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Dr. Charles Vollmer, Pancreatic Surgeon
Charles M. Vollmer, MD, is a nationally and internationally respected surgeon, researcher and thought leader in the field of pancreatic cancer and gastrointestinal surgery. He is the immediate past president of the Americas Hepato-Pancreato-Biliary Association (AHPBA), the world’s preeminent society of surgeons performing pancreatic surgery.
In this interview, Dr. Vollmer discusses pancreatic cancer and it’s current surgical techniques and treatments, including the Whipple procedure, neoadjuvant therapies, as well as the benefits of the multidisciplinary team approach at Penn Medicine to ensure best possible treatment plans and outcomes.
Podcast Interview Transcript
Melanie Cole (Host): Pancreatic cancer will afflict over 55,000 people a year in the US, often referred to as the silent disease, because most people do not experience symptoms until it’s later stages. Pancreatic cancer is annually, the second most mortal cancer. The five year survival rate is just 8% for all patients with the diagnosis but improves to around 25% if surgery can be performed.
Penn Surgery has one of the strongest most expert pancreatic surgical specialty units in the country. Penn Medicine’s group of five surgeons directed by Dr. Charles Vollmer performs nearly 200 major operations including Whipple resections a year.
They provide state-of-the-art surgical expertise which integrates with the other strengths of Penn Medicine including medical and radiation oncology and associations with basic and translational scientists in the medical school. They also offer the region’s only dedicated multidisciplinary program for premalignant pancreatic cysts.
Dr. Charles Vollmer is a professor of surgery at the Perelman School of Medicine at the University of Pennsylvania. He is a nationally and internationally respected researcher and thought leader in the field and the immediate past president of the AHPBA, the world’s preeminent society of surgeons performing pancreatic surgery. His research focuses on improving pancreatic surgical outcomes especially in the most impactful problem, pancreatic leaks.
Today, we are talking about the Pancreatic Cancer Surgery Center and the Whipple Procedure Program at Penn Medicine.
Welcome. Dr. Vollmer I’m so glad to have you on with us today. Why is pancreatic cancer commonly caught so late and why is it so hard to treat?
Charles Vollmer, MD (Guest): Well basically, the problem is that it’s caught in the Netherlands of the abdomen. And what I mean by that is it’s not obvious externally through palpation or visualization as other cancers of the body often are like melanomas or breast cancers and the like. So, basically, it’s a situation in the depths of the abdomen makes it very hard. And the second this is that the only real sign that comes about for most people that is obvious is the onset of jaundice and that’s when the tumor is situated as it often is, near the common bile duct and gets to the point of blocking that, that that becomes the first sign. However, it can take a long time for a tumor from it’s genesis to get to that point.
Secondly, there are a number of tumor – and when I say a long time, I’m talking on the order of five to fifteen years biologically from the onset of that tumor to getting to the point of blocking the bile duct. And then secondly, there are a number of places in the pancreas other than around the common bile duct. So, there could be tumors throughout the rest of the gland that really do not manifest in a physical symptom at all. So, it’s oftentimes that the tumors are found quite late because they are silent basically.
Host: Really good information. So, Dr. Vollmer, tell us about the Whipple procedure and Penn’s expertise. How does someone go about choosing a surgeon or a program that performs it and what would you like other providers to know about referring?
Dr. Vollmer: So, the Whipple procedure is, I’ve always considered it the largest surgery, elective surgery that there is in terms of the scope of the procedure. It’s what we call high acuity surgery and it combines two elements to that. There is incredible technical expertise necessary to pull it off. It’s long operation. But it also brings with it a certain package of what the patient is physiologically. This is not surgery on young people. This is very most often from the age of 65 and above for most people. And many of those people have comorbidities.
You are balancing not only a very precise technical operation, but you are dealing with patients who are should I say more rickety or more vulnerable physiologically to undergoing such a hard procedure as well. So, there’s a lot of expertise that goes into it.
In general, the operation is done about eight to ten thousand times a year in America. There’s been a large seismic shift I guess in my career over the last 25 years of having this centralized at centers that do this frequently and often in what we would call regionalization or at specialty centers. The reason for that is that as I said before, the difficulty of what it takes to do this, to learn it and to actually get the learning curve to be good at it, requires that this be done often.
