Cancer Consult: RCCA Medical Oncologist Ian Horkheimer, MD, Explains How We’re Making Slow but Steady Strides Against Pancreatic Cancer

Pancreatic cancer has long been one of the most challenging cancers to treat successfully. That’s partly because most of its symptoms don’t appear until the cancer has already spread to other areas of the body, or metastasized, and a potential cure like surgery to remove the tumor or pancreas is no longer viable. Unfortunately, no practical routine screening tests, such as those for breast and colon cancer, are available for people at average risk.

Yet, despite those obstacles, the survival rate for pancreatic cancer in the United States has been slowly edging upward. A decade ago, only about 6% of people were expected to live for at least five years after their initial pancreatic cancer diagnosis. Today, that percentage has nearly doubled to 11%, according to the National Cancer Institute.

The man had pain in his stomach. Concept of sick stomach ache or gastritis.

While an 11% survival rate is still distressingly low, some modest but promising treatment advances have been made, says Ian Horkheimer, MD, a board-certified hematologist and medical oncologist at the Little Silver clinic of Regional Cancer Care Associates (RCCA), one of the nation’s largest networks of cancer specialists. Even so, pancreatic cancer remains difficult to treat.

Dr. Horkheimer urges patients diagnosed with pancreatic cancer to seek out a cancer center that treats a high volume of pancreatic cancers and that has access to the latest therapies, like RCCA. “I see a lot of pancreatic cancers, and it is a cancer that requires a team approach with a medical oncologist, a radiation oncologist, and surgeons skilled in treating the disease,” he notes.

Pancreatic cancer symptoms

The pancreas is a thin, 6-inch-long gland that lies under the liver, near the stomach, gallbladder, and bowel. Its job is to produce digestive enzymes, which help break down food, and the hormones insulin and glucagon, which help regulate blood sugar levels.

Symptoms of pancreatic cancer include jaundice (yellowing of the eyes and skin), pain in the abdomen or back, pale or gray stools, loss of appetite, unexplained weight loss and fatigue. But most patients don’t experience any of those symptoms until the disease has reached an advanced stage. As a result, more than 80% of patients have pancreatic cancer that’s metastasized by the time they’re initially diagnosed, according to the American Cancer Society. And once the cancer has spread beyond the pancreas, treatment options are limited.

Surgical removal

If pancreatic cancer is discovered before it has spread into surrounding nerves, blood vessels and other tissues, surgery to remove the tumor or all or part of the pancreas offers the best chance for long-term survival, with five-year survival rates of 18% to 24%. In the past, some patients were deemed unable to tolerate the complex surgery required. However, improvements in surgical techniques have allowed surgeons to operate on more patients who once were considered ineligible to undergo the procedure, Dr. Horkheimer says.

He explains that laparoscopic surgery or laparoscopic robot-assisted surgery, while still complex, is less invasive than traditional open surgery and so may be an appropriate alternative for some patients. Laparoscopic surgery involves making a few tiny incisions in the abdomen through which small tools are inserted to remove the pancreas or tumor. Patients who undergo laparoscopic surgery usually have less blood loss and pain, spend a shorter time in the hospital, and recover more quickly than open-surgery patients.

Another increasingly common approach is to administer chemotherapy (sometimes combined with radiation therapy) before surgery. Called neoadjuvant chemotherapy, the treatment aims to shrink the tumor so it can more easily be removed surgically.

Chemotherapy and beyond

Dr. Horkheimer also points to the development of better chemotherapy drugs and new drug combinations over the past five to 10 years as one reason for improved survival rates. “When I started, only one chemotherapy drug was available, and it was marginally helpful,” he notes. “Now, there are more chemotherapy drugs — and combinations of drugs — that can be helpful. They offer treatment options that weren’t previously available.”

Chemotherapy is typically the first-line treatment for metastatic pancreatic cancer. It’s also commonly administered after surgery to help stop the cancer from returning. New, stronger drugs or new combinations of drugs can help prolong survival, slow the cancer’s spread and relieve symptoms. Chemotherapy may be combined with radiation or immunotherapy and targeted therapy.

Dr. Horkheimer is encouraged by immunotherapy, which helps spur the immune system to find and destroy cancer cells. “Our hope is immunotherapy drugs will continue to be modified and develop in ways so that they can coax the immune system to help battle pancreatic cancer.”

The U.S. Food and Drug Administration (FDA) has approved one form of immunotherapy for metastatic pancreatic cancer. It’s effective in patients who have an inherited abnormality, or mutation, in a BRCA1 or BRCA2 gene — the same gene mutation that can cause breast cancer and ovarian cancer. The gene is present in about 8% to 10% of patients with pancreatic cancer. Other immunotherapy drugs are available through clinical trials where they’re still being studied, often in combination with chemotherapy, radiation therapy or other drugs. (If a drug is not approved by the FDA to treat a specific form of cancer, its use in a clinical trial involving patients with that cancer is considered investigational, even if the drug is approved to treat other forms of cancer. When considering participating in a clinical trial, it is important to talk with a physician or other clinician to obtain a full understanding of the trial and the drug being studied.)

Scientists are studying other treatments targeting gene mutations that aren’t inherited. These acquired mutations can develop from exposure to cancer-causing chemicals such as cigarette smoke — or they can develop for no known reason. One type of gene, called KRAS, is of particular interest to researchers. About 95% of pancreatic tumors contain an acquired mutation in a KRAS gene. Researchers are using targeted therapy to prevent tumors with mutated KRAS genes from growing and spreading. The drugs are designed to attack only specific areas of the tumor’s cells without harming surrounding healthy cells, which makes the treatment less harsh than chemotherapy.

