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Nikki Mitchell Foundation Premieres PSA at Traler Park Show

On June 18, 2019, 300 guests arrived at the Franklin Theatre for a rare and sold-out performance from the Traler Park. Jamey Johnson, Lee Brice, Rob Hatch, Dallas Davidson, Jerrod Niemann and Randy Houser took the stage to share both their music and the stories behind it. Before the show kicked off, the audience was the first to preview the Nikki Mitchell Foundation’s public service announcement.

The PSA shares the experience of two pancreatic cancer patients and a caregiver. “It is imperative that we get resources into the hands, the minds and the laboratories of innovative researchers,” explained the caregiver during her speech prior to the Traler Park performance.

The foundation was able to raise close to $60,000 towards their mission of providing comfort and relief for those affected by pancreatic cancer, while raising awareness and searching for the cure.

 

 

Safety of Robotic Whipples

 

Above is a photo of the da Vinci Surgical System. Not seen, is the surgeon’s console station. At the console, the surgeon sits aside the robot and can manipulate the robot’s arms to perform the surgery. Whereas a surgeon only has two arms, the robot seen above has four. These additional arms give the surgeon more options during the surgery.
Image credit: https://www.intuitive.com

The following summary comes from Emanuele F. Kauffmann, MD and colleagues, and was recently published in Surgical Endoscopy in January 2019.

Link to article: https://link.springer.com/article/10.1007%2Fs00464-018-6301-2

Over the recent decades, improvements in preoperative management and introduction of new surgical techniques has seen a substantially declined the morbidity (rate of complications) associated with pancreatic surgery. Among these, the most intriguing innovations has been the introduction of the surgical robot as a tool to assist the surgeon. When using this platform, surgeons may enjoy increased control, a 3-D view of the abdomen, and greater magnification of the surgical field, while minimizing the length of required incisions. In this article, the authors sought to evaluate the outcomes of robotic pancreatic oduodenectomy (also known as the Whipple procedure) as compared to its classic open counterpart. The authors chose to evaluate immediate oncological outcomes including resection margin status (see our August blog post on resection margins for more information). Additionally, they evaluated long-term patient outcomes including recurrence of disease and overall survival.

In order to draw meaningful conclusions, the authors performed a propensity score match. It is a widely used statistical tool that allows us to balance groups of patients that otherwise in the real world might not be similar due to various aspects of clinical decision making. Based on features of patients in one group, patients with similar characteristics are identified from the other group that serve as a control. Once done these selected groups are compared rather than the entire patient population.

Encouragingly, there were no differences observed in the rates of negative resection margins in both groups. Additionally, the authors found that the long-term outcomes including recurrence of disease and overall survival were equivalent regardless of robotic or open surgical approach.

Take home points:

  1. Surgeons can perform the same procedure, using either techniques to achieve similar rates of tumor clearance.
  2. Patients who undergo a Whipple via either technique have similar long-term outcomes.

It is important to remember that each patient and their disease is unique. Consequently, some patients may not be ideal candidates for a robotic approach. Furthermore, surgical experience and training in using a robotic console are required to use it effectively. Therefore, it should be expected that these similar outcomes are achieved when the surgeons performing the robotic procedures are trained in the field, and are past their learning curve.

NMF Raises $7,000 from Annual Online Auction

The Nikki Mitchell Foundation’s annual auction closed Monday, March 25th.  The auction raised over $7,000, sold 10 items and brought in around 40 bidders from 12 states. Funds raised benefit the non-profit whose mission is to prevent, detect and cure pancreatic cancer.

Nikki Mitchell, the foundation’s namesake, was Waylon Jennings’ business manager for 22 years and the foundation has close ties to the music industry. The auction included items from Jamey Johnson, Kris Kristofferson, Willie Nelson, Alison Krauss and Brad Paisley. In addition to the country music auction items, unique art like a hand carved skulls and wood signs were sold.

Oral Microbiota Mouth Off in Cystic Pancreatic Tumors

Article reposted from Genetic Engineering & Biotechnology News March 15, 2019.

Scientists at the Karolinska Institutet report that the presence of oral bacteria in cystic pancreatic tumors is associated with the severity of the tumor. The team, whose study (“Enrichment of oral microbiota in early cystic precursors to invasive pancreatic cancer”) appears in Gut, hopes the results can help to improve the diagnosis and treatment of pancreatic cancer.

“Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cysts that can progress to invasive pancreatic cancer. Associations between oncogenesis and oral microbiome alterations have been reported. This study aims to investigate a potential intracystic pancreatic microbiome in a pancreatic cystic neoplasm (PCN) surgery patient cohort.

