Episode Transcript
[00:00:00] Speaker A: Welcome to Ingest, the podcast series designed for primary care and brought to you by the Primary Care Society for Gastroenterology. I'm Charlie Andrews, a GP with an extended role in gastroenterology based near Bath. I am delighted to have Dr. John Leeds here with me again. This is for part two of our series about the pancreas. So in this episode we're going to be talking about malignant pancreatic lesions or conditions.
If you haven't already done so, I would highly recommend that you go and have a listen to part one, where we talk a lot about kind of what the pancreas does and it will really set the scene for you. And there's so much useful information in that episode talking about chronic pancreatitis, which you might well touch on in this episode, pancreatic insufficiency. So do have a listen to that before you have a listen to this one if you can.
But yeah, absolutely delighted to have you here. John, do you want to. Just for those who perhaps haven't listened to the last episode, could you just introduce yourself again?
[00:00:58] Speaker B: Yeah, no worries. I'm John Leeds. I'm a pancreatic, a biliary physician and endoscopist. I work at the Freeman in Newcastle and a professor of pancreatic, A biliary medicine at Newcastle University.
[00:01:08] Speaker A: Brilliant, thank you. So we're going to be focusing here, our attention on pancreatic cancer, really. And the first thing I'm going to ask, you know, is just thinking about. Pancreatic cancer is often diagnosed at quite an advanced stage. Unfortunately, we. What sort of early warning signs could you recommend that primary care clinicians can look out for or be particularly vigilant about that might indicate a malignancy of the pancreas?
[00:01:35] Speaker B: Sure. I guess one of the biggest problems is early detection rather than fast diagnosis. And it's a bit similar to the chronic pancreatitis thing we talked about in the previous podcast, where actually the issue is more around that it's actually really hard to make a diagnosis. It's one of these things that the pancreas is again, so deep inside you that you coming out behind you before you even get to doesn't press on very much. So things can grow in the pancreas to quite a size and therefore invade other organs before you get any symptoms whatsoever.
So particularly tumors of the kind of body and tail, there's a lot of room. These things can grow big and invade all kinds of stuff. And if you think of the blood vessels and things around there, the thing that makes something inoperable is the fact it's usually invaded an artery, veins, perhaps you can remove some of the veins, but if it started to wrap itself around one of your major arteries, so your celiac axis, your superior mesenteric artery, you can't remove that. That's the blood supply to a pretty huge part of your gut or liver or whatever it might be. So we know that often means it's spread further anyway.
Whereas in the head, sometimes you catch it a little earlier because it takes out the bile ducts. And that's why people present with jaundice still often still, you know, it's very, very close to some of the other quite major structures. And so even, even if it's, it's done that, it's still on often quite late. Even in that diagnosis, the earliest one you're ever going to get is right on the ampulla. So imagine right at the bottom of the bile duct. You don't have to have something very big for it whacks out the ampulla. That's away from a load of vessels. That's very, very treatable. Unfortunately, they're a minority.
So early symptoms. Well, there are not that many.
What's the other thing I was thinking? There's not really that many, the subtle ones. So early jaundice, weight loss. Again, by the time you get in weight loss, you probably got to, you know, most of the symptoms on any of the upper GI referral forms are often those of advanced cancers. We don't have a great early, early, early finding.
So weight loss, I guess maybe early pei, which you sometimes get with with pancreatic cancers. The other one people often are interested in is new diabetes.
Now, of course, diabetes is really common. As far as I understand it. It's what, 4 million people in the UK have got diabetes, something like that.
It's a reasonably big number, most of whom will have pretty standard diabetes. You know, you standard, most of which are type two, obviously. And it's. Whilst it's all based on the pancreas, in that case, it's actually based on the fact you've got insulin resistance, isn't it? And you type ones, well, okay, yes, they get weight loss because they've got insulin deficiency, but normally not, not in a group that you think it'd be a pancreas problem. Because they're normally younger people, aren't they? Not everyone, but they'll be younger people.
And there's been various studies where they're trying to kind of think, well, does new diabetes increase your or Mean you perhaps, you know, they're a high risk group to look at and they're not really getting a big yield from that as I'm sure you imagine. If you took 100 people with new type 2 diabetes, I suspect most of them have just got new type 2 diabetes, you know, but there may be a group of, within that that, you know, what if someone isn't, you know, got a higher BMI? What if they've got a more normal BMI developed type 2 by B. So you got to think, well actually is it type 2? So maybe you have to think more about. But no one's really that certain.
So yeah, early symptoms are often really vague or absent and I think that's often the problem. So it's your standard kind of upper gi, bit of dyspepsia, a bit of weight loss. Jaundice is obviously a big red flag symptom. There aren't many causes of jaundice that aren't serious.
