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.

Breast Cancer: Genetic Testing Helps Reduce Anxiety for Some

iStock_000020255467XSmallA few months ago in The New York Times, actress Angelina Jolie shared her story about testing positive for a faulty gene that increases the risk of breast cancer. She said she went public with her decision to have a preventive double mastectomy, “because there are so many women who do not know they might be living under the shadow of cancer.”

The “shadow” she refers to is an inherited genetic mutation that affects specific genes, identified as BRCA1 and BRCA2. In Angelina’s case, her mother had breast cancer and died of ovarian cancer: a significant clue that Angelina might carry the mutation. Since the children of a mother or father with a BRCA mutation have a 50 percent chance of inheriting it, the actress chose to be tested.

For many women, the media coverage likely raised more questions than answers: Should I find out if I have the BRCA gene mutation? What does increased risk really mean? What can I do if I have the mutation?

Fortunately, Virginia Mason helps women answer these questions through the expertise of hereditary cancer risk consultant Cathy Goetsch, ARNP. Providing cancer genetics services for more than 17 years, Cathy is uniquely qualified to assess women’s personal risk of cancer and determine if genetic testing is appropriate for them.Cathy, who sees patients referred from all over the region for her specialized services, looks at a number of factors that not only clarify if a patient should pursue genetic testing, but also help ensure testing is covered by a patient’s insurance plan, if they have one. Criteria vary based on individual history, but can include:

  • A known BRCA mutation in the family
  • Two or more same-side family members with breast cancer, or a member with breast cancer before age 45
  • First degree relative with ovarian cancer
  • Male family member with breast cancer

“Ideally we want to first test a family member who has breast or ovarian cancer to confirm their cancer is actually caused by a BRCA mutation,” says Cathy. “Then we know that if the patient without cancer tests negative for the mutation, they have no higher risk than the general population. But if they are the first tested and are negative for a specific BRCA mutation, despite cancer in the family, that doesn’t eliminate the possibility they are at higher risk for another reason.”

It’s the gray areas – such as whether a BRCA mutation or some other inherited risk may be affecting a family – that make Cathy’s role so important. Then there’s evaluating the risk itself. Studies show women with a BRCA mutation face a 40 to 87 percent lifetime risk for breast cancer, and an 11 to 54 percent risk of ovarian cancer. But Cathy will tell patients it’s not as simple as that.

“More recent studies, using broader patient populations, are showing the lifetime risk may not be as high as once thought,” Cathy says. “And what those statistics don’t tell you is that better technology for breast cancer detection means the majority of these cancers, if they happen, are caught early at a very treatable stage.”

An important distinction Cathy makes for her patients is she is there to help them manage their cancer risk, not take it away. Part of that distinction is educating women who are considered high risk about their treatment options. There is close surveillance, which consists of a prescribed schedule of exams and advanced imaging to monitor for the disease. Chemoprevention, which involves a drug regimen that fights cancer by manipulating hormones, is proven to reduce cancer risk in certain patients. Finally, preventive mastectomy, the surgery undergone for Angelina Jolie, is shown to reduce the risk of breast cancer by about 90 percent (even with the surgery, a woman’s risk is never completely gone).

While mastectomy can be an appropriate choice for a BRCA-positive woman, it may not eliminate her need for further treatment, particularly if early cancer already exists. Drug therapy, chemotherapy and radiation can still be needed following surgery, or in the future.

For some women, 90 percent reduction is a number that works and is worth the effort, while others are encouraged to learn that having a BRCA mutation does not mean a 100 percent chance of getting breast cancer, so they don’t rush into surgery.

“Many people feel reassured by genetic counseling and subsequent testing because they are empowered by the knowledge,” says Cathy. “They are having it done for their kids or other loved ones, and they learn there are things they can do to manage their risk – the choice is up to them.”

To learn more about hereditary cancer risk, call Cathy at (206) 223-6193 or visit the Hereditary Cancer Risk Assessment Web page.