What are your thoughts about surgery or other treatments for my husband’s pancreatic cancer?
My very healthy and athletic 66-year-old husband has a stage 1B diagnosis (uncinate tumor) with currently negative PET scan. He’s had five rounds of Folfirinox and we are aiming for twelve before surgery. A month ago, a CT scan showed stable progression (decrease not considered statistically significant) though the doctor interpreted the scan in a positive manner. He was very encouraged with what he saw in terms of the effect of chemo. He even suggested that surgery could be an option after eight rounds, followed by the the remaining four of chemo, though this has been decided against.
At the time that he proposed this idea, he was unaware of the two most recent CA19 results. Since mid-August, these have been approximately 343, 1050, 1560, 1690, and 1995 (two weeks ago). The surgeon’s nurse indicated that he likes to see this marker drop to 600 for surgery.
We understand that this marker can be elevated for other reasons, etc., but it is, of course, distressing. Any thoughts related to surgery or other treatment here? The oncologist says a clinical trial is only appropriate once you are finished with standard treatment.
The Next Gen solid biopsy failed due to not enough material, but the liquid one shows no pathogenic variants and no detectable MSI-HI. His genetic testing showed no genetic mutation but a VUS of unknown significance.
Sorry to hear about your husband, but think the question you raise is an excellent one, and would encourage you to keep pursuing answers. After reviewing the information you provided regarding the recent CT scan showing a "decrease but not considered statistically significant" in addition to the rising CA19-9 results, I agree with your concern that the FOLFIRINOX alone may not be enough to get him converted to an operable status.
However, with some decrease in size, it may be worth checking if the shrinkage continues after a few more rounds and also to confirm that the surgeon requires a CA-19-9 of 600 or less. You can then ask for the likelihood of achieving either of these goals and what alternative options exist to potentially get him there.
Here are some altenative ideas we researched that you can discuss with his medical team or other doctors via a second opinion:
1. One idea is to switch from FOLFIRINOX to Gemcitabine/Abraxane, which is considered another 'standard' therapy and has some chance (about 25%) of significantly shrinking the tumor. It is likely that his oncologist could provide this treatment, since it is considered standard.
2. There is a very interesting innovative approach being offered in Sacramento (and potentially at UCSF too by an Interventional Radiologist). It is studying a new device to administer the gemcitabine (mentioned above) directly to the tumor. The device is called the RenovoCath, which administers the medication into the artery directly that leads to the tumor. Dr. Christopher Laing is the one offering the trial at Sutter health and though your husband doesn't qualify for the trial, I think it would be great to get an assessment from Dr. Laing if the tumor could shrink with this therapy, and if your husband is suitable for the treatment (off study). If you were to pursue this technology at UCSF, I would recommend asking Dr. Nicholas Fidelman the same questions.
3. There are also other possibilities to add onto the current treatment. One is with external beam radiation therapy with either techniques called EBRT or SBRT, as exemplified by a trial at UC Irvine, which is studying a special kind of radiation therapy (Electron Beam Intraoperative Radiation Therapy) during the operation for patients who have already received chemotherapy and radiation together. They require that the external radiation be received prior to the surgery. In addition to discussing with your medical team, you should consider getting a consultation (at UCSF is fine) with a Radiation Oncologist about the current situation.
4. Finally, some doctors are studying the addition of an immunotherapy drug, pembrolizumab, to standard FOLFIRINOX, as exemplified by this trial at UCLA. The trial requires patients have no prior treatment, but you could bring this idea to his oncologist and see if they would be willing to treat him similarly with this combination off-trial.
We hope these ideas are helpful, and will give your husband a shot at getting to a definitive surgery. Please let us know if you have any follow-up questions, and would encourage you to tell us about the VUS genetic change. VUS (aka variation of unknown significance) is generally disregarded by doctors, but with our analysis they may lead to possible innovative treatments to try.
Jason Sager, MD
