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Hello I’m Bob Folberg Founding Dean of the Oakland University William Beaumont School
of Medicine and Chief Academic Officer for Beaumont Health System. Welcome to Finding
Hope, an important medical education collaboration between the Digestive Health Center of Excellence
at Beaumont and the Oakland University William Beaumont School of Medicine.
We hope you find this unique continuing medical education offering to be helpful to you. It’s
all about finding hope for patients with pancreatic cancer.
“I don't mean to alarm you and it's probably nothing, but I just got your CT report and
they see a little something on your pancreas.”
There may be no more frightening words in medicine than "a little something on your
pancreas." Even the remote thought of pancreatic cancer brings to light thoughts of Patrick
Swayze, Luciano Pavarotti, Randy Pauch and the many others whose struggles with the disease
have become so well known. Unfortunately, it's the phrase "the deadliest of all cancers"
that resonates louder than any others when an affected patient or their family begins
their unwelcome journey through the work-up and treatment of pancreatic disease. In addition
to the challenges of conquering a disease that is difficult to detect, biologically
aggressive and strikes without warning, we are faced with a widespread nihilistic attitude
toward pancreatic cancer that blocks access to care and limits funding for this important
disease.
This program, "Finding Hope 2011: Prevention, Early Detection and Treatment of Pancreatic
Cancer,” has been created to bring our team of experts to physicians, students and other
health care providers, to create awareness surrounding the conditions which lead to the
development of pancreatic cancer and the most recent advances in treatment available today.
In our unique "dual-track" format, we are providing a parallel lecture series to patients,
family members and other non-medical professionals to provide knowledge and support to help those
affected by or at risk for the disease.
This program will focus on hope. Every day in the life of cancer patient will bring challenges
to that hope. Together in this program we hope to find new ways to combat those challenges
and to uncover the scientific realities that help us to find hope for better outcomes in
the fight against pancreatic cancer.
Let's start with the stark reality. A simple Google search for the term "pancreatic cancer"
yields over 11 million references beginning with the National Cancer Institute’s home
page for pancreatic cancer. There we can see that (slide) 44,030 cases of pancreatic cancer
will be diagnosed in the U.S. in 2011 with as many as 37,660 dying from the disease.
Over 212,000 cases are diagnosed worldwide, affecting men and women with near equal frequency.
Pancreatic cancer occurs at almost any age after 20 with a mean age of 72 years. It is
estimated that 1.4% of Americans or one out of 71 men and women will be diagnosed with
pancreatic cancer during their lifetime. Currently, a large majority will ultimately die of their
disease.
Naturally, the newly threatened patient will click next to "survival” where hope now
really takes its dive. The 2007 SEER data show an overall 5-year survival rate of only
5.5% with only 21.5% 5-year survival among those with localized disease. While we've
made great strides in improving survival among patients affected by leukemia, lymphoma, breast
and colon cancer and many others, long term survival rates or cure among pancreatic cancer
patients has remained virtually unchanged. So where does the individual faced with a
new diagnosis of pancreatic cancer find hope in that?
As a pancreatic surgeon and often one faced with delivering a diagnosis of pancreatic
cancer, I do my best with phrases like, "Remember...statistics apply to groups, not individuals..." and “I
see patients who break the rules all the time..." But this reason for hope is stated far more
eloquently in the classic essay by Harvard evolutionary biologist Stephen Jay Gould in
his essay entitled, "The Median is Not the Message.” In this essay, Mr. Gould, when
faced with a seemingly incurable cancer, used his expertise as a statistician to really
explore how those grim survival statistics might really apply to him as an individual
in his quest to maintain hope. He describes his essay as “a holy war on the downgrading
of intellect by telling a small story about the utility of dry, academic knowledge about
science” while noting that the "heart and head are focal points of one body, one personality."
Recognizing the proven link between positive attitude and improved immune function, Gould
goes on to state that “variation itself is nature's only irreducible essence" and
that "variation itself is the reality." To place oneself amidst the variation is where
hope is found.