You know, we always find that if someone's yellow, we normally find something wrong with them, whether it's the liver, the bile duct or a tumor or something of that kind of nature.
So, so yeah, not a, not a huge number of people, unfortunately not a great number of things you can go looking for. It is the golden bullet of pancreatology which is to find some kind of biomarker or proper high risk group or strategy to case find these people.
Because as with any cancer, the earlier you find this, the better it will be. And the problem with pancreas is it's, it's often very, what we call systemic. So often by the time you can see it, it's often actually a lot further on than you realize. And there's been some changes. I think we'll come to this later. But things like PET CT have actually shown you think you've got a relatively small lesion in your pancreas. And the PET goes and shows actually there's more widespread disease than you realize, which is why we're moving a bit more towards things like neoadjuvant treatment. Because actually there's probably more there than you realize then you can actually see on the CT scan. And that's what that's there for. So unfortunately we don't have a great number of things say yes, look for these things. They're the obvious ones I'm sure you all know about.
We are working towards biomarkers. In fact, we're doing a study in Newcastle at the moment looking at the microbiome in the pancreas. Which I didn't think there'd be any bugs in your pancreas. Turns out I don't know anything.
There absolutely are. And maybe there's a signature within that. We're a very early stage, but it might be in the long term what we end up with is some kind of mouth swab to look at your microbiome and that maybe gives these the group of people who are higher risk. Now, they're not all get it, but these are the ones to look for. These ones we can forget about. Who knows? That's the kind of thing you'd love to have or something. There is no fit test, if you like, for. For pancreas, that's what you're looking for. CA19,9 is not a screening test. Please don't do it. As a screening test goes up in all kinds of different things, same as ca. They're not useful for those kind of things. They go up in lots of other diseases and it's unhelpful if it's isolatedly erased. So that's not what they're meant for.
[00:07:38] Speaker A: Okay. Yeah. Well, really difficult, isn't it? I think I'm casting my mind back to med school days and thinking about painless jaundice and Courvoisier sign. I think that's it. Have I just made a fool of myself?
[00:07:50] Speaker B: No, no, that's absolutely correct. Yeah, that's a palpable gallbladder.
[00:07:53] Speaker A: Yeah, There we go. Got it. Okay, good. I've still got it. So.
Really difficult, isn't it? It's so hard to work this out. So do you think there is a role for screening for pancreatic cancer in high risk groups? I think you've already mentioned that it's really hard to find out who those high risk groups are. I mean, I'm wondering about sort of. I know that there's interest in finding people who are diabetic and, you know, looking at weight loss in those patients. Is there a role here in case finding? And if so, you know, who would you kind of consider for screening and how might you do that? Screening?
[00:08:25] Speaker B: Yeah, very good question. So there is something called the Uropac study, which is run from Liverpool, runs across Europe because there are some familial versions of this. So that's a group that do get this, but they're quite the minority. So unlike some of the tumors. So, you know, breast, for example, even colorectal, really very familiar. Or a lot of them are very familial or hereditary, shall we say?
I think it's less than 10% in pancreas cancer that's actually familiar. Most of it's sporadic and you're unlucky.
So for those who. And there's criteria. So you have to have the right criteria. So if you've got, I don't know, you've got, you know, family full of people who've had pancreatic cancer, well, that would make you wonder. And there are some genes and even some of the things like the fap, you know, familial adenomatous polyposis coli patients, they have an increased risk. So there's a bunch of other underlying genetic and germline tumor mutations that do increase your risk. Again, they're quite the minority of people in general.
So we do have a cohort of about, about 400 patients again in Newcastle area who are under screening or surveillance or whatever you want to call it. For high risk family members or high risk family history, it's quite stringent. You know, it can't just be your dad had it, you know, you normally have to have several members and it usually has to be under the age of, you know, 60, if not 50 for it to be considered that because, you know, most of these tumors will occur in the 60s and 70s. That's just normal, that's bad luck or whatever you want to call it. So if it's picked up earlier, then that's when you might then think, well, actually is this familial? They get a combination of different ways of surveying, but usually annual screening, whether that's MRI or CT or we sometimes use endoscopic ultrasound.
Again, the other groups are those with hereditary pancreatitis. They have a significant increased risk, a bit harder to screen because actually the pancreatic changes are already there. It's abnormal and so you know, you're not. So in the first group with the high risk family, they've got a normal looking pancreas and you're looking for a small blob featuring as if you've already got chronic pancreatitis because of a gene, your pancreas don't look normal in the first place. So you know, proper needle in a haystack stuff.
