 Welcome to Winthrop. I'm Michael Mazalorso, I'm the Chief Medical Officer at Winthrop University Hospital. And I'd like to welcome you to Winthrop University Hospital for this session on pancreatic cancer. Pancreatic cancer is a disease that unfortunately is the fourth leading cause of cancer death in the country. A very serious disease and I want to share with you my perspective as an internist, a geriatrician who's involved in general care, primary care of patients over the past 25 years. Briefly, the pancreas is an organ in the abdomen that has more than one function. It has two major gland type elements. One type produces juices containing enzymes that help digest food. The other element are endocrine tissues and those endocrine tissues are tissues that form hormones. Those hormones are very important. Now tumors can arise from either type but the vast majority of people with pancreatic cancer develop tumors in the glands that produce those enzymes. Pancreatic enzyme producing glands. That accounts for 90 to 95% of cancers of the pancreas. So that will be the bulk of what we'll be talking about today. But it's not to dismiss the other types which are uncommon. Unfortunately, this is a disease that doesn't have a great screening test. Often the outcomes are based on when people present with the disease. It tends to be more advanced than we would like it to be. But we are in search of screening tests. At this point none are truly available for the general population. And people can present with most commonly, they can complain of weight loss, jaundice which is yellowing of the eyes or skin. Often associated with that yellowing, significant darkening of the urine. And at times pain. The pain that people may complain of is in the epigastrium, the upper abdomen, or generalized abdominal pain. They may have back pain. They may have pain specifically in one position or another. It's not clear cut. It's not something that every single person has. People can feel weakness, fatigue. They may develop, again, jaundice which is yellowing of the eyes, yellowing of the skin. The urine may become deeply yellow. Why? Because of Billy Rubin that backs up. They may have changes in their stool. They may have diarrhea and they may have something called malabsorption. Because remember when I talked about those juices that are formed by the pancreas. Those digestive enzymes from the pancreas basically pour into the small intestine. And as such, they break down the food that we've eaten and allow the nutrients from the foods to be absorbed. So you may have that malabsorption that occurs and people may have the weight loss on that basis. They may have weight loss and stools that become this color, basically devoid of color. They become pale and they may float. I know it's a wonderful thing to talk about, but again, this is part of the way this disease can show itself. Now seeing a physician, a primary care doctor like myself, we often don't find many things on exam that clearly tell us that that's what's going on. The history might suggest that if we have someone who already has jaundice, yellowing of the eyes again, yellowing of the eyes or skin when it's more advanced, it may suggest it again, but it's the history that makes us usually go on our expedition. What might we find on an exam? Well, other than the yellowing, we may find signs of muscle wasting, something called concaxia associated with the weight loss. We may find a mass in the abdomen, something that we can actually feel and infrequently we may be able to actually feel the gallbladder on the exam, which may be suggestive. Is that usually the case? No. Again, the physical exam often doesn't reveal it to us. So in the course of one other comment regarding the exam, we can find an enlarged liver at times. But generally speaking, the exam doesn't give it to us. We may find evidence of more advanced disease, fluid in the abdomen, something called as cites. Again, nothing is 100% for this. We can find a constellation of findings that make us think about the disease, but we still have to look further. Once the suspicion is there, your doctor will be ordering routine, some quote-unquote routine blood tests that look at liver, bone, blood counts. If there is a suspicion on the basis of x-rays, special radiologic tests that are done, we may do that tumor marker that some of you may have already read about those of you who have an interest in learning more about this disease. But again, we tend not to do it unless we're using it for diagnosis and to follow it once the diagnosis is established. It's not used as a general screen. And that tumor marker, that blood test is called a CA-99. So often blood testing may be abnormal, but it doesn't clearly tell us what we're dealing with. Usually our next step is some radiologic testing like an ultrasound, a sonogram of the abdomen, or a CAT scan, one way or the other we will pursue. That's because some of the very symptoms that I told you about could easily be caused by a stone in the common bile duct. That's where the bile that comes from the liver and that's partially stored in the gallbladder join to the small intestine. And it can actually block that tube, that duct that goes into the small intestine. That's also the same place where the pancreas has a channel, a duct, that joins to the small intestine. So that's a major area for where digestion takes place. And that also creates some of the concerns about the anatomy here and the major approach to this diagnosis, which is predominantly surgical if cure is intended, if cure is possible. But we'll come back to that. So ultrasound, sonogram, CAT scan, again very much involved in the diagnostic evaluation for people who present with this kind of series