Unfortunately, this is not like cardiac surgery where there is many more procedures to be had, the disease process is more prevalent, etc. So, it’s not like these procedures are out hanging on trees. And to get that expertise, really requires that you be in a centralized place that has a strong referral base for this.
The next most important element to this is that it’s not just about the surgeon and the operation; it’s very much about the center and the multidisciplinary care of the patient both before the operation and after the operation. Particularly in the ability to recover, to deal with tough physiologies and tough patient care as well as to recover complications which are frequent in this operation.
Host: Then let’s speak about patient selection criteria. Who is this procedure indicated for and what are some of the clinical contraindications for performing the procedure?
Dr. Vollmer: So, in general, if we are going to talk about – this procedure, the Whipple procedure means removing the head of the pancreas, the duodenum and the gallbladder. And its what’s used on the front end of the pancreas when the pathology is situated there. Pancreatic resections also happen on the other side of the gland, that’s called a distal pancreatectomy and you can even take the whole pancreas out in certain circumstances.
In general, I can talk about the whole gamut of what it takes to do a pancreatectomy. Generally, these are done mostly for cancers. About 50-60% of our reasons for pancreatectomy are for malignancy of some sort dominated by adenocarcinoma of the pancreas. We also do neuroendocrine tumors which falls into that and then any of the other periampullary tumors which constitute things on the duodenum or the ampulla of vater.
However, there are other indications to do these procedures that are not just about cancer and any specialty center will do the full gamut of these. And these would include pancreatitis, as well as cysts, pancreatic cysts which are generally felt to be premalignant and in which some of the operations are more on a prophylactic basis for this.
So, we have a lot of different reasons why someone would come in with a need for a pancreatectomy. The big picture story is at this point in time, going on to 2020 at this point; there aren’t a lot of daunting contraindications to us in terms of physiology. We are able to perform this operation on people who are very, very sick in terms of comorbidity and in essence, there are very few things from a cardiac or pulmonary standpoint that would stop us from proceeding.
Some things that are kind of a little bit more contraindicated would be things like cirrhosis of the liver, and dementia and chronic pulmonary function where someone is on oxygen support at that point. And a lot of this has to do with the effects of recovery thereafter and the need to invest in the operation both physically and mentally thereafter.
We, as surgeons, would like to see patients in our office and make the decision as to their suitability for resection rather than having someone assumed not to be resectable or operative, I should say.
The other thing is that age is quite commonly thought of as a problem let’s say for going to operation. It really has nothing to do with the patient’s numerical age but more about their physiologic age and their state of wellness basically and fitness. I’ve done these Whipple operations on 90-year-olds plus. I’ve also done them on 18-year-olds. So, age by itself is not a contraindication and we in specialty centers can pull off a pancreatectomy with equivalent outcomes for people over 75 and greater as compared to those younger than that.
Host: What an interesting point you were making. Dr. Vollmer, so, tell other providers some approach considerations or technical considerations you’d like them to know about. Are there certain things that you are doing that you would like them to be aware of?
Dr. Vollmer: Well sure. The operation itself has really been streamlined into a pretty reproducible technical endeavor these days. The early days of the frontier of operating on the pancreas are well behind us at this point and I would say there was probably a couple of errors along the way but around 1980 is when we would call the more modern era of pancreatic surgery where people actually could get the operation and not regularly die from it. and that was a big switch in time.
And then I think in the new millennium here in the 2000s is where we’ve really become refined and sophisticated with this operation and one of the things about that is that the training process for this has evolved and matured. The early pioneers who did the operation were basically on the wild, wild west frontier and trying to figure out what they could and could not do in the abdomen, what they could get away with and what the results of what they did would be on the patient thereafter.
We have got a huge library of knowledge at this point to bring this down to a very tidy elective procedure. The element of the training is very important because we are now into a situation where virtually everyone who is doing this, either has exceedingly big experience from years or decades of having done it or they have come up in a fellowship training paradigm in the last 15 years or so. And we now have somewhere on the order of 20 to 30 or 40 fellowships around the country that are teaching people how to do the operation and condensing the expertise into a very focal period such that they can come out and pull this off successfully.
