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Friday, Feb 6, 2009 11:43 AM UTC

How bad is pancreatic cancer?

Supreme Court Justice Ruth Bader Ginsburg underwent surgery on Thursday. One doctor assesses the risks.

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Topics: Environment, Cancer, Supreme Court, Ruth Bader Ginsburg, Science

During a recent routine abdominal CAT scan, U.S. Supreme Court Justice Ruth Bader Ginsburg, 75, was discovered to have an asymptomatic, 1 centimeter tumor in the center of her pancreas. Based upon imaging studies, the tumor was considered to be surgically removable, and Justice Ginsburg, who suffered a bout of colon cancer in 1999, underwent the surgery Thursday.

Pancreatic cancer is one of the most dreaded of malignancies; the overall survival rate is barely 5 percent at five years, in stark contrast to the 80 to 90 percent five-year overall survival of prostate and breast cancer victims.

Sadly, only 13 percent survive one year from diagnosis.

In large part this is because the tumor usually isn’t symptomatic until it is advanced; by the time one experiences pain or jaundice, the tumor has spread to involve surrounding abdominal structures or the common bile duct where complete removal isn’t generally possible. Nevertheless, surgical removal remains the one treatment that offers the possibility of cure. Even so, the removal of the pancreas, which supplies the enzymes of digestion, is itself fraught with major post-operative complications.

Given the scanty information to date, it is impossible to make an accurate prediction of Justice Ginsburg’s outcome. The good news is that, on imaging, the tumor is small, isn’t causing symptoms, and is located in the center of the pancreas, where surgical removal might be less extensive.

According to the press release, Justice Ginsburg’s tumor falls into the small subcategory of the 10 percent of pancreatic cancers that are felt, at the time of diagnosis, to be entirely contained within the pancreas. Half of those are found to be removable at the time of surgery. For those patients who undergo attempted curative surgery, the five-year survival rate is about 20 percent.

However, if the imaging studies are confirmed at surgery, and there is no evidence of spread to adjacent organs or lymph nodes,  newer figures from the American Cancer Society suggest that, at best, she might have a 37 percent five-year survival rate. Of course this is also dependent upon tumor type, degree of malignancy, and whether or not all of the visible and microscopic tumor was removed. Only when the operative report and final pathology report are made public will the statistics be more precise.

The other major problem facing Justice Ginsburg is the post-surgical set of complications. Depending upon the exact location of the tumor and the extent of her surgery, she may have had removed the head and perhaps part of the body of the pancreas, small intestine, gall bladder, part of the bile duct, adjacent lymph nodes and sometimes, part of the stomach.

Needless to say, even in the best of hands, the surgery carries a significant initial risk with up to a 4 percent surgical mortality rate at the best centers. Even with a skilled surgeon, about 30 to 50 percent of patients will suffer complications from the surgery. These include leaking from the various surgical connections, infections and bleeding. The pancreas produces enzymes required for food digestion; common long-term consequences of the surgery include impaired absorption of nutrients from food, weight loss, development of diabetes and chronic abdominal pain.

Additionally, treatment after surgery is often recommended, and it may significantly increase three- and five-year survival rates.  With one of the more promising drugs — gemcitabine — treatments are carried out via 30-minute infusions spaced out every few weeks for several months. Side effects are similar to those of many chemotherapeutic agents –nausea, vomiting, loss of appetite, fatigue, lowered resistance to infection, anemia, easy bleeding.

Depending upon the extent of surgery and chemotherapy and the degree of complications sustained, recovery from initial treatment might be expected to be at least several months. In addition, radiation may also be offered, though the results are more controversial.

In short, it is too early to make any predictions as to how Justice Ginsburg will fare; now is the time for us to offer good wishes for an optimal recovery. Political pundits will just have to wait for greater clarification.

Robert Burton, M.D., is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not." His column, "Mind Reader," appears regularly in Salon. More Robert Burton.

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