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The PancChat Podcast is a collaborative effort from Let’s Win Pancreatic Cancer and the Pancreatic Cancer Action Network (PanCAN), inspired by the long-running #PancChat Twitter/X chat.
Hosted by award-winning journalist Alisyn Camerota, each episode features conversations with leading researchers, clinicians, patients, and advocates who are shaping the future of pancreatic cancer care and research. Together, we deliver expert insights, personal journeys, and the latest breakthroughs—bridging the gap between science and lived experience.
Whether you’re a patient, caregiver, healthcare professional, or simply want to learn more, join us to connect, be inspired, and learn how you can help to accelerate progress in the fight against pancreatic cancer.
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Julie Fleshman: Hi, I'm Julie Fleshman, President and CEO of PanCAN. On today's podcast, we are taking a closer look at surgery for patients who have been diagnosed with pancreatic cancer.
Alisyn Camerota: Hi, everyone. I'm Alisyn Camerota. Welcome to episode seven of PancChat. Today's episode focuses on surgery for pancreatic cancer, including the Whipple procedure. We want to thank our sponsor, Revolution Medicines, and I want to introduce our guest.
Dr. Niraj Gusani is a board-certified general surgeon and surgical oncologist with more than twenty years of experience in cancer surgery. He currently serves as the Chief of Surgical Oncology at Baptist MD Anderson Cancer Center in Jacksonville, Florida. So welcome, Dr. Gusani.
Great to see you.
Dr. Niraj Gusani: Oh, thank you, Alisyn. Great to be here.
Alisyn Camerota: Okay, so as I understand it, there are a couple of different types of surgery. The first one is used to treat symptoms. In other words, inserting a stent, say, to open a blocked bile duct. And then there is the kind of surgery that tries to actually cure the patient of pancreatic cancer by removing the tumor, and that's the one that we want to be talking about today. So let's start there.
Can you explain where surgery fits into pancreatic cancer treatment?
Dr. Niraj Gusani: Yeah, thank you. You know, as you said, there are a lot of options at every stage for every patient to help them with symptoms, blockages, etcetera. And so palliative surgery is an important part of cancer surgery for pancreas cancer and for many other cancers. But today, let's focus a little bit more on what we call curative intent surgery. And that would be basically you have a tumor that's localized to the pancreas or the area of the pancreas, and we're trying to remove it completely, to help in the treatment of the patient with an attempt for cure.
Now, it's really important to remember, surgery only works in combination with other treatments. Pancreatic cancer is not a disease surgery alone can cure. We need all patients to get a combination of treatments, usually chemotherapy and surgery in different orders, depending on the patient, and sometimes radiation as well, sometimes immunotherapy, vaccines, a lot of the newer things that we're doing for pancreatic cancer treatment.
Alisyn Camerota: In my just very limited experience, my impression is that very few patients are eligible for surgery because it has to be caught at such an early stage. Is that accurate? And do you have any, can you give us any idea of what percentage of patients?
Dr. Niraj Gusani: Yeah, so as you're suggesting, unfortunately, most pancreatic cancers are caught at a very late stage and we're working on early diagnosis and screening and so on. But the reality is that a lot of people are not going to be candidates for curative surgery, but a large percentage are, and we're increasing that pool by shrinking the tumors with chemotherapy, with immunotherapy, other treatments first, so we can get to surgery. I would say early on upfront, the percentage of patients who have a resectable tumor is quite small, ten or fifteen percent, but we can get that number higher with modern treatments.
Alisyn Camerota: Good, I do want to talk about that, how we get there. So first off, how do you decide if a candidate is a good one for surgery?
Dr. Niraj Gusani: Yeah, so it's a bunch of different things that we have to look at. So the very first thing, we start just because it's cancer, we start to know, we want to know all about the tumor. So we want to know anatomically where it lies, is it involved with the pancreas, is it involving other organs, is it involving blood vessels? God forbid, could it have spread to other organs? So we do staging, looking for signs of tumor elsewhere. So we want to know all the details about the tumor itself.