of complaints. Other types of testing, you may hear people having an MRCP, which is Magnetic Resonance Collangial Pancreatography, not as good as an ERCP, which is done by a gastroenterologist who is an expert in advanced endoscopy, an ERCP and endoscopic retrograde collangial pancreatography. That's helpful. That's why we say ERCP. An ERCP allows us to look for stones, allows us to look at anything that may be causing blockage of that common bile duct. It allows us to take pictures of the pancreas. And more importantly, it can allow us to intervene. Meaning the advanced endoscopist right then and there can be able to put a stent like a straw to overcome a blockage that may be present from a tumor or a stone or other things. It also allows potentially the opportunity to perform a biopsy of a suspicious lesion, a suspicious abnormality that's seen on a CAT scan. So it's actually a very effective test that we'll be speaking about a little bit later. So when all is said and done, this allows a physician to come to an understanding as to what might be causing the symptoms. It may raise the suspicion that we're dealing with a cancer of the pancreas. And by the way, age doesn't seem to be as much of an issue here, even though we tend to see this in older individuals, you can see it in the youngest person I've seen personally. My own experience is a young woman of 30 with this diagnosis. So again, we're talking about the disease of adults, but it's not necessarily a disease exclusively of the elderly. So in the course of these tests that we perform, we get a sense of what we're dealing with. And we try to come up with a stage. And because that stage, meaning, is the disease just in the pancreas? Is the disease outside the pancreas locally invasive? Or is the disease more widespread? Does it go to the liver? How has it already gone to the liver? Has it already gone to bone or lung? It's usually liver or lung less so bone. But is it in that stage already, in a category that we refer to as metastatic disease? The stage determines what the likely prognosis is, what the outcome will be. Now I can share with you the first time I took care of or was involved in the care of a patient with pancreatic cancer was as a medical student rotating on the surgery service. And that first patient had carcinoma up ahead of the pancreas. Now the pancreas comes in three sections. It's all one organ but we divide it as head, body, and tail. Most of the time we're talking about carcinoma of the head of the pancreas and that head of the pancreas is adjacent to that small intestine, adjacent to that common bile duct. So it becomes a more difficult surgery to remove that tumor, a surgery referred to as a lipoprocedure. So my first experience was assisting surgeons caring for a patient having a lipoprocedure. And that procedure was a 12-hour procedure. It was a very long surgery and had lots of complications associated with it. The problem is not everyone and even today many people are not candidates for removing the tumor. And that determines our prognosis. Can we remove it? Is the person able to undergo such a surgery? Thankfully that 12-hour surgery of almost 30 years ago is now very much shorter procedure and we'll hear from a very gifted surgeon about that procedure. So when all is said and done, the outcome is going to be based on the stage. The stage in turn will require a team of doctors to determine adequately. You need an expert radiologist. You need an advanced endoscopist who can perform that ERCP well. You need the surgeon who is gifted in performing this procedure because we do know that familiarity and repetition with good outcomes clearly determines which surgeon is better at performing this procedure. An oncologist, a medical oncologist who can prescribe a chemotherapy that can have true impact on this disease. And last but not least, a radiation oncologist who may be necessary to deal with the tumor if it can't be removed or to make it smaller, to shrink it so that the tumor can be removed. So it does require a well-oiled machine, a real team of experts in this area to accomplish the best possible outcomes. Now I will tell you if you happen to look on the internet, you'll find lots of information and a lot of it can be very discouraging. Much of what you'll see is based on old information and I can share with you personally that I'm not just talking as a physician, I'm talking as a patient as well. Because I personally, it's now two years and eight months that I've underwent this particular sequence of events. I had back pain. I ultimately had jaundice. I needed the services of all the individuals that we spoke about. I had radiation, chemo, and I had what was initially locally invasive pancreatic cancer, which didn't lend itself so easily to surgery. After the chemo and radiation, I was able to then undergo the surgery a little more than a year ago. I'm less bulky than I used to be, I'm still here and I'm still working. I can tell you that this is a disease that requires that team effort, that symphony to be performed. I can tell you that the speakers who will be addressing it this morning are my own doctors. Dr. Hindenburg, my medical oncologist, Dr. Stavropoulos, the advanced endoscopist who performed my ERCPs, put my stents in, and Dr. John Allendorf who performed the surgery on me a little more than a year ago. I did get a flavor of other hospitals in reference to this, but I can tell you that team experience that I had here with John Haas who was my radiation oncologist, Doug Katz who was the radiologist involved in over-reading all of my studies. That group dynamic helped me achieve the outcomes that I have today of living with it, of living with a diagnosis and not being a victim to it.