Multidisciplinary Pancreatic Cancer Care
Cancer of the pancreas is a uniquely challenging disease. Yet medical science is beginning to make progress in the fight against it, with new medical therapies and approaches, and surgical and radiotherapy advances.
UT Southwestern physicians are battling pancreatic cancer on multiple fronts, with the goal of improving not just patient survival, but personal well-being. In the Simmons Comprehensive Cancer Center’s Multidisciplinary Pancreatic Cancer Program, the battle starts with the logistical support that is needed to ensure that every needed specialist can evaluate each patient promptly and thoroughly in just one day. These specialists—nationally and internationally recognized experts in the medical, surgical, endoscopic, and radiotherapy tactics deployed against pancreatic cancer—develop a strategy that is tailored individually for each patient and his or her disease. As treatment progresses, that plan is revised or adapted, as circumstances warrant, by the same expert group. And from the outset, a team of supportive care professionals and volunteers is available to help patients cope with their cancer and its physical and emotional complications.
“What’s unique about our program is that it is truly interdisciplinary and integrated. We triage patients, determine everything they need, connect them with multiple specialists, and formulate and facilitate their treatment plan so they can begin treatment the very next week,” says Dr. Rebecca Minter, Surgical Director of the Multidisciplinary Pancreatic Cancer Program. “Otherwise they can end up with all of these parallel and sequential appointments, like being referred to a medical oncologist after a surgeon, then requiring additional tests, then needing a port placed for their chemotherapy—and the next thing you know it has been several weeks before they actually start their treatment.
“And obviously, with pancreatic cancer, time is of the essence.”
UT Southwestern physicians apply the same approach in their care of pancreatic cancer to patients at Parkland Hospital, Dallas County’s safety-net care provider and the university’s primary teaching facility.
In UT Southwestern’s Multidisciplinary Pancreatic Cancer Program, patients benefit from:
- Expedited testing and imaging at onsite facilities, with standardized radiology reports to ensure that patients’ tumors are precisely staged;
- Same-day development of a personalized treatment plan by the program’s multidisciplinary Tumor Board;
- Expertise in a range of complex surgical procedures, including minimally invasive operations that can speed patient recovery and the ability to perform complicated vascular reconstructions required to remove some tumors;
- The latest evidence-based chemotherapy, radiation, and combination treatment strategies;
- Access to novel immunotherapy treatments through Simmons Cancer Center’s robust clinical trials program;
- Proactive symptom management;
- Genetic counseling and testing, where appropriate;
- Cutting-edge UT Southwestern facilities and technology;
- Oncology-certified nurses and other professionals with expertise in cancer care;
- Easy access to experts in social work, nutrition, and music therapy who work regularly with pancreatic cancer patients, along with cancer-specific support from specialists in physical rehabilitation, psychology, and palliative care; and
- The opportunity to have specimens stored for ongoing and future research.
The comprehensive, coordinated care provided in the Multidisciplinary Program begins with one phone call to the patient intake specialist. From that point, a multitude of needs—procuring medical records and previous imaging; arranging for additional testing, biopsy, or port placement; facilitating travel for patients from out of town; and coordinating care with hometown physicians—are anticipated and managed by the Multidisciplinary Program’s patient nurse navigator, in collaboration with the program’s physician assistants.
“One of the biggest things patients are experiencing when they call us is a significant amount of anxiety, whether it’s a new diagnosis (of pancreatic cancer) or they’re coming for a second opinion because their first therapy isn’t working,” says Lan Vu, MPAS, PA-C, physician assistant for Division of Surgical Oncology. “That first contact tells patients, ‘We’re here for you, we’re giving you our undivided attention, and we’re already looking at your case now rather than just when you come for your first visit,’ ” she says.