Next, we want to know about the tumor biology. So is it something that is very aggressive, has been growing fast, has high tumor markers in the blood suggesting shed potentially into the blood. Those things help us determine how aggressive that tumor is, and under the microscope, we look at the pathology as well. And then finally, we look at the patients.
So, you know, unfortunately, most patients with pancreatic cancer are older, they're in their seventies, is the average age, and so they may have other medical issues, they may have medical comorbid conditions that make them not great candidates for major surgery. The good news is that we can get people through these operations now more than we ever could, and we're routinely operating on older and older patients. We're making the operations safer and safer, but we need to look at the patient as a whole and make sure they're a good candidate for major surgery.
Alisyn Camerota: So what if they have mixed results? What if it appears that the cancer is still localized in the pancreas, however, they have high cancer markers that suggest that something's in the blood? I mean, what do you do then?
Dr. Niraj Gusani: Yeah, so we're moving more and more toward treating the tumor first with treatments to the whole body. So chemotherapy, immunotherapy, something that treats the whole body, because we think that there's a high chance this tumor could have already spread. We can't see it with our best scans, but it's there. If we do an operation which only treats the part near the pancreas, it may come back very quickly, unfortunately.
And so in the old days, people got surgery upfront. The minute you got diagnosed with pancreatic cancer, if it was removable, you had an operation within the next few weeks. Nowadays, most of the time, we're trying to shrink the tumor first with chemotherapy and other treatments, and then operating, and that gives us a chance to understand the biology of that tumor. Tumors that respond to chemotherapy are the ones that are also going to stay away after we do major surgery.
Alisyn Camerota: That's interesting. So let's talk about that. So you start treating with chemo or immunotherapy, and then what's the trigger for when you can do surgery?
Dr. Niraj Gusani: Yeah, so there's a few different categories and we don't need to get into all the nuance, but some of the tumors are upfront, they're resectable, they're smaller, or they're not involving major blood vessels, they're not involving other organs. If I wanted to, I could do an operation next week, but we want to shrink the tumor with, you know, check the response to chemotherapy, we want to make sure we treat this tumor because a lot of patients can't get chemotherapy easily afterwards because of surgical complications. So if we treat first, we usually treat for a few months at a time, and then we do all the staging studies again, the scans, the CT, the MRI, the tumor markers, and we look, once we know the tumor has shrunk, we can operate. So it's usually just a few months in those cases.
In other tumors, the tumor's more advanced. It's involving major blood vessels. We need to shrink it before we can do an operation. And so in that case, the period of treatment upfront may be longer, may be more complicated. We may do chemotherapy and radiation. We may do a combination of things.
Alisyn Camerota: Let's talk about the location of the tumor and how that advises what you'll do.
Dr. Niraj Gusani: Yeah, so the pancreas is an organ in the back of the abdomen. It's long and thin, and so some people think it looks like a fish. So we named the parts of the organ for the parts of the fish. There's a head, the business end of things, with a mouth where the digestive enzymes go into the intestines. That part is very closely connected with the first part of the small intestines and other area, you know, other organs, the bile duct, and so on.
Then there's the back of the pancreas up toward the patient's left that is less connected to other organs, is involved with the spleen. That's called the body and tail. And so we divide our major pancreas operations into these two parts, the ones that involve the head of the pancreas and the ones that involve the body and tail, and they're two separate operations. Very rarely, a tumor's right in the center and we actually have to take the whole pancreas out. We'll discuss that another time, but that's called a total pancreatectomy.
But for most patients, there's two major operations.
Alisyn Camerota: You can take a whole pancreas out of a patient, and then, and then what?
