Pancreatic Cancer, the Silent Disease

A MedicineNet doctor-editor's perspective on his own struggle with pancreatic cancer

Medical Author: Dennis Lee, MD
Medical Editor: Melissa Conrad Stöppler, MD

The diagnosis

I was diagnosed with pancreatic cancer on May 25 of this year. On a routine yearly blood test, I was found to have slightly elevated blood levels of liver enzymes (my alkaline phosphatase, ALT, and AST were mildly elevated). Since I had no symptoms of abdominal pain or weight loss, both my doctor and I felt quite confident that these liver abnormalities were merely due to the statin that I was taking to lower cholesterol. For the sake of completeness, my doctor ordered a liver ultrasound, which showed multiple liver tumors. A subsequent CAT scan of the abdomen done that same afternoon showed an orange-sized mass in the tail of my pancreas with multiple metastases (spread of tumor) in the liver. A liver biopsy confirmed that it was pancreatic cancer.

It was a shock

At the time of my diagnosis, I was a healthy, reasonably fit 57-year-old newlywed working as a gastroenterologist in a thriving medical practice in South Orange County. My wife and I just bought a new home and were in the process of decorating it and putting in the landscaping.

I have no risk factors for developing pancreatic cancer. I do not drink alcohol and do not smoke (smoking cigarettes is a risk factor for pancreatic cancer). None of my parents and relatives had pancreatic cancer. I never had diabetes mellitus (diabetes mellitus is another known risk factor). I exercise vigorously almost daily (four days per week of tennis, and one to two days of strength training). I maintained a healthy weight (obesity is also a risk factor for pancreatic cancer).

Ironically, since the spring of this year, I have been researching the topic of pancreatic cancer prevention. I have attended several lectures given by experts who postulated that pancreatic cancers arise from certain cysts and small lesions along the pancreatic duct, and early detection and removal of these lesions and cysts can prevent pancreas cancer. I was in the middle of gathering information in this area so that I could write an article for MedicineNet viewers and my colleagues when this bad news hit.

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More bad news

One week before my cancer diagnosis, I had noticed some shortness of breath when I played singles tennis. Since I had a busy on-call night that week and a busy week at the office, I attributed these mild symptoms to work fatigue. However, two days after the CAT scan, I noticed shortness of breath when climbing stairs. My radiologist re-read my CAT scan and noticed blood clots in my pulmonary arteries (arteries in my lung). A blood clot in the lung (a condition called pulmonary embolism) is a dangerous but common complication of pancreatic cancer. I was immediately hospitalized to receive anticoagulants to dissolve these clots and to prevent new ones. In the hospital, I was found for the first time in my life to have developed diabetes mellitus. Pulmonary embolism and diabetes mellitus are both diseases caused by certain substances produced by the pancreatic cancer.

In one week, I went from a healthy, active doctor to a disabled patient with advanced pancreatic cancer complicated by diabetes and pulmonary embolism-it wasn't fun.

What is the treatment?

Since most pancreatic cancers are discovered late (the cancer has usually spread to other organs at the time of diagnosis), only a handful of lucky ones ever get cured by surgical resections. Therefore, the prognoses for pancreatic cancer patients were mostly poor, and treatments had generally been ineffective. Survival of these patients was measured in months, not years.

Based on my CAT scan findings of liver metastasis, I know I am not a surgical candidate. Therefore I was not surprised when my oncologist at USC Norris Cancer Center offered me chemotherapy. My oncologist, Dr. Lenz, is in active practice and conducts clinical trials on gastrointestinal cancer treatments at USC.

I was started on a combination of gemcitabine (Gemzar) infusions every Monday for two weeks, with one week off, along with daily oral erlotinib (Tarceva) and capecitabine (Xeloda). Gemzar infusion leaves me with several days of fatigue, nausea, and low-grade fever. The soles of my feet became dry, cracked from Tarceva, and I also developed constant and painful mouth sores from Xeloda. Otherwise, I feel well enough to play tennis on weekends and weekdays during the off-week.

How is my cancer responding to treatment?

My cancer is responding quite well to chemotherapy. I have had three CAT scans in the past five months to monitor treatments. All three CAT scans showed progressive shrinkage of the liver metastases. My blood liver enzymes levels have also completely normalized, coinciding with shrinkage of the liver metastases. Another way to monitor treatment response is by measuring tumor marker (tumor markers such as CA19-9 are substances usually produced by the cancer in large quantities) levels in the blood. A progressive decline in CA19-9 blood levels signals tumor shrinkage. Since my CA19-9 levels were normal initially even before chemotherapy, my doctor cannot use CA 19-9 to monitor my progress.

My oncologist is quite pleased with my progress. Shrinkage of pancreatic cancers with chemotherapy can occur but is not common. In his words, not many metastatic pancreatic cancer patients are playing tennis either. But he cautions that only time will tell whether my responses to chemotherapy are sustainable. Many patients who initially respond develop resistance to the drugs, and their cancers recur.

There is hope

My wife and I attended a symposium on pancreatic cancer put on by Pancan last weekend. Pancan is a volunteer organization that provides education and support to pancreatic cancer patients and their caregivers, funds scientific research, and galvanizes the government to fund research.

At that meeting, I was astonished by the number of attendees who are multiyear pancreatic cancer survivors. I was also impressed by the energy and enthusiasm of the Pancan volunteers.

Many bright young scientists are working on treatment and prevention. Many new anticancer drugs are under development. There are also new ways of delivering existing drugs to make them less toxic and much more effective. Some gastroenterologists are doing research on using EUS (endoscopic ultrasound, a procedure that combines the techniques of endoscopy and ultrasound) to inject antitumor substances directly into the pancreatic cancer. Some radiologists are doing research on using computer-directed radiation and heat devices to destroy tumors without damaging surrounding tissues. Treatments of all types of cancers are improving.

How am I really feeling?

The outpourings of support from my family, friends, colleagues, nurses, and many of my patients have been phenomenal. Many are praying for me on a regular basis. Thanks to my wife, my family, and friends, never once have I felt alone, isolated, or sad. I am living every day to the fullest.

Yes, all my journal readings and past experiences as a doctor tell me that my prognosis is poor. But let me share with you a small secret: In tennis terms, I believe the match is going to be decided by a long tiebreaker in the fifth set, and I am afraid I will win this one.

There are just too many things I want to do in my backyard with my family and Fabio. Fabio is our new white 55-pound standard poodle puppy and the joy of my life.