Why Comprehensive Treatment Matters
The UT Southwestern/Simmons Cancer Center Multidisciplinary Pancreatic Cancer Program offers each patient a precisely coordinated, individualized treatment plan, using the latest evidence-based approaches to achieving the best possible outcome for the disease. The Multidisciplinary Program:
- Engages a team of highly skilled surgeons, radiation and medical oncologists, and other physicians who focus exclusively on pancreatic cancer / gastrointestinal malignancies;
- Offers review of each and every case by an expert panel, in order to develop a personalized, optimal treatment plan, and access to clinical trials, allowing patients to benefit from the newest and most promising therapies and technologies;
- Provides holistic support to help patients avoid complications and minimize side effects from treatment; and
- Features expedited, one-stop care, with testing, treatment, supportive care for overall well-being, and treatment records integrated at the same site.
Specialists at the Ready
The first clinic visit is designed so that physicians come to the patient, rather than the patient bouncing from one location to another. After the day’s appointments are completed, the full range of specialists in the Multidisciplinary Program meets, along with other professionals, as part of the Pancreatic Cancer Tumor Board.
Discussing and debating the details of each case, the board develops a consensus on the best plan of action for cancer treatment and related care. Instead of having to piece together a picture of their treatment from multiple specialists they meet one-on-one, patients at UT Southwestern leave the one-day clinic with a treatment plan in hand. That plan, along with treatment updates, is communicated to referring and primary care physicians.
“Everyone has input on each patient,” Associate Professor of Radiation Oncology Dr. Jeffrey Meyer, who specializes in pancreatic cancer and other gastrointestinal malignancies, says of the Tumor Board meetings. “It’s truly multidisciplinary input. There are going to be unique aspects to everyone’s case, so that’s why multidisciplinary input is essential.”
A key task of the board is to first classify each person’s cancer as metastatic or nonmetastatic, then further determine which of the nonmetastatic cancers appear resectable (versus borderline resectable, locally advanced, or currently unresectable; see sidebar). From there, the team develops an individualized plan, says Multidisciplinary Program Medical Director Dr. Muhammad Shaalan Beg, who is also Medical Director of the Simmons Cancer Center Clinical Research Office. “It is essential to take time and understand what the goals of care are—not just the medical team’s goals, but the patient’s goals. Fifty to 60 percent of the time we tweak ‘textbook’ approaches for some personal reason, which is directly related to the patient,” he says.
Developing a consensus on each case is important both for seamless care and patients’ peace of mind. “It’s very important to set the expectations for patients up front,” Dr. Beg says. “Patients leave knowing what their cancer is, how we approach that cancer, and they get the same message from every surgeon, every medical oncologist, and every radiation oncologist they see.”
At the same time the Tumor Board is reviewing cases, another expert team—comprising supportive services professionals, along with a volunteer from the Dallas-Fort Worth affiliate of the Pancreatic Cancer Action Network—is conducting the program’s Patient/Family Support Session. The session supplies information about the supportive care services that the Cancer Center and the Pancreatic Cancer Action Network have to offer, allowing patients and their caregivers to access important adjuncts to treatment when they are needed. These services can include minimizing the side effects of treatment, providing effective pain management strategies, and offering guidance regarding optimal nutrition and food choices.
“Pancreatic cancer has a significant emotional impact,” Dr. Minter says. “The Patient/Family Support Session is designed to ensure that patients have much more than just their medical needs met. Our goal for patients is a longer quantity of life and a better quality of life.”
Why Tumor Board Review Matters
Patients receiving care in the UT Southwestern Simmons Cancer Center Pancreatic Cancer Multidisciplinary Program benefit from expert, same-day review of their cases and development of their treatment plans. Review by the Pancreatic Cancer Tumor Board:
- Engages a full range of specialists—including surgical, radiation, and medical oncology, radiology and cancer genetics, as well as other disciplines—to scrutinize the details of each patient’s specific case;
- Relies on the latest scientific findings in pancreatic cancer to guide its review and recommendations, developing an evidence-based consensus opinion on the most promising course of treatment;
- Offers access to clinical trials testing the newest potential therapies for pancreatic cancer; and
- Provides ongoing review of each patient’s response to treatment, and always considers the best next step for each individual patient.