And then there's some of the groups like, I mean like one of the BRCA mutations is associated with pancreatic cancer, as is fap, as is things like Pert Jaegers. So there's some, some other genetic groups. Chronic pancreatitis on its own is not, is one that you probably get an increased risk. It doesn't currently quite meet the criteria for screening for pancreatic cancer. And actually I think in a lot of those patients smoking might be to blame for a lot of it. So smoking is a big risk factor for pancreatic cancer and a lot of patients with chronic pancreatitis smoke. And that alone maybe accounts for a bit more of the increased risk than we realize. So there's other things you could go looking at for that and there probably are a few other kind of more random smaller groups that we look for. Again, partly what we did and again it's been in the previous podcast, pancreatic cyst patients. What we're really looking for is tumors. So you've got a cyst and it's a marker that something's not quite right in the pancreas. So you're doing a CT scan or an. Mr. Every so often to see if something's growing.
But actually again, that's quite low incidence. So. And it's a slightly different mechanism to screening in other situations. So there are a small group that we'll do that for. Again, we're back to if we had a biomarker, that'd be the ones to go looking for. So if someone had their pancreatic, you know, blah test was abnormal, they would either, you know, if they were suitable, maybe they go for surgery early, who knows, or they get very close screening. Well, you got to remember if you do lots of CT scans, you'll eventually give someone cancer. So, you know, there's a, there's a, there's a trade off here. Plus all the things that we talked about. Cysts, incidentalomas, what a nightmare. So every time you do a scan on somebody, yeah, you might pick up the thing you're looking for, but then you find three of the things that you think, oh, I've got to now follow up this, you know where lung nodule, they've got something weird in their adrenal and they mentioned some weird fatty change in the retroperatively and what the heck is all that? So you end up with more people get over investigated, over medicalized and what do they call it? Scanxiety. So you have to. We underestimate the morbidity of telling people, I'll just do a scan again in six months. They often sit there thinking, well, I hope it's all right, I hope it's all right. And you as the doctor is thinking, I'm doing that because I think it'll be fine and I've got nothing to worry about. And I'm just doing it to reassure myself the patient's thinking, you think there's something there. You think there's something there, don't you? And you're not yet telling me. You want this to tell me, you know what I mean? So there's real negatives in screening in the wrong situation. So we have to pick it correctly. And again, the evidence for screening people with pancreatic cancer at the moment is pretty limited. So what we do is we enter them into the EuroPAC trial. Most of the time, which just involves there's a fairly straightforward protocol for how to follow those patients through, but it's a very small number of people.
[00:13:49] Speaker A: And do you think that looking at the diabetic population is a good way of trying to move forwards with some of this?
Is that somewhere where we can find some of these patients or what's your thoughts around that?
[00:14:02] Speaker B: I mean, the answer will be yes, but again, number needed to scan to identify one tumour is quite high, I think at the moment. Again, there are some. There is a national study and I've completely forgotten its name right now, that is looking at that so that there is a full protocol running. It will come to me later on, I'm sure. But yeah, they're looking at it. So in people with new diabetes, it isn't just everyone with new diabetes, I think you have to have other criteria. So if you've had weight loss for no good reason or family history of pancreas problems or there's a bunch of things that, you know, if that's the case, they should have a ct. Not everybody with new diabetes, because most people who need diabetes don't have anything at all to find in their pancreas. As simple as.
[00:14:49] Speaker A: I think it gets a bit more complicated, doesn't it? Because then with new diabetes, often type 2, we're saying, can you lose weight? And patients are often very effectively losing weight, so it feels like a minefield, very difficult.
[00:15:02] Speaker B: I think that's right. I think that's one of the tricks, isn't it? Is. Then how do you set that apart? Yeah, how do you work that out? And people with type 1 or insulin deficient type diabetes will often lose weight as well.
So, yeah, not a, not, not an easy, easy call on that.
And then given the number of patients that there are who develop new diabetes and it's not infrequent, that's a lot of people you'd scan possibly for not a lot of benefit, you know. So, yeah, I'll see at some point if I can find the name of that study, but that, that Might be the way to do if you've got patients like that. Maybe enter into the.
And enter into a study to look for it.
[00:15:47] Speaker A: Yeah, really interesting. Thanks. Yeah, it's just so hard, isn't it? I think, you know, we've gone into this podcast and we're already identifying so many challenges around diagnosis.
Just pivoting a little bit here to a slightly different type of tumor. Can we. Can I get your perspective on neuroendocrine tumors of the pancreas? I feel like they have quite a different presentation sometimes. Maybe they don't, but. But could you just talk to us a little bit about the presentation of them and some of the prognosis compared to adenocarcinoma?
[00:16:17] Speaker B: Yeah, no, definitely. They are very different. So there's several parts. So one is they're a rarer version by a long shot.