Recently, the FDA approved a lung cancer drug that targets one specific KRAS mutation, KRAS-G12C. The same mutation is present in 1% of pancreatic tumors. Researchers hope that further study will lead to the development of similar drugs that will target the more common KRAS mutations found in pancreatic cancer.

Researchers continue to study immunotherapy and targeted therapy in clinical trials, often combined with chemotherapy and other drugs, while working to better understand pancreatic cancer’s biology. People diagnosed with pancreatic cancer should ask their oncologist if they should participate in a clinical trial, such as those offered at RCCA. Participants in clinical trials receive new anticancer agents or drug combinations in addition to the standard treatment.

A final word

Keep in mind that while estimated pancreatic survival rates are low, they don’t necessarily apply to everyone. Individual factors, such as age, overall health and lifestyle, can affect outcomes. And treatment that doesn’t work for one person may work for another.

***

After receiving his bachelor’s degree in biochemistry and molecular biology from the University of Wisconsin, Dr. Horkheimer earned his medical degree from the University of Wisconsin Medical School. He then completed a residency at Barnes Jewish Hospital-Washington University School of Medicine in St. Louis and a fellowship in hematology and oncology at Duke University Medical Center. He has practiced in the Little Silver/Red Bank area since 2006.

Dr. Horkheimer is among the 90 cancer specialists who treat patients at more than 25 RCCA care centers in New Jersey, Connecticut, Maryland and the Washington, DC, area. Those oncologists see more than 23,000 new patients each year and provide care to more than 225,000 established patients, collaborating closely with their patients’ other physicians. They offer patients the latest in cutting-edge treatments, including immunotherapies and targeted therapy, as well as access to a wide range of clinical trials. In addition to serving patients who have solid tumors, blood-based cancers and benign blood disorders such as anemia, RCCA care centers also provide infusion services to people with a number of non-oncologic conditions — including multiple sclerosis, Crohn’s disease, asthma and rheumatoid arthritis — who take intravenously-administered medications.

To learn more about RCCA, call 844-928-0089 or visit RCCA.com.  

References

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  2. American Cancer Society. Pancreatic cancer early detection, diagnosis, and staging. https://www.cancer.org/cancer/pancreatic-cancer/detection-diagnosis-staging.html. Accessed September 9, 2021.
  3. American Cancer Society. What causes pancreatic cancer? https://www.cancer.org/cancer/pancreatic-cancer/causes-risks-prevention.html. Accessed December 30, 2021.
  4. Net. Pancreatic cancer: Types of treatment. https://www.cancer.net/cancer-types/pancreatic-cancer/types-treatment. Accessed December 27, 2021.
  5. De Dosso, S, Siebenhuner A R, Winder T, et al. Treatment landscape of metastatic pancreatic cancer. Cancer Treat Rev. 2021 May; 96:102180. doi: 10.1016/j.ctrv.2021.102180. Epub 2021 March 17.
  6. National Cancer Institute. Advances in pancreatic cancer research. https://www.cancer.gov/types/pancreatic/research. Accessed September 9, 2021.
  7. National Cancer Institute. Chemotherapy change improves pancreatic cancer outcomes. https://www.cancer.gov/news-events/cancer-currents-blog/2018/pancreatic-cancer-chemotherapy-regimen-change. Accessed September 9, 2021.
  8. National Cancer Institute. Olaparib for pancreatic cancer with BRCA mutations. https://www.cancer.gov/news-events/cancer-currents-blog/2019/pancreatic-cancer-olaparib-brca-mutations. Accessed September 9, 2021.
  9. National Cancer Institute. Pancreatic cancer treatment (adult) (PDQ)—Health professional version. https://www.cancer.gov/types/pancreatic/hp/pancreatic-treatment-pdq. Accessed September 8, 2021.
  10. National Comprehensive Cancer Network. NCCN guidelines for patients. https://www.nccn.org/patientresources/patient-resources/guidelines-for-patients/guidelines-for-patients-details?patientGuidelineId=33. Accessed on December 24, 2021.
  11. Pancreatic Cancer Action Network. 2020 year in review: research progress. https://www.pancan.org/news/2020-year-in-review-research-progress/. Accessed December 24, 2021.
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  13. Pancreatic Cancer Action Network. 5 things to know about targeting mutant KRAS in pancreatic cancer. https://www.pancan.org/news/5-things-to-know-about-targeting-mutant-kras-in-pancreatic-cancer/. Accessed September 9, 2021.
  14. Pancreatic Cancer Action Network. New study describes treatment approach for a subset of pancreatic cancer patients. https://www.pancan.org/news/new-study-describes-treatment-approach-for-a-subset-of-pancreatic-cancer-patients/. Accessed on September 9, 2021.
  15. Pancreatic Cancer Action Network. Treatment by stage. https://www.pancan.org/facing-pancreatic-cancer/treatment/treatment-types/treatment-by-stage/. Accessed September 9, 2021.
  16. Roth M T, Cardin DB, Berlin J D. Recent advances in the treatment of pancreatic cancer. 2020 Feb. 21; 9:F1000 Faculty Rev-131. doi: 10.12688/f1000research.21981.1. eCollection 2020.
  17. American Cancer Society. Cancer facts & figures 2011. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2011.html. Accessed on December 31, 2021.
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