We’re actually the biggest healthcare system in Wisconsin, covering about a third of the state patient population with over 8,000 new cancers a year. We have the luxury to see about 200 cancers of the pancreas a year. So for that reason in our institution we have developed the role of pathways for management, mostly because we have a broad, very wide geographic area that we have to treat. With more than forty oncologists and 400 miles to cover, pathways were the way to be able to standardise care, provide utmost up-to-date care for patients and make them available for research purposes, particularly in pancreas cancer where survival is still quite sadly dismal.

So our pathways were based more on following what we call the oncology pathways in which we have three tenets for treatment. One is the efficacy, the effectiveness, of the therapy – we will look at treatments that are most effective. We follow these by the ones with least toxicity for the patients and third, but not last, would be cost to the institution and the patient. But clearly effectiveness is our number one goal so we can provide utmost care to the patients.

In light of those pathways we were discussing how we have developed internally our treatment modality for patients. This is based on what we call total neoadjuvant care for pancreas cancer. We understand that pancreas cancer is a multidisciplinary systemic disease, not just a local disease, and even in early stages survival is quite bad at 18-24 months unless treated as a systemic illness. So we will be looking at developing treatments for total neoadjuvant care in which people get their chemotherapy before the surgery. Yes, surgery is still the tenement of cancer care for pancreas cancer, we still need to have surgery, but with the role of chemotherapy before we are able to select the right patients for the right treatment so hopefully we end up having what we call conditional survival. If patients get to live two years they have a 66% chance of getting to five. That has improved their survival hopefully from 18-24% to 45-48% at five years. The role of this is by doing chemotherapy up front in which we use usually FOLFIRINOX if the patient is young enough or we use a gemcitabine-based regimen with gemcitabine and the nanotechnology based taxanes, so the nab paclitaxel regimen. We make that decision based on age, comorbidities, weakness, strength and how the patient is doing. We try to do the six months of treatment first, if the patient is fully resectable from the beginning it’s six months of chemotherapy followed by surgery. If the patient is borderline resectable we will do the six months of chemotherapy probably consolidate with radiation and then surgery. We have decided, and we made the internal comment, that patients can tolerate the six cycles of chemotherapy much better before surgery than after surgery. If we do the chemotherapy after surgery most patients will not complete the chemotherapy regimen and we do believe that that does impact on overall survival. So that’s the goal of treatment.

Metastatic disease is a little bit more complicated because we understand that there is not a lot of options. Everybody will be treated, we try to do one to two regimens. We have chosen the gemcitabine nab paclitaxel regimen just because irinotecan is our mainstay treatment in our research protocols where we enrol patients in.

The use of pathways has allowed us that we have 85% of our patients are treated under the same guidelines, therefore giving us a way to provide outcome information to the patient so they know what they’re looking into. More importantly it allows all patients to be enrolled in studies. As a community-based system we are able to enrol more than two hundred and something patients a year on studies, not just pancreas cancer but all types of cancers because we do follow pathways for most of them.