A Full Range of Care
The Multidisciplinary Program features specialists from multiple medical and oncology disciplines, who focus exclusively on pancreatic and other gastrointestinal cancers, to expeditiously address issues specific to each patient. For instance, individuals with a newly identified pancreatic mass might see gastroenterologist Dr. Nisa Kubiliun, who specializes in interventional endoscopy.
In a procedure known as endoscopic ultrasound (EUS), Dr. Kubiliun guides a thin tube into the mouth and down into the stomach and first part of the small intestine. At the tip of the tube is a small ultrasound probe that emits sound waves. The sound waves bounce off surrounding structures, such as the pancreas, bile ducts, and liver, and are recaptured by the probe and converted into black-and-white images that the physician interprets. Because it sits next to the stomach and small intestine, the pancreas can be imaged in great detail with EUS.
Pancreatic tumors also can be biopsied in a minimally invasive way via EUS in order to establish a diagnosis.
Another endoscopic procedure, ERCP (endoscopic retrograde cholangiopancreatography), is used to address a common pancreatic cancer complication, jaundice, which can result from an obstructed bile duct. “An obstructed bile duct leads to a variety of different problems: infection, malabsorption (of nutrients), fatigue, inability to receive some chemotherapy agents,” notes Dr. Kubiliun. ERCP can be used to diagnose the site of obstruction, image the problem in anticipation of surgery, or to place a stent to relieve blockage of the biliary tree. Stenting can alleviate the obstruction, help improve liver function and perhaps allow for additional treatment such as chemotherapy or surgery, Dr. Kubiliun says.
“Fewer than 20 percent of patients have operable pancreatic cancers at the time of diagnosis, and we know only surgery can offer a chance for cure,” notes Dr. Minter. But pancreatic cancer is unique, and notorious, in that a large proportion of cancers come back after surgery. Offering treatment—chemotherapy and/or radiation—before surgery can increase the chance of a successful operation.
That highlights the importance of strong collaboration across disciplines to provide a full range of therapies for the treatment of pancreatic cancer—attacking it from multiple angles. Chemotherapy, a systemic therapy that circulates in the bloodstream, is used to treat patients with metastatic cancers. It also can treat microscopic tumor implants that have not yet grown big enough to be visualized, providing additional treatment following surgery, or it may shrink a tumor before an operation—rendering a more advanced tumor more easily resectable.
Radiation therapy is a third treatment strategy that can be used to treat tumors that cannot be resected, or as an adjunct before or after surgery. How these treatments are sequenced depends on each patient’s unique scenario.
UT Southwestern’s surgical oncologists are among the most experienced in the United States, skilled in performing an array of intricate procedures. This expertise is evidenced in the fact that they outperform peer institutions with respect to peri-operative mortality for pancreatectomy as measured by Vizient, the University Hospital Consortium, and perform in the top 20 percent of institutions as measured by the National Surgical Quality Improvement Program (NSQIP).
“One of the advantages of our approach at UT Southwestern is that every patient is guaranteed to see an expert in their particular disease,” says Associate Professor of Surgery Dr. John Mansour, a surgical oncologist in the Multidisciplinary Pancreatic Cancer Program. “We have the depth of talent among our surgeons to make sure that each patient is cared for by someone who has the most contemporary, patient-centered, and innovative approach available.”
This allows the surgical team to provide the approach best suited for each individual case, and to minimize complications. Surgeons on the team perform high volumes of potentially curative operations, including the complex Whipple procedure (the most common surgery to remove tumors in the head of the pancreas). The team also has expertise in minimally invasive—robotic and laparoscopic—pancreatectomy, an approach that can facilitate a faster recovery.
“If you have pancreatic cancer, it’s critical that you go to a high-volume center that takes care of a lot of patients with pancreatic cancer,” Dr. Minter says. “Surgeons’ expertise, as evidenced by a high volume of cases, has been demonstrated to equate with improved surgical outcomes.”
