When it’s Time to Put Your Pancreatic Cancer Patients on a Diet

Last week, I had a discussion with a friend and colleague regarding our work and its application to cancers of almost every stripe. During our chat, I received a call from the infusion center requesting the clarification of an order. I responded to the nurse’s inquiry and returned to our conversation. Apropos, my guest inquired whether I ‘d had much success in pancreatic cancers. I smiled and explained that the call I had just received was regarding a patient with that exact diagnosis who is now approaching the one-year anniversary of our first meeting in June 2010.

At 59 years of age, the patient found himself diagnosed with pancreatic carcinoma that had virtually overtaken his liver. Visits to his oncologist and subsequent second opinions at UCLA and City of Hope offered few options. He returned to my care and we conducted a biopsy to examine his drug response profile. The patient could hardly have been more ill. Uncontrollable pain, abdominal distention, a liver that extended almost to his pelvic brim and tumor markers in the thousands that were doubling ever one to two weeks. We certainly had our work cut out for us.

I remember starting his treatment and leaving town for a week to attend the American Society of Clinical Oncology meeting in Chicago. After my departure, I was informed that his CA 19.9 (on his first cycle of therapy) had continued upward, cresting at 6,000 (normal is 0 — 30). I was greatly disappointed by the news. Pancreatic cancer is hard to treat, but I had felt confident that this patient would respond. And then, his pain diminished and he started winding off the industrial doses of narcotics that he had once required. His appetite and exercise tolerance both improved as well. The tumor markers began falling precipitously. And, over the coming month, that giant liver returned to normal.

The best news was the PET/CT that confirmed his dramatic response. The better news still, the subsequent PET/CT that revealed virtually complete resolution of all measurable disease. Oh, and yes, the normalization of the tumor markers.

I turned to my guest and said, “Yes, we can even fix pancreatic cancer in some patients. Would you like to meet one?” We walked together to the infusion center and I introduced the patient to my friend. As the patient sat receiving the final hydration of his, now maintenance, therapy, I realized how much weight he had gained. In fact, I said only half jokingly, “I’m going to have to put you on a diet.”

Now, there’s a change, a pancreatic cancer patient a year after diagnosis for whom my principle current concern is his weight gain. Weight Watchers anyone?

A Pancreatic Cancer Patient – Seven Years Later

More than seven years ago, I was asked to see a patient in consultation. This vigorous 54-year-old gentleman had already undergone a Whipple procedure for the treatment of a pancreatic carcinoma. His skilled-surgeon had resected most of the tumor, but could not clear the margins. With each successive attempt, he identified additional tumor. Unable to achieve a complete surgical resection, the patient was closed, recovered and visited me for a discussion of therapeutic options.

We identified a two-drug combination to be used in conjunction with external beam radiation, a regimen that few — if any — investigators would have suggested. Adjusting the doses to achieve a tolerable schedule, he completed the entire course of therapy with acceptable toxicities. Contrary to his surgeon’s expectations, the patient achieved a complete and durable remission. He returned to his active lifestyle, remarried and became an advocate for the aggressive management of pancreatic cancer.

Now, seven and a half years later with a rising CA 19.9, he is identified to have a focus of uptake on PET CT in the body of the pancreas. A surgical exploration to remove the tumor provided adequate tissue for an EVA-PCD analysis. The patient was once again tested against the standard therapies used in this setting. Among the drugs we examined are the EGFR inhibitors, the taxanes, the combination of EGFR inhibitor + gemcitabine and the platinum + 5FU combination. Each one of these would be a reasonable choice. Indeed, FOLFOX, Tarceva + gemcitabine, the GTX regimen and — most recently — Taxol-gemcitabine based combinations, would all be favored choices for medical oncologists in the U.S. today. Yet, this patient was sensitive only to cisplatin + gemcitabine and none of the others.

Following publications from a group in Scottsdale, Arizona, many oncologists are utilizing Taxol + gemcitabine. There are proponents for Tarceva + gemcitabine, and those who prefer FOLFOX. At least for this patient, none of them would’ve been right. Interestingly, after more than seven years later the patient’s profile reflects the same combination that was used initially. It is interesting to ponder, based on this finding, whether this is a new primary or a sanctuary-site recurrence with so long a disease-free interval to remain sensitive to the platinum-based combination. We now hope to provide him seven and a half more excellent years… at the very least.

What Can We Offer Patients With Pancreatic Cancer?

Recently, I received a call from a previous patient for whom I was not the treating oncologist.  Originally, she had heard about our work on a radio interview and asked her physician in Ohio to send a sample to our laboratory. The results of her assay concluded that a three-drug combination (cisplatin plus Taxol plus gemcitabine) — not commonly used in a pancreatic cancer — was her best option.

Unbeknownst to me, after beginning therapy, the patient had a prompt and dramatic response. When the patient recently contacted me, I cursorily examined the chart prior to our discussion and noted the date of June 24. At first, I thought the patient was showing evidence of progression barely two months after our analysis. Recognizing that no test is perfect and that even our best recommendations may not work, I contacted the patient to discuss her case. It was only then that I realized that indeed the assay data was from 14 months ago and that her response had been excellent for more than a year.

After congratulating the patient on her good outcome and discussing modifications in her therapy (predicated on some x-ray findings of early progression) I asked what her physician’s reaction to the good result had been. The response was muted. Indeed, the physician, having witnessed a rather remarkably good response, only commented that she knew the patient wouldn’t be cured. Recognizing that metastatic pancreatic cancer has an objective response rate measured in single digits and a median overall survival of 4-6 months, I was disappointed to realize that a patient who was well 14 months after diagnosis didn’t seem to impress the treating oncologist.

We are now engaged in reviewing the patient’s diagnostic studies to determine if the EVA-PCD findings will provide information to further guide therapy. While I was very realistic with the patient — explaining that there is no certainty that further benefit can be obtained — there are, in fact, a number of drugs that could hold benefit for the patient. These including: erlotinib, irinotecan and a number of novel combinations. We will be interested to see if further good results can be obtained and are gratified by the patient’s good outcome to date.