A pancreaticoduodenectomy is as scary as it sounds (break it into parts to pronounce it: pancreatico-duo-denectomy). It’s a surgical procedure to remove the pancreas and parts of the stomach and small intestine to treat patients with cancerous tumors in the pancreas. The surgery is more commonly called a Whipple procedure, named after Allen Whipple, the Columbia University surgeon who pioneered it in the 1930s, although University of Chicago surgeon Alexander Brunschwig performed the first true pancreas removal in 1937.
It’s also the only option that can potentially cure pancreatic cancer, the fourth most common cause of cancer-related deaths in the United States, and not a great one at that. Only 20 percent of people who undergo this surgery are cured, and on average it adds about six months of life expectancy. The decision to undergo such a major procedure is difficult, to say the least, especially for elderly patients who are more likely to have pancreatic cancer in the first place.
To help patients and doctors weigh these difficult decisions, University of Chicago Medicine geriatrician & palliative care physician William Dale, MD, PhD, oncologic surgeon Kevin Roggin, MD, and their colleagues have been testing tools that can predict a pancreatic cancer patient’s chances for a good outcome from Whipple surgery.
In a recent research study, they conducted geriatric assessments in a group of patients undergoing a Whipple procedure. The assessments included a series of survey questions and simple physical performance tests to assess a patient’s muscular strength and fitness, such as walking speed, balance and repeated chair stands. The results, published recently in the Annals of Surgery, showed that worse scores on these assessments could predict poorer outcomes from surgery, making them a useful tool for helping to decide if surgery is the right option for an older patient.Dale, who is chief of the Section of Geriatrics & Palliative Medicine, said the most striking findings came from two simple questions about the patients’ level of exhaustion. They asked patients to reflect on the following statements about the past week: “I felt that everything I did was an effort,” and “I could not get going.” If they agreed with at least one of those, they were three to four times more likely to suffer a serious complication from surgery, end up in the ICU and have a longer hospital stay.
“That was the most striking finding in the whole study, that these two relatively straightforward questions from a frailty assessment were really predictive of major outcomes,” he said. “This was even after accounting for the patient’s age, BMI, comorbidity burden, and the anesthesia assessment of surgical risk.”
Dale said that despite the risks, the Whipple procedure is actually the first option for patients with pancreatic cancer because it can remove tumors before they spread—that is, it’s the only known curative treatment. New tools to assess a patient’s fitness for surgery could expand the pool of potential candidates.
“It’s such a large procedure, it just hasn’t been done for many people because of the worries,” he said. “It used to be that above a certain age, you just wouldn’t do it because it was considered too risky. But as large surgical centers like ours have gotten more experience, the surgical mortality has dropped. Given that this cancer occurs more often in older people, we’ve continued to push the envelope and enroll more older patients.”
The remaining questions are: What should be done when an older patient scores poorly on a geriatric assessment? Is the risk of surgery worth it if a patient is more likely to have a major complication and end up in the ICU?
Dale said that pancreatic cancer is a very serious diagnosis, and better assessment tools before surgery will allow doctors and patients to anticipate possible complications. For instance, they could set appropriate expectations for recovery time, provide additional support in the hospital to the most vulnerable, and help families anticipate a likely stay in a rehabilitation facility after discharge.
“We can treat these patients in a different, hopefully better, way in planning their care,” he said, “This is both in the hospital and following discharge.”
The current phase of research on surgical outcomes from Whipple surgery was supported by a donation from the Michael Rolfe Pancreatic Cancer Foundation. Dale and his colleagues are continuing their research on improving care for all patients with pancreatic cancer under the Pancreatic Cancer Genomic Medicine Initiative, a new project funded by University of Chicago Medical Center trustee Gordon Segal and his wife Carole, the founders of Crate & Barrel.
In addition to more detailed geriatric assessments, the team will collect tissue samples of tumors over the next three years and work with computational geneticist Kevin White, PhD, director of the Institute for Genomics and Systems Biology, to sequence the genomes. This data will be compared with the genetic sequences of thousands of tumors already collected by the National Cancer Institute, along with clinical and survey data from patients. The goal is to find genetic biomarkers that can predict outcomes and develop better treatments for pancreatic cancer.
Dale said all of this work brings to light how doctors and patients make decisions about end-of-life care for terminal diseases. He hopes that better tools can help people make more informed decisions while we work to cure the disease.
“I like to think we would make more open-eyed decisions about those tradeoffs so that patients made more informed choices. I’m not sure that happens all the time right now,” he said. “On the other end, for those we can’t cure, we should point out all of the available options. I’m also a palliative care physician, and I think there’s a lot that can be done to aggressively treat symptoms in people who have incurable symptomatic disease and optimize their qualify of life. As Hippocrates said, ‘Cure sometimes, treat often, comfort always.’”
Dale W., Hemmerich J., Kamm A., Posner M.C., Matthews J.B., Rothman R., Palakodeti A. & Roggin K.K. (2013). Geriatric Assessment Improves Prediction of Surgical Outcomes in Older Adults Undergoing Pancreaticoduodenectomy, Annals of Surgery, 1. DOI: 10.1097/SLA.0000000000000226