Tossapol Kerdsirichairat, MD discusses pancreatic cancer and the disparities in the African American Community. Tossapol Kerdsirichairat, MD is a …
Hi, my name is Tos. I'm a clinical
associate professor, a director of the
National Pancreas Foundation pancreatic
cancer center program and a co-director
of the pancreas program at Geisinger.
Today I would like to thank the National
Pancreas Foundation for giving me the
opportunity to share information about
pancreatic cancer in african-american
I would like to start with the
epidemiology of pancreatic cancer.
It has been projected that by 2030 pancreatic cancer will become the second
leading cause of cancer-related death
because the overall 5-year survival of
all stages is less than 10%. The only curative treatment is surgical
resection combined with neoadjuvant or
adjuvant therapy such as chemotherapy
and/or radiation. However the majority of
the patient presents at late stage when
it is too advanced for curative
treatment. African-american population
has the highest incidence of pancreatic
cancer up to 15 to 17 per 100,000
population as compared to
non-hispanic whites with the incidence
of 12 to 15 per 100,000 population. They
also have the worst pancreatic cancer
prognosis of all U.S populations with
more advanced stage and more non
resectable disease at presentation as
well as less surgical treatment.

In another national cohort even though
african-american patients appeared to
present with comparable rates of
resectability, they receive care that
might deviate from guidelines. Insurance
status might be one of the factors
associated with inferior profiles of
resectability and treatments. Multiple
studies demonstrated that socioeconomic
factors could be associated with
disparities in the utilization of
surgical resection. This is a study based
on national cohort of more than 17,000
patients between year 2004 and 2011. Of
these approximately 45% of patients underwent surgical resection. The study
shows that white patients as compared to
african-americans, non Hispanic ethnicity,
marriage status, insurance coverage and
patients in northeast region were
associated with improved utilization of
resection. They also demonstrated that patients
underwent resection had significant
improved survival compared to those who
did not undergo resection. In terms of
regions patients in the Pacific west, north
East and the Midwest had improved
survival compared to those in the
southeast region. All the geographic
location was independently associated
with survival in patients undergoing
resection. On the other hand patients in
resectable stage might previous surgery.
Factors that were associated with
refusal of surgery included older age,
female gender, those with several chronic
medical conditions, african-american
patients and those who are on Medicare
or Medicaid insurance. They were more
likely to refuse surgery if they were
seen in non-academic settings. As a
result patients who were recommended
surgery but refused had significantly
worse survival compared to those
underwent surgery. More recently a large
cohort from a single large insurance
system from over 2,100 patients for
which more than half of the patients
presented with stage 4 disease showed
that minorities were not disadvantaged
in pancreatic cancer care. This might be
promising that such disparities have
improved over time however we need to
verify these findings in larger cohorts
from other regions of the country.
Pancreatic surveillance is recommended for selected high-risk patients
to detect early pancreatic cancer and its high-grade precursors. These are genes
that are associated with increased risk
of pancreatic cancer based on the most
recent expert consensus. Based on the
consensus, it is recommended that
banqueting cancer surveillance should be
performed in a research setting by
multidisciplinary teams in centers with
appropriate expertise. The studies of
these genes included only a modest
number of african-american population
limiting evaluation of associations in
this high-risk population. More
specifically, recent study showed that a
pathogenic germline mutation in the gene
named cdkn2a tumor suppressor gene could
be more commonly found in
african-american population compared to
non-hispanic whites. The mutations in
this gene are rare and associated with
highly penetrant familial melanoma and
pancreatic cancer in the form called
familial atypical mole melanoma syndrome.
It was associated with moderately
increased pancreatic cancer risk among
African Americans.

There are several non-genetic risk factors for pancreatic cancer that are applicable to
general population.
These include tobacco, diabetes, obesity
and chronic pancreatitis. It is debatable
if these risk factors are solely based
on racial disparities given that the
results of the studies were not quite
reproducible. More recent study in a
multi-ethnic cohort showed that diabetes,
especially with an onset diabetes was
associated with higher risk of
pancreatic cancer in african-americans
and Latinos.
There was another study aiming at
answering the risk of obesity and
pancreatic cancer mortality in
african-americans. Not surprisingly
pancreatic cancer mortality was
associated with higher degrees of
obesity. These associations were
independent of gender, and a history of
I consider that the strategies to improve the quality of care in pancreatic cancer in african-americans should be initiated at multiple levels of care.
At individual levels, patients should be aware of
modifiable and non-modifiable risk factors.
Those who have a strong family
history of pancreatic cancer or cancer
syndrome should be in consultation with
your providers for possible referrals
and further workup such as genetic
workup and referrals to a large academic
center patients should be aware that
even a rapid onset of weight loss and
diabetes could be an early signs and
symptoms of pancreatic cancer also
patients should be aware that they
should better control other modifiable
risk factors such as smoking alcohol
intake and obesity on a large scale more
policies should address on racial
disparities especially for
african-americans, female and uninsured. The rate of clinical enrollment to the
clinic trials surgical referrals and
referrals to a large academy or research
settings should be improved

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