Pancreas & Hepatobiliary Cancer Program

INCIDENCE AND PREVALENCE

The National Cancer Institute estimates that 55,440 adults in the United States will be diagnosed with pancreatic cancer in 2018. Pancreatic cancer is the fourth leading cause of cancer death in men and women. The incidence of primary liver cancer has tripled since 1980; an estimated 42,220 adults in the U.S. will be diagnosed with primary liver cancer in 2018. It is three times more common in men than in women. An estimated 12,190 adults will be diagnosed with gallbladder and other biliary cancers in 2018. Women are at least twice as likely as men to develop gallbladder cancer.

PROGRAM OVERVIEW

Hoag’s Pancreas & Hepatobiliary Cancer Program provides advanced care for cancers of the liver, both primary and metastatic; bile duct; gallbladder; and pancreas including neuroendocrine tumors of the pancreas.

Robert R. Selby, M.D., is the director of Hoag’s Pancreas & Hepatobiliary Cancer Program. He is professor of surgery, director of the Liver Transplantation Program, and chief of the Division of Hepatobiliary and Pancreas Surgery at the Keck School of Medicine at USC. Dr. Selby leads the multidisciplinary pancreas and hepatobiliary cancer team comprised of Hoag and USC liver and pancreas surgeons who are board-certified and fellowship-trained, gastroenterologists, board-certified interventional gastroenterologists, medical oncologists, radiation oncologists, interventional radiologists, and pathologists. Somewhat unique to the program is integration with a hepatologist who provides a level of expertise for pancreas and hepatobiliary patients, care not often available in community-based programs. The team collaborates in a variety of settings to provide integrated, personalized care to patients.

DIAGNOSTICS

Hoag’s interventional gastroenterologists are highly skilled in the use of endoscopic ultrasound (EUS) for the diagnosis and staging of pancreas and biliary tumors, critical to the effective management of these cancers. In addition, Hoag offers endoscopic retrograde cholangiopancreatography (ERCP) with expertise in complex cases including altered anatomy and post-surgical ERCP. With the availability of both EUS and ERCP at Hoag, patients can receive diagnosis and treatment in one procedure.

The program also offers high-resolution MRI imaging through Hoag Radiology to detect pancreatic cancers and hepatobiliary disease. MRI and MRCP are particularly beneficial in detecting cystic pancreatic cancer.

Gallium-68 Dotatate PET/MRI or PET/CT scanning, recently approved by the FDA for neuroendocrine tumors, are new advances available to patients at Hoag with neuroendocrine tumors of the pancreas. The modalities provide enhanced images for the detection and evaluation of staging of neuroendocrine tumors.

In 2017, Hoag implemented ultrasound elastography for detection and evaluation of cirrhosis of the liver, which can be a precursor to liver cancer. The noninvasive ultrasound exam can be part of a routine abdominal ultrasound exam and takes an additional five minutes. It measures liver stiffness and assesses the degree of liver fibrosis without the need for biopsy. In early stages, cirrhosis may be reversible with medication and/or dietary changes.

TREATMENT

Tumor Board

Liver Case Conference integrates liver surgeons, hepatologists, gastroenterologists, medical oncologists, radiation oncologists, interventional radiologists, advanced endoscopists, pathologists, and nurse navigators to discuss patient cases.

Liver Case Conference is held on the 2nd and 4th Thursday of every month at 5:30 p.m. at the Patty & George Hoag Cancer Center in Newport Beach and via videoconferencing at Hoag Cancer Center Irvine. It is moderated by Tse-Ling Fong, M.D.

Pancreas cancer cases are discussed at the GI Tumor Board, which is attended by GI surgeons and surgical oncologists, medical oncologists, gastroenterologists, advanced endoscopists, radiation oncologists, pathologists, radiologists, palliative care specialists, and nurse navigators.

GI Tumor Board is held on the 2ND and 4TH Monday of every month at 12:30 p.m. at the Patty & George Hoag Cancer Center in Newport Beach and via videoconferencing at Hoag Cancer Center Irvine. It is moderated by John Lipham, M.D., James & Pamela Muzzy Endowed Chair in GI Cancer.

To submit a case for the Liver Case Conference, please contact Nurse Navigator, Shelley Morrison, A.C.N.P., at 949-764-5316 or [email protected]

To submit a case for the GI Tumor Board, contact Nurse Navigator, Shelley Morrison, A.C.N.P., at 949-764-5316 or [email protected] or GI Cancer Nurse Navigator, Diane Eadie, R.N., at 949-764-8267 or [email protected]

Surgery

The Pancreas & Hepatobiliary Cancer Program’s boardcertified surgeons are highly experienced in the surgical management of hepatobiliary and pancreatic cancers, routinely performing complex surgeries. They use minimally invasive approaches, including robotic-assisted liver resections and laparoscopic or robotic-assisted pancreatectomies when appropriate. The Hoag USC surgeons are trained in transplantation, which enhances their skill and ability in replacing blood vessels with grafts during complete resections.

