Exciting Developments for Pancreatic Cancer Care

**By Flavio G. Rocha, MD**

After successful treatment for pancreatic cancer, one of our patients shared her story. Life after cancer is not normal, she said, it’s better than that. She talked of being inspired by the dedication of the Virginia Mason team. As a member of this team, a cancer surgeon and a clinical researcher, I am inspired by the progress we and other organizations are making toward better treatments for this disease. Working together to discover new therapies and the potential for early detection, the future of treating pancreatic cancer has never felt more hopeful.

Today Virginia Mason sees almost a third of all pancreatic cancer patients in Washington state, with decades of experience delivering care as a multidisciplinary team. This collaboration across specialties – along with advances in imaging, surgical techniques, specialized treatment and safety protocols – contributes to a doubling of the overall survival of our patients compared to the national average, as reported by the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program.

researchVirginia Mason is also invested in world-renowned medical research with Benaroya Research Institute (BRI), offering patients access to clinical trials investigating new therapies for all stages of pancreatic cancer. As a BRI affiliate investigator, I see a new wave of disease-fighting possibilities ahead, based on the latest research involving cancer cell microbiology, genetic testing and immunotherapy.

Reach Goal: Early Detection

Despite improvements in treatment, an estimated 46,000 people in the U.S. will die of pancreatic cancer this year. That’s because 90 percent of cases are diagnosed in later stages, when the cancer has already spread to other tissues or organs or requires preoperative therapy to reduce tumors. Virginia Mason, in partnership with BRI and other research collaboratives, is focused on looking inside the pancreatic cancer cell to identify biomarkers that signal a precancerous condition.

A specific protein, for example, was found in a clinical trial to be significantly elevated in the pancreatic fluid of patients known to have premalignant lesions. These results suggest that testing the fluid for this biomarker could detect disease in patients at increased risk, before becoming pancreatic cancer. Other research around early detection focuses on developing special blood tests, diagnostic imaging and other screening tools to find disease at its earliest stages.

Hereditary Cancer Testing

In July 2018, the National Comprehensive Cancer Network (NCCN) issued a new guideline that all individuals with a diagnosis of pancreatic cancer must meet criteria for hereditary cancer testing. Studies suggest up to 10 percent of pancreatic cancer is caused by an inherited mutation in BRCA1 or BRCA2, the so-called breast cancer genes. Other genetic mutations have been linked to an increased risk of pancreatic cancer as well.

Is there a benefit in genetic testing if the patient already has pancreatic cancer? Yes, for two reasons:

  • Knowing about an inherited genetic mutation may help direct treatment decisions. BRCA-associated cancers, for example, are known to respond to certain treatments, including specific types of chemotherapy. This concept of “personalized medicine” is expanding through clinical trials of other agents that target cancers linked to genetic mutations.
  • Identifying a mutation can be valuable knowledge for family members, who can choose to be tested and learn if they are at higher risk for developing certain cancers. That’s because the same mutation that is linked to pancreatic cancer is also associated with breast, ovarian and other cancers. Family members who test positive can engage in screening or risk-reducing strategies for other forms of cancer, as available.

Boosting the Body’s Immune System

Leveraging the power of the body’s own immune system to fight cancer is the science behind immunotherapy, variations of which are already prescribed by oncologists to treat a variety of cancers. While success has been limited using immunotherapies in the treatment of pancreatic cancer, ongoing clinical trials are testing multiple forms of the therapy, including pancreatic cancer vaccines (designed to “program” the immune system to attack cancer cells), and immune checkpoint inhibitors (shown to reactivate immune cells shut down by cancer cells). Other forms of immunotherapy utilize modified viruses to infect tumor cells, or modifications of the body’s own cells to disrupt cancerous activity.

The Future of Research is Now

Virginia Mason is one of 12 clinical trial sites selected nationwide by Precision Promise, the Pancreatic Cancer Action Network’s groundbreaking initiative to improve patient outcomes and double the pancreatic cancer survival rate by 2020. Starting this year, patients will be able to enroll in Precision Promise through the participating sites, accessing trials of multiple novel therapies alongside standard care approaches.

Through Precision Promise, clinical outcomes data will be continuously tracked and analyzed, accelerating findings that can be shared across the trial sites. Analysis methods, including the use of genomic data, will be matched to patients’ responses to therapy to quickly identify effective treatment options. As breakthroughs emerge, Precision Promise will adapt clinical programs to help get successful therapies out to patients faster than traditional research models.

