Cancer Of The Pancreas

i have the good fortune over mycareer to be able to speak to a number of different audiences,locations, and this is about as meaningfulan audience and event that i've been given the privilege toparticipate in, and i think being able to communicate or tryto impart a little bit of what we're doing to try to helpfolks, to a audience of women is extraordinarily meaningful forme. told my wife last night,love for her to have the opportunity toattend one of these events.

and as serena has sobeautifully put it this morning, she's the motherof two young boys. bigger boy who's perhapsthe hardest to take care of. and it's hard to put yourselffirst, and commend you all for doing that. thank you forhaving me and serena, i really appreciate yourcomments resonates deeply with me, have been able to havenumerous conversations with folks in private about whatthey go through personally.

and it's really these sorts ofopportunities that motivate me deeply, personally, andprofessionally to try to do more, to advance inthe field of medicine. so i appreciate that. also, on a little bitlighter note, i was very very impressed with the committeewho's celebrating, of course, the changing of johns hopkinsall children's, the name of it. and yesterday i wasgoing from the hotel to john hopkins all children'sto meet with physicians there to

start up researchcollaborations. and i'm not a tech savvy guy. i only started usinguber a couple days ago. and, i'm not on facebook, i don't know anythingabout twitter. and, i needed to get toall childrens, and so i picked up the uber app, andi typed in all childrens. and literally it popped up, do you mean the johns hopkinsall childrens hospital? and-

>> [applause] >> i said wow. people [laugh] people at the johns hopkins all children'shospital really know how to do it, so hats off to dr. ellen andthe group here for that. but, with all that being said, i'm one of the neurosurgeonsat johns hopkins. i do all my practicein baltimore, and probably say about75 to 80% of my

practice is taking care offolks who have brain tumors. and certainly a great deal ofmy day is spent taking care of folks in the operating room, buta tremendous amount of time and passion is spent in the researchenvironment, in the laboratory, trying to advance ourunderstanding of cancer, and so that's what i'dlike to spend just the next few minutes talkingabout is what are some of the advancesthat are happening? what are the things thatwe're doing to help people?

and i think it'sincredibly exciting and hope to impart that excitementto the audience today. in january of this year,president obama made a landmark statement, and that was themoonshot to try to cure cancer. i don't know if many of youheard about that pledged initial commitment of one billiondollars to try to cure cancer. and this is much needed fundsto try to advance our fight against cancer. and this is reallya landmark moment.

just a few days ago we were ableto celebrate vice president biden who visited the johnshopkins east baltimore campus. to help inaugurate the launchof the immunotherapy center at hopkins, made available to a generous number of giftsthat totaled $125 million. and so forthose that follow the cancer field have probablyheard about this. really, immunotherapy, using the immune system to fighttumor cells, fight cancer cells.

revolutionizing the waywe take care of so many differenttypes of tumors and cancers, attempting to prolonglife and cure people that were previously had no options,so incredibly exciting. and so when president obamamade this committment, to make a credible impact on the way wetake care of people with cancer. the reason i thinkit's appropriate or more appropriate to think aboutthat as a tangible goal now versus what was done many yearsago when president kennedy

launched the war on canceris because our understanding of the biology and the scienceis rapidly accelerating. one of the reasons i'vededicated my life to working on cancer is because it's somethingthat affects all of us. heard about personal storiesthis morning from serena, of friends, family, associates, acquaintances, all thatare touched by this. and the numbersare incredibly staggering, this year alone 600,000people are estimated to

pass from cancer inthe united states. 1.5 million peopleare estimated to be diagnosed with cancer this year alonein the united states. by 2030 cancer's predicted tobe the number one leading cause of death in the u.s. with over2 million people diagnosed and over 800,000 peoplesuccumbing to their disease. and these are daunting, staggering, almostdepressing numbers. but the reality is i don't thinkthere's been a greater time for

optimism and hope forfolks who are battling cancer, being infected bycancer than today. and that's really the messagethat i hope people leave with, is that there are numerouspeople, countless people, working tirelessly, ad-hoc in other institutionsaround the world to make those numbers more tolerable,to provide more hope for people. and one of the areas that ithink is incredibly exciting, this arena ofpersonalized medicine.