Hoag offers a specialized program for patients with hepatocellular carcinoma, which includes an algorithm leading to liver transplantation when appropriate and interventional steps prior to transplantation to ensure the best possible outcome. When it becomes time for transplantation, patients can remain at Hoag for intake and post-operative management and undergo the surgery at USC. Thanks to clinical nurse navigators and ongoing communication among both providers, transplantation is as seamless as possible for patients.

Medical Oncology

Subspecialized GI medical oncology is a unique asset to the program. The GI medical oncologist, pancreas and hepatobiliary surgeons, and interventional gastroenterologists work cohesively in the same clinic, which is a noted benefit to patients.

Recent advances and new therapies for locally advanced pancreatic cancer have led to an evolving paradigm shift toward more aggressive neoadjuvant therapy for earlier cancers. This is an effort to further downstage the patients and improve their pathologic prognosis. While research in this area is ongoing, early results indicate patients are being converted to node negative status with earlier stage tumors with the expectation that their long-term survival and cure rate could be enhanced as well. For patients who have surgery up front, more aggressive chemotherapy regimens after surgery are also leading to improved outcomes.

Immune therapy continues to show improved survival rates for patients with primary hepatocellular cancers that are otherwise unresectable disease. A number of clinical trials are testing the combination of immune therapies with novel agents to improve on those gains even further.

Hoag’s medical oncologists apply a precision medicine approach to patients with advanced disease. Tumor genomic profiling at the beginning of treatment as well as when appropriate during the treatment phase provide medical oncologists with knowledge of any new resistance mechanisms that may be building in the tumor. Any potentially targetable genetic alterations are aligned to therapies that may be off label or available through a clinical trial.

Radiation Oncology

Stereotactic body radiation therapy (SBRT) with focused, image-guided modalities such as TomoTherapy® HD, Elekta Versa HD™, and CyberKnife® Radiosurgery System, in collaboration with the Newport Diagnostic Center, offers an accurate method of delivering targeted radiation with fewer side effects for patients with inoperable localized pancreatic disease. These technologies can also be an effective neoadjuvant treatment to help surgeons achieve clear margins. Some patients may also benefit from SBRT post-surgery.

Interventional Radiology

Interventional radiology is an important discipline in the treatment of pancreas and hepatobiliary cancers and Hoag’s department offers the full spectrum.

While both radiofrequency ablation and microwave ablation are used to treat primary and metastatic liver cancer, microwave ablation is typically faster, uses smaller probes, and achieves a larger treatment zone than radiofrequency ablation. The outpatient procedure can be done under general anesthesia or IV sedation.

Yttrium 90 radioembolization, a good option for patients with hepatocellular carcinoma and liver metastasis, delivers radioactive Y90 via glass microspheres (TheraSphere) to the blood vessels feeding the tumor. The outpatient procedure is a two-step process that begins with arterial mapping. A post-treatment scan utilizing Hoag’s PET/ MR significantly enhances the interventional radiologists’ ability to see the distribution of the Y90, providing the clearest picture possible to immediately determine if the dose was distributed accurately or if additional treatment is needed.

Chemoembolization is often a viable treatment option for hepatocellular carcinoma patients who are not candidates for Yttrium 90 radioembolization.

Therapeutic Advanced Endoscopy

Hoag’s program offers state-of-the-art therapeutic EUS techniques including EUS biliary intervention. EUS guided biliary or gallbladder drainage through the deployment of

a stent directly from the bowel lumen into the bile duct is available to patients with advanced disease when traditional ERCP is not feasible due to the anatomy. The option allows patients to avoid surgery in some cases.

CLINICAL RESEARCH

Access to phase I and II clinical trials testing novel agents for the treatment of hepatobiliary and pancreas cancers can offer additional treatment options not common in a community setting. Hoag Family Cancer Institute, in alliance with USC Norris Comprehensive Cancer Center, continues to expand its portfolio of early phase clinical trials. The following clinical trials have opened for patients with pancreatic or hepatobiliary cancers. For a list of trials currently open, please contact Leila Andres, M.S., at 888-862-5318.


(132-17) 3L-16-4 A Phase Ib/II Clinical Study of BBI608 in Combination with Sorafenib or BBI503 in Combination with Sorafenib in Adult Patients with Hepatocellular Carcinoma(Phase 1 clinical trial, appropriate for patients with liver cancer.)


