Integrative Tumor Board: Pancreatic Cancer Integrative Physician's Perspective

Pancreatic cancer is one of the most aggressive cancers, and our patient in this case study presented with an aggressive histology of moderately to poorly differentiated adenocarcinoma. He also received his diagnosis at an advanced stage of disease, with liver metastases already present. Pancreatic cancer is, unfortunately, like ovarian cancer, still a largely “silent” disease in its earlier stages, and tends not to be diagnosed until it is quite advanced. Nevertheless, this patient has shown an excellent response to treatment. His CA19-9 had been 3667 at his first visit. However, after 6 cycles of treatment with gemcitabine and capecitabine, it fell to 133, and to 88 after 8 cycles. This was accomplished without using the recommended erlotinib, which was not covered by insurance. Furthermore, the patient maintains a good quality of life, although suffering from abdominal pain at the time of the case writeup—subsequently alleviated after further surgery. In regard to the patient’s dietary history, testing done at the Block Center indicated elevated levels of IGF-1, fibrinogen, and retinol, whereas total antioxidant capacity, vitamins, coenzyme Q10, and phytochemical levels were low. Fibrinogen is generally associated with elevated levels of inflammation. Inflammation in the form of chronic pancreatitis is a common precursor of pancreatic cancer. An inflammatory state in pancreatic cancer is also associated with the very commonly observed cachexia that is typical of this cancer. We see many patients with advanced cancers who have low levels of vitamins and phytochemicals. This is especially true of patients who have received significant prior chemotherapy treatment, but the patient in this case did not receive chemotherapy prior to presenting at the Block Center. The low antioxidant levels may thus be linked to his history of taking an American diet. Lise Alschuler and Dan Rubin present the naturopathic approach to this patient. They initially analyze the chemotherapy regimen provided to this patient, mentioning the low median survival time of patients treated with gemcitabine of 6 months. A recent meta-analysis of clinical trials of gemcitabine in combination with other agents highlighted 2 areas of particular interest in this case. First, combinations of gemcitabine plus capecitabine appear to have a higher survival than those of gemcitabine alone, nearly 10 months in one trial. Second, the combination regimens specifically benefited patients with good performance status; patients with poor performance status received little benefit from the added agents. Specifically, there was a near 25% reduction in likelihood of mortality in the good-performance-status patients relative to those with poor performance status. Thus, efforts to keep up the performance status of patients, which are typical of integrative clinics, can have a direct positive effect on outcomes. The patient in this case has maintained good performance status well into his treatment. His good physical condition should help him to be one of the 50% of patients who, by definition, will survive longer than the median survival time. The TheraGuide test mentioned by Alschuler and Rubin was introduced at the end of July 2007, actually too late to have been applied to this patient who, it is now apparent, was not one of those highly susceptible to severe side effects of capecitabine. It has the potential to be a useful pharmacogenetic test to predict occurrence of side effects and thus allow more individualized tailoring of treatment regimens. Its coverage by insurance companies is not yet entirely certain—insurance coverage is already an issue for this patient, who was unable to obtain the erlotinib recommended by the Block Center oncology team. Sarah Kranz, physical therapist at the Block Center, has contributed a very thorough evaluation and series of recommendations for this patient, which illustrate the potential of physical therapy to improve the quality of life and, as we see in the gemcitabine meta-analysis, the medical outcomes of pancreatic cancer patients. She begins with discussing general recommendations that include noncontact physical activities. In this context, “noncontact” means not only avoiding football and other contact sports but also avoiding other activities in which the patient is exposed to risks of injury from contact with various objects or with the environment. Rock-climbing and baseball are contact activities, whereas bowling and swimming would be classed as noncontact. A very useful reminder in Kranz’s discussion is the importance of tailoring exercise recommendations to activities that the patient enjoys and that he easily can make part of his daily life. Trying to fit patients into rigid clinical exercise protocols, although theoretically of potential benefit, does not work in practice, because patients simply will not adhere to recommendations. Framing recommendations in the context of preparing for activities such as this patient’s expressed interest in hunting or home projects adds to the potential for adherence. When I was in medical school in the 1970s, cancer patients were definitively recommended rest as a way to optimize their stamina. Through clinical observations and research since then, we are coming to see that resting all day is the last thing that cancer patients and others need to do. Kranz summarizes some of the benefits of regular exercise for cancer patients: increased tissue oxygenation, better energy levels, improved balance, and less nausea, 112 Integrative Cancer Therapies / Vol. 7, No. 2, June 2008