So, I think that’s really helped the operation come along. And you asked me sort of about technical scenarios. I guess we could get back a little bit to the suitability and selection of doing the operation particularly for cancer and that is that essentially for pancreatic cancer, only about 20% of the patients that have that disease will be eligible to get a curative attempt operation. And that’s a very sad, sobering fact that goes back to your first question about the hard detection of this.
One of the biggest things that is a real contraindication for us is metastatic disease. It realistically is something that should not be considered in this day and time as a reason to go forth with the operation. A lot of people will not even get to our office because of that. On the other hand, we have resectable disease which is clearly evident that the tumor can come out physically through the operative setting but what’s been fascinating for us in this current era is the gray zone in between those two and that’s called locally advanced or borderline pancreatic tumors. And we are actually a field where that term borderline is the only field in oncologic surgery where we use that word and that word means we are not sure if it can come out or not completely with a clean margin.
And there’s about 30% of the patients who present with this disease who have that scenario and it’s become a very, very challenging field for us because we are working with our peers in medical and radiation oncology to try and downstage tumors to make them resectable. And one of the concepts for that is neoadjuvant therapy which we might get into a little bit later with other questions. But the idea is to downsize tumors to get them to the point where we can technically attack them at this point.
But to sum it up, I would say that the operation itself, at this point, is very well understood and reproducible and sort of cookbook in a way. We are not experimenting and exploring and the people who have been around the block with this have seen the variations and the nuances of this enough to be able to take on anything that presents itself from a technical challenge standpoint.
Host: Well you certainly did segue into my next question on neoadjuvant therapies and also, I’d like you Dr. Vollmer to speak about follow up. How long is it done and how does it take place in a multidisciplinary manner that involves many different expertise?
Dr. Vollmer: Yes, so I’ll talk about neoadjuvant at first and then follow up with follow up. Neoadjuvant is a process. So, the word adjuvant means additive therapy. That’s the base of it. And generally, historically, for most cancers, chemotherapy would come after a curative resection of the tumor. There have been other tumors of the body where the paradigm has been shifted and the chemotherapy and radiation approach would be given preoperatively in a manner to either get tumors to be more amenable for surgery or even improve their survivability thereafter and the outcome oncologically.
This has been championed mostly in rectal cancer, some settings in breast cancer and esophageal cancer. And pancreas – we in the pancreas have sort of lagged behind with this but there have been certain centers in the country that for about 25 years now have tried to push this concept of giving the therapy ahead of time.
What it does is it provides us an ability to actually see the biology of the cancer in real time.
We can treat it in a way, in a form, but we can also find out how aggressive it is in terms of its behavior. If it’s going to go on and become very aggressive and spread to metastatic disease; we’d like to know that such that it doesn’t – so that we don’t do an unnecessary operation that has little value. So, it’s got an ability to be – help us with the selection of our patients to help you get – the patient get to a winning situation in terms of cancer free survival thereafter.
It's been used more and more frequently, and it’s commonly used in these situations where the tumor itself is uncertain whether it will come out based on its technical considerations particularly having to do with the apposition to major blood vessels in the upper abdomen. So, we use the neoadjuvant approach to figure out if those patients are going to be able to get the surgery and who among them will do the best. So, it’s going on. It is still in its basic infancy in terms of results and knowledge base about it. But virtually every major center dealing with pancreatic cancer is converting to doing more and more neoadjuvant therapy because it has worked in other places.
Now the other question I believe was about follow up and I think you are talking about thereafter. You did bring up the word multidisciplinary and what that basically means is that the decision making for pancreatic cancer care should not be in the hands of any single doctor. This really is a team sport. And it requires people to make good decisions and care for the tumor in different ways.
And it also requires other doctors in the medical center to help with the recovery of problems thereafter.
So we are talking about a full array not only the oncologist that we work with and radiation oncologist but also teams of radiology doctors, gastroenterologists, pathologists, and the like to bring together a full multidisciplinary care. That basically is the foundation of going forth to the operation is having a good collaborative team helping to make the decision about who is appropriate for the surgery and how you are going to attack the patient care before and thereafter.
