove these types of tumors.
Surgery is only part of the treatment for
pancreatic cancer patients. In addition
to surgery, treatment usually involves
both chemotherapy and chemoradiation
that can be given before or after surgery
depending on how patients present.
Surgery also plays a role in palliation.
Palliative care is an area of healthcare
that focuses on relieving and preventing
the suffering of patients. There are a
number of pancreatic cancer patients
whose quality of life can be improved
by surgery even though we will not be
able to cure them of the disease. These
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QUESTIONS TO ASK YOUR DOCTOR
ABOUT SURGERY
The amount of expertise your surgeon
has may add months or years to your
life. In fact, an experienced surgeon
may operate on pancreatic tumors that
less experienced surgeons might
declare inoperable. Here are some
questions for you to ask your surgeon.
You have the right to have all questions
answered to your satisfaction.
1. Why will I have this surgery?
2. What are the risks and benefits of
this surgery?
3. How many pancreatic surgical
procedures have you done, and
how often do you do them?
4. How many pancreatic surgical
procedures are done at this
hospital, and how often?
5. How long will the surgery take?
6. How long will I be in the
hospital?
7. What are all of the complications
that can occur?
8. Do I have to make a decision
right now, or can I take time to
get a second opinion?
9. How much time do I have to
think about other options, or to
get a second opinion?
Excerpted from Understanding Pancreatic
Cancer: A Guide for Patients and Caregivers.
©2012 The Lustgarten Foundation
1111 Stewart Avenue • Bethpage, NY 11714 | 516-803-2304
THE LUSTGARTEN FOUNDATION
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interview with
an Expert: Interview with an Expert: Surgery
surgeries typically are to help food pass
from the stomach to the small intestine.
Fortunately some new medical and
radiological technologies, in addition to
more aggressive surgical approaches,
are increasing the number of patients
we can now operate on to take out their
cancer.
LF: Is a course of chemotherapy
usually the first step in treating
pancreatic cancer?
“
LF: What should a patient expect right
after the Whipple surgery?
ST: Generally, the Whipple operation
will take anywhere from three to eight
hours, depending on complexity.
Patients will then often be in the
recovery room or intensive care for the
first night. Patients generally do not need
to be in a monitored setting for
more than one night. Their
length of hospital stay is in the
range of 7-12 days, usually
based on the patient’s ability to
drink, eat and take care of the
activities of daily needs safely.
More people diagnosed can
now be surgical candidates
giving them hope for a cure.
ST: Pancreatic cancer requires a
multi-modality approach
requiring the medical
oncologist, radiation oncologist,
gastroenterologist and surgeon to work
together. Such a team approach can
provide the support needed to design
the best treatment for a particular
patient.
Pancreatic cancer is aggressive and
usually metastasizes very early, so in
certain centers most of their patients will
receive neoadjuvant (upfront) therapy.
However, in other centers the choice of
when to add chemo and chemoradiation
is dependent on the patient’s tumor. For
example surgery will likely be offered to
a patient as a first option in cases where
a tumor is small and clearly resectable;
while patients with large local tumors
may be offered chemoradiation as a first
step prior to surgery to shrink the tumor
before it is removed completely. Of
course, if the patient has a locally
advanced unresectable tumor they may
be considered for combinations of
chemotherapy and chemoradiation first
and then be re-evaluated for surgery in
the future.
LF: The Whipple procedure is the most
common of the surgical procedures.
How has this procedure changed over
years, in terms of the recovery that
patients can expect?
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ST: The Whipple is a major surgical
procedure, but one that is now safer for
the patient. Over the last few years we
have developed some more minimally
invasive approaches though. Some
surgeons now do the Whipple
laparoscopically or using robotics, but
none of these approaches have
significantly improved outcomes for our
patients. Recovery from a Whipple
regardless of the approach will take
about 4-6 weeks.
What we must keep in mind however is
that the pancreas is an organ that plays a
vital role in both digestion and in
glucose regulation. So, the things that
we worry about most for our patients
following a Whipple are chronic
diseases like diabetes and problems
with digestion. The patients who do
develop diabetes will need to regulate
what they eat and will likely take insulin
to regulate their glucose.
Sometimes, when a large part of the
pancreas is removed, digesting food
becomes difficult resulting in diarrhea,
gas and cramping etc. So the patient
may need to take an enzyme called
pancreatic lipase that helps the body
break down fats and proteins in their
diet so they can be absorbed properly
by the body.
In most cases, by six weeks patients can
hopefully expect to be eating at least six
small meals a day and to be able to
maintain their weight.
“
Occasionally, there are complications
from pancreatic surgery. First, there
could be an infection that would require
antibiotics to treat. There is also the
possibility of a leak from one of the
points of connection. The most common
place for a problem is where the
pancreas is reconnected – if there is a
small leak in the area between the
pancreas and the intestine, it would
usually require the placement of an
additional drainage catheter to help the
area heal.