So the vast majority of cancers or tumors in the pancreas, or PDAC as we call them, pancreatic ductal adenocarcinoma, there's then a whole bunch of other rare reversions of things from something called a spend to various in things. But neuroendocrine is not an infrequent one. We see a number of those per year, but they come from a different part of the pancreas. So as I said in the other podcast, you've got the kind of ductal bit that, that makes you lipase and you've got a load of endocrine tissue. And they come from the endocrine tissue. Generally they are more indolent, they have a better outcome, they're easier to treat, the slower growing, but. But you have to work them up adequately. So the majority on are non functional. So they're just a bit of overgrown bit of neuroendocrine tissue. Some of them are functional. So you'll have heard that there's various functioning versions of tumors. So insulinoma is probably the most common of all of those. We've all heard of those. Basically it's just producing insulin for no bloody good reason. Gives people hypos and weight gain and all kinds of stuff. Difficult, difficult to sometimes work out what's going on, but when found and treated, you know, do very nicely. And then there's like gastronomas, vipomas, somatostoma, statinomas. Again, they're all quite unusual. Some of them have got these well recognized syndromes. But the vast majority of neuroendocrine tumors are just a lump in the pancreas that aren't producing additional hormones.
So they present as a Mass they often present as quite a discrete mass. They kind of sit quite nicely. There'd be any part of the pancreas we bite them using endoscopic ultrasound to be, to be sure. And really it comes down to what their, their grade is. And we use something called the Ki67. You might see that on reports. That's basically a proliferation index. So the higher that number, the more turnover there is in that tumour. Can be a bit patchy in the tumor, but there's grade one, two and three. So grade one is about 1 to 2% KI67 and then 2 to 20 is grade two. That's quite wide and anything over 20 is grade three. Grade threes are a bit more like a cancer and usually get systemic treatment. Most of them are grade one or grade two. And if they're grade one and less than 20 millimeters usually, and the non functioning usually, you've got it's back to the kind of concept of the colonic polyp got years before anything bad will happen. So they'll often go for observation, look at annual CT scans. If it starts growing or gets over 20 millimeters or something changes, then they'll resect. If it's grade 2 or greater than 20 millimeters, the evidence is they should probably be resected. Of course this is all down to how fit is your patient again, isn't it? As we're talking about things like Whipples or major pancreatic resections, these are not small operations and the patient needs to be suitable for that. Some of them get treatment with what we call analog, so octreotide inhibitors, which I'm sure you've come across them. There's a whole bunch of different ones. They're short acting, long acting.
And again, at the top of my head, it's completely gone from what the hell they call that stuff.
But we actually have a specific. So we have a pancreatic cancer mdt, we have a liver cancer mdt. We actually have a neuroendocrine one specifically because again, they're not just in the pancreas. You can get neuroendocrine tumors all over the body and lots of different types landreotyped. That's the stuff we tend to use, that's the long acting thing. And what that tends to do is block it's any action it's got, but also kind of inhibits its growth. So these guys, they get worked up, they get biopsied, we stage and grade them and again many of them will just get observation, some will get surgery Some get treated if they're more advanced, like an actual cancer. But again, the types of things they can use are quite different. So there's different kinds of chemotherapy than you'd use in standard pancreatic cancer. They can even now use. There's something called Lutetian therapy, which again, you may have seen some patients have. It's a way of using the receptors actually on the tumor, the neuroendocrine receptors specifically, and you can give an agent that's got something attached to it that basically homes in on that tumour and then attacks that tumour cell. So some very clever stuff they can do. Again, there are relatively small number of those and again, there's a number of other manifestations of neuroendocrine tumors. So people have always heard of the.
Of the. The ones where you get, you know, flushing and this kind of stuff. Most patients we see, we just. If it's just in the pancreas, you don't see that. That's more what we used to call carcinoid, which is not really the right term anymore. Neuroendocrine is the right term for it. You can get them anywhere in the body. So you see them in luminal tube missing with, you know, any part of the gut, you see them in the lung, you see them in all over the place. So, yeah, but even those people who've got metastatic neuroendocrine tumors still live a lot longer than you would if you had metastatic pancreatic ductal adenocarcinoma. Seems just be a bit easier to treat.
The treatments work more effectively and, you know, patients have a longer survival in general.
Brilliant. They'll also remove a lot more stuff. So if, you know, even if it looks like it's invaded other things, if they can take it all out, they'll take it all out. So I've had people who have what I. Yeah, they've had like their distal pancreas, their spleen, the left kidney, the left adrenal bit of the stomach, what I'd largely call a left upper quadrant ectomy, you know, because they get all the tissue out and that's quite morbid surgery. But if you get through that and they've rejoined everything, actually, you might go on to live a lot longer life afterwards. So they'll be more aggressive because they've just got a better outcome.
