INDIANAPOLIS (WISH) – Americans across the U.S. are grieving the loss of Ruth Bader Ginsburg. The former associate justice served on the Supreme Court for 27 years until she died from pancreatic cancer at age 87. While the cancer affects just 3% of the population, it is considered one of the deadliest.
News 8 spoke with Dr. Nicholas Zyromski, professor of surgery at IU School of Medicine and IU Health. Zyromiski discussed how pancreatic cancer is treated, the critical need for screening tools and why this type of cancer in particular kills so quickly.
Gillis: What does the pancreas do?
Zyromski: The pancreas is an organ in the body that has two jobs. One job is to help regulate your blood sugar by making hormones such as insulin and glucagon. The second job of the pancreas is to help with digestion by making about 2 liters of digestive fluid every day.
Gillis: Can you remove the pancreas?
Zyromski: People can live without a pancreas. It’s common for various problems of the pancreas that we remove a portion of the pancreas and occasionally we need to remove the entire pancreas. It’s challenging when the entire pancreas is removed because it makes it more difficult for people to regulate their sugar, primarily. Also, the other job of the pancreas in terms of digestion is compromised, but we can replace the digestive enzymes with pills.
Gillis: If you remove a portion of the pancreas, is it like the liver and can regenerate?
Zyromski: The pancreas does not regenerate. You’re correct. When we remove a portion of the liver, the liver grows to fill the space. The removed part of the liver is gone. But the pancreas does not regenerate itself.
Gillis: Former Associate Supreme Court Justice Ruth Bader Ginsburg was diagnosed in 2009, was in remission…but when you’re in remission, can you still have a little bit of cancer floating in your body? Or is it completely gone?
Zyromski: From what we understand in terms of cancer…it’s a systemic problem. Every cancer starts in one cell and the cells in the body are programmed to live for a certain period of time and then die.
Cancer cells obtain the ability to grow and divide and multiply without some of these checks and balances and then eventually spread outside of the organ from where it starts and that’s how we fundamentally define a cancer tumor–as the ability of a tumor to spread beyond its initial starting point. So when anybody develops cancer, we think about it as a systemic disease and that’s why multiple approaches to treating cancer including surgery, which removes the primary cancer…chemotherapy works at a systemic level. Chemotherapy is a medicine that goes into your bloodstream and it kills small cancer cells that are circulating through the system and then occasionally radiation therapy–which is a therapy that focuses radiation beams on a single cell or a single spot in the body. So, the treatment of cancer generally speaking is multidisciplinary and these treatments work together. They are not independent.
So, Justice Ginsburg’s cancer was treated and there was no sign of cancer for a long period of time. But then the cancer recurred. And that is a little bit unusual in terms of the cancer biology timeline, but it really speaks virulence of the tumor — how deadly pancreatic cancers are. Even after a long period of time with no signs of the cancer…the cancer recurred and ultimately spread and claimed her life.
Gillis: So, the first thing we would say is remove the tumor. Then radiation specific to the pancreas or any other organ. Then we would say chemotherapy because it is systemic and is this because it gets into the lymphatic system?
Zyromski: Cancers can spread in a couple of different ways. One way is through the lymphatic system–the lymphatic channels carry fluid and immune cells through the body. Another way that cancer spreads, particularly pancreas cancer is through the bloodstream and that’s why pancreas cancers, particularly, which are located close to the liver…the cancer cells invade the liver or into the lungs or around the abdominal cavity.
In terms of treatment, the complementary nature of these treatments–that chemotherapy to treat systemic disease, surgery and/or radiation to treat the local disease–work as complementary treatments and the sequencing of treatment really depends on the individual patient and where the tumor is located. Most of the time these days our group, particularly at Indiana University–the pancreatic cancer group–recommends a little bit for people with operable cancers, we recommend a little bit of systemic chemotherapy first, followed by surgery, followed by completing the chemotherapy and then plus or minus radiation if necessary.
Gillis: This woman was diagnosed and in remission and she was 77 at the time. And pancreatic cancer is one of the more aggressive types of cancer…you don’t really notice it or get diagnosed until Stage 4. Is that correct?
Zyromski: The American Cancer Society predicts that about 57,000 Americans will be diagnosed with pancreatic cancer–adenocarcinoma of the pancreas. This is sort of the garden variety and most common pancreatic cancer. There are several different tumors that can start in the pancreas, but the most common is adenocarcinoma.
The number in the United States is about 57,000 in this year 2020 and that accounts for about 3% of all cancers that will be diagnosed in the United States. Among the 57,000 people who are diagnosed with pancreatic cancer, about 47,000 people will die with pancreatic cancer as the main cause of their death. So, we think of this cancer as a very very aggressive cancer that is resistant to all of our treatments–including surgery and including chemotherapy.
We’ve had breakthroughs in chemotherapy in the past few years and there are more effective chemotherapy regimens. But still even with the more effective chemotherapy treatments, most people with pancreas cancer will die as a consequence of the disease
Gillis: What is the average timeframe before someone passes?
