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]g.org.
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