Recent surgical advances are making it safer for pancreatic cancer patients with more advanced, delicately situated cancers to undergo tumor resection. UT Southwestern is one of just a handful of institutions in Texas that is skilled in these complicated operations, which can require removal and reconstruction of major blood vessels near the pancreas. “This means that a tumor that someone else may deem unresectable may actually be resectable, and we can resect it,” Dr. Minter says.
One of the most important steps a surgeon taking care of a patient with cancer can make is to pause and consider nonsurgical aspects of care. “A critical aspect of planning surgery is the participation in planning all phases of care including chemotherapy and radiation,” Dr. Mansour says. “At UT Southwestern, we stress the importance of collaboration with the rest of the oncology team in order to get the best results for our patients. Often that means shrinking the tumor with chemotherapy or radiation prior to removing it.” Combining treatments in that way can lead to faster recovery and improved patient survival.
Why Your Surgeon Matters
Surgery for pancreatic cancer can be highly complex, and is a critical component of care for some pancreatic cancer patients. UT Southwestern’s pancreatic cancer surgical oncology team:
- Performs a high volume of pancreatic surgeries, including intricate Whipple procedures, making UT Southwestern one of the most experienced sites in the region for such operations;
- Offers minimally invasive (robotic and laparoscopic) surgeries for removal of pancreatic tumors, which can speed patients’ recovery;
- Is skilled in reconstruction of blood vessels affected by pancreatic cancer, a sophisticated procedure that can help patients with advanced tumors; and
- Collaborates closely with other members of each patient’s treatment team to ensure appropriate follow-up treatment and supportive care.
For the vast majority of pancreatic cancer patients, chemotherapy plays a vital therapeutic role. In metastatic disease, the stage at which nearly half of cases are diagnosed, chemotherapy is used almost exclusively as a primary treatment, and can help stabilize a cancer and extend patient survival.
Combination chemotherapies have been found to lengthen patient survival and improve well-being compared with previously used treatments, says Dr. Beg, a medical oncologist.
“More cancers are shrinking; more patients are living longer with better disease control and quality of life,” he says.
In patients with borderline resectable or locally advanced cancers, treatment with drug regimens, sometimes followed by a separate combination of chemotherapy and radiation, may be used in an effort to shrink a tumor, pulling it away from major blood vessels to make surgery viable and to improve the odds of a complete resection. Hence, more and more pancreatic cancers are becoming operable.
Studies have suggested that when these combination chemotherapies are used, “even if we don’t see a response on imaging, we can still frequently achieve a negative [tumor] margin for those patients ” Dr. Minter says. “That has really changed how we think about patients with borderline or locally advanced tumors, and we are more willing to take them to surgery following chemotherapy or chemoradiotherapy.”
In patients whose cancers appear resectable from the start, follow-up chemotherapy is generally administered. And researchers at Simmons Cancer Center and elsewhere are testing whether chemotherapy given to these patients additionally before surgery might improve long-term cancer control—without the delay in initiating any chemotherapy that currently occurs while a patient recovers from an operation.
Outside the clinical research environment, administering chemotherapy first for resectable cancers is considered at UT Southwestern on a case-by-case basis, Dr. Beg says. “The only reason we can do this is our multidisciplinary team can discuss options thoroughly for each patient and get buy-in,” Dr. Beg says.
If it turns out such a cancer is no longer resectable after a couple of months of chemotherapy, doctors know that surgery would have been unlikely to stop the cancer to begin with and the patient is spared a big operation, he adds.
In Search of Better Medicines
Patients in the Pancreatic Cancer Multidisciplinary Program are continually evaluated for clinical trials. Trial coordinators attend the weekly Tumor Board meetings, noting which patients are eligible for trials open at Simmons Cancer Center.
“At UT Southwestern, we have the advantage of working with top-notch scientists who are at the cutting edge of basic science discoveries,” says Dr. Beg, who is principal investigator for multiple studies testing medicines for pancreatic and other GI cancers. “These scientists are leading studies to understand the molecular makeup of pancreatic cancer, and developing drugs to target those changes. Such discoveries are being tested in clinical trials at the Simmons Cancer Center.