“Paired cyst fluid and plasma were collected at pancreatic surgery from patients with suspected PCN (n=105). Quantitative and qualitative assessment of bacterial DNA by qPCR, PacBio sequencing (n=35), and interleukin (IL)-1β quantification was performed. The data were correlated to diagnosis, lesion severity, and clinical and laboratory profile, including proton-pump inhibitor (PPI) usage and history of invasive endoscopy procedures,” the investigators wrote.

“Intracystic bacterial 16S DNA copy number and IL-1β protein quantity were significantly higher in IPMN with high-grade dysplasia and IPMN with cancer compared with non-IPMN PCNs. Despite high interpersonal variation of intracystic microbiota composition, bacterial network and linear discriminant analysis effect size analyses demonstrated co-occurrence and enrichment of oral bacterial taxa including Fusobacterium nucleatum and Granulicatella adiacens in cyst fluid from IPMN with high-grade dysplasia. The elevated intracystic bacterial DNA is associated with, but not limited to, prior exposure to invasive endoscopic procedures, and is independent from the use of PPI and antibiotics.

“Collectively, these findings warrant further investigation into the role of oral bacteria in cystic precursors to pancreatic cancer and have added values on the etiopathology as well as the management of pancreatic cysts.”

Pancreatic cancer is one of the most lethal cancers in the west. The disease is often discovered late, which means that in most cases the prognosis is poor. But not all pancreatic tumors are cancerous. For instance, there are cystic pancreatic tumors (pancreatic cysts), many of which are benign. A few can, however, become cancerous.

It is currently difficult to differentiate between these tumors. To rule out cancer, many patients therefore undergo surgery, which puts a strain both on the patient and on the healthcare services. Now, however, researchers at Karolinska Institutet have found that the presence of bacteria inside the cystic tumors is linked to how severe the tumor is.

“We find most bacteria at the stage where the cysts are starting to show signs of cancer,” said corresponding author Margaret Sällberg Chen, DDS, PhD, docent and senior lecturer at the department of dental medicine, Karolinska Institutet. “What we hope is that this can be used as a biomarker for the early identification of the cancerous cysts that need to be surgically removed to cure cancer, this will in turn also reduce the amount of unnecessary surgery of benignant tumors. But first, studies will be needed to corroborate our findings.”

The researchers examined the presence of bacterial DNA in fluid from pancreatic cysts in 105 patients and compared the type and severity of the tumors. Doing this they found that the fluid from the cysts with high-grade dysplasia and cancer contained much more bacterial DNA than that from benign cysts.

To identify the bacteria, the researchers sequenced the DNA of 35 of the samples that had high amounts of bacterial DNA. They found large variations in the bacterial composition between different individuals, but also a greater presence of certain oral bacteria in fluid and tissue from cysts with high-grade dysplasia and cancer.

“We were surprised to find oral bacteria in the pancreas, but it wasn’t totally unexpected,” said Sällberg Chen. “The bacteria we identified has already been shown in an earlier, smaller study to be higher in the saliva of patients with pancreatic cancer.”

The results can help to reappraise the role of bacteria in the development of pancreatic cysts, she noted. If further studies show that the bacteria actually affect the pathological process it could lead to new therapeutic strategies using antibacterial agents.

The researchers also studied different factors that could conceivably affect the amount of bacterial DNA in the tumor fluid. They found that the presence of bacterial DNA was higher in patients who had undergone invasive pancreas endoscopy, a procedure that involves the insertion of a flexible tube into the mouth to examine and treat pancreatic conditions thus the possible transfer of oral bacteria into the pancreas.

“The results were not completely unequivocal, so the endoscopy can’t be the whole answer to why the bacteria is there,” Sällberg Chen continued. “But maybe we can reduce the risk of transferring oral bacteria to the pancreas by rinsing the mouth with an antibacterial agent and ensuring good oral hygiene prior to examination. That would be an interesting clinical study.”

After Neoadjuvant Therapy, Imaging No Longer Provides a Clear Answer

The following summary comes the article by Dr. Cristina Ferrone and was published in the International Journal of Radiation Oncology, Biology, Physics. The full article can be found here.

Image credit: Ferrone CR, Marchegiani G, Hong TS, et al. Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg. 2015;261(1):12-7.

Patients with a presumed diagnosis of pancreatic cancer are initially evaluated by radiological imaging (Pancreas protocol CT-scan). Imaging provides a great deal of information regarding the tumor including tumor size, involvement of nearby blood vessels and organs, and distant spread of disease. Patients with tumors that involve nearby blood vessels may not be a candidate for a surgery-first approach and have been shown to benefit from upfront chemotherapy followed by potential surgical resection (see October blog post, Outcome of Patients with Borderline Resectable Pancreatic Cancer in the Contemporary Era of Neoadjuvant Chemotherapy for more information on vessel involvement).

