The Lipscomb family at the wedding of son David Jr. (center). Left to right: Robi, daughter-in-law Amanda, David Jr. (DJ), David, and son Dale.

The day David Lipscomb was diagnosed with pancreatic cancer he had run two-and-a-half miles as part of his training for Nashville’s Country Music Marathon. At age 44, with a wife, Robi, and two college-age sons, Lipscomb was active and seemingly healthy. He and a partner were running Overflow Management, a Christian music artist management company based in Franklin, Tenn. He had no idea that his recent bouts of intense nausea were symptoms of a silent killer that would threaten this fast-paced life.

“On Christmas Eve we ate a big meal with our family, and that night I was violently ill,” Lipscomb remembered. The same thing happened after a big meal a week later on New Year’s Eve. His family physician thought the symptoms could be the flu. But a few days later when Lipscomb returned from that run, Robi looked at his eyes and realized they were yellow.

“I told him this is something serious,” Robi said. “I had seen some TV shows, and I knew that was a bad thing.”

Hours later in a local hospital emergency room – after an ultrasound, MRI and a CT scan – the ER doctor gave the couple the grim diagnosis. The tests had revealed a tumor in Lipscomb’s pancreas; it was almost certainly cancerous.

“When I was in the MRI, I was praying to be peaceful. I had this sense that God was preparing me for something bad,” Lipscomb said. He had no idea how difficult the coming journey would be.

Cancer of the pancreas is an especially lethal disease. According to the National Cancer Institute there were approximately 37,680 new cases in 2008 with 34,290 deaths, making cancer of the pancreas the fourth leading cause of cancer death in this country. Only 5 percent of patients are still alive after five years.

The pancreas is a thin, elongated gland about six inches long that lies behind the stomach. It produces juices to help digest food and hormones to help control blood sugar levels. In the early stages of pancreatic cancer, there may be no symptoms at all. Even when the disease advances, symptoms like abdominal discomfort, back pain or weight loss may be mistaken for other diseases. Many patients don’t suspect they are sick until they develop yellow skin or eyes, a symptom of jaundice. Because of these often subtle symptoms, most pancreatic cancer is diagnosed at an advanced stage when it is much more difficult to treat.

Until his bouts with severe nausea and jaundice, Lipscomb was unaware that he was sick, suffering from a form of cancer that had not yet gained wide recognition in the public consciousness.

Only recently has the spotlight begun to focus on pancreatic cancer – due in part to actor Patrick Swayze’s diagnosis and Carnegie Mellon University Professor Randy Pausch’s “The Last Lecture,” a primer for his children on living your dreams, that became an Internet phenomenon and sparked TV appearances and a book. Pausch died of the disease last year at age 47.

“There aren’t many celebrities talking about it or holding fundraising events on TV because they’re not around to do that,” Lipscomb said. “I want the public to understand this is a very serious and terrifying disease, and it’s under the radar.”

After a biopsy, Lipscomb discovered he was one of the luckier patients; his tumor was blocking a bile duct at the head of the pancreas – the one place where tumors may be surgically removed.

After doing some research through the Pancreatic Cancer Action Network (PanCAN) and other organizations, Lipscomb decided to be treated at a comprehensive cancer center by a surgeon who performed a high volume of aggressive pancreatic cancer operations. He found Nipun Merchant, M.D., associate professor of Surgery at Vanderbilt-Ingram Cancer Center, who performs nearly sixty complex pancreatic cancer operations a year.

“Surgery is the primary treatment,” said Merchant. “Unfortunately only about 15 to 20 percent of patients are appropriate for surgery. If the tumor has already spread beyond the confines of the pancreas – to the liver or the lining of the abdomen – taking out the tumor in the pancreas is not going to help the patient since all of the tumor will not be removed.”

The location of the tumor is also vitally important. The head of the pancreas wraps around two major blood vessels that supply blood to the liver and the intestines.

“If the tumor is wrapped around those, and if we cannot remove all of the tumor – even if we leave a little bit behind – it’s the same as not doing the operation,” Merchant explained.

“In the past, these operations were considered high-risk,” Merchant said. But thanks to improvements in surgical techniques, “in high-volume cancer centers, the mortality for this procedure is less than 2 percent. We’re very aggressive here at Vanderbilt-Ingram when it comes to operating in tight spots.”

Dramatic improvements in imaging also help physicians identify the best candidates for surgery. “We are so much better now at taking the appropriate patients to surgery,” Merchant said. There is a lot of progress being made in terms of defining characteristics of which tumors are resectable, unresectable or borderline resectable based on the involvement of the surrounding blood vessels.”

