Pancreatic lesion 89 yr old dad. Dr not sure if he can be treated.

Difficult to offer any advice until you receive the MRI results, but I totally understand how you feel as my dad got the pancreatic cancer at 77, but was misdiagnosed with food poisoning and by the time they did a CAT scan it was too late for any treatment. Prayers for you and your dad.

Can you say how the lesion was found, ie what type of scan and why the scan was done in the first place? Often cysts called IPMN's are seen when imaging is done for another reason and is called an incidental finding. Most of these are small, don't create any symptoms and are just watched for a period of time to make sure they don't appreciably grow or change characteristics.

Is the MRI he is having called an MRCP? This is a special MRI that only views the biliary tree that includes the liver, gallbladder and pancreas. Normally it is this test where they measure the size of cysts and define their nature. It can also give a significant amount of information for any other abnormalities found in these organs such a duct dilations. I had an MRCP done specifically for another issue, but it picked up a couple of these cysts.

Do you have other information about the lesion? I ask because heading straight to a surgical discussion alludes to more than a simple cyst. Either way I wish the best for your dad and your family.

Disclaimer: I have zero medical training, just some experience dealing with my own pancreatic cancer and several relatives with other types of cancer.

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A lot depends on other aspects of your dad's health, whether the lesions are cancerous or not, exactly where they are on the pancreas, if a full-body CT or PET scan finds metastases elsewhere, etc...

If there are mets, they almost always rule out surgery and instead go with systemic chemo if appropriate.

If the lesions are suspected to be malignant cancerous tumors, a biopsy will probably be done to get tissue and determine the exact tumor type. That type of biopsy is often done during an endoscopic ultrasound (EUS) procedure under general anesthesia. It's rare but possible to get a false negative result from the biopsy; if that happens, they'll probably at least track the CA19-9 tumor marker, and order another MRI/MRCP or CT and CA19-9 test in 6-8 weeks to see if things have normalized or progressed.

If there is only one tumor, then the most common procedure to remove it from the head of the pancreas is called a Whipple procedure, or distal pancreatectomy (sometimes with splenectomy) to remove it from the tail. If it's in the body between head and tail, then it's totally the surgeon's call on how much to remove and (if any) what procedure to use. Whipple entails about a week in the hospital and 6-8 weeks of recovery at home.

If surgery would be too hard on him, radiation might be possible if the tumor is not in too sensitive a location, possibly in combination with a "mild" oral chemo pill called Capecitabine to provide some systemic control and help sensitize the tissue for radiation. If he is rather frail, then you might ask whether shorter durations of higher-intensity radiation would be better, or lower doses and spread out over time. Also ask if they have access to a proton beam or carbon ion radiation machine; these do less damage to surrounding tissue.

There are other less invasive and non-invasive methods of treatment, but no gold standards of any sort. TTF (Tumor Treatment Fields) is a small array of antennas in a wide belt you wear for 18 hours a day, ongoing indefinitely. If generates a low-frequency electromagnetic field that is supposed to disrupt the tumor's ability to reproduce. Basically zero side effects, but only seems to help when combined with some type of chemo.

IRE (Irreversible Electroporation) is another treatment that uses electric fields to kill tumor cells, but instead of dragging on for months, it's done one time in a surgical setting. They insert several (six?) "antennae" probes to build a "fence" around the tumor and then electrify the fence. I understand it can be done percutaneously or open; not sure about laparascopically. Percutaneous is far less invasive, but a bit more risky in terms of puncturing other tissue/organs when inserting the probes.

The Civa Sheet is one of several brachytherapy techniques to ask about. Brachytherapy is really a form or internal radiation. It would have to be done surgically, but doesn't involve cutting out any organs, so it's much easier to recover from than something like a Whipple procedure. The older techniques would put a radioactive pellet somewhere near the tumor and let it do its job. But the radiation can spread out in all directions and affect other tissue. The Civa Sheet is a newer technology that has multiple pellets on a sheet backed with gold to prevent radiation from escaping out the back. They basically just wrap the sheet around the tumor and let it go to work. I think the radiation decays first, then the sheet dissolves (iirc) afterward and doesn't have to be removed. (I could be wrong on this!!!)

Although you'd like to think the response to pancreatic cancer is like a TV episode of "House" where a whole team stays up 24/7 thinking about your case, the most likely outcome is a recommendation for "Standard of Care" therapy.

One thing to make sure of is that they're writing the treatment recipe for an 89-year old with Crohn's Disease, and not just for the mythical median patient.

For systemic chemo, they would probably avoid Folfirinox because of his age. They would probably go with Gemticabine if he can handle infusions (at least biweekly, maybe 3 weeks out of 4). They can add Abraxane and/or a platinum-based drug to that regimen, TBD by the docs. The platinum drug of choice is generally Cisplatin, but considering his condition and age, I would think a "milder" substitute like Carboplatin might be used instead. If infusions are ruled out, you should still ask whether they would consider oral Capecitabine.

My gut feeling is that a Whipple procedure would be pretty hard on your dad, and not really improve his quality of life. Similarly, my gut feeling is that anything beyond Gemcitabine alone for an IV would also not improve his quality of life much, but you know your dad better than I do, so a lot depends on how much energy and fight he has in his system, and how much longevity is typical in his family.