In terms of follow up thereafter, in terms of surgery; we basically need to get the patient through the initial storm of the operation. And this operation takes a wallop on a patient and I tell people it takes about three months to get over the operation to be to the fitness and the feeling of perfectness that you were before the operation, the baseline health that you have. I used to tell people that was six months back when I was training and when we had patients in the hospital for about three weeks at a time. Now we have patients in the hospital for about a week and the recovery is about 70 to 80% there when they leave the hospital. And then it’s going to take about another three month period to get to the point of full wellness with that, thereafter.
In the short term period, the surgeon is very important in being the quarterback and the captain of the care thereafter. And then at that point on, usually about a month after the operation or so is when we get involved with the medical oncology doctors for cancers and sort of pass the baton of the cancer care to them to take on the next phases of the multidisciplinary care.
I personally see a patient at one month after the operation, four months after the operation and then a year and basically checking up on the anatomical and surgical implications of the operation but in that whole period of time; there’s a transition to the oncology expertise that goes on thereafter.
Host: Wow. Really a great explanation. Dr. Vollmer what is current research indicate for future developments in treatment? Give us a little blueprint for future research and while you are doing that, please wrap it up and tell other physicians what you’d like them to know about the Pancreatic Cancer Surgery Center and the Whipple Procedure Program at Penn Medicine.
Dr. Vollmer: Okay, so the research elements are – I will tell you, I’ve always told people that we are currently warriors against this disease and that compared to other fields of cancer particularly GI cancers; we are really lagging by about 30 years and this has a lot of reasons. First of all, the operation and the incidence of the disease is a lot less than other cancers of the body.
There are fewer doctors at the research level or the clinical level who are interested in the pancreas as an organ and the diseases that there are and as we started the show off, there is a difficulty in the detection aspects for this as well as acquisition of tissues. It’s a lot different than let’s say a melanoma situation where you can have something seen and available and they can get the tissue directly to the scientists who are really looking for the cellular breakthroughs.
The real future of this is going to be in the genetics of the disease and what I mean genetics, is not inherited genetics as much as the gene elements that make cancer start and flourish. So, that’s really the future and what we need more than anything else to win with this disease better than we do now is a good strong chemotherapy that’s effective. Right now we have things that work, but it’s really on a sort of haphazard hit or miss basis whether a patient is going to – whether their tumor is going to respond very well to those therapies.
So, we really need to be bringing in the work of our basic scientists to then be testing new drugs for this. Immunotherapy is a situation. We have a lot of that going on here at Penn in terms of the scientific intrigue for it. It’s got a lot of promise. It’s not quite there for prime time in terms of patient care at this point in time. But there is an idea that to augment the care against this disease, we’d like to help jack up the patient’s own physiology and own immune system against the tumor. So, that’s really, I think a big promise for the future going on.
I think the last thing to size up for you in terms of referral and who should be seeing the patients. I would always say that I think the surgeon in general is sort of the fulcrum point of the decision making on pancreatic cancer. And we would love to see patients earlier in the process. In general, many of our patients come to us between four to six weeks after an initial onset of symptoms and diagnostic maneuvers come about and we often see them about three to four doctors into the line of fire.
What we’d like to say is that the real thing about winning with pancreatic cancer is you need a surgery to remove the tumor to be able to survive. And so that very, very important node in the thought process is that you’ve got to be able to determine if someone is surgically resectable or not.
We, as surgeons, have a lot of general collective background on the whole nature of pancreatic cancer. We are not just the technicians that take the tumors out. But we are also keen to the biology and the multidisciplinary aspects of these things.
I think an early referral to a specialty center like we have here at Penn with people who have vast experience in this. The four surgeons who do pancreatic surgery here have done over 1500 resections in our careers and we’re doing about 200 resections on a yearly basis between the four of us.
We would very much relish to see these patients and we are very available to see them early and fast. It takes just a few days to be seen by us rather than weeks. So, we’re very keen to help patients with this and see your patients to help us get the efficiencies of their care going faster.
Host: Thank you Dr. Vollmer so much for sharing your expertise and coming on with us today and explaining this very complex procedure and what is available for patients and when it’s important to refer. You’ve given us some really great information also about the future for pancreatic cancer and the like. So, thank you again for that.
That wraps up this episode with the experts at Penn Medicine. To refer a patient please visit www.pennmedicine.org/refer, or you can call 877-937-PENN.
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