Our success in the management of complicated cancer patients has engendered a loyal following. I am always pleased to receive referrals from my colleagues and do my best to accommodate them. But one recent referral had an unexpected twist. A long-term friend who practices internal medicine in Southern California contacted me in March to ask whether I would see a patient. When I inquired regarding the diagnosis, he replied “inoperable pancreatic cancer”. Though this is a challenging tumor to manage, I went on to explain our interest in this disease and our belief that it can be successfully treated, even in the most advanced stages, with the right combination. As I obtained additional information, however, I noticed the patient’s date of birth: June of 1934.
85-yr-old with Stage 4 Pancreatic Cancer
I called my colleague and inquired whether he truly wished for a consultation, as she was soon to be 86 years of age and I feared that she would not be a candidate for therapy. As he knew the patient well, he reiterated the request that I consult. On March 11th 2020, I met the patient and her daughter. Her CT scan revealed a 4 x 4.7 x 4 cm mass in the tail of the pancreas, encasing the splenic vein and superior mesenteric vein. Numerous small lesions were noted in the liver. The patient's CA 19-9, a marker for pancreatic cancer, returned at 4860. With a normal range of 0-37, her CA 19-9 result was fully 130 times higher than the upper limit of normal. We scheduled a confirmatory biopsy and the patient asked whether a tissue culture might be conducted on the sample. We agreed that a study could be conducted and I hoped we might find a treatment that would be mild enough for an 85-year-old patient to safely tolerate.
The Most Common Drugs for Pancreatic Cancer - Toxic and Low Percentage of Success
The most widely used drug combination for this disease, FOLFIRINOX, provides only a 31% chance of response and can be difficult for even young patients to tolerate. The next most widely used combination is Abraxane plus gemcitabine with a response rate of 23% and its own share of toxic side effects including hair loss, low blood counts and nerve injury. The biopsy provided adequate tissue for us to compare the standard chemotherapy regimens along with some of the milder forms of treatment that we have developed.
Her Functional Profiling Results - Promising
FOLFIRINOX appeared moderately active, but a much milder drug triplet appeared superior, certainly from a standpoint of toxicity and tolerance. In early April, I met with the patient and her daughter and we began a very low-dose combination of chemotherapy drugs that the laboratory had identified for her. The patient tolerated the treatment without side effects; no hair loss, no nausea, no vomiting. In fact, there were virtually no side effects whatsoever.
Of course, we kept the doses to a minimum and needed to monitor white blood counts that fell mildly during the treatments. However, it was immediately evident that the cancer was responding. The weight loss that had plagued the patient stopped and she began to gain weight. Her appetite improved, as did her energy level and performance status. With each successive cycle, the patient's CA 19-9 fell by almost 50%. During visits the patient explained that she had none of the usual symptoms that we associate with chemotherapy in this disease: None
Her Treatment Continues
From April to May, to June, to July, her condition continued to improve. As August approached, the patient declared that she was planning a trip to Texas to visit with family and would miss a week of her scheduled treatment. I whole-heartedly encouraged her to travel and explained that we could easily skip a week without undue risk.
As I pondered her excellent outcome, I was reminded of some prior work. Several years earlier, I collaborated on a study examining the impact of age on chemotherapeutic response. One of my colleagues was traveling to France for a Geriatric Oncology meeting and we submitted an abstract. We set about comparing the activity of chemotherapy drugs in younger versus older colon cancer patients.
Age Doesn’t Matter
The results showed no significant difference, suggesting that older patients remain as sensitive to chemotherapy treatment as younger patients. Armed with that experience, the unique knowledge that this patient had a higher likelihood of response, and our laboratory’s ability to select the least toxic combinations, we were able to provide the patient an extremely good outcome with almost no down side.
Getting Back to a Normal Life
The patient's tumor markers continue to fall. She continues to tolerate treatment with virtually no side effects and has returned to a normal life. Most striking is that this now 86-year-old patient, who celebrated her birthday in June, might not have been treated at all.
As treatments for pancreatic cancer are punishing, many physicians might have suggested no treatment whatsoever.
The question I pose therefore is – should there be an age limit on who can receive chemotherapy for advanced pancreatic cancer?
Based upon this experience, my answer would be no.
As always, I appreciate your thoughts and comments.
Dr. Robert Nagourney, has been internationally recognized as a pioneer in cancer research and personalized cancer treatment for over 20 years. He is a TEDx speaker, author of the book Outliving Cancer, a practicing oncologist and triple board certified in Internal Medicine, Medical Oncology and Hematology helping cancer patients from around the world at his Nagourney Cancer Institute in Long Beach, California. For more info go to NagourneyCancerInstitute.com