Pancreatic Cancer Awareness Month, 2021: A Conversation with Dr. Michael Kluger


Most people don't know that November is Pancreatic Cancer Awareness Month. In fact, let's be honest, many people may not know what a pancreas is, or what it even does. Dr. Michael Kluger, a pancreatic surgeon here at Columbia’s Pancreas Center and the medical director of the inpatient surgical oncology unit here at New York Presbyterian, answered some questions on all things pancreas.

Dr. Kluger is a board-certified general surgeon, who is specialty trained in liver and pancreas surgery. He has expertise in the operative management of pancreatic cancer, as well as liver cancer and gallbladder disease.

The following conversation includes a general overview of the pancreas and pancreatic cancer, the current state of diagnosis in late 2021, where medicine is falling short, where doctors are making steady progress, and areas where surgeons and oncologists hope to improve. The talk also explores who should consider themselves at risk, plus how people can mitigate these risks.

[Note: This conversation was lightly edited for the page]

Thanks for doing this, Dr. Kluger.

Pleasure to be here.

So November is Pancreatic Cancer Awareness Month, and we're delighted to talk to you about all things pancreas today. So just to get some readers up to speed, what exactly is the pancreas and what does it do?

So that's an important question that patients often ask us when we first see them, because it has a lot of implications with regard to why they're getting sick, some of the symptoms they may have, and some of the consequences they may have from different therapies that we do.

But the pancreas is a pretty important organ. It's not an essential organ, because we actually have medications now that replace its functions for people. So if it gets damaged, or even has to be removed in total sometimes, people could have a pretty good quality of life based on studies that we've done and that other centers have done.

But the pancreas basically has two major functions. The first one is to help balance our blood sugar. When we eat, our digestive system digests the nutrients, and then our system has to balance the amount of sugar in our blood so that we are able to function well. So that all of our organs, our body, our muscle, our mind, everything works well. So that's one of the things, is to balance the sugar. When that balance is really off, we call that diabetes.

The other thing that the pancreas does, is that it functions to produce enzymes that help with digestion. So when we eat fat or protein our body has to break those down, and the pancreas produces the enzymes that help with that digestion. Now, as I said, these are two really essential functions for our body to work. But when they're damaged, either by pancreatic cancer, or pancreatitis, or other diseases where we may even have to remove the pancreas, we are able to replace those functions through different medications that patients can take.

That's a relief. And I know we're talking about pancreatic cancer. But just to backtrack, you mentioned pancreatitis. What is that? And does it increase the risk of having cancer?

So anytime you hear the word "-itis" at the end of any kind of organ, it usually means inflammation. So pancreatitis is inflammation of the pancreas. Now, acute pancreatitis is just a short-lived inflammation of the pancreas, and it doesn't really increase your risk of pancreatic cancer in the long term. And very often, it doesn't even increase your risk of having any kind of long-term pancreas problems.

Now another kind of pancreatitis, called chronic pancreatitis, is very different. Because what happens with chronic pancreatitis is that slowly, over time, your pancreas starts to get destroyed for different reasons. Sometimes it's autoimmune, meaning your body attacks the pancreas itself and damages it. Sometimes it's from alcohol consumption, so taking too much alcohol damages the pancreas. Other times it's a genetic problem. So there's something called hereditary pancreatitis, and that's where there's genes in the pancreas that don't function well, and that causes the pancreas to get chronically inflamed. And then there's a few other causes of chronic pancreatitis.

But those processes that cause the pancreas to be inflamed, and cause chronic pancreatitis over time, those do increase the risk of pancreatic cancer. And depending on the exact cause, anywhere from a few percentage points to almost a guarantee that somebody will develop pancreatic cancer.

And so sometimes for those conditions, do you have to take the pancreas out, even before it becomes cancer, maybe?

That's a great question. So in something called hereditary pancreatitis, where we see in families over time that young people, usually below 20, start to develop episodes of pancreatitis, the recommendation is to remove their pancreas early. To prevent, A, chronic pancreatitis, which has pain associated with it and also affects, as I said before, their sugar, their digestion, but also really increases their risk of pancreatic cancer. We will take out a patient's entire pancreas at a young age to prevent them from having those problems as they get older.

That makes a lot of sense. Now, onto pancreatic cancer. It's certainly been in our mind lately because of some high profile cases in the last year or two. Is pancreatic cancer just becoming more prevalent, or are we just talking about it more?

It's an interesting question. I mean, obviously with the death of Alex Trebek from Jeopardy and Ruth Bader Ginsburg from the Supreme Court, it's definitely been a little bit more in the mind of people. Just to be a little bit specific, the one that we're really talking about is pancreatic adenocarcinoma, as opposed to the neuroendocrine pancreatic cancers. Because those have a much better prognosis, and they don't take the lives of as many patients as the pancreatic adenocarcinoma does.