Dr. Niraj Gusani: Yeah. So that's a thing people need to understand. It's we don't do it and take it lightly, but you can live without a pancreas. The pancreas does two major things. It produces insulin and other hormones that help us with our sugar control, and it produces enzymes that help us with digestion of fatty foods primarily.
So we can replace all of that. We can give people insulin. We have great systems to measure sugars and treat insulin. So in the old days, people became very brittle diabetics without a pancreas. Now it's quite routine that we can control their sugars.
And we can also give supplemental enzymes. So yes, if you needed to, you could live without a pancreas. We choose to keep as much pancreas as we can for the most part, but if you had to, you could take it all.
Alisyn Camerota: That's remarkable. I actually have just learned something. I didn't know that that was possible. So between the more traditional, the tumor in the head or in the tail, is there one that's easier for surgery?
Dr. Niraj Gusani: Yeah, you know, I like to think nothing is too easy, but, yes, there are, the tumors in the back of the pancreas, the body and tail, tend to less commonly involve other organs, and so the operation to remove them involves taking that back half of the pancreas, taking the lymph nodes around it to make sure the tumor hasn't spread, sometimes some of the blood vessels in the area, and sometimes, and usually the spleen. But beyond that, we're not taking a lot of other organs. And the good thing about that operation is we don't have to do any reconstruction. We suture off or staple off the back of the pancreas, the remaining enzymes flow toward the head, and the patient can function quite well. So it's an operation that's easier to recover from.
It's still a major operation, but a lot quicker recovery, and sometimes a quicker operation as well.
Alisyn Camerota: Is that one the Whipple?
Dr. Niraj Gusani: No, that's called a left-sided or a distal pancreatectomy. The enzymes flow to the right, and so the left side is the body and tail of the pancreas. So if you have a tumor in the body and tail of the pancreas, we do a distal pancreatectomy, taking the back half of the pancreas, again, with the lymph nodes, maybe the spleen.
Alisyn Camerota: Okay. Now let's talk about the Whipple. What does that entail? Because that's the one that I think more people have heard of.
Dr. Niraj Gusani: Correct. This is the you know, so seventy percent of pancreatic tumors start in the head or near the head. And so this is the much more common scenario. Those are the patients that develop yellow jaundice. They get dark urine and light stools, and they become itchy and so on, and that's usually how they present.
Those patients have a tumor in the head part of the pancreas. And as we talked about, that area involves a lot of other organs, and they need a bigger operation, this thing called the Whipple procedure, named for a surgeon at Columbia, but done by many other surgeons and perfected, or at least made a lot safer in the last thirty or forty years, such that now it's a pretty routine operation.
Alisyn Camerota: Well, let's talk about that, because I actually, I had a friend who probably eighteen years ago now was diagnosed with pancreatic cancer and she had the Whipple and she lived for a long time. I mean, something like fifteen years after that. However, it does take I remember that back then it really took a toll. It was a very invasive surgery. Has it improved since then?
Dr. Niraj Gusani: Absolutely. Look, it's still a big operation. There's still a major toll, a major recovery and so on. But we've found ways to make this operation relatively routine if we do it a lot, to get excellent outcomes and to give people great function. As we talked about, there's two things the pancreas does, making the insulin and making the enzymes, and about twenty-five to thirty percent of people will need replacement of those after a Whipple procedure, but most people don't.
Most people's remaining pancreas functions really well. Some people will have postsurgical issues, but again, long term, the thing we worry about most is cancer recurrence, but most people's functional outcomes are excellent. Absolutely, it's a big surgery. Absolutely, it can be a slow recovery, but I want to make sure everybody understands that the long-term outcomes can be excellent.
Alisyn Camerota: And when you say slow recovery, just paint a picture for us. I mean, how long are we talking?
Dr. Niraj Gusani: Well, these are big operations. They take four to eight hours, can take longer if things are stuck. There's a lot of reconstruction involved. Patients can be in hospital for four days, but can be in the hospital for a week or even longer if they have some issues. So there's a little bit of a postoperative recovery.