and so this has become morepopular in late the press you may have read about it. wall street journal, new yorktimes, and the concept is very, very simple. and that is that we knowthat almost any disease effects each of us differentlywhether it's a simple cold which you get from you child,child may get over in a day, which we may struggle with for aweek, or something more serious, like heart disease,diabetes, or cancer.

and what we've understood withcancer is that it's really not one disease. it's actuallya multitude of diseases. i treat innumerable diseases and each person hasa different cancer. even thought he diagnosis may bethe same, what they experience emotionally, physically andbiology is very different and we're now in an era where weare able to understand these differences ata molecular level.

what do i mean by that? the turn of the century,after 15 years of work and about three billion dollarsof investment from public tax payer dollars,in my mind one of the greatest accomplishments of modernscience was performed, and that was the completionof the human genome project. and why is that suchan astounding feat? well, every cell inthe body has dna. what is dna?

dna is sort ofthe genetic code that tells every cell inthe body what to do. incredibly complex. 3 billion base pairs. and every cell has it. and this genetic material, this dna, is organized in thecell in very reproducible ways. an analogy i often liketo use to describe it is an encyclopedia.

so these threebillion base pairs are organized into 46encyclopedia books. all of us get 23 of theseencyclopedia books or chromosomes from mom and23 from dad, and each book is organizedinto 100 pages. in each page are 1500characters and this is in every cell inthe body, incredibly complex. and scientists were able todecipher what is it that makes up these 46 encyclopedia books.

and what's amazing is thatwe've begun to understand that a cancer cell that previouslywas completely normal, completely healthy, functioningas it should, turns abnormal, starts growing, replicatingin ways that we don't quite understand because of just a fewmistakes in this encyclopedia. in pediatric cancers it canbe as few as one or two. but for most cancers it'sas few as 40 mistakes. so what do we meanby these mistakes? could be a missing apostrophe.

missing comma. a page that's duplicated. two pages that are missing. so if i challenged the grouptoday to work together to pour through an encyclopediaof 46 books to pick out the 40 mistakes that exist, wecould spend our entire lifetime together and never find all 40. but now the technology is ata place where we can do this cost $3 billion at the turnof the century, 15 years.

today it can be done inless than a week and cost a few thousand dollars. so that is an astronomicaldifference in understanding. and we now understandcancer at a breadth and depth that has never beenable to be done before. so the real question is howdo you apply this technology. i'm a clinician, a surgeon,i take care of patients. and really that's why i lovescience, because it's a tool, a mode to help people.

so there is lots of way to usethis and it's being implemented. and one of the ways we are usingthis is the concept of a liquid biopsy. and that's one ofthe focuses of our group. we've been blessed to work witha number of extraordinarily brilliant scientists at hopkinsaround the world on this concept and that's what i'd like toshare the next few minutes on how we're applying thistechnology to help people. so, the concept of liquidbiopsy is very simple.

what does that mean? it means understand what'shappening with the cancer or tumor without going in,sticking in a needle, taking a piece of it for biopsy. we're going in as a surgeon,operating on it and taking it out. why is this important? we've all had proceduresby our physicians, whether it's a simple blooddraw or as invasive as surgery.

all of these things haverisks associated with them. so we wanna do things thatare minimally invasive. minimally risky. so finding ways to detect and track cancers without havingto do invasive procedures is of obvious importance,but it goes beyond that. it's the core ofthe understanding of the disease itself. so when we do a biopsy,we take a very small sample.

oftentimes, the tipof my finger and we often able tomake a diagnosis. get a lot of useful information,but we're beginning tounderstand that the insight that a biopsy gives us islimited and why is it limited? its limited in several reasons. one is that if an individualhas a cancer that's deposit itself in three area's say thebrain, the lungs and the bone we not understand that eacharea behaves very differently.

and so if someone has a biopsyof their bone mass, it actually could be quite different fromwhat's going on in the lung and brain and why is that important? it's important, because we needto be able to treat all those areas effectively, to be able tomaximize our chances for a cure. maximize our chances forlong survival. and so, these cells that lodgein different parts of the body can behave very differently. can have different ways ofbeing sensitive to medicines,

different ways of beingresistant to medicines. so having a way to understandthat heterogeneity is very essential. another concept that we've began to understand is to saythat there's only one match. just do a small biopsyof that one mass. even in that one area, thecancer cells are very different. so it's like takinga bag of m&m's. put your hand in there.