So, yeah, if you're going to choose a tumor, the pancreas, choose that one.
Most of the time you're not going to need anything done and you'll Just be watched or you'll have a bit of lamutide. That's about it.
[00:22:20] Speaker A: And just coming to the end now, John, I'm thinking about kind of the future here. Okay, so how has the management of pancreatic cancer changed in recent years? And are there particular advances in treatment that are giving you hope of better outcomes for these patients?
[00:22:37] Speaker B: Yeah, it's been pretty dismal. It has been for a long time. As you, if you go onto The Pancreatic Cancer UK website, the five year survival, 6% or something like that, it's awful.
And for those who have surgery, it's only something like 25 to 30%. It's still pretty low.
And what that really, really tells us is that this tumor is not as localized as we think. So there's been a large move towards giving systemic therapy, so chemotherapy generally speaking to most patients, whether they get an operation or not. The idea being. So we used to call it downstaging. It's a terrible word for what things are. It doesn't downstage. You're dealing with micrometastases. You always were. That's what adjuvant chemo does. So you go back to the old esophagogastric data. They used to do an esophagectomy and they resected a bit of rib to get into your chest to be able to get to it. And actually when they looked at that, you found cancer cells in the marrow of the bone. So that means it was all over the place, you just couldn't see it. So what the adjuvant treatment we thought was doing, and even neoadjuvant treatment is actually dealing with those micro mets that you can't see, that is small bits that have tried to branch out, kill them early, and then when you remove the primary, there's no other seeds knocking around. That's the idea. The problem we have in pancreas is that so far we've got very little in the way of very effective chemotherapy. So colorectal, breast, lung, even upper gi, you know, very sensitive tumors, or particularly some of them, very sensitive tumors to chemotherapy. Whereas actually pancreas, not so much. Even with newer regimens like folfirinox, which again is a chemotherapy regimen I'm sure you may have seen, it's called platinum in it, a whole bunch of other stuff, immunotherapy starting to come through. But again, I think the big problem with the pancreas tumors is that they are, they're actually what we call palsy cellular. So when you biopsy them. A lot of it is not cancer. A lot of it's kind of the stroma and the reaction around it as opposed to cancer.
And it causes so many other things. So when we manage these patients, they get a number of, say they may have jaundice, so they may therefore get a stent to treat their jaundice. But you've got to think the head of pancreas very often is sitting right by the stomach in the duodenum. So they get gastric outlet obstruction, they get a degree of pancreatic insufficiency, they often get diabetes. And there's a whole bunch of things that's going on.
And, you know, thinking that one simple thing will sort it out is quite a multiple symptomatic and tricky condition. And it really, really knocks your nutrition very quickly. So they often lose weight in front of your eyes. I'm sure you've met these patients. They go from someone you'd seen two years ago, they walk in like a skeleton. You're thinking, oh, crap. You know, they, they melt away before you very quickly. So some people, even if you've got operable disease, aren't yet aren't fit for the operation because it's, it's actually a hell of a thing to go through.
As I said, you know, Whipple's procedure has about a 30, 40% morbidity alone and a 1 to 2% mortality. That's even in the best of units hands, you know, it's really hard to get down from that. It's just such a big operation, which is why it was centralized to big units to do lots of it and do it, or to try and do it as best as possible.
So. Yeah. What's changed? Well, we're trying to work on more rapid pathways. That helps in a way, but the problem is once you've already got a mass in your pancreas, you know, it's important to get patients through your pathway as fast as possible. But to be honest with you, you've got what you've got. What you wanted to do was detect it four months ago when it was smaller and more removable. You know, just get. The problem with some of these rapid pathways is they, they. They move everyone the same. I don't have a problem with that. People need to be seen and treated as fast as possible. But you're moving through people who've always got metastatic or unresectable disease very quickly. That's not a problem. But if you really want to get those people who are operable through they, they need to perhaps be singled out somehow. And that's quite hard to do that.
And it's, it's hard to find those patients as well. So, yeah, the big change is now moving a bit more towards upfront chemotherapy. So 10, 15 years ago, 20 years ago, easily, if someone turned up with a mass in the pancreas of jaundice, they probably go for an operation, remove it. Oh, great, that sounds like a good idea. And then within 18 months, they've got recurrence. Well, that's because you haven't dealt with that underlying other bit of disease.
And so the problem people sometimes is like, well, it looks operable now. You're like, yeah, but we know what happens in 18 months time. So if you give them chemo first, we're still trying to prove this, but we think that's likely to lead to better survival. It's also a bit of a test of biology and we're getting this idea that not all tumors are the same. So, you know, someone with a head of pancreas tumour, that's important it gets dealt with. But some progress faster and slower than others. Some will be more chemo sensitive, receptive than others.
