Meet The Professors: Pancreatic Cancer Edition, 2016 - Video 1494-year-old man with cancer in the tail of the pancreas
5:50 minutes.
TRANSCRIPTION:
DR BROOKS: I met this lovely man in July of 2015. And at that point, he was 94 years old. And he had been coming, and I think for about 80 years, in the summer. He was happy to be there. He’d already presented down South — and by “down South” I mean anywhere south of Boston. And to my amazement, he looked great and felt great, but he’d been diagnosed several months before after having abdominal pain with a massive pancreatic cancer in the tail of his pancreas and had been offered and was treated with a Whipple — I mean, with a pancreatectomy. DR LOVE: How did he do? DR BROOKS: He did great. DR LOVE: So before you go on, I’ve got to ask: The oldest patient, Margaret, you’ve seen go through a Whipple, and do you have — I mean, we talk about this, but is there kind of an arbitrary age cutoff that really — we were talking about this with bone marrow transplants with the AML. DR TEMPERO: There isn’t an age cutoff, obviously. I think the oldest one I’ve ever heard of is 99. DR LOVE: Wow! Ninety-nine-year-old had a Whipple. DR TEMPERO: Yes. DR LOVE: Wow! DR TEMPERO: A tailectomy, which is what your patient had, is a very easy operation compared to a Whipple. DR LOVE: So did he have a tailectomy or a Whipple? DR BROOKS: It was a mass in the tail of the pancreas. To be honest with you. I don’t recall that now. DR TEMPERO: That, in the oncologic pancreatic world, is a very easy procedure, because you don’t have to do such an extensive resection. You really block off the tail and do a splenectomy, often. DR LOVE: So what was seen in the path there? DR BROOKS: So he had a positive retroperitoneal margin. And he had 2 of 11 nodes positive when he had the surgery. And then again, he had a PET-CT done at that point, and he had what looked like a supraclavicular node. And he actually went on and had treatment — this is before I saw him. He had radiation to the pancreatic mass, and they added some radiation to the left supraclavicular node. And when I saw him, I was a little amazed at the — but I will say, he was 94 years old. He was acting like a 74-year-old and felt fine. DR LOVE: So just to backtrack on that one a little bit, radiation therapy to a supraclav node, Margaret? DR TEMPERO: My suspicion is that they wanted to do something, because they were concerned about that and were hesitant to do chemotherapy. DR LOVE: Interesting. So what was the next step? DR BROOKS: I saw him. He felt fine, but I think I did CTs. This is a guy who felt great, was coming to me and wanted an aggressive approach to treatment. He was a great guy. And we found pulmonary nodules. So at that point, I did treat him with single-agent gemcitabine. DR LOVE: And Tony, how would you be thinking through this case at the point at which these pulmonary nodules showed up? And the patient was still asymptomatic? DR BROOKS: He had a little fatigue, but he was coming to me looking forward to doing some activities. But overridingly he wanted treatment. DR LOVE: I’m curious about how you would treat off protocol, but also, for example, right now if a patient like that came to your center, would there be a trial the patient could enter? DR BEKAII-SAAB: So assuming after surgery and all that other stuff done, this patient would be treated about the same, given the age, either single-agent gemcitabine or a fluoropyrimidine, capecitabine or 5-FU. DR LOVE: So you wouldn’t use a doublet purely based on age? The guy just went through surgery. DR BEKAII-SAAB: Yes. I’d be very concerned about doublet chemotherapy. I mean, even patients that are older than 83, 82 to 85, you start having significant issues with doublets. DR LOVE: Margaret? DR TEMPERO: We use gemcitabine and capecitabine in patients who we think are not quite fit enough for the more rigorous regimens. DR LOVE: You think gem/cape is more tolerable than gem/nab? DR TEMPERO: So yes, it is. We have a regimen that we developed, which is alternate week capecitabine with fixed dose-rate gemcitabine, also alternate week. And when we see an elderly patient who we think could handle more than gemcitabine monotherapy, that’s what we use. DR LOVE: So what happened there, Phil? DR BROOKS: He had 4 cycles of gemcitabine, tolerated it amazingly well, had a little diarrhea. He tolerated it very well, but after 4 cycles we did restage him. And his CA 19-9 had gone up, and we stopped treatment. And it took a lot to talk to him about palliative care and going to hospice, but that’s what he did. And he died about, I think, 3 months later. DR LOVE: How long ago was that? DR BROOKS: This was last summer, though I treated him in the fall. DR LOVE: What was the discussion with him like, and do you end up having that with most pancreatic cancer patients? I mean, it sounds like he was in pretty good condition at the point at which you said “palliative care.” DR BROOKS: Yes. I mean, at that point, he was 94. He had been through a lot of treatment. So seriously, because I really would have had trouble. I think even if he had twisted my arm very hard, I would have had trouble doing much more. DR LOVE: He accepted that? DR BROOKS: He did, but not without pushing me a little bit. But no, he did accept it. Yes. But it took a significant discussion. DR LOVE: Were there other family — spouse, family members — involved in the discussion? DR BROOKS: Yes. He had an elderly wife who kind of was a little passive in the discussion. DR LOVE: And how long was he in hospice before he died? DR BROOKS: He was in palliative care, and I think we got him started, and I think he actually went to his other home in, like, October. And I think I got word about 4 months into palliative care and hospice that he died. |