grab a few. take a look. you have two blue,three green, four red m&ms. but if you were to put your handback in there and sample another time, you're probably gonnaget a different set of m&ms. the reason is there'sdifferences in that bag of m&m. you're just samplinga little bit, but it may not be representativeof the whole bag. same thing withthese cancer cells.

so, we get an idea. very, very important. but not necessary,giving us a whole picture. so the idea of liquid biopsyis to try to encapsulate, try to understand the entirepicture without having to do invasive procedures. and the one concept that's verysimple that we have all probably remember from high schoolbiology is that our blood supplies oxygen and nutrientsto every cell in the body.

every cell in the body needs it. and so the question we began toask is that, do cancer cells that need the same oxygen thesame blood that healthy cells? do they shunt thingsinto the bloodstream? they gave us insights intowhat's happening to these cells at the very molecular level. and the answer is amazingly, yes that we're able toget a global picture. it's not 100% perfect.

it needs a lot ofwork to be done, but the principals are there. what does this mean? well, it means that we havenew opportunities to intervene hopefully sooner andearlier to help people. and so, i'll talk to you abouta few different applications of this concept of a liquid biopsy. the marker that we look at,the tumor shed into the blood or other fluids,there's dna markers.

but other scientists use rna or protein orall sorts of other things. all these technologiesare complimentary and all of these are building a basis forbeing able to help people in the future, and the specificsreally are not that important. so we began our efforts a fewyears ago by looking at a panel of around 620 blood samplesfrom people who had cancers from all over the body,brain, lung, colon, skin. we ask a very simple question.

is it only certain typesof cancers are shed into the bloodstream? one or two, or is it reallya large number are probably applicable as this approach? and amazingly, the vast majority of the cancersthat we tested actually did shed molecules that we wanted todetect in to the bloodstream. so, that gave us great hopethat this was in technology and approach that can impactlarge numbers of people.

but again,it's not enough to just say, this is the observation. how do you help people? so one of the ways that wethink we can help people is for understanding drug resistance,what is this? we know that when people getcancer we give them medication or chemotherapy, but thenunfortunately in some cases, the cancer stops responding. that the cancer found waysto become resistant and

escape the drugsthat we're giving. and currently, the best waywe know how to detect this recurrence is to watch people. see how they'redoing clinically. how did they feel? get pet scans or cat scans ormri scans or x-rays or all of the above. use the other blood monikerslike psa, or cea or ca 129. all wonderful things.

but unfortunately,they all have limitations. so we wanna add somethingto this armamentarium. so, we took a cohort of peoplewho were receiving treatment for lung or colon cancer using avery specific drug that targets a very specific gene. and we ask a verysimple question, can we see science thatthis drug is stopping its effectiveness that the cancercells are becoming resistant? we tested two or three cc'sof their blood teaspoon.

and so, can we see these signsof resistance before treatment? and can we see itafter treatment? and incredibly, all but one patient in our small cohortshowed signs of resistance. the cancer cells were findingways to escape the treatment. well, you can say, wow, that's really disappointing,incredibly discouraging. i like to flip the coin and say, that's amazing informationto have as a clinician

as someone who helps to takecare of people with cancer. this is a paradigmthat's not foreign to the medical profession. we all know about hiv. something that continuesto be an incredible world health problem. but in the 80s and 90s, it was an epidemic, ravagingyoung people all over the world. but today, a young persondiagnosed with hiv who can take

his or her medications tolerateit has a life expectancy that's not much different than someonewho has no hiv infection. that's in our lifetime. that's in the last 10 to 15years and that remarkable. that's not to say, we don'thave problems with hiv or more work shouldn't be done. of course not, but it'sprogress in a monumental and significant way. why do i talk about hiv?

well, one of the reasons i thinkthat hiv has been able to be better treated is that thisconcept of personalized medicine has already been in place forthe infectious disease doctors. what typically happens forfolks diagnosed with hiv, the virus that sequencedto understand for that particular patience andinfection. what are the achilles heel forthat virus? what are the drugs most likelyto help that patient and what are the drugs that are leastlikely to work for that virus?