And actually, if you give someone basically two cycles of neovadual chemotherapy and they progress on that, well, isn't the chance that they were never going to do very well in the first place? So actually it's been a good test of biology to see what happens to them. Whereas if you give someone, if you get somewhere, it shrinks away. You think, brilliant. This is chemo sensitive disease. An operation be great. So we'll remove the primary and actually we'll take care of the rest of the disease. So, yeah, a lot of what we're really waiting for is that breakthrough they've had in other cancers where they find an agent that works on a lot more of the cancers than it currently does. And so most patients present to us, unfortunately, as either locally. So there's, there's about three or four different groups. So it's purely operable. That is, you've got a lump, it's away from everything, it could be removed quite straightforwardly. You've got locally advanced. And what we mean by that is it's, you know, it looks like it's attached to something pretty important, like one of major arteries. Probably not going to operate on that straight away because one, you won't get it all out and two, well, why would you want to do that, you know?
And then there's metastatic. Now metastatic is quite Obvious it's usually to the liver, they're palliative. There's also borderline resectable. And what we mean by that is the kind of one where you think if you give it a bit of chemo and it shrank back a bit from that vessel that might be able to come out. They're another group that you kind of, you want to identify those. There's maybe about 10, 15% of the patients turn out to be that. But currently the response rates to the chemo are so, you know, not great that even if you find that you kind of. Yeah, you wouldn't operate on them now, but you're kind of hoping some of them respond and some do.
So they're, they're the kind of groups, but there's so many other things to manage. So we, we commonly talk about managing their exocrine insufficiency that blocked off the pancreatic ducts. I mean, to be honest with you, the evidence for using enzymes in this group isn't as good as you might think it is.
But you know, it's not an unreasonable thing to do. Sometimes you have to manage the diabetes and get quite aggressive form of diabetes because they become diabetic very quickly, often progress onto insulin. That's a bit of a mind job when you've. It may account for some of their weight loss, but you know, all this is going on. If they've got jaundice that needs managing, sometimes operatively, that's what a Whipple will do. But very commonly these days via endoscopy, we tend to need to do a biopsy. So we do a lot of kind of one stop shop. So someone turns up jaundiced, we go down with an endoscope, take a biopsy, then change to a different endoscope and put a stent in, do that all in one set of sedation and sort it all out. You also don't need to be in hospital for this. So, you know, jaundice is one of these things that used to get people admitted all the time.
If you're gonna get, if you can get tests rapidly enough. Being yellow doesn't mean you need to be in hospital. Now sometimes it does, don't get me wrong, but most people with a cancer don't get cholangitis. They tend to have a sterile obstruction and it's only when we fiddled with it that then gets you can we contaminate it. So if you're just a bit yellow and itchy, do you need to be in hospital and they're going to be interested to know what your access to things like rapid access jaundice clinics are because they're patchy. I don't think everyone has them, but that'd be the kind of thing you need, is don't admit them to hospital because they're going to sit around for a couple of days while we do scans. And this on the other jaundice clinics are great. You get seen, you get your bloods done, you get a scan done at the same time, whether it's ultrasound or ct. And then if we confirm that, you then go through the MDT and the following, you know, if you get that on the Wednesday, you get your scan on there Thursday, you can get your ERCP on the Friday. So actually you don't need to be in hospital at all. It's much more efficient use of everybody's time and they get a diagnosis, see a surgeon, see an oncologist, see whatever you need to get done.
But again, we've started to advance the way we're managing these things endoscopically. So we've got some more advanced ways of draining jaundice. And even on Friday, for example, we're going to be doing an endoscopic gastrojejinostomy. So what used to be an operation we can now do down an endoscope. It's quite a clever way of doing it down endoscope. Don't be wrong. But there are definite ways of, I won't say preventing surgery because that sounds like I don't like surgeons. I work with them very closely, but using surgery appropriately. So there are alternatives to stents and there are ways of improving patient symptoms by using more advanced endoscopy techniques, for example. So there's a lot to manage in these patients and pain, again, can sometimes be very difficult in these kind of patients with pancreatic cancer. It's actually interesting how a lot of them don't have that much pain often to start with. It's when it starts to invade into stuff again, we tend to go for opiates. I've not been again that convinced that this is as good as we think it is. And adjuvant other agents I think are useful and we do not an infrequent number of celiac plexus blocks or neuralyses. So particularly in someone who's never getting operation. So we're talking the more palliative person who may be, you know, go and see the palliative care people for, for pain relief.