Now, are we just seeing it more or are we hearing about it more? And it's a combination of both. Yes, we are hearing about it more because of these high-profile cases. But we are actually seeing it more. And the number of patients dying from pancreatic cancer, and the number of patients who get pancreatic cancer per-year, is on the rise.

Back about a decade, two decades ago, there were about 40,000 patients a year. Now it's in the high 50,000 patients a year 55, 56,000 patients a year are getting it. So yes, it is becoming more common.

Also what we're seeing is a lot of advancements in other cancers, in the way we treat them. So, whereas pancreatic cancer is the 12th most common cause of cancer, it's moving to be the second, third, most common cause of cancer death.

Which basically means other cancers that are much more common, such as colon cancer, lung cancer, prostate cancer, breast cancer, we're making so much progress in the treatments of those cancers that even though they occur much more often, the treatments are getting so good that many fewer patients are dying from it. And that's very different from pancreatic cancer. We're just still not making enough progress in being able to treat these patients. So we're seeing a lot more people pass away from pancreatic cancer as opposed to other cancers.

Why do you think there is a little bit of a rise? And is it related to environmental risk factors or is it lifestyle, modern lifestyle? What do you think?

I think the data shows that modern lifestyle is really the big thing. When we look at the risk factors for pancreatic cancer some are avoidable, some aren't avoidable. Probably the biggest, clear risk factor for pancreatic cancer is age. And age, obviously, is not avoidable. We're trying, but it's not avoidable.

So as we see the average age of the population increase, we're seeing more pancreatic cancer for that reason. So as we have a healthier population that lives longer because we're able to treat other diseases, it gets them to an age where they're more likely to get pancreatic cancer.

Other risk factors include the Western diet. So a high-fat, low fiber diet, lots of sugar, high calorie foods, is definitely a risk factor for pancreatic cancer. Obesity, a risk factor for pancreatic cancer. Diabetes, which is also linked to the way we eat, and our body, and to age and to obesity, also a risk factor for pancreatic cancer.

Some of the ones that we could really control are smoking. So of the really behavioral risk factors for pancreatic cancer, the two big ones are weight and smoking. And if we could decrease smoking across the board, we would actually be affecting not just pancreatic cancer, but most cancers, most heart disease. It's probably the number one thing that people could do to prevent themselves from having health problems as they get older.

Makes sense. What about non-modifiable things, like your family? If you have a family member with pancreatic cancer, does that increase your risk?

Sure. So although we'd like to get rid of our families in a lot of cases, it's not that easy.

No, not that easy, you can't choose where you came from. But there are some genes that are related to families that increase your risk. So one big one that we talk about, and a lot of people are familiar with, are the BRCA genes, BRCA one and two. Most people think about these when they're thinking about breast cancer or ovarian cancer, but it's really important that people recognize that there's up to about a 7% chance of getting pancreatic cancer in patients who have one of these mutations.

Multiple times per-year at the pancreas center, we see patients who have had a bilateral mastectomy, meaning they've had both their breast removed, and they've had their ovaries removed as steps to get rid of their risk of either developing ovarian cancer or breast cancer. But nobody's thinking about their pancreas, and then they come in with pancreatic cancer.

So looking at your family heritage, looking at if there are lots of family members with either melanoma, breast cancer, ovarian cancer, colon cancer. If you have parents or siblings with those cancers, you have to be thinking that there may be a gene associated with those family members that may put you at risk of pancreatic cancer.

Now, we need to be realistic about this. Because only about 10% of pancreatic cancers are genetic in origin. So it's not a big risk factor compared to other risk factors, but it's something that is potentially preventable because we could survey them earlier. And we know that probably the best way to treat pancreatic cancer is to find it early. So if we're able to know that a patient may be at risk, we could do different forms of surveillance to try to find it early when we could still treat it more effectively.

Other risk factors, there's something called Peutz-Jegher syndrome that increases the risk of pancreatic cancer. There's, as I said before, hereditary pancreatitis that increases the risk, and there are a few other different genes that do it. But really, when you look back at your family members, if you're having multiple brothers, sisters, parents with different kinds of gastrointestinal cancers, melanoma, you have to be thinking that there may be a familial risk factor.

That makes a lot of sense, and probably a good incentive to catch up with your family?

See your family for the holidays. It makes for a morbid Thanksgiving conversation.

It seems to me that if you have a known hereditary cancer syndrome, or you have a history of cancers, or you know that family members have had cancer, that would make sense to sort of be high on the radar screen, get some screening if you need that done. And certainly, it's on your mind.