Gould goes on to make a final point about statistical distributions. They apply only
to a prescribed set of circumstances – in this case, to survival under conventional
modes of treatment. If circumstances change, the distribution may alter. Gould looked at
his opportunity to be placed on an experimental protocol of treatment, giving him the hope
to be part of the first cohort of a new distribution with high median and a right tail extending
to death by natural causes at advanced old age. So what happened to Stephen Gould? He
lived 20 productive years after his diagnosis of cancer, skewing that survival curve far
to the right. Was this simply a matter of natural variation? The result of changing
circumstance brought on by his clinical trial? Or simply the product of hope and a positive
attitude? Since we'll never really know, we can only keep fighting to affect our circumstances
and find our hope.
So where do we find hope? We find our hope in science, in technology, in education, in
advocacy, in philanthropy and in faith. We find hope in our national organizations like
the American College of Surgeons, the National Comprehensive Cancer Network and the American
Society of Clinical Oncology that have worked collaboratively to develop quantitative measures
to improve cancer care. Work groups from the American College of Surgeons have identified
and validated 43 structural and clinical indicators aimed at reducing variability in the delivery
of care and providing guidelines to hospitals to monitor and improve outcomes.
We find hope in education and communication to overcome the attitude that pancreatic cancer
is a death sentence and cannot be beaten. In a study published in 2007, Bilimoria and
others examined the care of nearly 10,000 patients with stage I pancreatic cancer, potentially
curable by surgery. Strikingly, over 70% did not undergo surgery with more than 38% never
being offered the option! Those less likely to undergo potentially curative treatment
included patients over age 65, African Americans, the less wealthy, the less educated, the less
insured and those receiving care at low volume centers. The development of interdisciplinary
teams of dedicated specialists has led to recent regionalization of care for pancreatic
cancer. This alone has resulted in a reduction of perioperative mortality for major pancreatic
resection to less than 3 % compared to double-digit rates seen only two decades ago. These multidisciplinary
teams have increased access to clinical trials and neoadjuvant protocols, increasing the
number of patients eligible for potentially curative surgery while monitoring safety and
comparing outcomes. As primary care physicians face the demand of caring for diverse patient
populations with increasingly complex disease, we rely on educational outreach like this
web-based program to inform and promote easy access to care for their patients.
Perhaps most significantly, we find hope in research. Complicated and costly research
has now successfully mapped out the genome of pancreatic cancer, identifying 4 major
gene mutations KRAS, CDKN2A, TP 53 and SMAD4, along with 35 lesser-seen mutations. Correlating
these mutations with 12 known core signaling pathways leading to the development of malignant
cellular behavior we now have the opportunity to develop new paradigms of targeted therapy.
This gives us the hope that we will one day understand the unique biology of each patient’s
tumor and to appropriately select treatments to maximize efficacy and reduce risk.
Understanding the genetic makeup of pancreatic cancer gives us the hope that early detection
and effective screening will become a reality. Based on our current understanding of precursor
lesions and the pathways of malignant progression, the evolutionary timeline from the initiation
of cellular transformation to death from disease, spans over 21 years. This includes an interval
of almost 7 years from the time a cellular clone becomes invasive until achieving the
ability to metastasize and an additional 2.7 years until death. As we currently are unable
to effectively diagnose pancreatic cancer until late in that third phase, we clearly
have plenty of opportunity to do better. The discovery of applicable biomarkers is a major
focus of translational research at Beaumont and around the world.
Finally, our greatest hope comes from the community of dedicated individuals determined
to beat this disease. Tens of thousands of patients, family members, health care providers
and scientists work hard every day to improve the lives of those affected and to search
for a cure. National organizations like the Pancreas Cancer Action Network provide promote
philanthropic support to provide advocacy to increase the much needed funding so that
vital support for pancreatic cancer research and awareness takes place.
Please take advantage of the “Finding Hope” program and most importantly, never give up
the search for a better tomorrow.