The last type of complication is related
to the physiology of putting the patient’s
gastrointestinal tract back together
again. Occasionally the stomach may
not empty normally into the intestine
after surgery. This delayed emptying
occurs in about 1 out of 5 patients and
can necessitate a longer period of
specialized support to achieve adequate
nutrition and fluid intake. Many
surgeons will place feeding tubes in the
small bowel to assist with fluid and
nutritional intake when the stomach isn’t
emptying normally.
The opposite may also happen where a
few weeks after surgery food and liquid
will travel through the gastrointestinal
tract too quickly. This phenomenon of
rapid transit of fluid and nutrients can
result in dehydration and nutritional
depletion. This is uncommon, occurring
in less than 5% of patients. However, it
can be a source of significant frustration
and delay in further treatments. Though
most patients will be ready to be
released from the hospital in 7-12 days,
they will require additional time for
recuperation and recovery upon
returning home. It is often 2 months
after surgery before patients can expect
to feel “normal” because it takes time
to gradually adapt to changes in diet
and digestion, find the right pancreatic
enzyme dosage, and gradually increase
physical activity.
LF: How can patients feel assured that
the physician they have selected will
identify the best treatment plan for
them?
ST: Two things are really important for a
patient to consider. Firstly, you want to
Clinical Classification of
Pancreatic Cancers
Resectable Cancer can be surgically
removed. These tumors may lie within the
pancreas or extend beyond it, but there is no
involvement of the critical arteries or veins
in the area. There is no evidence of any
spread to areas outside of the tissue
removed during a typical surgery for
pancreatic cancer.
Locally Advanced Cancer is confined to the
area around the pancreas but may not be
surgically removed because the tumor may
be intertwined with major blood vessels and
may have invaded surrounding organs. No
evidence of spread to other areas of the
body can be found.
Metastatic Cancer has spread beyond the
area of the pancreas and involves other
organs, such as the liver or lungs, or other
areas of the abdomen.
go to a center that deals particularly
with pancreatic cancer and you consult
with a physician who has considerable
experience and expertise in dealing
with this particular cancer. Second,
clinicians in larger centers have the
resources to continually learn and
adapt their approaches to treat
pancreatic cancer as our understanding
of the disease evolves. Because of the
nuances of this cancer, you’ll want to
be treated by physicians who stay on
top of the research that is being done,
have access to new treatment protocols,
and who are able to cope with setbacks
that may occur and determine the best
regimen for you at every step in your
treatment.
LF: Pancreatic cancer can be difficult
to diagnose which is why it is often
diagnosed when it is far advanced.
What symptoms should a patient know
to look for?
LF: How long are patients followed by
the surgical team?
LF: What are the most hopeful and
encouraging developments in the
battle to conquer this disease?
ST: Most patients are followed
indefinitely; and during the first year of
diagnosis they will be followed by their
medical oncologist, radiation oncologist
and surgeon. The first appointment after
surgery is usually within three weeks of
the operation. Then depending on how
they are doing, will be back again at 68 weeks post-op to make sure they
recovered enough to continue on with
their next phase of therapy. Then we
will continue to see patients every three
months for that first year. Most surgeons
will at least follow their patients for a
year or two. Unfortunately we know
that the majority of our patients will
recur, even the ones that we think are
cured within the first two to three years
after surgery. After three years, the
chances of recurrence are substantially
lower and after five years although we
have had rare patients recur, we believe
that the patients will be cured if they no
longer have any evidence of the disease
at that time.
ST: Patients can present with painless
jaundice (turning a bright yellow color).
This type of presentation is suspicious
for pancreatic cancer and a workup,
which includes an abdominal CT,
looking for a mass in the head of the
pancreas is usually undertaken.
However, the majority of the patients
present with vague symptoms such as
back pain, fatigue or abdominal
discomforts that are usually ascribed to
more common conditions such as
gastritis or biliary colic.
ST: More people diagnosed can now be
surgical candidates giving them hope
for a cure. Over the last two years we
have had success with new multiregime chemotherapeutic protocols that
have resulted in meaningful improvements
in survival. However we still have much
to learn before we can conquer
pancreatic cancer and this will come
from insights gained from research.
Because of the support of the Lustgarten
Foundation, we have been able to
accelerate our discoveries in pancreatic
cancer and are starting to see positive
results. We see what research has done
for many other diseases, for example,
AIDS which first appeared as a lethal
disease has now been rendered a
chronic disease. Only with increased
research will we be able to achieve a
consensus on the best treatment
approaches so that we can increase the
survival and cure rates in this deadly
disease.
1111 Stewart Avenue • Bethpage, NY 11714 | 516-803-2304
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