Always think about whether you can do it because we can do it via endoscopic ultrasound. We can find the celiac axis and put a whole load of, well, we use one of two things. So we, we inject some local anesthetic and they can either use steroids or in these cases, they tend to use absolute alcohol and just ablate their superior nerve. And it's very good for pain and can help de escalate some of the rapid use. As you imagine opiates, they can be good for pain, but you get constipation and all kinds of other stuff related to that, and I sure don't need to tell you that. So if you can de escalate some of their pain meds, it actually helps some of the other symptoms. So there's a bunch of different stuff to manage in these patients and we get very excited about trying to get them to surgery. Majority who don't get surgery and what we don't have are people who take a lot of interest in those who don't need an operation because oncology's idea is to give them chemo, that's fine. But again, there's a bunch of them who won't be suitable or don't want it. So what treatment are they getting? And there's other things that need to be done. So are we managing these other areas? Like I'm saying, it can be quite difficult to get that right. I think nutrition, I think, is a big deal in these patients.
[00:33:33] Speaker A: It's a huge topic, isn't it? And there's so much there around treatment and different things that are going on. But it's all really focusing on getting in early, isn't it, and trying to identify these patients. I think, you know, we've, we've discussed it. The challenge is really there. We've come to the end, John, of this, of this podcast and what I'd like to do is give you the opportunity to kind of talk to our primary care audience and which you could do fantastically already, but just to kind of your, your kind of key take homes. Are there sort of a couple of key take homes that you'd like our GPS to leave this podcast, either based on what we talked about in part one or on part two, you'd really like them to go away with, you know what, what sort of real take homes have you got that you want to impart?
[00:34:19] Speaker B: Wow, okay.
Yeah, well, pancreas stuff. I, I think the, the big area, the big thing about pancreas is it's, it's a bit of one of those kind of Cinderella specialties within Medicine, isn't it? So most people are pretty good at cardiology, respiratory, even endocrine. In primary care, you're very good at that kind of stuff. And even within gastroenterology, you guys manage quite a lot of stuff very well. Pancreas scares the crap out of everybody and it shouldn't. So most of these things, I'd say break it down. So it always seems complex, but actually complex things are generally lots of simple things. They just happen to have happened all at the same time.
So break it down. So whether it's chronic pancreatitis, whether it's pancreatic cancer, what are the issues? So pain. Okay, well, you guys are great at pain. I don't need to teach you about managing pain. But again, like I said, for the chronic pancks, nerve ending pain blockers are possibly better than opiates. And again, in the, the chronic pancks, we'll think about things like celia plexus block, particularly, sorry, angular cancer, celiac plexus block. And because actually it can be really very useful in the right patient. Not everyone's suitable and you shouldn't do it in someone's operable, but they'd be the, they'd be the people to look at. The main thing in the pancreas is to think, could it be pancreas? I think that's often the thing that people don't even think. They've gone through a whole bunch of different symptoms with patients and because in the end the gut certainly got so many things it can do. You've got bellyache and diarrhea. I mean, how many different things is that? That's hundreds, you know, that's why it's difficult to work out what's going. The symptoms are no help.
I mean, they are, but they're nowhere near specific enough, are they? And so, you know, you have a reasonably low thresh. Consider imaging. So whether it's for. If you're worried someone might have pancreatic cancer or worried they might have chronic pancreatitis, a CT scan be really helpful because if they don't, then brilliant and it's no bad thing to do. Think about that for age. If they're 20, maybe not so much, but if they're over 50 and you're a bit concerned, I don't think there's a problem with that.
I mean, I get gps write to me all the time and I'm very happy to write back with advice or see a patient or whatever it might be. I think that interaction with your secondary care or tertiary care Providers is really important.
I'm sure it's a bit variable in different places. And I see this even when I speak to people like dietitians in secondary care settings. I'm a fairly specialist person in what I do. There isn't someone like me absolutely everywhere.
So sometimes your more general gastroenterologist doesn't have as much experience with pancreatic capillary stuff, and that's okay.
And sometimes you might need to go and find someone like me. There are, there are people like me all over the country. But yeah, identifying that person isn't always very easy. And we are often a little, few and far between. As I said, Cinderella type specialty.
But yeah, break it, break it down is my biggest advice. So if it's pain there with pain, if they're jaundiced, they were jaundice. You know, what if it's nausea, if it's diabetes? You're very good at diabetes. You know, if you think they might have P.E.I. from any of the causes, you know, investigate that image them, you know, have a reasonably low threshold to try them on some enzymes. I don't like the concept of a trial of enzymes because actually some people get better when you do that. But actually it's probably placebo. So it's not, it's not that on its own isn't a test for it. But if someone who's got, if you've got someone who's got chronic pancreatitis and GI symptoms, well, that's fine. Or someone who's got, you know, they've had half the pancreas removed and got GI symptoms and respondent enzymes, well, it makes sense to, to do so. But yeah, break those things down.