The Lipscomb family knew how fortunate they were that David was a candidate for surgery, which provides the only hope for a cure.

“It was a three-centimeter tumor and honestly, had it been a centimeter either way and not on that bile duct, we wouldn’t be having this conversation,” Robi explained.

Still, David knew the surgery would be tough.

On Jan. 22, 2008, Merchant performed the Whipple procedure, removing one-third of Lipscomb’s pancreas, his gallbladder, a small piece of his liver, and part of his small intestines.

While the surgery went well, there were setbacks and Lipscomb spent nearly three weeks in the hospital. Over the next few months he underwent chemotherapy and then combination chemo-radiation therapy.

Lipscomb’s medical oncologist, Laura Williams Goff, M.D., prescribed a chemotherapy drug called gemcitabine.

“I always feel good about offering gemcitabine to patients with pancreas cancer because it was approved on the basis of improvement in clinical benefit, improvement in pain and
overall energy levels,” said Goff, an assistant professor of Medicine at Vanderbilt-Ingram. “Most people don’t lose their hair, and they have minimal nausea and vomiting. It’s a pretty well-tolerated regimen.”

While chemotherapy after surgery does improve survival, it is difficult to cure the disease. Some patients also receive radiation therapy, which may be helpful especially for high-risk tumors.

“There has been a lack of progress in clinical trials for adjuvant therapy after surgery,” said Merchant. “Based on all of the clinical trials so far, there is still a great deal of controversy regarding the role of radiation therapy. It’s unfortunate that we haven’t been able to come to a consensus because there are such limited options for our patients.”

Since 80 percent of patients are not eligible for surgery, cancer researchers are diligently trying to develop new drug treatments for pancreatic cancer. So far, the only targeted therapy approved by the Food and Drug Administration (FDA) is erlotinib, known commercially as Tarceva. While the drug normally extends life by a few weeks, the fact that it works at all is reason for hope in a disease that has proved difficult to understand and treat. Even when patients are successfully treated with surgery, chemotherapy, radiation or Tarceva, the chance of a recurrence is dramatic; the cancer returns in about 80 percent of patients.

Researchers are also starting to identify the genetic pathways that mark the progression of the disease.

“We have known for some time that the K-ras gene is mutated and overactive in pancreas cancer,” Goff explained. “It seems to happen early in the development of pancreas cancer, but figuring out how to turn it off or to target that abnormal K-ras has so far eluded us.”

Hal Moses, M.D., Director Emeritus of Vanderbilt-Ingram, and colleagues have developed a mouse model of pancreatic cancer – by coupling a K-ras mutation with another mutation – that closely resembles human disease. This model could provide new opportunities for studying the disease’s progression and for investigating potential therapies.

Goff hopes that it will be possible to individualize chemotherapy or targeted therapies for different types of pancreas cancer.
“There have been preliminary efforts to try to segment types of pancreas cancer by groups of genes – similar to what has been done for breast cancer or lung cancer – but that research is very early and is not ready for prime time,” she said.

The successes in treating and curing breast and colon cancer make the lack of success in pancreatic cancer even more frustrating for physicians and patients. And they all point to the same fact: the dramatic difference in levels of research funding. While pancreatic cancer is among the top five cancer killers, the disease constitutes less than 2 percent of the National Cancer Institute’s research budget – far less than funding for other major cancer types.

“For more than 30 years we have been talking about waging a war on cancer,” said Jordan Berlin, M.D., associate professor of Medicine and clinical director of Gastrointestinal Oncology at Vanderbilt-Ingram. “But when you look at the amount of money devoted to pancreatic cancer research, it’s more like a skirmish.”

“One of the reasons we have made so many inroads in
treating breast or colon cancer is because we have devoted so
many financial resources to basic and clinical research,” Berlin said. “With an aging population, we are going to see many more pancreatic cancer patients, and we need to start focusing our research dollars on this disease.”

David Lipscomb and family agree with that sentiment – and hope to help raise public awareness of this disease.

Nine months after surgery, Lipscomb had regained some of the weight he lost and was starting to exercise again. He had even managed to keep working during much of his recovery. But the battle is far from over.

“Even though the percentages are bleak, somebody always beats the percentages,” Lipscomb said. “Why not me? Somebody has to. How humbling to think only two out of 10 patients who get this can have surgery. I can’t help but feel hopeful because I’ve already beaten the odds.”

Editor’s note: As Momentum was going to press, David's cancer returned and progressed quickly. He passed away on Feb. 25. For those who would like to help patients like David, his family requests that donations be made to the Pancreatic Cancer Action Network (www.pancan.org ), an organization that sponsors research and advocates for more public awareness of this disease.