the id doctors treat the viruswith the medications most likely to work. don't give the ones thatare likely to fail and they monitor it. and they monitor the virus tosee if it's developing ways of developing resistance,escaping the drugs. and that infectious diseasedoctors say, listen, we see early signsof resistance. let's modify the drug regime.

and sowe're fortunate that for hiv, there are lots of very effectivetreatments now, but this is a paradigm that i believe canone day be implemented for cancer that we can havemechanisms of doing blood test or testing other body fluids. ways of saying, the cancersinvading the treatment this person's getting today. once we change it beforeit gets out of control. why don't we offer new therapiesto try to control things?

and so, i feel like this liquidbiopsy is one potential hope for that type of application. another potential applicationthat's near and dear to me, as a surgeon is thisidea of residual tumor. we know that for many tumorstypes, when it's been able to be removed entirely by the surgeoncan actually cure people. if there are nocells left behind. and as a surgeon when we dothese types of surgeries, we feel like we've gotten allthe tumor out at the time of

surgery. post op mri looks beautiful. we know that unfortunately stilla small fraction of those people for whatever reason, will recur. likely because thereare tumor cells or cancer cells that are leftbehind that we can't see, that we can't detect. and wouldn't it be wonderfulto be able to tell people, we think we got it all.

there may be a few cells left. let's go ahead and find waysto attack those few cells and improve the chances for a cure. improve the chances forlong term survival. so we did a very simple study, looking at people who had coloncancer undergoing surgery. these folks had surgery,the surgeon thought he or she got it all out. post op scans looked great.

and we got their blood again,tested a teaspoon of it, when they came back to see thesurgeon at a month and a half or two months. i said can we see thesetumor markers that we're interested in? and in those individuals thatwere recurred we could see signs of that recurrences earlyas six or eight weeks. and wouldn't it be wonderfulto be able to initiate treatment forthose folks at that early stage,

rather than waiting to see ifthe ct scan shows a mass or an mri scan lights up, orclinical symptom arises. because we know the earlierwe're able to intervene, the better we are able to treat. so another application that forme, as a surgeon,extraordinarily promising. but while all these applicationsare exciting, i think the one that's most promising, the onethat has the highest potential to help people is withregards to screening.

so, what does screening mean? screening very simply, meanstesting folks that are otherwise healthy forthe presence of a disease. we have all probably done it. pap smears for cervical cancer. mammography for breast cancer. colonoscopy for colon cancer. these are all very effectiveways to diagnose cancers early and a way for us to cure peopleof their cancer before it grows.

so for pap smears, which isone of the most revolutionary screening technologiesimplemented. 50% of adult womenaround the world are recommendedto get this test. really that goal of that testis to diagnose cervical cancer. and it's been extraordinarilyeffective in that, but when the test was recentlydescribed in the mid 1900's, they thought that they wereactually discovering cancers of the uterus, butfuture studies said no.

it's only the cervix and cancersthat arising there that we're able to detect, but we knowanatomically, the ovaries, fallopian tubes, the uterus,are all connected to the cervix. and the cervix is where the gynecologistsperform the pap smear. so we asked a verysimple question. is it possible to findtumor markers, not just for cervical cancer in the papsmears, but for ovarian or uterine, otherwise knownas endometrial cancers.

and very small study, we were incredibly blown awaythat we were able to diagnose all the endometrial cancersthat we were testing. it's a small cohort, but evenearly stage endometrial cancers, we're able to see signs of themarkers in the same pap smears that women get done today. that we're able to see signsof half or so of the ovarian cancers from women thatthese pap smears came from. so incredibly excitingtechnology for me, for

those that work on this, because this has the potentialto help thousands of women, millions of women aroundthe world, endometrial cancer. the fourth most commoncause of cancer in women. that's no screening test. ovarian cancer, same thing. but i caution the audienceto know that screening, of course, is the last thingthat we're able to implement. because has the highestthreshold tests that 50% of

the total population gets,should do no harm first and foremost, so it needs lots ofinformation to make sure it's accurate, sensitive,doesn't harm people, but does detect what wethink it's detecting. so it's going to take lotsof years, lots of studies. but the message i want to leavethe group with here today is that of hope, that thesetechnologies, that these efforts from countless people around thecountry, countless people around the world, working tirelesslyday and night, literally.

that there is this hope and that these technologieswill become available. that they will help people and that we'll continue towin this war on cancer. thank you very much.