And I guess the other thing is that these patients often are complex. And actually we did something called a psp, which is a partnership thing with patients and family members. It was about 18 months ago, and they've done this in other areas.
And what was interesting, we were trying to find out what the top 10 research priorities were in pancreas diseases. And that included, as in pancreatitis, it wasn't in cancer.
And what was amazing what came out of that was, I thought were things that we knew the answer to, and actually it turns out we often don't. And this is the patient's perspective of saying these things we feel are unanswered.
So education was a big one and that it was very common that people went to hospital and even if they knew they had some kind of pancreas problem, the people there didn't even know what they'd had and didn't know how to manage it. And they, or they assumed it was all due to alcohol. So please don't assume everyone with pancreatitis is an alcoholic. Absolutely don't do that, same as liver disease because if they aren't, they'll get incredibly angry with you. You can understand why. And in acute pancreatitis the most common cause is gallstones. It's not alcohol by a long shot. And same evening chronic pancreatitis, only about 30% of them have actually got alcohol related problems. So it is not the most common cause, despite what people think. You might see a lot of those patients because they can be troublesome, don't get me wrong, but there are a lot of causes that are nothing to do with alcohol whatsoever. Do not make that assumption.
And in fact most of the time, by the time they see me, they know that's what it is and they've dealt with it.
So yeah, you know, have a low threshold to chat with someone about these things, that complicated things, education is important and break down the different parts of what's going on.
And you know, as I say, never be afraid to ask for advice. These are difficult patients with complicated, often quite unusual conditions.
So yeah, feel free to phone people up and ask and sometimes just a phone call or an advice and guidance or even a letter in, you know, can be really helpful. And again I say in the chronic pangs, don't forget their bone mineral density. What I would say is FRAC score is useless in those groups. So don't do the frax just to just measure their bmd.
[00:40:28] Speaker A: Brilliant. Well that's a great note to finish on John and I, you know, from my perspective, one of the key things that I've taken away is kind of think pancreas, you know, because you know that abdominal pain could be due to pancreas or you know, that presentation, that diarrhea. We just got to think about it and you know, it's similar with quite a lot of conditions. It's just about, you got to think about it, it's got to be there in your mind otherwise you just won't consider it. And we need to be considering it. And also that really holistic approach. Actually I think primary care probably is a really good, good place for these patients to be managed actually in many ways with support from secondary care. Because you know, we are very good at managing pain in primary care. We do it all the time. Got the diabetes side of things, you know, it's lots of things that actually, you know, we can bring to the table in primary care working in conjunction with our secondary care colleagues.
[00:41:16] Speaker B: So I don't do much diabetes at all. So, you know, you guys manage diabetes on a routine basis. Actually, it was a year ago I got diagnosed with type 2. I've had my thing come through today saying you need to come back for your annual review. That's my GP doing that. I've never seen anyone secondary care because I don't need to. I've lost three stone. I think that's what's probably helped. But you're right, you know, we underestimate so it's that ivory tower thing, but we underestimate how good primary care is. I actually personally think it's the hardest job to do well. It's a very easy job to do badly, but it's the hardest job to do well because you actually have to be up on nearly everything all the time. Now that's, that's a lot of different things. You know, you don't, you don't have to know everything about everything, but these days you seem to need to know quite a bit about most stuff and I think that's the problem, that's very hard to do. So I'm always very impressed with what the GPS do. But yeah, for a lot of the gastro and pancreas related stuff, other than our interventions and surgery or chemotherapy for example, most of it is about things like pain relief, diabetes management, enzyme provision and some other symptom management.
That isn't something that you couldn't do in primary care.
But you've got to understand what it is you're doing with those patients and why and how.
[00:42:36] Speaker A: Brilliant. Well, John, look, thank you so much for joining me. You've been so generous with your time, so thank you very much.
And to our audience, thank you for joining us. I hope you found this a really interesting episode exploring pancreatic cancer. This is obviously part two, so if you haven't listened to it already, go back to part one. John will talk to you all about non malignant causes and conditions within the pancreas. If you've enjoyed this episode, please click subscribe. It's great for you to do that and then we'll notify you whenever we bring out an episode. And we love feedback, we really love to hear from you. We love to hear about different episodes that you'd like us to do. So if you want to provide feedback, you can do that either through the Primary Care Society for Gastroenterology website or on Spotify. Let us know what you think. We're always really interested. So thank you very much, everyone, for joining us, and thank you so much. John.
