Answer: The No. 3 cancer killer in the United States.

Question: What is pancreatic cancer?

No, Alex Trebek, the longtime host of the popular game show “Jeopardy,” didn’t use the familiar answer-question format to frame his March announcement that he had been diagnosed with the disease. But he undoubtedly helped intensify attention on pancreatic cancer, a deadly and often silent killer.

The numbers are daunting. The five-year survival rate for people like Trebek who have been diagnosed with stage 4 pancreatic cancer – meaning the malignant cells have metastasized to other parts of the body – is 3%.The disease exacts a heavy human toll, said Dr. Richard Schulick, chair of the Department of Surgery at the University of Colorado School of Medicine and director of the University of Colorado Cancer Center.

Many lives lost

Schulick said an estimated 57,000 people will be diagnosed this year with cancer of the pancreas, an organ that regulates digestion and blood sugar levels in the body, and 46,000 people will lose their lives to the disease.

The biggest potential to reducing those numbers is prevention, Schulick emphasized. “If everyone stopped smoking, watched their weight and exercised regularly, about 40 percent of pancreatic cancers wouldn’t happen,” he said.

Prevention aside, Schulick predicts that pancreatic cancer will nudge colorectal cancer from its berth as the No. 2 cancer killer relatively soon .

“Pancreatic cancer will become number two in the next five years or so because our ability to detect and care for colorectal cancer is rising very fast,” Schulick said. The primary obstacle to decreasing pancreatic cancer mortality, he said, is that providers lack reliable screening tools for early detection of warning signals, such as molecular biomarkers or cancer cells shed by the tumors. But he acknowledged that a highly sensitive test might be a decade or two away.

“If you catch any cancer at an early stage, you have a much better chance of curing it,” Schulick said. “With colorectal cancer, we can do colonoscopies; with skin cancer, we can look [for signs on] people’s skin; for breast cancer we can do mammograms. With pancreatic cancer, there is no great test available to us.”

Anatomy also presents a formidable challenge, Schulick said, because the pancreas sits deep in the body, barring easy detection of a tumor. A mass that blocks a bile duct at the head of the organ will produce jaundice, with its telltale yellowing of the skin and whites of the eyes, but if the tumor sits in the middle or tail of the organ, the disease can easily spread to other parts of the body with few or no warning signs.

“About 60% of pancreatic tumors metastasize before detection,” Schulick said.

Expanding treatment options

In the treatment realm, the familiar triad of surgery, radiation and chemotherapy – and combinations thereof – are the primary weapons available to providers. A “new kid on the block,” as Schulick put it, is emerging in the form of immunotherapy. The approach, which uses engineered T cells as “checkpoint inhibitors” to malignant cell growth, have produced great results in some cancers, Schulick said.

A major immunotherapy success, for example, was development of CAR-T (chimeric antigen receptor T-cell) therapy, approved by the FDA in 2017, to treat acute lymphoblastic leukemia (ALL) in children whose disease resisted other treatments, including bone marrow transplants.

The same can’t yet be said for pancreatic cancer, but work is underway to change that, Schulick said. He noted the UCHealth Anschutz Medical Campus has recruited two immunotherapy experts: Dr. Terry Fry from the National Cancer Institute – who played an integral role in the CAR-T research for ALL – and Dr. Eduardo DeVila, a PhD researcher who joined the CU Cancer Center from the University of Maryland School of Medicine. Schulick hopes their expertise will contribute to developing immunotherapies that target solid tumors in the pancreas and other organs.

While those discoveries remain on the horizon, Schulick noted strong advances in the effectiveness and decreases in mortality of surgeries like the Whipple Procedure, which involves resecting tumors by removing the head of the pancreas, the gallbladder and parts of the small intestine and bile duct and reconnecting what remains. Distal pancreatectomy leaves the head of the pancreas intact but removes tumors lodged in portions of the body or tail of the organ. Both of these operations can now be done laparoscopically, potentially shortening recovery times. Radiation regimens are far shorter and spare more healthy tissue than before, while chemotherapy treatments have made “dramatic jumps” in effectiveness, Schulick added.

Team defense

But Schulick emphasized that he believes the best chance for patients with pancreatic cancer today is to get treatment at a multidisciplinary clinic with extensive experience evaluating cases and making evidence- and team-based decisions on what is likely to be the most effective therapy.

