State of the Union: Pancreatic Care Today

An interview with John A. Chabot, MD, Chief of the Division of GI/Endocrine Surgery and Executive Director of the Pancreas Center.

Read our previous conversation with Dr. Chabot, State of the Union: Pancreatic Care in 2024.

Vaccines and Targeted Therapies

Last year, we talked about pancreatic cancer vaccines, AI, and rethinking operability. Looking back now, what feels like the most meaningful progress in those areas?

Not very much has happened on the AI front. But we still have a vaccine trial up and running, which we started a year ago.

Will you tell us the latest about the vaccine trial?

It’s a messenger RNA vaccine that’s custom-designed to each patient’s tumor. This is for patients who have operable pancreatic cancer. We remove the tumor, send a portion of it to BioNTech in Germany, and they use that tumor tissue to create a personalized vaccine. We deliver the vaccine back to the patient before they start postoperative chemotherapy with the goal of decreasing the risk of recurrence.

Are you seeing promising early results?

It’s a phase 2 trial, so we don’t yet have data from this stage. And last time we spoke I mentioned how phase 1 results were written up in The New York Times; there was a very exciting immune response to the vaccine. Patients who developed an immune response were doing quite a bit better at the last monitoring point than those who did not. So yes, there’s a lot of promise here, but not too much more to share yet.

What about immunotherapy in pancreatic cancer? Has anything become standard of care yet?

Not yet. Everything is still in clinical trials.

You also mentioned metabolism-targeted therapies last year. Any new molecular targets?

Nothing new on the metabolic front, but there’s a whole new category of drugs now—RAS inhibitors.

95 percent of people with pancreatic cancer have a mutation in the gene that makes the RAS protein, which plays an important role in the development of the disease. Developing effective RAS inhibitors has been a longstanding goal, and these agents have finally started to emerge. We’re one of the first centers using them in clinical trials, and it’s a very exciting development.

Surgery and Operability

Are you seeing more patients become surgical candidates after chemotherapy or these newer treatments? Has that changed the definition of operability?

We haven’t seen a huge step forward yet because most of these new agents are still in trials. But we’ve identified a small number of highly selected patients who’ve undergone surgery and would not have been candidates before. I fully expect that as these agents improve and become more widely available, we’ll be doing more surgery, and our cure rates will go up.

Last year, you described a “Whipple plus” concept, where you refresh blood vessels along with tumor removal. Has that technique evolved?

These are very risky operations, so we remain extremely selective. Anyone who’s frail or has significant vascular disease wouldn’t be considered. And the patient has to have responded very well to preoperative chemotherapy.

Is robotics playing a role in pancreatic surgery yet?

It is, but I remain on the fence about whether patients materially benefit. We’re doing robotic procedures, and for some pancreatic operations, it clearly helps recovery. For the big one, the Whipple, it’s less clear that there’s a real benefit. It’s widely used around the world now, and we can say confidently that it’s safe, but it’s harder to argue that it makes a major difference in outcomes.

Looking ahead, what are you most focused on to improve surgical outcomes?

I think the real progress will come from medications that make surgery more effective. As we develop better systemic treatments, more people will become eligible for surgery and that’s how we’ll improve cure rates. I don’t foresee dramatic changes in surgical technique itself.

How might these new medications expand what’s surgically possible?

If the RAS inhibitors and other agents continue to improve, we might reach a point where small metastases outside the pancreas can be sterilized with medical treatment—and then we can move forward with surgery to remove the primary tumor. That approach has already worked in other cancers as chemotherapy regimens have advanced. I think pancreatic cancer will follow the same path.

Early Detection and Artificial Intelligence

Are there any advances in early detection, biomarkers, or imaging that you’re particularly encouraged by?

That’s where I think AI will eventually play a major role—it’s just not mainstream yet. The science is solid; the foundation is already a year and a half or two years old. The issues now are organizational: Who has the data? Who owns the data? To do this right, you’d need access to medical records across an entire population, and that raises complicated ethical and logistical questions. It’s not the science holding us back—it’s everything around it.

If AI-driven early detection becomes possible, how would that change pancreatic cancer care?

It would be a game-changer. The reason we do as poorly as we do with pancreatic cancer is that we diagnose it late. Every cancer with an effective screening program—cervical, breast, colon—has dramatically better cure rates when caught early. Pancreatic cancer would be the same. We’ve just never had reliable screening tools.

How are you currently using genetic or molecular testing to guide treatment?

We test everyone. Every patient with pancreatic cancer gets genetic testing. That allows us to customize chemotherapy, usually for recurrent disease rather than first-line treatment. And if we identify an inherited mutation that contributed to the cancer, we enroll family members in a screening program.

Do you see pancreatic treatment eventually becoming as individualized as in breast or lung cancer?

We’re still a little behind. Those fields have had more therapeutic options to choose from, and once we have that same breadth, we’ll be able to use biomarkers to tailor therapy more precisely. But we’re moving in that direction.

Chronic and Hereditary Pancreatitis

You’ve spoken before about pancreatitis being mismanaged. Has awareness improved?

Not really—especially with chronic pancreatitis. It’s an orphan disease in many ways. Most practitioners see very few cases, so it’s hard to build real expertise. And these are challenging patients; the dominant issue is chronic pain.

Are there new approaches changing the way you treat chronic pancreatitis?

The most important one is remembering to consider total pancreatectomy with auto-islet transplant. We remove the entire pancreas, process it to release the insulin-producing cells, and then give those cells back to the patient. We’re the only program in the New York area that performs this. It’s an incredibly resource-intensive procedure, but it can make a life-changing difference.

What should patients and families know about chronic or hereditary pancreatitis that may not have been emphasized before?

Seek expertise. It’s a complex disease, and you want a team that truly understands it.

The Future of Pancreatic Care

Looking five years ahead, what do you hope will feel different for patients?

That we’ll be diagnosing most people with stage 1 cancer.

That would be enormous.

Yes, it would change everything.

What’s the most important message for someone newly diagnosed with pancreatic disease right now?

That there’s hope. Don’t look at old statistics, look at what’s happening today. When I used to meet someone with metastatic pancreatic cancer, I’d tell them, “We’ll keep you alive and feeling well as long as we can.” Now my message is, “Our goal is to keep you alive until we find the next improved treatment.” It’s a very different message.

Is there anything else you’d like patients to know?

Yes—just because one surgeon says a case is inoperable doesn’t mean we would say that.

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