Patients undergoing surgical procedures for any cancer must sign an informed consent.
This allows the surgeon to make the best decision and undertake the best surgical procedure to render the patient free of disease.
But when a patient is under anesthesia the surgeon is unlikely to wake them up for additional discussions of the proposed intervention. This was a big problem in the past for women undergoing breast surgery that awoke to find they had unexpectedly undergone a mastectomy, based upon the operative finding. This became the subject of editorials (Thomson, H. J., British Medical Journal, October 1980). Fortunately, with improved preoperative diagnostic evaluations this is now much less of an issue.
A New Dilemma
However, a new dilemma has arisen; the failure of surgeons to comply with patient’s wishes to have tissue submitted. This is exemplified by one of my current patients with locally advanced pancreatic cancer.
This 54-year-old gentleman was found to have operable pancreatic cancer and scheduled for a Whipple procedure. We left word for his surgeon to ask that a portion of the fresh, sterile tumor be submitted to our laboratory.
The surgeon communicated to the patient that he would provide the requested tissue sample and we eagerly awaited the receipt of the specimen.
We knew there was ample tissue as the mass measured 2.8 centimeters. By quick calculation this constituted 8 cubic centimeters (8 grams) of tumor. We only need 1 to 2 grams for all of our studies combined.
The Surgical Sample Arrives
But when the sample arrived, it was just 0.3 grams, 1/27th of the total resected amount and demonstrably too small for us. The result: No laboratory analysis could be conducted.
The final pathology confirmed lymph node positive cancer (Stage IIB). Based upon national data, Stage IIB pancreatic cancer carries a 65 to 90% chance of causing death within 5 years and the patient now confronts the highly unattractive option of receiving randomly selected largely ineffective chemotherapy.
This is a particularly disappointing experience. After all, the greatest chance of curing this patient is first line therapy, but with FOLFIRINOX offering a 31% response rate and Abraxane & gemcitabine only a 23% response rate, his odds are far from good.
Even if he is fortunate enough to be in the 31% of pancreatic cancer patients who respond, his chance of survival remains dismal and I cannot do anything whatsoever to help him. His surgical team made absolutely sure of that.
This does not instill a sense of comfort in a person confronting a lethal diagnosis.
Whatever the surgeon or institution’s bias, laboratory analyses using human tumor three-dimensional explants are here to stay. The literature is compelling and the results overwhelmingly positive as we recently reported from over 10,000 patients (Nagourney, Proc AACR, 2023). If a patient wants to get the best treatment for their pancreas cancer, they’ll need to stand their ground and demand that their physicians comply with their request for tissue. This is not negotiable.
Patients should be forewarned that their positive outcome is more important to them than it is to their surgeons or to the institution conducting the procedures.
If you want to find out what treatments are likely to cure you, make it very clear to your surgeon that you expect him to comply. Your life depends upon it.