Hi, welcome to Partners in Pancreatic Cancer. My name is Alok Khorana, and I am a Medical Oncologist who specializes in the care of patients with pancreatic and other gastrointestinal cancers. I direct the GI Cancer Program at the Taussig Cancer Institute of the Cleveland Clinic. I also participate in guidelines from the American Society of Clinical Oncology.
Three guidelines related to pancreatic cancer were recently published in the Journal of Clinical Oncology. A frequently asked question regarding diagnosis of pancreatic cancer involves the question, “After a histopathology confirmation of pancreatic adenocarcinoma, what initial assessment is recommended before initiating therapy?” This is a question that is addressed by the American Society of Clinical Oncology guideline on potentially curable pancreatic cancer, as well as by locally advanced and metastatic pancreatic cancer guidelines. It is very important that the appropriate workup for patients with pancreatic cancer be conducted before there is a rush into treating the disease. Although it is very important that patients be treated as early as possible, it is equally important that the appropriate staging and workup be conducted so that the patient’s team of physicians, surgeons, radiation oncologists, and other providers, as well as the patient and the family, understand the burden of the disease, the options for treatment, and which path to proceed for treatment.
The guidelines recommend that once we have a tissue diagnosis of pancreatic adenocarcinoma, which is the most common histologic diagnosis in patients with pancreatic cancer, a full staging workup be conducted. Especially important is the pancreas protocol, CT scan, or an MRI that focuses on the pancreas to completely understand the anatomic staging, the involvement of the blood vessels, and the presence or absence of metastatic disease. It is really crucial that this type of assessment be conducted in a multidisciplinary setting, that it is not just one doctor making the decision on whether a patient has resectable pancreatic cancer or not, but that doctor works as part of a team. A multidisciplinary team includes physicians from different disciplines including surgery, radiation oncology, and gastroenterology, so that all disciplines provide input on the best care that can be offered to this particular patient moving forward. In the treatment of pancreatic cancer, it is really a team support. A decision about whether surgery can or cannot be offered to a patient is best made in the context of a tumor board discussion or multidisciplinary clinic, where all of these different disciplinary physicians have had a chance to review the images and provide input to the patient.
Once the decision is made whether a patient is potentially resectable or borderline resectable, which means that there is a potential for surgery but additional treatment needs to be offered before surgery can be offered, or whether the cancer has spread and is no longer resectable, then that treatment can be instituted. Again, it is very important that the correct imaging modality, which is a pancreas protocol CT or an MRI of the pancreas, be conducted. The guidelines also recommend that additional staging be conducted, which includes a chest x-ray, and other modalities, such as the scan of the chest, or other scans specifically directed toward symptoms can be addressed, but are not recommended routinely. My patients often ask me, for instance, whether a PET scan is necessary. The guidelines do not recommend that because nearly all the information that you need can be obtained from a pancreas protocol CT and MRI combined with a chest x-ray. Additional imaging modalities do not add that much to the staging of the cancer and can often add to radiation exposure and certainly to the cost of care. Complementary studies can also be done. These include an endoscopic ultrasound, which involves a gastroenterologist using endoscopic techniques, including ultrasound, to identify or complement the staging that is already observed on the pancreatic protocol CT or an MRI. The EUS or endoscopic ultrasound can also be used to obtain tissue to help make the diagnosis if there is question about the diagnosis or if the diagnosis has not already been made. Finally, we also recommend a serum CA 19-9, that is a tumor marker that is often but not always elevated in patients with pancreatic cancer, that can be drawn before the start of treatment. If it is high, then it can be followed during the course of treatment as one of the ways to assess whether the treatment is being effective or not. Again, that applies broadly across all settings of pancreatic cancer, including resectable, unresectable, and metastatic disease. In many patients, however, the CA 19-9 is not elevated at the time of the diagnosis. If it is not, then following this measure over time is not necessary because it is not a good indicator of what is happening with the cancer in that particular patient.
These are some of the recommendations of the ASCO guideline regarding workup prior to initiating treatment after histopathologic diagnosis of pancreatic adenocarcinoma. Thank you for viewing this activity, and for additional resources, please be sure to view the other educational activities on PartnersinPancreaticCancer.com.