Next step, I'm excited to welcome back Kathleen Haden and Dr Vanessa Shami, also Less Cancer board member, just to give you all the heads up. They will be talking about pancreatic cyst, Kathleen had presented at the workshop several years ago, and had given us a heads up on what to look for. And it was very helpful. I was interested in this because I've had some people very close to me, address deal with pancreatic cancer, and also die from pancreatic cancer. So, it's a very relevant piece in my life. So when she was speaking, I raised my hand. I was like, I want to get screened. I'll write about it, so which I did. However, I discovered I myself have pancreatic cysts, of which they have helped me managed. And they've done an incredible job. So, I have a personal connection with both of them. I'm super grateful to them. You will learn about how pancreatic cysts are really neuroplasms. And they are not malignant tumors, but they have the capacity of the being malignant. And so, my friends at the University of Virginia, keep an eye out on me. And I'm so grateful to these two healthcare providers, they're really heroes in their field. And we're very lucky to have them here today. But professionally and personally, I'm so grateful you're both here. Thank you. >> So welcome, everybody. Major reason why we're talking about pancreatic cancer detection in general, is that it has a very high mortality. It is actually, the third leading cause of cancer death in the US. And its incidence is increasing worldwide, and the incidence is actually doubled in the last three decades. Over 10% of patients diagnosed with pancreatic cancer are candidates undergo potentially curative surgery, making the five year survival less than 10%. So in other words, most patients who have pancreatic cancer, have disease that's too advanced to be even potentially cured with surgery. These grim statistics, make identifying risk factors for pancreatic cancer, as well as identifying which patients are at risk for developing the disease, all the more important. So Kathleen and I, just so that you guys all know, we've worked together for over eight years. And she's done a wonderful job, in creating the pancreatic cancer screening clinic. And with the data, we've acquired over the years, we've really been able to identify risk factors. For pancreatic cancer, as well as the genes or genetic makeup of individuals, who are more likely to go on to pancreatic cancer. And with that, I was going to ask Kathleen, are there things that we can do as a population to decrease our chances of getting pancreatic cancer? >> Yeah, I think it's important to know, and working in oncology for 30 some years. It's such a helpful thing, that we can actually look at prevention. Finally, you know, from the 80s, and we know through research throughout the years, the identifiable risk factors for pancreatic cancer are obesity. Obesity alone, having a BMI that your body mass index greater than 30, 20% of more of those people will go on to develop pancreatic cancer. We also know that tobacco use 25% of the patients with pancreatic cancer, go on to develop pancreatic cancer, because of smoking. So, we work with our smoking cessation counselor, and refer all of our patients as a big modifying risk factor, and help them quit smoking. And studies have shown over years if they quit, they don't bring it down to zero, but almost close to zero. And also, we know an increased risk factor is alcohol use. We know heavy alcohol use, is usually more than two drinks a day. So we try to modify to one drink a day for a woman, two for a man and that over time, or sustaining at all from alcohol would be the best choice. And so, we counsel patients on that as well, during our visit to our clinic. The thing that also is emerging is the role of diabetes, and the development of pancreatic cancer. So how we can educate our providers in the community, are internist, the nurse practitioners, PAs. And how to look for those patients that all of a sudden, they're older than 50 and they developed diabetes. That could be a risk factor actually, or identifying an early pancreatic cancer. So, there's actually guidelines in place now to think about gosh, does this person just develop diabetes or is actually pancreatic cancer, and this lead time bias. If all of a sudden they're losing weight, and they developed diabetes more than 50, it actually could be an underlying cancer. People that have diabetes type two, which we hear about most, about eight to ten years they go along. Their increased risk is two fold, so managing the diabetes. So it goes along again with the obesity, so reducing the risk. One thing we're blessed that we've instituted in our high risk clinic, and we continue to struggle and try to find things for our patients, is most of our patients have BMIs higher than 28. A lot of them 30, and every one of our patients do meet a nutritionist dietitian, when they come to see us. And we try to counsel them on ways to modify their diet. And using resources like American Cancer Society, the American Institute of Cancer Research, telling him what to eat, how to eat, lowering high sugary drinks, processed meat and eating mainly a plant based with a variety of colors of fruits, vegetables and beans, of course, and trying to help them look at their exercise program. So, we also talk about, How can we modify? And we know through the American Cancer Society, that we really need exercise about 150 to 300 minutes a week. And studies now are showing that diet and exercise, truly make a difference not only in pancreatic cancer, but so many other cancers. >> So, are there any high risk groups that you tend to