In February 2014, as Jack Jackson emerged from a post-surgery anesthesia haze in a BIDMC recovery room, his wife of more than 30 years leaned in to whisper in his ear. “They completed the surgery,” Cindy said. “And they got the whole tumor out.”
The surgery was a textbook defying Whipple performed to remove a malignant tumor in Jack’s pancreas. It was scheduled after more than a year of chemotherapy, radiation, watchful waiting and constant evaluation, all under the devoted care of a multidisciplinary team made up of more than 30 clinicians who continued to see Jackson as an individual, yes with metastatic pancreatic cancer, but also with options.
“An important lesson for all of us is that even in the age of advanced technology, the face-to-face discussions between doctors and between the patient and doctors is what allowed Jack this unique opportunity,” said Jack’s oncologist, Rebecca Miksad, MD, MPH, who specializes in treating patients with pancreatic cancer. “What’s so significant about our multidisciplinary approach here is that Jack wasn’t stuck in the stage four cancer box the way he could have been.”
“We looked beyond the literature, so to speak, in Jack’s case,” said pancreatic surgeon, Mark Callery, MD. “If we’re going to claim any progress against this terrible disease, we have to think out of the box quite a bit.”
A Devastating Diagnosis
A year and a half earlier in 2012, Jack woke one October morning, looked in the mirror and noticed that his eyes were bright yellow with jaundice. “I saw my doctor that afternoon and was admitted to Beth Israel Deaconess that night where they found a tumor in my pancreas,” he remembered. A brush biopsy obtained by Mandeep Sawhney, MD, a gastroenterologist who specializes in advanced endoscopic procedures, confirmed pancreatic cancer. “I knew I had one of the deadliest forms of cancer there is. I went right from anger to acceptance because I knew I didn’t have time.”
“It was devastating,” said Cindy. “I have no memory of talking to my children after the diagnosis.”
“The best chance for curative treatment is to get the tumor out before it has a chance to spread or progress,” said Callery, an internationally recognized expert in pancreatic surgery and the Whipple procedure. “Unfortunately around the world at the time of presentation of pancreatic cancer, 80 percent of patients are not operable, so we first had to determine whether or not Jack was operable.”
Close evaluation of all of Jack’s clinical data and imaging gave the team the green light to proceed with major surgery. One week later, he came into BIDMC for a Whipple, the most common operation to remove pancreatic cancer, but one of the most difficult operations that’s performed in the abdomen. During a Whipple the head of the pancreas containing the tumor is removed. The surgeon then reconstructs the anatomy to drain the liver, pancreas and stomach that remain after the tumor is out.
Just two hours into the usually six hour operation, the procedure had to be stopped.
“To our complete surprise and, frankly, despair, not too long into the operation, I identified that Jack had a small, but evident, mass in his liver, which was worrisome,” said Callery. “It was a cancer metastasis. That becomes an absolute red light under agreed-upon approaches to pancreatic cancer. We had to stop the surgery. For such patients, continuing with the Whipple would add only risk and no benefit to survival from cancer.”
Callery removed the entire tumor in the liver and concluded the operation.
“I said, ‘How long?’ and they said maybe nine months,” recalled Cindy. “And we all just got together as a family and said we’ll get through this.”
In November 2012, at the same time Jack’s family was gathering for what they thought would be their last Thanksgiving together, Jack started an aggressive chemotherapy regimen called FOLFIRINOX, a relatively new and intense drug combination used to treat advanced pancreatic cancer.
“I responded to it very well, it seemed to stabilize the tumor. My weight stabilized and my tumor counts kept improving,” said Jack.
Putting Surgery Back on the Table
As the months began to tick by Jack’s case continued to be reviewed at the weekly multidisciplinary clinic and tumor board meetings that occur throughout a patient’s course of care. The nine month mark passed and then one year. Jack’s team began to think about novel ways of treating him going forward. They talked with Jack and Cindy about considering a second attempt at the Whipple, a highly unusual course of action. While it’s not uncommon for cancer patients to come back in for additional surgery to remove a metastatic lesion that appears some time after the primary tumor is removed, the process is virtually never done in reverse for pancreatic cancer patients.
“The textbook says he should have only gotten systemic chemotherapy for pathologically proven metastatic pancreatic cancer,” said Miksad. But, while seven months of FOLFIRINOX followed by Cyberknife radiation stabilized Jack’s tumor markers, over time it wasn’t enough to maintain control. Jack’s tumor marker started to increase again and there was evidence that the tumor in the pancreas was active. “We took an out of the box approach in thinking about what would give Jack the best chance for long-term survival. As a team, we decided that the cancer in the pancreas represented his biggest problem – we could use more radiation or we could try to remove the tumor in the pancreas completely with surgery.”
“When we heard that they were recommending Jack for surgery, we wanted to call around, do some research. This seemed like a nonstandard approach and we wanted to see what the data looked like,” said Cindy. “We were told there are no other cases quite like this.”
“We understood that we were quite unorthodox in offering a type of treatment strategy like this, but we could not really come up with anything that disqualified Jack from a shot at it,” said Callery. The team could find no evidence that Jack’s cancer had spread. Ultimately, they decided there was no reason, other than convention, not to do the surgery. “But, we were very frank. We explained to them on clear terms that this was a new horizon that we were trying to move forward. That said, we knew what the horizon would hold if we didn’t do the surgery.”
“Dr. Miksad’s advice was to make the decision based on what I thought my larger regret would be down the line,” said Jack. “I realized I wanted the surgery. Cindy and I were 100 percent in agreement with the approach.”
Just over two weeks later, Jack underwent a Whipple procedure and the tumor was removed. This time, Callery found no evidence that the cancer had spread.
“We were so delighted by the results of the surgery. While Jack remains at risk for recurrence like all patients with resected pancreatic cancer, I am confident we have changed the game for him. He is now chemotherapy free and we continue to monitor him closely.” said Miksad. “I’m honored to work with such a talented multidisciplinary team, to contribute to Jack’s great outcome and to witness Jack’s growth as a person through all of this. It’s the reason I’m an oncologist.”
Miksad and Callery are encouraged that Jack’s case offers hope for the future of pancreatic cancer treatment.
“A big part of this is that we are seeing some dramatic tumor responses with our new and improved chemotherapy regimens,” said Callery. “I think in the future it’s possible that we’ll be able to convert more patients like Jack who were not operable to operable.”
“In the last five years we’ve made a lot of progress in terms of chemotherapy for pancreatic cancer, although it’s certainly nowhere near where we want it to be,” said Miksad.”The best possible care for patients with pancreatic cancer is to work with a multidisciplinary team, where all the clinicians look at the case and say yes, we’re going to follow the standard of care, or no, your situation merits a little bit of out of the box thinking.”
“I never felt like a number here. I’ve always felt like an individual patient whose case is being considered. I have a surgeon, I have an oncologist, there’s an infectious disease expert, gastroenterologist, endocrinologist, all these specialties have been pulled together in my case and I’m the beneficiary of all that,” said Jack. “It makes me feel pretty darn special and very alive.”
In September, Jack turned 60. In October he and Cindy will dance at their son’s wedding. In November they’ll celebrate their 32nd wedding anniversary and then comes another Thanksgiving followed by the prediction of another cold and snowy winter.
Jack laughs. So long as the winter comes, he’ll gladly accept whatever challenges it brings.
“If the weather won’t let me out, there’s always Skype,” he said.
BIDMC Contact: Kelly Lawman