Genetic testing should be done as soon as possible to help steer his treatment.

I would look for clinical trials outside the Standard of Care arena as a first-line option to try and get the most bang for the buck -- a better response with fewer or less debilitating side effects.

Wishing you both the best!

Wow a lot of good helpful information from Mark..

Supportive friend of 90 yr old with pancreatic mass. Released from hospital to her home with 24 hr care. Very jaundiced. She had cancerous tumor removed from breast last year. Doctor thinks cancer metastasized and doesn't recommend surgery or chemo. Looking for guidance on palliative and hospice care.

The vast majority of clinical trials have an upper age limit ranging between 75 to 85 years. It is extremely rare to find a trial today that accrues patients that are 89 years old which is the upper limit of any trial I have found on clinicaltrials.gov and those trials occurred more than a decade ago. Phase I and II trials accept healthier and younger patients and are the ones more likely to be open label trials where all patients receive the test drug. Some phase II trials are randomized and can be single or double blinded to mask knowing who is receiving the drug until the trial is concluded.

Phase III trials accept less healthy patients although with limits in age restriction and the co-morbidities that can result in exclusion. All phase III trials are randomized. A computer does the selection so the patient nor the oncologist has any say in who is in the test arm and who is in the control arm receiving standard of care.

There are surgical oncologists who will perform the Whipple and Distal Pancreatectomy with splenectomy on patients of advanced years. The criteria is not age but the ECOG health status of that patient, generally being 0 to 1 and no serious co-morbidities. The famous Whipple surgeon John Cameron who practiced at Johns Hopkins in Baltimore and now retired performed a Whipple on the oldest patient being 103 years old. Flavio Rocca MD in Portland, Oregon did a Whipple on a patient that was 94 years old. John Chabot MD of the Pancreas Center at Columbia Presbyterian also does Whipple surgery on patient of advanced years.

@judithbramson12 had Whipple at Mayo/Jax (Dr. Stauffer) in 2022, which would have been age 82 if I read her post here https://connect.mayoclinic.org/discussion/bloathas-anyone-experienced-bloat/?pg=2 correctly. That's absolutely amazing.

My dad was 84 and in OK health when his pleural mesothelioma was discovered, but every surgery on the books was ruled out as too hard on him. He took an immunotherapy treatment for about 4 months, and that about killed him. Once off that, he survived about 7 months of up and down, mostly down.

My father-in-law was 83 and in so-so health when he needed a heart stent and treatment for kidney cancer. The surgeons in both camps didn't want to touch him, basically daring the other one to go first. He wound up eventually getting both a few months apart, but we almost lost him a couple times. He's still on an adjuvant immunotherapy from the kidney removal, but testing negative for his cancers. One tough SOB (and former USMC).

@stageivsurvivor is correct about performance status being a bigger eligibility determinant than age. A quick search of trials at https://clinicaltrials.gov/search?cond=cancer&locStr=USA&country=United%20States with generic criteria of Location=USA and Condition=Cancer for all ages returns 45,510 trials.

If you add a filter limiting age to 65+, it returns 42,233.

If you manually specify an age range from 65 to 85, 99, or 1000, it returns the same 42,233.

That may be a limitation of their search engine or how they specify age items in their database, but it reinforces the idea that age (outside of adulthood at 18 or senior status at 65) is not a strict criteria for many trials.

Unfortunately, I couldn't find a search filter for performance status in my brief trip through the site.

I’m aware of the age restriction on clinical trials from my position as a research patient advocate on the GI Cancers Committee of the non-profit ECOG-ACRIN (Eastern Comprehensive Oncology Group-Academy of Clinical Radiology and Imaging Network. They are one of the larger organizations that propose, design and conduct clinical trials of all cancer types. This is also the organization that developed the ECOG patient physical assessment score to determine eligibility into a clinical trial.

I am also a research patient advocate on the Cancer Communications Committee of the American Society of Clinical Oncology (ASCO)-the largest cancer organization of its type for oncologists with worldwide membership. In my role on this committee, I am required to read hundreds of abstracts of clinical studies submitted prior to publication. Many of the abstracts deal with GI cancers such as colorectal, lung, esophageal, pancreatic, liver, bile duct and ampullary cancers. I don’t recall any having a patient cohort over age 85.

Hello jgran26,
How are you and your dad doing? Have you received the MRI results yet?

@avxk, thank you for supporting your friend. Here's some information that you might find helpful:
- Palliative Care: What is it? How do I get it?
https://connect.mayoclinic.org/discussion/palliative-care-1/
- Palliative care vs hospice care: What's the difference?
https://connect.mayoclinic.org/blog/take-charge-healthy-aging/newsfeed-post/paliative-care-vs-hospice-care-whats-the-difference/
- Palliative care for people with cancer designed to fit the needs of each patient
https://connect.mayoclinic.org/blog/podcasts/newsfeed-post/palliative-care-for-people-with-cancer-designed-to-fit-the-needs-of-each-patient/

Do you know if she qualifies yet for hospice care?