“The Multidisciplinary Pancreatic Cancer Program allows us to find the right patient for the right trial. We can then expose our patient’s cancer to drugs that may not be available in the market for many years. At the same time, we learn how to advance these drugs in the battle against pancreatic cancer.”
The number of new cases of pancreatic cancer, unlike other cancers, is on the rise. Yet science has a lot of catching up to do in developing medical therapies for pancreatic cancer compared with, say, lung or breast malignancies. “A pancreatic cancer patient has one or two choices; a breast cancer patient has many, many more,” says Dr. Beg, who is part of the National Cancer Institute’s (NCI) Pancreatic Cancer Task Force, which makes recommendations for clinical trial planning.
Clinical trials at UT Southwestern frequently are initiated by the university’s own faculty, based on their scientific discoveries, with principal investigators who participate in numerous national trials. The Simmons Cancer Center’s pancreatic cancer investigators regularly present their findings in leading journals and conferences. As an NCI–designated Comprehensive Cancer Center, Simmons has opportunities to open clinical trials supported by that agency or by collaborators in the pharmaceutical industry, which are frequently paradigm-defining studies.
That’s important to patients because “it shows that our teams are broad as well as deep,” Dr. Beg says, describing a collaboration involving noted UT Southwestern diabetes researcher Dr. Philipp Scherer. The work is shedding new light on how diabetes that develops due to pancreatic cancer differs from diabetes in the broader population. Such an insight might someday help in screening for pancreatic malignancies, or make chemotherapy more effective by incorporating an existing diabetes medicine. “We are able to understand the processes that are driving these cancers,” Dr. Beg says.
Scientists at UT Southwestern are leading a multipronged approach to understand how to best treat patients with pancreatic cancer. Research includes trials of two new chemotherapies for pancreatic cancer. One, a phase I trial, is testing a drug called beta-lapachone that was developed in research led by Simmons Cancer Center Associate Director of Translational Research Dr. David Boothman.
Beta-lapachone was initially discovered in the bark of the Pau d’Arco tree and chemically synthesized. Dr. Boothman has shown that the drug is activated by an enzyme present on cancer cells and makes hydrogen peroxide, which damages DNA and kills the pancreatic cancer cell. The activating enzyme, called NQO1, is not present in non-cancer cells, which are spared.
To explore this strategy in clinical trials, Dr. Boothman and Dr. Beg have been awarded a series of grants by the Pancreatic Cancer Action Network and have published their findings in highly regarded journals. Most importantly, these clinical trials have a robust strategy to send patients’ tumor tissue back to the laboratory to understand why, or why not, the drug is working.
It’s essential to have a pipeline of trials to test various strategies, says Dr. Beg, noting that such work—which translates findings from the laboratory to the clinic, and then back to the laboratory—requires a high degree of coordination and leadership. That’s possible only in Comprehensive Cancer Centers, where collaboration between multiple disciplines is woven into the fabric of the institutional culture, he says.
The Role of Radiation Therapy
Radiotherapy can play a role in pancreatic cancer at any stage, although how best to deploy it at different stages can be subject of debate. “Radiation has a long history of use in pancreatic cancer, but it’s certainly not a black-and-white issue,” says Dr. Meyer.
In patients with metastatic cancers, radiotherapy may help alleviate pain caused by the primary tumor or metastases. For borderline resectable cancers, the goal of radiation—usually administered up front in combination with chemotherapy- is to enhance the likelihood that surgery can follow and that negative tumor margins may be achieved, Dr. Meyer says. “We’re trying to get these patients to the OR,” he says. “For me, it makes sense to ‘throw the kitchen sink’ at the tumors to enhance the likelihood that we will get a margin-negative surgery.”
A conventional course of radiation is given daily on weekdays for 5.5 weeks. However, Simmons Cancer Center researchers are also experimenting with shorter courses (and more concentrated doses) that are delivered with a radiotherapy technique called stereotactic ablative radiotherapy or stereotactic body radiation therapy (SBRT), in which a total of just five treatments are given. In pioneering research at UT Southwestern, SBRT has proved to be a powerful tool in fighting other cancers such as lung cancer.