What Keeps Us Going? Our Patients

The pancreatic cancer survivor who shared her story described the joy of seeing her daughter graduate, and teaching her son how to drive. As physicians we are privileged to not only treat disease with our best skills and knowledge, but to nurture hope in our patients that they will return to the lives and people they love. We have seen the pancreatic cancer survival rate increase 3 percent during the last three years, and momentum is building. The time for changing everything we know about diagnosing and treating this disease starts now.


Flavio Rocha, MD
Flavio G. Rocha, MD, has advanced training in surgical oncology and specializes in liver, biliary tract and pancreatic cancer. He is director of research in the Digestive Disease Institute at Virginia Mason and an affiliate investigator at Benaroya Research Institute. Dr. Rocha practices at Virginia Mason Hospital and Seattle Medical Center.

Awareness and Surveillance: Critical Tools in the Fight Against Anal Cancer

**By David Aboulafia, MD**

Anal cancer is a subject most people would rather not discuss, because of its anatomical location, along with an unfortunate stigma attached to the malignancy. Although tragic, actress Farrah Fawcett’s openness about her diagnosis helped create much-needed public awareness during her battle with the disease, which she lost in 2009 at the age of 62.

stop-cancerCloser to home, a 51-year-old White Center resident named Ed was impressed with Fawcett’s openness and advocacy. He now feels very fortunate that he listened to his physician and decided to have an anal Pap test following many years of HIV (human immunodeficiency virus) treatment and participation in a surveillance program. Despite having put off the screening for a few months, Ed knew that since he had HIV, he was at higher risk for HPV (human papillomavirus) and anal cancer.

The anal Pap test showed cells, which were concerning for cancer, and a subsequent biopsy of a suspicious-looking lesion proved to be cancerous. After additional studies, Ed was diagnosed with early stage anal cancer. The fortuitous discovery in October of last year allowed him to forgo surgery and, instead, receive six weeks of chemotherapy and radiation.

Although his treatment was challenging, the holidays and the month of January allowed Ed to rest and recover. In February, he felt good enough to return to work and subsequently began following a vegan diet, exercising regularly and better managing diabetes and stress. Due to the clarity that accompanied his hardship, Ed said he almost feels lucky to have gone through this experience because of everything it taught him — especially the importance of educating yourself, finding a good care team and learning to be his own best health advocate.

Anal cancer and HPV

Anal cancer occurs when skin cells grow out of control in the anus. The causes and location of anal cancer should not be confused with colon or rectal cancer, which are different.

According to the American Cancer Society, about 90 percent of anal cancers are caused by HPV. It is important to know that there are many strains or types of HPV and not all of them cause cancer. Most cancers of the cervix and anus are caused by HPV strains 16 and 18, while other HPV strains cause genital warts. HPV is the most common sexually transmitted disease and most people are exposed to HPV numerous times over their lifetime.

Thankfully, HPV infection usually goes away on its own. However, when the immune system is damaged by HIV and other causes, HPV infection can last longer and cause changes to the skin inside the anus, which is called “dysplasia.” Over time, some of these HPV-damaged cells – called “High-Grade Squamous Intraepithelial Lesions” or HSIL – can develop into cancer. Although HSIL is not the same as cancer, it is an indication that cancer may develop in that spot at a later date. Unfortunately, researchers do not currently know why some HSIL go away on their own while others worsen and become cancerous.

Who is at risk?

Anyone can get anal cancer, even people who have never had anal sex. However, it is much more common in people who are HIV-positive. For perspective, in HIV-negative people the chance of developing anal cancer is one to two people per 100,000. In HIV-positive people, it is between 30 and 131 per 100,000. (The rate in HIV-positive women is lower than in men.) In fact, even HIV-positive people on successful antiretroviral therapy have a higher risk of anal cancer than HIV-negative people.

Risk factors

The most common risk factors for anal cancer include:

  • Infection with certain strains of HPV
  • Age (risk increases with age)
  • Having a low count of T-helper cells, a type of white blood cell
  • Smoking
  • For women: a history of HPV-related cervical and vulvar dysplasia and/or cancers
  • History of genital warts

Symptoms

Early stages of anal cancer are often not accompanied by symptoms, which means most people are unaware when they begin to develop it. In later stages, the most common symptom reported is pain, which can be felt constantly or only when having a bowel movement or anal sex. Other symptoms can include a lump or bleeding from the anus. Unfortunately, anal cancer is often misdiagnosed as a hemorrhoid. If you are having any of these symptoms, it’s important to tell your doctor.