Zyromski: When we think about cancer survival — five years is a mark where a lot of times in many cases we’ll consider them cured or in remission. And so the five-year survival rate overall for patients with pancreatic cancer is only about 10%. That includes people who have early stage disease like Justice Ginsburg had, whose cancer was diagnosed incidentally and patients who have widely spread metastatic disease, which is what we call Stage 4 disease. So, for all of these patients the survival rate is only about 10%. Obviously those who get diagnosed at an early stage have better survival rates than patients with metastatic disease.
Gillis: Are there signs and symptoms?
Zyromski: You alluded to the fact that many people are diagnosed in the very late stages and that’s true. Probably 75 or 80% of patients have cancer that has spread, which is what we call metastatic cancer at the time of their diagnosis of pancreatic cancer.
One of the problems with pancreas cancer is there are no early signs or symptoms and we do not have a great screening test for pancreatic cancer. In fact, most people don’t even know they have a pancreas quite honestly. So, when you think about other common cancers like colon cancer…we have stool blood tests, colonoscopies that are recommended at age 50 and over or breast cancer … women get mammograms. For cervical cancer, women get Pap smears to detect precancerous problems that can be removed before they turn into cancer. But there’s nothing like that for pancreatic cancer.
Many people with pancreas cancer, it starts in what we call the head of the pancreas and it blocks the bile duct and they will show up at the doctor’s office with jaundice. The bile backs up and people notice that their eyes are yellow or their skin is yellow and they start itching and that’s a very common sign of people with pancreas cancers in the head of the pancreas.
Sometimes people will present with pain in their back, particularly in the mid-back. But a lot of times, pancreatic cancers are asymptomatic and have very few symptoms and that’s why people show up at a later stage in the disease process.
Gillis: If your body isn’t producing the bile your body needs for digestion, are you going to lose weight? Would that be a symptom?
Zyromski: Yes, weight loss can be a symptom, but it is subtle and insidious. It happens slowly over time. Sometimes people will also report not being able to eat, anorexia, nausea and vomiting. But a lot of the time those are later symptoms and the disease has already grown.
Gillis: And who is at most risk? Do we know?
Zyromski: The adenocarcinoma pancreas cancer occurs as we get older. The incidence of the cancer is higher. There seems to be a slightly higher risk in men than women. There may be a slightly higher risk in African Americans as opposed to Caucasians, but I think those data are not quite as clear.
The risk factor for pancreas cancer is smoking cigarettes or tobacco exposure are clearly risk factors and beyond that, there are very few specific risk factors for developing pancreas cancer. There are a few genetic syndromes and there is a hereditary form of pancreatitis, which is inflammation of the pancreas that can turn into what we call chronic pancreatitis. In patients with chronic pancreatitis–they have a higher risk of developing adenocarcinoma. But beyond that there are not many well-known risk factors.
Gillis: I want to circle back to the lack of a screening tool for pancreatic cancer. Can you talk more about that? Is there anything IU Medical School is doing on that front?
Zyromski: Those are areas of very active areas of intense research: to find a screening tool for pancreatic cancer. And my colleagues, Dr. Max Schmidt and Dr. Eugene Ceppa, developed a pancreas cancer early detection center here at IU.
If I could speak to our program just for a moment, we have a very robust pancreas program–both cancer and what we call benign non-cancerous pancreatic disease cysts. Dr. Mike House, my partner and friend, leads our pancreas cancer program. We have the second busiest pancreas surgery program in the entire country behind Johns Hopkins and we have a very diverse, multidisciplinary team. It’s a team sport when it comes to this cancer, which we hope will help us find a screening tool and treatments. We have clinical trials going on to test new chemotherapy agents and immunotherapy agents because we want to improve this 10% survival because it’s terrible. This is a terrible cancer.
Gillis: How aggressive is this in terms of other cancers? Where would this rank?
Zyromski: That’s a great question. If you consider the common cancers…and in the United States, the most common cancer in the United States is lung cancer. There are about 250,000 to 270,000 people who are diagnosed with lung cancer. Number two is breast cancer and then prostate cancer followed by colon cancer. But the outcome of those cancers is dramatically better than pancreatic cancer.
For example, many early stage colon cancers are curable so the five-year survival rate for early stage colon cancer is more than 90%. The five-year survival rate for the pancreas cancer is — in the very best circumstances — is only about 25 to 30%. That’s what we’re trying to figure out. What makes this cancer so aggressive.
Gillis: Health is multifactorial. This woman lived until 87, which is greater than the average life expectancy of the average American woman. What role do you think her job satisfaction, her supportive partner and her daily exercise routine played in her survival?
Zyromski: I think all of those things are incredibly important. I think that looking at the human being as a whole…we understand so little about how our psyche affects healing, how does our nutrition, physical fitness and strength and wellness affect healing…these are all the buzzwords of this decade and this century and we understand very little about it. I can tell you that if people come into surgery with a positive mindset…they generally do better.
This is the art of medicine–to be realistic, but help them go through their therapy with whatever disease with as positive a mindset as possible.
News 8’s medical reporter, Dr. Mary Elizabeth Gillis, D.Ed., is a classically trained medical physiologist and biobehavioral research scientist. She has been a health, medical and science reporter for over 5 years. Her work has been featured in national media outlets. You can follow her on Instagram @reportergillis and Facebook @DrMaryGillis.