Given the improvements in chemotherapy a majority of patients with pancreatic cancer are now managed via a neoadjuvant-first approach even when diagnosed at a resectable stage, given that systemic disease dictates long term outcomes. With this change in practice, a majority of patients initially receive chemo/chemoradiation therapy followed by a repeat scan (re-staging scan), and a potential surgical resection. Recently, it has become evident that post-neoadjuvant CT scans might not provide accurate assessment of disease. At Massachusetts General Hospital in Boston, MA, researchers have theorized that preoperative chemoradiation may cause tumors to appear worse on CT scans than before therapy. With this in mind, this group sought to find patients who received neoadjuvant therapy and had unfavorable imaging after the neoadjuvant therapy, but did have a good performance status and a decrease in pancreatic cancer tumor markers (CA19-9). These patients were taken to the operating room for surgical exploration to evaluate the true extent of disease. Promisingly, 92% of the first 40 patients underwent R0 resection margins, meaning there was no tumor seen at the resection plane (see August blog post, “The Importance of Resection Margin Status in Pancreatic Surgery” for more information on resection margins). What was observed on the CT-scans of these patients was most likely dead tissue with scarring that was mimicking living tumor.

In conclusion, patients with good performance status and decreasing tumor markers after neoadjuvant therapy should be considered for surgical exploration, even if CT scans demonstrate persistent tumor.

A special thanks for this summary by Michael Wright, Department of Surgery, Johns Hopkins School of Medicine and to Dr. Ammar Javed for his support.

FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer

Article reposted from The New England Journal of Medicine, December 20, 2018.

Abstract

BACKGROUND

Among patients with metastatic pancreatic cancer, combination chemotherapy with fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) leads to longer overall survival than gemcitabine therapy. We compared the efficacy and safety of a modified FOLFIRINOX regimen with gemcitabine as adjuvant therapy in patients with resected pancreatic cancer.

METHODS

We randomly assigned 493 patients with resected pancreatic ductal adenocarcinoma to receive a modified FOLFIRINOX regimen (oxaliplatin [85 mg per square meter of body-surface area], irinotecan [180 mg per square meter, reduced to 150 mg per square meter after a protocol-specified safety analysis], leucovorin [400 mg per square meter], and fluorouracil [2400 mg per square meter] every 2 weeks) or gemcitabine (1000 mg per square meter on days 1, 8, and 15 every 4 weeks) for 24 weeks. The primary end point was disease-free survival. Secondary end points included overall survival and safety.

RESULTS

At a median follow-up of 33.6 months, the median disease-free survival was 21.6 months in the modified-FOLFIRINOX group and 12.8 months in the gemcitabine group (stratified hazard ratio for cancer-related event, second cancer, or death, 0.58; 95% confidence interval [CI], 0.46 to 0.73; P<0.001). The disease-free survival rate at 3 years was 39.7% in the modified-FOLFIRINOX group and 21.4% in the gemcitabine group. The median overall survival was 54.4 months in the modified-FOLFIRINOX group and 35.0 months in the gemcitabine group (stratified hazard ratio for death, 0.64; 95% CI, 0.48 to 0.86; P=0.003). The overall survival rate at 3 years was 63.4% in the modified-FOLFIRINOX group and 48.6% in the gemcitabine group. Adverse events of grade 3 or 4 occurred in 75.9% of the patients in the modified-FOLFIRINOX group and in 52.9% of those in the gemcitabine group. One patient in the gemcitabine group died from toxic effects (interstitial pneumonitis).

CONCLUSIONS

Adjuvant therapy with a modified FOLFIRINOX regimen led to significantly longer survival than gemcitabine among patients with resected pancreatic cancer, at the expense of a higher incidence of toxic effects. (Funded by R&D Unicancer and others; ClinicalTrials.gov number, NCT01526135; EudraCT number, 2011-002026-52.)

Article by: Thierry Conroy, M.D., Pascal Hammel, M.D., Ph.D., Mohamed Hebbar, M.D., Ph.D., Meher Ben Abdelghani, M.D., Alice C. Wei, M.D., C.M., Jean-Luc Raoul, M.D., Ph.D., Laurence Choné, M.D., Eric Francois, M.D., Pascal Artru, M.D., James J. Biagi, M.D., Thierry Lecomte, M.D., Ph.D., Eric Assenat, M.D., Ph.D., for the Canadian Cancer Trials Group and the Unicancer-GI–PRODIGE Group

“Country Boots Cancer” Show Raises $40,300 for Johns Hopkins Medicine

“Country Boots Cancer,” the Aug. 19 benefit concert featuring Jamey Johnson and hosted by the Nikki Mitchell Foundation, raised $40,300 for Johns Hopkins Medicine.