focus on Kathleen, those patients that you send for? >> Yeah, so we know that you and I see these patients that come in, and we follow guidelines that are not just here at the University of Virginia. They've been established for many, many years, through the CAPS-5 currently screening program at Hopkins in many centers, throughout the country that are developing these high risk pancreatic screening clinics. So, together with collaboration, we use these guidelines for screening. It's not just a few, one family member We usually say two or more family members with pancreatic cancer history. Typically, one is probably being a first degree like a sibling, mom or dad. Then any patient with a mom or dad, interesting enough I have a handful of patients in our collects that we follow, that both are mom and dad had pancreatic cancer, so they are eligible for screening. And then, it's amazing when, I start working with Cancer Genetics in 1995, and we started the program here we had two genes, which is BRCA 1 and 2. BRCA 1 and 2 are both linked to pancreatic cancer, So how we educate all the providers in the community to get a very detailed family history. Because germline mutation testing, which used to cost thousands and thousands of dollars, it's about $250 now, maybe, but it's identifying those families that are increased risk. And now we know there's 15 hereditary genes that we inherit from mom or dad, that can increase your risk of pancreatic cancer. So, Dr Sami and I see these patients in clinic, that have these mutations or perhaps a strong family history, and we talked to them about screening. The exciting thing is, there are studies out there, I know the Lustgarten foundation. There's a study called Generate study, where if you have a known family member with the mutation, they will do all the genetic counseling and testing via telemedicine, which is kind of cool. And it is a study, and we're learning that by identifying these people, emerging data is saying that most pancreatic cancers, as you were saying earlier, are unresectable, meaning we can't, the only way we can cure it is cut it out. So they are unresectable in only 10 to 15% of the patients, but if you and I keep screening like we're screening, knock on wood, we haven't found really in our database maybe a few cancers. But studies are emerging small, the ends are like 2 to 300 people, but if we find it early, those people go on for surgical perception, like 90%. So there are five year survival, and some of the studies are going up to much higher, 25%, there's one small study, 85%. So we are seeing that we're impacting the disease. So modifying these risk factors, eating well, exercising, and really critical is our guidelines have stated that all patients with pancreatic cancer, should undergo genetic testing. And that's key, and it's very under utilized in many institutions. And then, Dr Sami and I, see the patients after the loved one has passed, and they want to get genetic testing or screening, and we don't have that DNA to test them. So it is now part of our national comprehensive cancer guidelines, that anyone with pancreatic cancer should undergo these genetic mutation testing. That's my part of the clinic, and then Dr Sami is the one that actually goes looking the early detection. So, she talked about a couple of modalities that we use. >> Only the two best modalities we have include, first there's MRI or magnetic resonance imaging, and it's the kind of the doughnut scanner. And it. You go into it, and it uses these strong magnetic fields and radio waves to generate images of the organs of our body. And the advantage is that it's non invasive. It's very safe and it's actually very accurate at detecting anything one centimeter and above and additionally visualizes again the surrounding organs. So not only not only we look at the pancreas, but we're looking at other organs as well. You know, the disadvantage is that you can see something so you can find a cyst or find a small mass in the pancreas. But you can't sample it. The other modality that we have, which is something that I do most of my practices endoscopic ultrasound. Or we say us and that uses a special endoscope that uses sound waves. And everybody knows ultrasound of the gallbladder from the outside of the body or the heart. The echocardiogram. Well, we do the same thing from inside out, so we use sound waves to produce images of the organs around the body. Unfortunately for us, the pancreas, the tail, body and neck of the pancreas. So the long part of the pancreas actually is right against the stomach wall. So I'm only a few millimeters away from the pancreas when my my scope is in the stomach and then the pancreatic head and the bile ducts right near the dragon, or the first portion of the small bowel. And again, all I have to do is advance my scope into the duodenum, and I'm able to see the pancreatic head. The advantage is it's a very accurate for lesions that are only a few millimeters, even in size. And even better yet, if I see something, you can actually sample it if it makes sense. So if you see a solid lesion or mass, you can actually put a needle right in X under ultrasound guidance and actually get tissue or cells. Looked at under a microscope immediately because we have those state pathologists come to the bedside. The potential disadvantage over MRI is that it's an invasive procedure. In other words, it's a procedure. So anytime you're putting a scope in the body, there are potential complications that can occur, albeit uncommon. And another potential factor in how accurate this test is really depends on the operator. So the more you do, the more likely you're used