(155-17) 0C-17-1: Phase I Multi-center Study of the Safety of Pharmacokinetics and Preliminary Efficacy of CBT- 101 in Subjects with Advanced Solid Tumors and C-Met Dysregulation (Phase 1 clinical trial, appropriate for patients with advanced solid malignancies.)


151-17/0C-14-11: A Phase 1, Open-Label, Dose Escalation Study Of Pf-04518600 As A Single Agent And In Combination With Pf-05082566 In Patients With Selected Locally Advanced Or Metastatic Cancers


(144-17) 0S-16-18:A Phase Ib Study of Guadecitabine (SGI- 110) and Durvalumab (MEDI 4736) in Patients with Advanced Hepatocellular Carcinoma, Pancreatic Adenocarcinoma, and Cholangiocarcinoma/Gallbladder Cancer (0S-16-18: PIb (SGI-110) and (MEDI 4736))(Phase 1b clinical trial, appropriate for patients with advanced liver, pancreatic, bile duct, or gallbladder cancer.)


187-17/0C-17-11: Phase I trial of ZW25 in patients with locally advanced (unresectable) and/or metastatic HER2- expressing cancers (Phase I clinical trial, appropriate for patients with HER2 expressing cancers.)


181-17/0C-14-2: An Open-Label, Phase 2 study of Neratinib in Patients with Solid Tumors with Somatic Human Epidermal Growth Factor Receptor (EGFR, HER2, HER3) Mutations or EGFR Gene Amplification


(106-16) 0S-15-5: A Pilot Multi-Arm Study of sEphB4-HSA in Combination with Different Chemotherapy Regimens in Patients with Specific Advanced or Metastatic Solid Tumors


(107-18) 0C-17-5: A Phase 1b/2 Study of BMS-813160 in Combination with Chemotherapy or Nivolumab in Patients with Advanced Solid Tumors (Phase 1b/2 clinical trial, appropriate for patients with colorectal or pancreatic cancer 157-17/0C-18-2: A Phase I Study of FID-007 in Patients with Advanced Solid Tumors


(211-17) 0C-17-14: An Open-Label, Non-Randomized, Multicenter Study to Determine the Pharmacokinetics and Safety of Niraparib Following a Single Oral Dose in Patients with Advanced Solid Tumors and Either Normal Hepatic Function or Moderate Hepatic Impairment (Phase 1 Clinical trial appropriate for patients with advanced solid tumors) 119-17: Noncoding RNA Biomarkers for Noninvasive and Early Detection of Pancreatic Cancer

SCREENING AND HIGH RISK SERVICES

Anita Erickson Pancreatic Cancer Early Detection Program

The recently launched Anita Erickson Pancreatic Cancer Early Detection Program is a clinical research study for individuals who are at increased risk for pancreatic cancer based on family history and/or positive genetic testing results for certain genetic mutations. The program brings together specialists in medical genetics, genetic counseling, pancreas surgery, imaging, advanced endoscopy, and precision medicine who meet monthly to develop individualized surveillance regimens for patients at high risk of developing pancreatic cancer as well as discuss ongoing management of these patients. The GI cancer nurse navigator assists with coordination and guidance for each patient enrolled, which may include referrals to Hoag Family Cancer Institute’s other high risk and early detection programs as appropriate. As part of the program, individuals submit their de-identified information to be part of a registry, shared by several other organizations.

Intraductal Papillary Mucinous Neoplasms (IPMN)

Patients with intraductal papillary mucinous neoplasms (IPMN) represent the largest population of patients at increased risk for pancreatic cancer. At Hoag, these are categorized as intermediate risk or high risk for pancreatic cancer based on fluid analysis, body imaging, and the disposition of the multidisciplinary group. Surgery is recommended for patients who are deemed high risk, and patients at intermediate risk are enrolled in a surveillance program involving annual or semi-annual screening utilizing advanced endoscopy and regular follow up.

EDUCATION AND SUPPORT

The program’s team of nurse navigators – Diane Eadie, R.N., and Shelley Morrison, A.C.N.P., – coordinate and guide patients through multidisciplinary treatment plans, provide education and support, and address other issues that may arise along the way.

Diane Eadie, R.N., leads the GI Cancer Support group, which meets monthly at the Conference Center at Hoag Hospital Newport Beach.

Patients also have access to a wide range of education classes and workshops and other support services through Hoag’s Integrated Cancer Support Services including registered dietitians and rehabilitative specialists.

For more information call: 949-722-6237