The show at Rams Head Live! in Baltimore, MD also featured Chris Hennessee, who performed songs from his new album “Ramble.”

One hundred percent of the profits will be donated to the new Pancreatic Cancer Precision Medicine Program (PCMoE) at Johns Hopkins Hospital. This program will offer precision testing, imaging, biopsy, assessment and treatment plans to all patients with aims of improving care for patients currently diagnosed and to support research efforts to find a cure. Through the precision medicine program patients can have their tumors sequenced to detect potential mutations that could guide their therapy, eliminating a ‘one size fits all’ approach.

The event’s speakers included Nikki Mitchell Foundation President Rhonda Miles, four-year pancreatic cancer survivor Lisa Eidelberg and Johns Hopkins Medicine surgeon Dr. Matthew Weiss. Nikki Mitchell Foundation would like to give a special thanks to Lisa Eidelberg and Lindsey Manos of JHM, who spent countless hours fundraising, recruiting volunteers and donations and promoting the show and the cause.

The Nikki Mitchell Foundation is named in honor of Waylon Jennings’ beloved late manager of 22 years, Nikki Mitchell, who died of pancreatic cancer in 2013.

One of Mitchell’s last wishes was for her foundation to continue to support Johns Hopkins, where she received excellent care and felt wholly supported on her cancer journey.

 

 

 

 

 

 

For more images, click here.

Artist photos by Brandon Amos at Low Light Photography.

The Importance of Resection Margin Status in Pancreatic Surgery

The following study was recently published in the British Journal of Surgery and below is a summary of the article.

Validation of at least 1 mm as cutoff for resection margins for pancreatic adenocarcinoma of the body and tail.

Hank, T., Hinz, U., Tarantino, I., et al.

One of the major goals of surgical resection of a pancreatic tumor is to clear the body of all local disease. A resection margin is the outer edge of the tissue that was removed. The margins of the resected specimen are reviewed by the pathologists and should ideally be free of disease. Traditionally, R0 represents no cancer at the margins, while R1 represents microscopic disease at the margin, and R2 is representative of gross disease at the margins (seen by naked eye). In recent times, the topic of an R0 resection with disease located within 1mm of the margin has gained interest in the surgical community.

Using an institutional database, the authors identified 455 patients and classified resection status as either R0, R1 less than 1 mm, and R1 direct.

Median survival (time from surgery to death)

  • R0: 62.4 months
  • R1< 1mm from margin: 24.6 months
  • R1 direct: 17.2 months

Postoperative chemotherapy group median survival

  • R0: 68.6 months
  • R1< 1mm from margin: 32.8 months
  • R1 direct: 21.4 months

An important aspect of the study was that the authors not only analyzed the survival rates of all patients but also studied trends of survival in patients who received postoperative chemotherapy. Since postoperative chemotherapy is known to be related with survival, the authors wanted to demonstrate that margin status was independently associated with improved survival.

The results of the study confirm the importance of resection margin as they independently predicted survival in these patients regardless of their postoperative chemotherapy status. In particular, the survival benefit of clean resection margins beyond 1mm are highlighted. The differences observed in all reported median survivals were statistically significant.

Note: published data suggests that the same findings hold true for Whipple procedures. In short, R0 resections are associated with improved survival of all pancreatic adenocarcinomas, regardless of pancreatic surgery type.

You can read the entire article here.

Summary by: Michael J. Wright, Department of Surgery, Johns Hopkins School of Medicine

An Activist and Survivor Shares Her Story

Lisa Eidelberg has been integral in raising funds for Nikki Mitchell Foundation’s “Country Boots Cancer” show, which is donating 100% of the proceeds to the future Pancreatic Cancer Precision Medicine Program at Johns Hopkins Medicine.

The pancreatic cancer activist and survivor shares her story: 

Lisa and her sons

“Peace Out Johns Hopkins”

Rhonda Miles, Jamey Johnson, Lisa Eidelberg

 

 

 

 

 

 

 

 

I am a very lucky four-year pancreatic cancer survivor!!