And then after that, I tell people, it's really going to take you two or three months till you're 100% back to normal. Now, you'll still be improving every week. Most people go home eating regular food, walking, pain is controlled with pills, they don't have drains or lines or tubes, but there's still a long recovery ahead of them.
Alisyn Camerota: Gosh, modern medicine is incredible that you've come this far with that. I mean, that's really a remarkable achievement. Well, what else, Dr. Gusani, do you want to say about pancreatic surgery?
Dr. Niraj Gusani: Yeah, so just to finish on that topic of the Whipple procedure or the pancreatoduodenectomy. This is a huge operation. It's really important to understand the anatomy and there's lots of resources both on Let's Win and elsewhere to help us understand these things. And you really want to go in to talk to your surgeon, understanding what you're about to hear about. It's important to ask all the right questions, talk about the surgeon's experience and about the institutional experience.
So institutions where you do a lot of the surgery, we have pathways to take care of the patients and to optimize the outcomes. This is not a surgery to be doing once a year, and so you have to ask those questions. And it's okay to be very forthright and say, how many of these do you do? How many does the hospital do? It's really important to understand that volume can affect outcomes for major pancreatic surgery.
Alisyn Camerota: That's wonderful, Dr. Gusani. Anything else you'd like to add?
Dr. Niraj Gusani: Yeah, so let's talk briefly about the back half of the pancreas, the distal or left-sided pancreatectomy. Again, a slightly smaller operation, still can take two to four or six hours, can involve blood vessel work, the tumors can be stuck, but thankfully we can do these operations with less and less invasiveness. They are straightforward operations without a reconstruction. Hospital stay can be as low as three days. Recovery is still six to eight weeks, but it can still be a challenge.
But again, most people have good functioning pancreas without the need for enzymes or insulin, and it's something that is done quite routinely in major centers.
Alisyn Camerota: Look, for people who can catch pancreatic cancer early, this is a godsend. I mean, this is what is so helpful. But again, as we've discussed, that's not the case for most people. So even with this invasive surgery, the idea that something this tough is the dream is sometimes first of all.
Dr. Niraj Gusani: No, and I agree with you, you're right. But I think it's important that every patient meets with a surgeon early on because we want to be planning the treatments together. Again, some patients benefit from treatment upfront, chemotherapy, other treatments may be radiation to shrink the tumor and then do surgery, but there's a very close coordination between all the teams. Other patients, surgery upfront is the right thing to do, and we'll get that operation done as expeditiously as possible, get them recovered and onto different phases of treatment. So I think the key messages are, get informed, talk to your team, go to a place where people do a lot of pancreatic cancer surgery, and then be involved in your care and ask as many questions as you need to feel comfortable.
Alisyn Camerota: Well, Dr. Gusani, thank you for informing us today. It's really great to talk to you.
Dr. Niraj Gusani: Thank you. I just want to let everybody know there is a lot of hope for pancreatic cancer. We have newer treatments all the time. Surgery is becoming less invasive and easier to recover from. All of our other treatments are getting better.
So, there's always hope for every patient with pancreatic cancer.
Alisyn Camerota: That's a wonderful message. Thank you so much.
Dr. Niraj Gusani: Thank you, Alisyn. Great to be here.
Alisyn Camerota: Thanks for listening everybody. I'm Alisyn Camerota. I'll see you next time.
Cindy Gavin: Thank you, Dr. Gusani and Alisyn for that informative discussion. I'm Cindy Gavin, CEO and co-founder of Let's Win Pancreatic Cancer. I hope you'll take advantage of all the resources available at Let's Win and PanCAN. You can find PanCAN's resources at pancan.org and Let's Win at letswinpc.org.
In our next episode, we will hear from Dr. Merchant about the latest surgical techniques for pancreatic cancer and what patients and families need to know. I hope you will tune in and continue to be part of the PancChat podcast. Thank you.
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