Any thoughts on the mRNA vaccine trials for pancreatic cancer?

@gamaryanne
I learned the term "TNT" for "Total Neoadjuvant Therapy" midway through my 12 pre-Whipple treatments of Folfirinox. "Total" means all before surgery, none after, unless obviously called for.

As much as I enjoyed the Folfirinox (sarcasm), I bought into the idea that this was an OK treatment approach. There was no evidence of disease anywhere outside the head of my pancreas before or after surgery. Pancreas was declared to have clean margins after the second cut, and 22 lymph nodes were clean.

CA19-9 was 12 a few weeks after surgery. MRI one month post-op was perfect. I was getting regular Signatera ctDNA testing that was supposed to detect microscopic residual disease long before imaging would. Two good post-op results with that, and I even self-paid for the Galleri ctDNA test which was also all-clear. Why suffer through chemo at this point if there is NED?

I had a minor suspicion of "no bueno" after adding CA19-9 to some other regular bloodwork at my PCP. It came back at 33, still in the normal range, but it was from a different lab, so I didn't overreact.

I finally let my guard down and celebrated. Three and 1/2 months later, after the first perfect MRI, follow-up MRI spotted a 1.2 cm mass at the original surgical site (where pancreas head was reattached to jejunum). CA19-9 at original/reference lab was 77.

EUS/biopsy was immediately ordered, and all 4 tissue samples came back negative for malignancy. It was declared as pancreatitis worthy of follow-up. New oncologist (my team had a shuffle) said he didn't think any chemo treatment in the interim would "change the outcome."

Seven weeks later, CA19-9 was 279 and the mass was 2.1 cm on MRI and one lymph node was lighting up as suspicious, and the radiologist didn't catch a little tiny met hiding elsewhere in my abdomen, but everyone was sure the now 2.1 cm mass was a fast growing malignant recurrence.

Immediate commencement of systemic chemo was recommended, but since the neoadjuvant Folfirinox was not very effective and the Gemzar-based alternatives they proposed generally regarded as less so, I spent 4 weeks seeking clinical trials and getting two expert consultations from outside CoEs. Imaging (CT) at one of them revealed another met and bloodwork showed a bigger increase in CA19-9 (to 623). I relented and started the Gem/Abrax/Cis with a CA19-9 level of 677 one week later.

If the new oncologist's original comment about a 7-week delay in starting (possibly unnecessary) treatment, wouldn't likely "change the outcome" I figured the 4-5 extra weeks of research wouldn't be a huge deal either.

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LONG STORY SHORT: A LOT OF LESSONS LEARNED HERE
Many omitted for brevity, but from the post-op perspective:

1) I should have done a lot more frequent CA19-9 testing after the Whipple. It's cheap, easy to do often, and rising levels gave earlier hint of my impending recurrence than MRI or the expensive ctDNA tests did.

2) I probably should have been on post-Whipple radiation and/or chemo from the get-go, but definitely at one of some point between the CA19-9 levels of 33 and 77 (which more frequent testing would have identified).

These might have preserved a second chance for surgery before mets rendered that a non-option.

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I'll close by attaching a paper from late 2021 that I found last year, and quoting a few parts of it below. Remember, I am just a sample of one, not medically trained, and the attached paper is not the final or only word on the subject. Please read the entire paper if possible so my two quotes below are understood in the full context.

"During the last twenty years, it has been well established that all surgical approaches to pancreatic cancer need to be supplemented by adjuvant therapy."

and

"The current debate on neoadjuvant treatment is certainly
the most controversial, yet evolving, field in pancreatic can-
cer treatment. Whereas it remains clear that resectable pan-
creatic cancer patients should not be treated with a neoadju-
vant therapy outside clinical studies, in borderline resectable
patients, the situation remains more difficult. In resectable
pancreatic cancer, studies on neoadjuvant therapy have failed
to show any advantage in terms of survival compared to the
benchmarks set by the above-mentioned adjuvant studies
achieving 2.5 to 4.5 years of median survival. In borderline
resectable pancreatic cancer patients, the current evidence
also fails to show a clear survival advantage, ..."