Treatments

Like most types of malignancies, the earlier anal cancer is found and treated, the fewer side effects people face from treatment. When caught early, anal cancer usually responds well to treatment. Some small cancers can be removed surgically. However, once the cancer spreads, treatment may require a combination of chemotherapy, radiation and surgery. Removing the affected areas can “cure” anal cancer, but there are often long-term side effects from surgery, radiation and chemotherapy, like needing to go to the bathroom more often.

Research: Virginia Mason, Harborview and The Polyclinic in national screening study

Thankfully, deaths from AIDS are way down. However, anal cancer among people living with HIV is on the rise. Researchers think anal cancer can be prevented by routine screening and removal of precancerous cells. In fact, researchers at Virginia Mason, Harborview and The Polyclinic are participating in a national clinical trial called The ANCHOR Study (ANCHOR stands for “Anal Cancer HSIL Outcomes Research”). This strategy has reduced cervical cancer rates by 80 percent. But to get health insurance companies to cover routine anal cancer screening and preventive treatment, researchers need to prove this strategy prevents cancer.

The best way to demonstrate effective prevention is to recruit people with HSIL into a study, with groups assigned randomly to a treatment arm or a monitoring arm. Researchers will then follow everyone for five years to compare the rates of cancer in both study arms. At the end of the study, researchers will know whether screening and treatment of HSIL are effective strategies in preventing anal cancer. Researchers will also learn a lot about HPV and other risk factors and why these sometimes cause cancer.

If you have any questions about whether this study might be right for you, talk with your doctor and have your provider call a local study site with any questions. For more information about The ANCHOR Study, including the list of study sites and contact information, visit ANCHORStudy.org.

Words of wisdom

Although Ed is not a candidate for participation in The ANCHOR Study, he now understands the importance of screening for anal cancer, especially among people living with HIV. Despite needing to come to Virginia Mason twice a year to be checked to make sure the cancer doesn’t grow back, Ed feels very thankful and encourages male and female friends who may be at risk to speak with their physicians about a Pap test. After all, knowledge is power.


David M. Aboulafia, MD, is board certified in Internal Medicine. His subspecialties include Medical Oncology, Hematology and HIV Clinical Care. Dr. Aboulafia is principal investigator of The ANCHOR Study at Virginia Mason and medical co-director of Bailey-Boushay House. He practices at Virginia Mason Hospital and the Floyd & Delores Jones Cancer Institute (1100 Ninth Ave, Seattle, WA 98101; 206-223-6193).

A version of this article previously appeared in the Seattle Gay News and the Queen Anne & Magnolia News.

Game Therapy Shows Promise for Treating “Lazy Eye” in Children

Hee-Jung Park, MD

Hee-Jung Park, MD

A common cause of decreased vision in children is amblyopia, also known as “lazy eye.” Often confused with strabismus, or the misalignment of the eyes, amblyopia refers to vision reduction in one eye due to the brain favoring the other eye. Any condition that affects normal eye function, including strabismus or problems with focus, can cause amblyopia. The longer one eye is suppressed, the greater the chance of permanent vision impairment.

Treatment for amblyopia in children frequently involves patching the good eye, forcing the use of the weaker eye. Disengaging the good eye does not, however, address the underlying cause of amblyopia: the loss of binocular function.

A promising new treatment option that helps the eyes work together has shown measurable improvement in participants’ binocular perception, visual acuity and depth perception in early studies. Known as binocular game therapy, the treatment involves a game played on an iPad. The player moves or rotates falling blocks on the screen to build rows of solid lines. By wearing special glasses during play, higher contrast images are presented to the amblyopic eye, while the normal eye sees lower contrast. The effect helps the player combine visual information from both eyes.

“Binocular game therapy is the biggest breakthrough we’ve had in the treatment of amblyopia in probably 50 years,” says Hee-Jung Park, MD, MPH, pediatric ophthalmologist.

Dr. Park is a participating physician in the Pediatric Eye Disease Investigator Group overseeing a new clinical trial to compare the effectiveness of game therapy versus eye-patching treatment. Funded by the National Eye Institute, the study will include more than 500 children across North America and Europe.

After a qualifying eye exam, study participants ages 5 to 16 years will be randomly assigned to binocular game therapy or eye patching. Vision and eye alignment will be checked throughout the study. All participants who receive the eye patching treatment during the 16 week study will be given the opportunity to try game therapy at no cost. Recruiting for the study is active now, concluding September 2017.

Complete clinical trial information for the Study of Binocular Computer Activities for Treatment of Amblyopia is available here. Virginia Mason Medical Center in Seattle is now a study site and provides qualifying eye exams for children by Dr. Park, performed in Seattle and Issaquah. To find out more about the clinical trial at Virginia Mason, please contact the clinical research coordinator at (206) 342-6598.