What about just sort of the average, seemingly healthy person? How is pancreatic cancer generally detected? How is it diagnosed, and is there anything new in early detection?

Sure. A lot of the symptoms that patients may have has to do with where the tumor is located in their pancreas. So your pancreas is somewhere about six to eight inches long, and it's actually across your spine where it lies. A lot of people don't know where their organs are, which is pretty normal, but the pancreas basically lays across your spine mid back. So sometimes if the tumor is in the middle of the pancreas, patients will present with more pain symptoms because it's close to a lot of nerves that are on the blood vessels in our body.

Now, we don't want everybody to think that, okay, they're having a little bit of back pain, that they have pancreatic cancer. So usually it's not just an episode of pain, it's weeks of pain, and it's not really related to physical exercise, or to sleeping, or to position. It's just a constant pain, a deep pain in your abdomen, but closer to your back.

Other patients present because the tumor blocks the little ducts that drain the liver, and that usually sets off an alarm in your skin and your eyes because you actually turn yellow when it happens. We call that jaundice. So that's another symptom.

Sometimes patients get diabetes, and new onset diabetes can precede our ability to identify a pancreas cancer by actually up to a few years. But when somebody develops diabetes and there's not a good explanation of why they did develop diabetes at their age, pancreatic cancer should be somewhere in the thought process. Obviously many more people have diabetes than pancreatic cancer, but it should be something that's being thought about in each new case of diabetes diagnosis as people get older.

Other symptoms, and probably the main symptom, is weight loss. We always kind of, it's not really a joke, but it's something to think about. When somebody's diet really starts to work, and they've been dieting their entire life and now they start taking off 10, 20, 30 pounds without an explanation, you've really got to be thinking about cancer somewhere in their body.

Because if you've never been able to lose that weight, and then it just starts peeling off, maybe even much more relative to the amount that you're either exercising or eating, you have to think about cancer. And pancreatic cancer in particular, since it does affect your metabolism through the production of insulin, since it does affect your digestion through enzyme production, patients tend to lose a lot of weight very quickly.

They often have what we call steatorrhea, which is a greasy diarrhea. It's different from diarrhea you may have when you're sick. And don't want to create too much of a visual here, but this is a symptom that we're talking about and a disease that we're talking about. But it really looks like an oil spill in the toilet water, which is very different from regular diarrhea. There's a lot of grease in there. So that's one of the things we have to think about.

So abdominal pain, diabetes, weight loss, jaundice, those are the main symptoms that people present with.

And given that pancreatic cancer diagnoses are often late into the course of illness, maybe symptoms have been around for a while. What should we know about early detection?

That's a really critical question, especially during Pancreatic Cancer Awareness Month, can we do a better job early detecting? And the answer is we're trying to, but we're not making a lot of progress.

So we see numerous patients per-year who just say, "But I was just at my doctor's office three months ago and I had totally normal blood work. My liver blood work was fine. My electrolytes, everything was perfect. Picture perfect." And now they come in and everything's totally out of whack.

And that's actually a very common presentation, because we don't have good blood tests yet that help us identify pancreatic cancer. And even the blood tests, a lot of people hear about PSA for prostate, for example, where it's a blood test that they could find prostate cancer potentially earlier. We don't yet have something like that for pancreatic cancer. And the other issue is that, since the pancreas is in our body where it is, it's very hard to do imaging tests to find it.

So breast cancer is easier to detect because of both women's ability to do a breast exam, but also because of mammography, an x-ray of the breast. Colonoscopy for colon cancer, prostate exam, although nobody likes a prostate exam. Prostate exam, to try to find an abnormally large prostate, and a mass and a prostate. We don't have that ability with the pancreas.

And what we've seen, even in studies where everybody gets, say, a CAT scan on an annual basis to look at the pancreas, we miss a lot of early pancreatic cancers, but we also find a lot of things that have nothing to do with pancreatic cancer, but then involve a lot of invasive workup and actually could cause complications in and of themselves.

And what about looking ahead? Are there any new advances on the horizon when it comes to earlier detection for pancreatic cancer?

On the horizon, potentially, are a lot of new tests where people are going to be able to look at the blood, or at the saliva, or even at the stool, and be able to find little pieces of DNA, little pieces of genetic information that may be related to pancreatic cancer. And each conference that we go to in the medical community, we're hearing more and more about these tests.

And if we're able to find one, that's going to be a real game changer. If we could find little pieces of DNA in the body fluids early on that detect pancreatic cancer, that's really going to change our ability to find these cancers early. Our understanding is that these cancers may be developing for as long as seven to 10 years by the time we find them. Meaning that they're slowly happening, slowly growing, until we see them on say a CAT scan or before a patient develops symptoms.

So we have a lot of potential lag, a lot of potential ability to find these earlier, if we could just find the right tests that work.