to seeing these lesions, so it is somewhat operator dependent. People ask Kathleen all the time. Are there any blood tests that you can do to identify patients that are high risk for having a pancreatic cancer? And really, the research is madly working on on producing a blood test. But there isn't one available at this point. >> And one thing I'm just going to bring up is, in a lot of the high risk clinics that are coming up in the country. Another question, Doctor shame and I get it is insurance reimbursement. Which is something we really need help for going forth is we are fortunate. We do get the endoscopic ultrasound typically paid for over the eight years we've had good success with that. But most carriers, unfortunately, will not cover for an MRI. I which is very difficult because it's another modality we'd like to use in screening. But unfortunately, insurance does not always recognize coverage for that. >> It's interesting, and I and I just because I think it's important for people to know it is state dependent. And so that is definitely what happens in Virginia. They won't pay for a non invasive tests like an M R I, but they'll pay for the endoscopic ultrasound. It sounds like it does very statewide. But it would make sense, for insurance companies to cover MRIs. I agree with you Kathleen, it is a little frustrating. And hopefully, someday they'll get to that point. So, the things we're looking for, Kathleen and I are looking for, we're looking for small masses, but we're also looking for potential pre cancerous lesions. And in one of these is a pancreatic cysts, so pancreatic cysts are fluid filled kind of cysts, that potentially can be pretty cancerous. They're very common. And so, if somebody happens to have a pancreatic cysts on cross sectional imaging, they get a CT for something else, and they have a pancreatic cysts. There's no reason to panic because again, the prevalence of these cysts increase with age, and greater than one in four patients older than 70, have a pancreatic cyst. So, keep that in mind. And the majority of them never turn into cancer. And the minority of them will go to cancer. So, once you detect a cyst, if it's greater than one centimeter, we tend to follow it based on pancreatic cyst guidelines. And there are several different guidelines that we follow. Again, these are pretty cancerous. It's really unnecessary for the general public. If you don't have any risk factors to just get imaging to look for pancreatic cysts. Things that we're looking for our size, size is a big thing to indicate to us, whether it's something we should follow and how often. I just want to mention in 2019, the US Preventative Services Task Force recommended, against screening for pancreatic cancer in asymptomatic individuals. So again, we look for the cysts, especially remember the patients that we're looking at them are high risk patients, so they would be significant and something we would follow. But we would not take everybody in the population, and screen them. I don't know if you have any other thoughts, Kathleen. >> Yeah, I mean, it's rare that I see our patients. We want to screen with the family histories, potentially with these genes and a family history, but we don't screen just everyone. So this is, we want to look at the highest risk, because the bottom line was screening. We don't want to cause harm. We don't want to be spending a lot of money on things that really are not necessary, and pancreatic cancer. We hear about a lot because people die commonly from it, but it's only prevalent about 1.6 people out of 100. It's pretty rare but of those, that small portion, potentially 10 sometimes 15 percent, could be related to a gene that we inherit. So we're trying to capture those patients, a large population with Dr Shami. And I see, well, I see in my clinic are these people with this cyst, and they typically never have a family history. They don't have a gene. We do see people but it's rare, that have the gene and a family history, and a cyst. But we're going to follow them, those people differently than the usual cyst population, without family histories or genes. And when we do find these people with a cyst, and they don't have cancer which is such a great thing, we can educate them and teach them how we follow. And if they come in and they have a cyst, and they're overweight or they smoke, we have that time to capture them just to decrease the risk of cancer in general. So. >> I agree, and I think the bottom line here is that if we have a disease that we don't have a great cure for, it's extraordinarily important to identify those that are high risk, and try to modify anything we can do environmentally, to decrease the chance. >> And we screened over thousands of patients, and we've been fortunate. And screening, I tell patients before I send them to you to get their scope, this is a choice. They don't have to, even if they have the family history origin. If you look at statistics and percentages, the risk is still pretty low. You know that they will go on to develop cancer, and to reassure them. And some people choose to screen, some don't. It is a choice for them. But I'm so happy that we can work together, and helping the patients who are at the highest of highest risk. Yeah, well, the disease yeah. >> And if there's ever a question, about somebody with a cyst. Where, if you have one yourself, you can always go to the institution, especially the ones that have this sort of collaboration to help you guide. What your next steps are, and how often to be followed? And which test to use to be followed? We call it surveyed. So that would be one tidbit. >> Yeah. Thank you so much.