For patients with resectable cancers, use of radiotherapy differs from center to center. At UT Southwestern, “in general, we will consider radiation in someone who’s had an operation and completed adjuvant chemotherapy, to try to reduce the risk of cancer coming back locally,” Dr. Meyer says. Radiotherapy would likely not benefit patients whose cancers metastasize during or soon after chemotherapy, he notes.
The use of radiotherapy also varies in patients with locally advanced pancreatic cancers. Generally at UT Southwestern, those patients will start with chemotherapy and be continually re-evaluated, depending on their individual circumstances. “If they’ve been on chemotherapy for a long time, sometimes toxicities arise, and we may switch them to chemoradiotherapy, Dr. Meyer says. SBRT’s short course of treatment doesn’t interfere with the ability to resume full-strength chemotherapy quickly, he adds. UT Southwestern is participating in a multi-institutional clinical trial testing chemotherapy with a regimen called FOLFIRINOX versus FOLFIRINOX then SBRT then a return to chemotherapy in patients with locally advanced, unresectable cancers.
In the future, pancreatic cancer patients may benefit from an entirely new type of radiotherapy, called carbon ion therapy. Like cutting-edge proton therapy, carbon ion therapy appears to be containable to targeted sites, rather than delivering radiation to healthy tissue too, as conventional X-ray beams do. Carbon ion radiation may also be more potent at killing cancer cells than comparable proton doses are. “There’s a lot of interest in carbon ion for both the physics and the biological aspects of it,” Dr. Meyer says.
Because carbon ion therapy is not yet available in the United States, UT Southwestern—in an effort driven by Associate Professor of Radiation Oncology Dr. David Sher—is partnering with institutions in Japan and Europe to compare the new therapy with conventional X-ray radiotherapy. Local patients in the study who are selected to receive carbon ion therapy would receive treatment overseas.
Banking for the Future
Patients in treatment at UT Southwestern are also invited to allow their blood and tissue samples to be used for research. Scientists are searching for biological markers that may help predict which pancreatic cancer patients are more likely to respond to specific therapies, and markers that could help monitor tumor response during treatment or detect a recurrence quickly, says Dr. Adam Yopp, Assistant Professor of Surgery.
“It’s kind of the holy grail in cancer, to figure out which biomarkers are predictive,” says Dr. Yopp, a surgical oncologist in the Multidisciplinary Pancreatic Cancer Program and Director of the UT Southwestern Simmons Comprehensive Cancer Center Tissue Management Resource. “Right now, unfortunately, it’s all really at the research level.” A blood test now used to evaluate disease status in pancreatic cancer is a far-from-perfect measure, Dr. Yopp says. The test, CA 19-9, measures proteins associated with pancreatic cancer, but the proteins also can be elevated when other conditions are present.
Science’s approach to classifying different cancers—and then treating them—is beginning to undergo a seismic shift, Dr. Yopp notes, from focusing on the physical location/organ site of a tumor to understanding the molecular pathways that drive unchecked cell growth. That reclassification will drive treatment decisions.
“Tissue banking and its subsequent research serves to eliminate a lot of these silos of one cancer versus another and looks at the disease as pathway-driven,” Dr. Yopp says. “That’s what the future is, chemotherapy based on mutational status and not just the cancer itself.”
On their very first clinic visit, patients have a chance to connect with supportive services team members as well as volunteers from the local affiliate of the Pancreatic Cancer Action Network. Participants in the session learn how to access a full range of support professionals that can address needs related to their physical, emotional, spiritual, and financial health.
“All these pieces are really important to a patient’s journey,” Dr. Minter says. “But they’re often minimized, or attention is not paid to them until there’s a crisis and the patients need help, and they don’t know where to get it.”
Dietary support for pancreatic cancer patients at Simmons is comprehensive and proactive, introducing patients to concerns they should be aware of before they start treatment, while encouraging them to maintain food intake in order to support their recovery. Then, if any of a number of dietary problems arises, patients know how to get help right away, says clinical dietitian Shelli Hardy, MCN, RD, LD.