Well, it seems like there's a lot on the horizon, especially in this era of molecular medicine and finding exactly, as you said, these genetic alterations that may be detectable a lot earlier than clinically detectable. So more on that, I guess, as things develop. So that's exciting.

And then, now to move to treatment of pancreatic cancer. Is it still a six-hour Whipple procedure, a big surgery to remove all the affected areas?

It is still a long operation to try to remove the majority of the cancer that we could see. The goal is always to remove the entire tumor, any lymph nodes in the area, and then do whatever reconstruction of whatever organs we need to remove, reconstruct them so that people are able to eat like normal and function like normal.

But the problem is that, if cancers are really developing over a seven to 10 year period, there's a lot of room for cancer cells to escape to other organs. So even when we are able to remove the entire tumor that we're able to see, we're always at risk that little cells are displaced somewhere else in the body, and can become what we call metastatic disease.

When it comes to surgery the problem is, by the time most patients present with pancreatic cancer, they are not able to undergo surgery. So if 10 people walk into our office in a single day, five of them are never going to be able to get surgery because there's already evidence that a tumor has spread. Three patients will be able to go to surgery, but will need to do chemotherapy first to try to shrink the tumor down. And then two patients could go right to surgery right away without anything.

Can you describe the operation, and what might a person expect? What should they know?

So the operations are long. The good thing for the patient is that they get to sleep through the entire operation and the surgeon gets to take care of it for them. But they are long operations, they take a lot out of the patient. And although the techniques haven't really changed, the safety of the operation definitely has.

And what we know is that patients who have operations at high volume centers, where people do lots of these operations a year, where the hospital sees lots of these operations a year. And that means the nurses, the medical assistants, the residents, everybody around is familiar with the operations, familiar with how the patients recover, are able to look out for early complications and take care of them quickly.

These patients have much better outcomes, undergo the operation and the recovery much more safely. So I think that's really one of the big areas where we've advanced, is really in better safety by doing more operations at single institutions.

Is there anything new in terms of technique or the kinds of surgery that's done? Tell us about that.

We've instituted laparoscopic and robotic techniques for some of these operations. And sometimes those operations take longer than they would take if we did them open, but recovery tends to be a little bit better for the patient with those.

Another technology we're using for patients who have tumors that would not typically be able to undergo resection, and in the past had relied only on chemotherapy, are using radiation in high doses, done by the radiation oncologist to help treat the tumor at its primary location.

And then another technology that we've been using since about 2010, so a little bit over a decade now, is something called IRE, or irreversible electroporation. And what that does is, it's using an open surgical approach, and we put special probes around to bracket the tumor, to destroy the tumor so that the body actually kind of eats the tumor up over time. But we don't have to use heat, we only use electrical energy to destroy the tumor.

And that's very important. Because behind these tumors are very often blood vessels, the bile duct which strains the liver, the pancreatic duct, which strains the pancreas. And if we use the electricity to kill the tumor, it actually does not kill those key structures, those blood vessels and those ducts, which allows the patient to basically, almost as if they're having their tumor removed, but we just destroy it in place. And that's a pretty new technology that we're using, and we're seeing some very nice results in those patients.

But the problem with pancreatic cancer is that it's often spread before we could even find it. So even when we're able to control it locally in its spot, we sometimes see it come back. Which is why chemotherapy is also a very important component of the care of these patients.

And really, in the last five to 10 years, we've seen two regimens of chemotherapy really excel far beyond the success of what we've seen prior to that.

And in the distant past, when we were giving chemotherapy for pancreatic cancer, we were really doing very little, the chemotherapies were very ineffective. But these two regimens that have been very well-studied now, and used in thousands upon thousands of people around the world, are really proving to be quite effective in killing those little cells that may have escaped somewhere else in the body, and really helping with a patient's long-term survival.

So it seems that there really needs to be quite a team assembled here that involves more than just the patient and the surgeon, but certainly all the supportive staff, and also maybe radiation oncology, the radiologists, certainly oncology or medical oncology. Everyone sort of needs to really be acting in concert in order to provide the best care for the patient.

How would you describe the team aspect of how everything works for a pancreatic cancer patient here at Columbia?

So the important thing is a multidisciplinary approach. Because a patient needs to be seen, discussed, and treated not by one person's blinders, but really a lot of people thinking about the patient, and how to provide the best possible care for the patient.

If you are seeing a surgeon one day and your oncology appointment's four weeks away, and then there's a GI doctor, they have to see somewhere in the middle, something's wrong.

You should be able to see everybody you need to see within a week, where everybody's talking about you, everybody knows about you, and you're the focus of everybody's care. That's what we do at Columbia. That's what needs to be done.

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