By Mary Hardin
Friday, February 22, 2019
Like Rodney Dangerfield, the pancreas doesn’t get much respect. In fact, people rarely think about their pancreas, until it gives them reason to. By then, people become painfully aware of the control it has over their lives.
Dr. Evan Fogel
A healthy pancreas is about six inches long and lies horizontally behind the lower part of the stomach along the back of the abdomen. It plays a key role in the digestion of food, neutralization of stomach acid and glucose control. The pancreas produces insulin and secretes enzymes and other hormones that help break down food and manage blood sugar. A poorly functioning pancreas can cause everything from digestion issues, diarrhea and vomiting to disabling pain, diabetes and cancer.
Indiana University School of Medicine gastroenterologists and surgeons lead the nation in volume of both endoscopic pancreatic procedures and pancreatic surgeries. Evan L. Fogel, M.D., professor of medicine in the Division of Gastroenterology and Hepatology, is a member of the ERCP (endoscopic retrograde cholangiopancreatography) team, which has been recognized by the National Pancreas Foundation for its multidisciplinary approach to the treatment of pancreatic disease. One of Dr. Fogel’s interests is screening for pancreatic cancer, which is the fourth leading cause of cancer death with only 8.5 percent of patients surviving five years, according to the National Cancer Institute.
The pancreas has many different types of cells, each of which can produce a different type of malignant tumor. The most common type arises from the cells that line the ducts of the pancreas and is called pancreatic ductal adenocarcinoma. In many cases, pancreatic cancer spreads to nearby or distant organs.
Due to several factors including an absence of early symptoms, pancreatic cancer often goes undiagnosed until it is advanced, which greatly reduces treatment options, Fogel said.
“Chemotherapy slows the progression of the disease, but it is not a cure. The only potential cure for pancreatic cancer is surgery and 85 percent of patients are not candidates for surgery because the cancer has already spread.”
Patients with pancreatic cancer often see a doctor with reports of pain in the upper abdomen or back, loss of appetite or unintended weight loss, new-onset diabetes, fatigue, jaundice or depression.
Diagnostic screening methods are not foolproof. Blood tests can be normal. CT scans and MRI scans also can miss small tumors. It is very difficult to diagnose in the early stages, Fogel explained.
Researchers continue to seek more reliable tools for diagnosing pancreatitis and pancreatic cancer earlier. Fogel speaks with optimism when discussing the National Institutes of Health-sponsored Consortium for the Study of Chronic Pancreatitis, Diabetes and Pancreatic Cancer (CPDPC). Fogel leads IU’s association with the group of only 10 member institutions.
The mission of the consortium is to develop tools for early diagnosis and treatment of chronic pancreatitis and its complications, including pancreatic cancer. People with chronic pancreatitis have a tenfold greater risk of developing pancreatic cancer. However, there is no magic safeguard against pancreatic cancer because anyone can develop the disease. A few risk factors have been identified, including cigarette smoking. People who smoke are twice as likely as nonsmokers to get pancreatic cancer. Other studies have identified obesity and inactivity as risk factors, as well as a diet high in fat and smoked or processed meats.
““The only way to beat pancreatic cancer is to diagnosis it earlier."Dr. Fogel
“The only way to beat pancreatic cancer is to diagnosis it earlier,” Fogel said.
At IU, scientists are involved with the four primary clinical studies funded by the National Institutes of Health, the sponsor of the consortium, as well as several other ancillary studies. These clinical studies are taking place at multiple centers, which allows for more people with a greater genetic diversity to participate and provides researchers with broader data.
Each of the four consortium studies, all identified by reassuring acronyms, takes a different approach to identifying biomarkers that can be linked to pancreatic cancer or pancreatitis. Combined the studies will enroll thousands of patients and follow some of them for two decades, a rare occurrence in clinical research. The biological samples collected from patients will be frozen so as science advances and new tests are developed, the samples can be examined in hopes they reveal additional information.
PROCEED will monitor patients with suspected or definite chronic pancreatitis. Patients with no evidence of pancreas disease also will be recruited to serve as a control or comparison group. Study participants will regularly provide biological samples for testing and banking. By noting the changes in chemistry of the samples, researchers hope to see a pattern that, over time, will identify biomarkers that signal disease progression or development of complications. Fogel is the principal investigator at IU for PROCEED.
Dr. Fogel is a co-principal investigator for a study evaluating MRI as a non-invasive method to detect pancreatic fibrosis in patients with suspected or definite chronic pancreatitis. The MINIMAP study is being performed at seven CPDPC centers, with IU serving as lead site.
INSPPIRE-2 is the pediatric version of PROCEED. Children with acute and/or chronic pancreatitis will be followed for years and the biological samples they give will be tested in search of telltale biomarkers.
NoD is focused on patients over the age of 50 with new-onset diabetes, which may signal the presence of pancreatic cancer. The consortium hopes to enroll 10,000 patients from across the country in this research study.
DETECT looks at patients with type 2 diabetes as well as diabetes related to chronic pancreatitis. Diabetes associated with pancreatic cancer also will be studied and patients will be evaluated to determine the differences in physiology and metabolic parameters in these three patient groups.
Individuals interested in participating or referring patients for participation in one of these studies should contact Dr. Fogel’s administrative assistant, Kimberly Britman, at 317–944–2816.
The Consortium for the Study of Chronic Pancreatitis, Diabetes and Pancreatic Cancer is funded by the National Cancer Institute and the National Institute of Diabetes and Digestive and Kidney Diseases, both a division of the National Institutes of Health. In addition to IU, the clinical research members are:
- Baylor University
- Cedars-Sinai Medical Center
- Kaiser Foundation
- Mayo Clinic
- Ohio State University
- Stanford University
- University of Florida
- University of Iowa
- University of Pittsburgh
The University of Texas MD Anderson Cancer Center is the coordinating data management center/administrative site.