Common concerns after a Whipple procedure, for instance, include diabetes, malabsorption of fat (and fat-soluble vitamins), and slow emptying of the stomach. Malabsorption can often be treated with enzymes, but if the underlying cause is an overgrowth of bacteria in the small intestine, eating probiotic rich foods such as yogurt and sauerkraut and minimizing snacking may be recommended.
Changes in appetite occur frequently regardless of what type of treatment the patient has received. In that case, patients are urged to eat small meals and make every bite count nutritionally (with guidance provided on how to increase protein and calories). Nutritional needs are likewise addressed for patients with nausea, who are counseled on how to take their anti-nausea medicines and on strategies to replenish fluids and electrolytes.
“I believe in letting people know that they shouldn’t tough anything out—nausea, poor appetite—because we’re here to help,” Ms. Hardy says. “And if you can tolerate your treatment, that’s your best shot at being successful.”
Music therapists are also available to pancreatic cancer patients at Simmons. Patients who are at the clinic when these professionals are present are likely to “hear us singing from the hallways,” says music therapist Christina Stock, MA, MT-BC.
Ms. Stock introduces herself to patients and caregivers at the Support Session, and when she meets with them one-on-one, she assesses how they are managing the many stressors related to cancer and its treatment. Music therapy addresses those concerns with calming music or a guided relaxation that can stabilize heart rates and increase oxygen saturation, she says. And learning a patient’s musical tastes, and what their cancer journey is like, can allow a therapist to write a new song, or rewrite lyrics of a familiar song, to fit the patient’s personal story and allow them to express themselves.
“Patients can benefit from music therapy if they're experiencing anxiety, pain, depression, emotional or spiritual issues, family or caregiver stress, anxiety toward an upcoming medical procedure, or body image concerns,” Ms. Stock says.
Oncology social worker Catherine Credeur, LMSW, OSW-C, helps ensure patients and families can access all the services they require and are supported in their efforts to cope.
Individuals from afar may need to find financial support and lodging to receive care at UT Southwestern, or arrangements to be made for care and support to be provided in their hometown, by phone, or online. Patients and caregivers might benefit from guidance in understanding the Family and Medical Leave Act, extending employer health insurance coverage, or applying for disability benefits and later Medicare. Oncology social workers also consider how people are functioning at home and what community resources, such as home health/rehabilitation services, might be needed.
Mental health support is also crucial. “It’s part of my role as a social worker to assess where people are in their coping and if they can have their needs met with peer support and their care team, or if they need more formal mental health services—and then making the appropriate connections for them,” Ms. Credeur says.
Cancer impacts not just each patient, but extended networks of family and friends, including in some cases young children, she says. As a social worker, she often assists with family concerns individually. Also, the Simmons Cancer Center’s EMBRACE survivorship seminar series for patients, caregivers, and other loved ones addresses various family issues.
“Many people are surprised there is a family-centered focus here,” Ms. Credeur says. “Oncology social workers look at the patient as part of a family system that is all impacted by the cancer. We talk about how to explain cancer to the patient’s children or grandchildren, how to help teens and young adults express their thoughts, and how caregivers can sustain their health throughout their focus on the patient.”
Pulling it All Together
Cancer centers across the U.S. have developed programs for pancreatic cancer patients. However, Simmons Comprehensive Cancer Center is among only a few that have assembled such comprehensive expert care at one site, with all of it centered on the patient experience.
“It’s one thing to get a couple of doctors in a room so they can huddle over a CT scan and call it a tumor board,” Dr. Beg says. “But to get all the supportive services together, standardize radiology reports, funnel the patients all through one channel for streamlined care—that’s really important.
“And having clinicians who attend basic science meetings and basic scientists who attend clinician meetings is something you won’t see in 99 percent of centers. It really shows these are people who have invested a lot in pancreatic cancer and made it their life’s mission to change outcomes in pancreatic cancer.”
