Transcript:Johanna Bendell, MD: We’ve discussed the metastatic patient, but what about that patient that has no signs of metastases? We have patients that come in and 20% of them could potentially be a surgical candidate. How do you work up a potential surgical candidate when you first see them in the office, John?

John Marshall, MD: We have a fairly standard routine. The patient gets scanned with special cuts through the pancreas. They almost all get an endoscopic ultrasound to try and better define the anatomy around the vessels. And then we sit in a room and all look at that information together and decide if they are resectable, locally advanced, or borderline.

And, of course, all of those definitions change with the expertise that’s in the room because of new techniques around surgical techniques, such as vascular grafting. So, this is based on the mood of the moment and the age of the patient. There’s anatomical descriptions for what each of those is. But, as I say, they’ve been changing. And then we generally make a decision about starting chemotherapy with the hope of surgery or chemotherapy without the hope of surgery—at least a plan for surgery.

Johanna Bendell, MD: So, in your institution, if a patient’s resectable, do you take them right in to the operating room?

John Marshall, MD: It depends if the surgeon’s about to go on vacation or not. I hate to say it, but a lot of times convenience, schedules, and all of these things affect decisions. Bias. I would say our plan has been, for the most part, to yes, take them right to the operating room. Given newer information around up-front chemotherapy, even in that resectable patient, there are positives to that therapy that enrich the experience for a patient who’s going to be a better surgical candidate downstream as well—better outcome from that surgery.

I can see that over the last 6 months, at our place, we’re shifting more to thinking about preoperative something or other. We’ve had some interesting very short stereotactic radiation studies (some window studies) that are starting to come in. So, we’re slowly shifting in that direction. I’m not sure it’s right, but I like the idea around it. I like the idea of giving systemic therapy and giving it early. I’m nervous that I lose my window to operate, but maybe that’s not a good patient to operate on anyway. But anyway, at least in our place, based on experiences of others, we’re starting to shift.

Johanna Bendell, MD: George, do you guys use neoadjuvant therapy for resectable patients?

George Kim, MD: We were doing that more and more, I think—bringing in chemotherapy before surgery. But I think it’s similar to John’s practice in who goes to surgery up front. A 1-cm tumor with no real warning signs (good healthy patient) probably would go right to surgery. But it is whimsical how that patient is deciding which way they’ll go.

Johanna Bendell, MD: So, let’s say you have a patient with a 1-cm tumor. Your baseline CA 19-9 is 2000. Do you do a staging laparoscopy?

George Kim, MD: It could be done. I think it’s reasonable. I think you’re looking for disease that is easily detectable so you can save the patient. Obviously, we’re not seeing it on the scan. As you know, peritoneal disease is very hard to see on imaging. So, I think it’s worth taking a peek. They’ll do it before the procedure—before the surgery—and not as a separate procedure. Not as a separate surgery day.

John Marshall, MD: Have you all been seeing this? I’ve been seeing fewer CT chest scans being done.

Johanna Bendell, MD: Yes.

John Marshall, MD: And it gets pushed back, and we have to make that phone call to the insurance company to get it. Are you seeing this too?

Johanna Bendell, MD: All the time.

John Marshall, MD: In a preoperative setting.

Transcript Edited for Clarity