This journey began on Saturday June 7, 2014 when I woke up, looked in the mirror and thought, “Mmm, I look a little yellow!”  A friend had stopped by, looked at me and confirmed what I didn’t want to believe; I was indeed yellow!  My husband Marc and I went to the emergency room of a local hospital where I was told I would simply need my gall bladder out, even as I was becoming increasingly yellow! Fortunately, the doctors in my family had me moved to another hospital where I would have an ERCP the next day.  Coming out of anesthesia, Marc had the most difficult task of delivering the bad news……I had pancreatic cancer.  We were all shocked!  I was 54 at the time, healthy, had no family history of it, was active and had two 19-year-old sons who still needed me!  In the four months prior to diagnosis, I had an endoscopy, colonoscopy, two ultrasounds and blood work (just six weeks before diagnosis) which were all normal!

Luckily for me, I got an appointment with Dr. Wolfgang and team at Johns Hopkins Hospital, which I was told was the premiere pancreatic cancer team. Boy is that true!  On Saturday June 14, 2014, I had a successful Whipple surgery.  Recovery was so much more pleasant because of the caring staff at JHH!  Aftercare with this surgery is almost as important as the surgery itself!   Following recovery, I had 10 rounds of Folfirinox and radiation at Overlook Hospital in Summit, NJ where again, I was fortunate to receive compassionate, quality care.

At a post-surgical visit with Dr. Wolfgang and Lindsey Manos, they urged me to reach out to the Nikki Mitchell Foundation founder Rhonda Miles.  Somehow, they got a vibe that I resembled Nikki in spirit and attitude, although we were completely different people in the way we lived our lives.  My attitude was always positive, but I made it my business NOT to read the sad stories of this dreaded disease, so why would I reach out to Rhonda? Nikki had sadly and bravely lost her battle with this demon.  However, I’m so glad I did!  It’s enlightened me to the fact that this disease does not discriminate.  There is no “stereotypical” person who is affected by this many time fatal disease.  It’s brought about a renewed outlook on life and others.  Just as pancreatic cancer doesn’t judge, I don’t either.

It is my privilege to work with both the Nikki Mitchell Foundation and Johns Hopkins Hospital to raise funds for the new Pancreatic Cancer Precision Medicine program which will enhance the patient’s experience.  This will be THE place, for competent, caring, compassionate and cohesive treatment for those afflicted by this ugly disease!

I personally look forward to celebrating many more survival anniversaries but look forward to having a lot more company in the future!!

Donations for this event can be made HERE and select the campaign “Country Boots Cancer.”

How Do We Make a Difference?

We love the fact Nikki Mitchell Foundation has opportunities to plan amazing concerts with big-time talent! You might think we spend all our time producing concerts and an annual golf tournament, right? As our events bring in funds and our revenue grows, so do our expenses. More money coming in means more going out, so more funds mean we are able to increase patient assistance and fund promising research.

On the flip side, sometimes days can be rough in the office.

This week, we took a pancreatic cancer patient client off of our active financial aid roster and moved them to our “closed file.” You can guess what that means…she wasn’t cured, and she fought her disease until she couldn’t fight anymore. This woman was someone we connected with on a personal level, Rhonda spoke with her on the phone and listened to her stories, fears, needs and hopes. She figured out her financial needs and sent her gas and grocery cards, paid co-pays and financed a second opinion at UCLA through our Bridge of Wings program. Rhonda became her cheerleader and supporter.

We then called the first name on our waiting list. The family requested assistance with their mortgage payment. The patient was unable to talk, and his wife was at work, so their 17-year-old son took charge and was organized, thankful, and on top of their needs.

After the first phone call, the realization hit…this teenager should be hanging with his friends, playing sports or just acting like a 17-year-old. Instead, five minutes after hanging up, he emailed us their mortgage information, followed up with a phone call, thanked us and told us to have a blessed day. This kid is having to grow up too fast and take care of things most kids never even think about, like how can house payments be made or what would happen if they lose their home as his dad is suffering from pancreatic cancer.

We keep 40 clients on the active list and 40 times a month, we ask them: what do you need, what can we do to help? As we help our patients and plan our events, we constantly think – what do we do if we run out of funds? What if this event doesn’t bring in enough to support the Bridge of Wings program? The foundation doesn’t just help patients one time and then leave them to figure out finances as their disease worsens. We help these patients every month, as long as they are in need. Forty patients a month is all we are able to financially handle at this time and all we are able to manage with our small office.

How do we do it? How do we make a difference? We do it through YOU, and through our events sponsors, our faithful donors, event attendees and our online auctions. Our mission and goal is bigger than these events, bigger than the foundation, bigger than each individual. It’s about making a difference for this 17-year-old kid who sent his parent’s mortgage information. It’s about helping patients who are fighting this horrific disease. It’s about awareness and finding a cure.

Let’s make the difference in someone’s pancreatic cancer battle and let’s honor Nikki Mitchell while we do this.

Please consider donating today.