Accessing the UT Southwestern Pancreatic Cancer Programs
Patients may be referred by a medical professional, or may refer themselves, to the Simmons Comprehensive Cancer Center’s pancreatic cancer programs. Patients with a pancreatic mass, pancreatic cyst, dilated pancreatic duct, or a high-risk condition for the development of pancreatic cancer should be referred for evaluation in these unique multidisciplinary programs. Making a referral is easy—contact UT Southwestern Simmons Comprehensive Cancer Center’s patient intake specialist at (214) 645-0100; fax (214) 645-9292. Referrals are accepted both for patient care and second opinion consultations.
Highlights of the pancreatic cancer programs include:
A single point of entry. Referrals are made through the pancreatic cancer programs’ patient intake specialist. The intake specialist is the sole point of entry for both the Multidisciplinary Pancreatic Cancer Program (for treatment of pancreatic cancer or other pancreatic tumors) and the Pancreatic Cancer Prevention Program (for patients with a finding of a pancreatic cyst, or a genetic or family history that increases their risk for pancreatic cancer).
Coordination and preparation. After the patient intake specialist schedules the appointment, the programs’ patient nurse navigator will collect necessary records and test results; determine logistical needs for patients coming from out of town; ask patients about symptoms, medical and family history, and previous genetic testing; schedule any additional testing or imaging as required; and build a case file.
“By gathering and reviewing records ahead of time, we are able to give patients an idea of what to expect, order necessary studies, and provide them with a point of contact should they have questions. By taking these extra steps, we’re ahead of the game and not waiting for the first clinic visit to order important tests,” says Lan Vu, MPAS, PA-C, physician assistant for the Division of Surgical Oncology.
A one-stop clinic. After each patient file undergoes a preliminary review, the patient nurse navigator will schedule a one-day clinic visit. At that visit, the patient will have appointments lined up with the various specialists needed for comprehensive preventive care or cancer treatment, with necessary tests scheduled and a treatment plan provided at the conclusion of the visit.
A proactive plan. Specialists in radiology, gastroenterology, and surgical oncology meet the same day of the patient’s clinic visit to evaluate each case and develop a plan of care that may include further testing or continued surveillance. In the case where a pancreas cyst has worrisome features, surgery may be recommended. The patient navigator arranges all necessary follow-up steps, either at UT Southwestern or through other providers, if needed, such as for out-of-town patients.
Multidisciplinary cancer care. For patients with pancreatic cancer, whose visit to the clinic is scheduled within a week of their initial referral, the Multidisciplinary Program is likewise comprehensive.
On the same day each patient is meeting with the necessary cancer care providers, his or her case is reviewed—and a treatment plan is developed—by the Multidisciplinary Program’s Pancreatic Cancer Tumor Board, a conference of specialists in medical, surgical and radiation oncology, radiology, cancer genetics, and clinical research.
“Patients are getting the opinion of multiple physicians, rather than just the one they’re seeing, streamlining the process rather than having different appointments over several weeks,” says Chris Bishop, BSN, RN, patient nurse navigator for the pancreatic cancer programs. “Our goal is that they have a visit with every physician they need to see, and by the time they leave that day they’ll have a treatment plan in place.”
Clinical trial evaluation. All patients evaluated in the program are also screened by the research team to see whether the patient is a candidate for a clinical trial at UT Southwestern.
Cancer genetics review. Certified genetic counselors review patients' personal and family histories for any suggestion of a hereditary condition that may be contributing to their cancer, and referral for formal genetic counseling (including possible testing) is arranged as appropriate.
Support and more. As part of the one-day visit, cancer patients and their caregivers are invited to take part in a lunchtime Patient/Family Support Session, which outlines a wide range of community and UT Southwestern support services and resources.
Communication with other providers. Details of each patient’s cancer care plan, treatment, and follow-up recommendations developed over the course of therapy are routinely communicated to the patient’s primary care and referring physician.
“That is really important for patients,” Ms. Vu says. “We want to make sure that their local physicians are kept in the loop. This type of communication is essential for achieving a continuum of care for our patients.”