He noted, for example, that he and his surgical colleagues perform about 200 surgical resections of the pancreas a year at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. Many others who are not surgical candidates get chemotherapy, radiation or combination therapies, depending on their specific case, and have their care coordinated through the UCHealth Pancreas and Biliary Multidisciplinary Clinic.

Experience is vital, Schulick said. “In general in the United States there is a lot of room for improvement in terms of getting patients the right therapies and the right sequence of therapies. It doesn’t do any good if you have a treatment, but you don’t give it to the right patient.”

Daunting diagnosis

With Schulick’s help, a rare series of treatment pieces fell into place for Brenda Harry, 58, of Princeton, West Virginia. In June 2016, Brenda saw her gastroenterologist after having oily stools, itching, jaundice and weight loss. An endoscopic image showed a mass on her pancreas that obstructed the bile duct. She had a stent inserted, then journeyed to Colorado to see Schulick.

He came well recommended. In 2005, Schulick, then at Johns Hopkins Hospital in Baltimore, had performed a Whipple Procedure on Brenda’s brother-in-law, Sam, to successfully treat his pancreatic cancer. Sam later moved to Colorado, as did Schulick, who continues to treat him at UCHealth. On July 1, 2016, Schulick diagnosed Brenda with stage 4 pancreatic cancer. He determined he could not remove the tumor and advised Brenda to return to West Virginia to begin chemotherapy.

Thus began more than two years of chemotherapy every two weeks at CAMC Memorial Hospital in Charleston, West Virginia, a 90-minute drive from her home. She stuck to the grueling schedule and returned to see Schulick in October 2018. The tumor had neither shrunk nor grown, but he was startled to find no other signs of the cancer that had spread when he saw her more than two years earlier. The tumor was now a potential target for surgery.

“Dr. Schulick said, ‘You are a miracle,’” Brenda recalled.

Overcoming the odds

The battle wasn’t over. Schulick recommended that Brenda go back to West Virginia to complete a 28-day regimen of chemotherapy and radiation he hoped would shrink the tumor. When that succeeded, Schulick scheduled her for a Whipple Procedure at UCH on Feb. 13, 2019. He removed the tumor successfully and found no other signs of cancer.

After a 10-day hospital stay, Brenda flew home, her hopes of recovery heightened immeasurably. She still has some soreness and she has to monitor her diet carefully after the Whipple, but the chances are good that she can put chemo and radiation behind her. She’ll go back to Colorado to see Schulick in August and can also call any time on Cheryl Meguid, nurse practitioner and coordinator of the Pancreas and Biliary Multidisciplinary Clinic, who managed her appointments and other details of her care “to a ‘t’”, as Brenda puts it.

Given the dismal odds for patients with stage 4 pancreatic cancer, Schulick acknowledged he’s surprised by Brenda’s recovery.

“She had metastatic cancer and we don’t see it anymore,” he said. “It’s rare to get that kind of outcome.”

Brenda credits his humanity and skill and her own spiritual strength for the improbable results.

“I felt confident because Dr. Schulick knew what he was doing. He sits down with me and will explain everything in detail,” she said. “And I felt God would take care of me.”

Happy homecoming

A nurse for 22-plus years, Brenda hopes to resume work at Princeton Community Hospital on light duty in May. Whatever that timetable, she’s savoring the prospect of more time with her two sons, Joshua and Clayton, four grandchildren, ages 18 months to 14 years, and husband Jim, who she says has been with her “every step of the way” during her long battle with illness.

“I love nursing. It’s my passion,” she said. “And my family is near and dear to my heart. I want to see my grandkids grow up.” The days ahead with them include miniature golfing, hiking and camping in West Virginia’s matchless state parks and treating them to the lasagna, spaghetti, peanut butter fudge and other favorites she’s perfected over the years.

For his part, Schulick said that while Brenda’s specific experience with pancreatic cancer will not often be duplicated – Trebek, for example, is 78 and will have to rely on chemotherapy to wage his battle – her story does underscore that fighting the stubborn disease requires that providers join hands, across institutions and communities that may be separated by many miles.

“We can’t ask everyone to show up on our campus every time they need a component of treatment,” he said. “We can do a better job of helping other hospitals. In general, my theory is that if there is anything that can be done locally and well that is near a patient’s home, it should be done there. Specialty treatments can be done here.”