Multidisciplinary Approaches to Pancreatic Adenocarcinoma

John Marshall, MD:Pancreas cancer is a very complicated disease to take care of, and I personally think it requires a specialized team to do it. You need a surgeon who does this all day, every day. You need a medical oncologist who’s skilled in this and in the regimens that are being used. You need a very good radiation oncologist. You need good palliative care and nutrition support. The team needs to work together in order to deliver the best care because our patients in this situation are often very ill. There are plenty of good community-based practices that can do this, but if you’re not one of those groups that has a very good, tight team, I think these are patients who should be seen in specialty centers.

A patient with pancreas cancer can enter into a healthcare system through a variety of ways. They can come in through a GI making the diagnosis, surgery, an emergency room visit, or an oncologist. We know that we have to then get all the other team members involved relatively quickly. We can’t just wait on the next appointment. Multidisciplinary care is critical, and every good place usually has a weekly meeting where cases such as this would be presented. The images would be shown by radiologists, the pathologist would show the tumor specimen, and everyone sitting around would say what the best strategy is for this patient at that moment. It really is wonderful because you then leave there with a plan for that patient. Patients are aware of this. Patients understand the importance of multidisciplinary clinics, multidisciplinary oversight, and tumor boards. They want to know what we think and why.

Now, on the flip side, patients also think that there is some magical algorithm that we get the tablets from that tells us this is the right way to treat this patient. But the little inside baseball secret is that we’re kind of making it up as we go. We’re trying to optimize by asking where that patient is in life, what the other medical comorbidities are, what resources we have in hand, and what clinical trials are available. In fact, each one of these is a somewhat unique recommendation that evolves out of a multidisciplinary tumor board.

Transcript edited for clarity.

May 2017

• A 64-year-old female was diagnosed with locally advanced pancreatic adenocarcinoma and referred for consultation at a high-volume center
• CT with contrast showed a 2.8-cm mass in the pancreatic body, invading the common hepatic, celiac, and splenic arteries, with abutment more than 180° to the superior mesenteric artery (SMA) but no encasement
• Staging laparoscopy showed no distant metastasis; peritoneal washing cytology showed no malignant cells
• She received FOLFIRINOX followed by capecitabine and concurrent RT

December 2017

• Six months after the initial treatment, the tumor size had decreased to 1.2 cm, and abutment to the main artery was diminished but still detectable
• She underwent distal pancreatectomy with celiac artery resection
• Histopathology showed fibrous changes around the celiac artery; Evans grade IIb
• No evidence of residual tumor at the periphery; R0