Pancreatic cancer advances in a particularly silent manner, as most of its symptoms are non-specific. For this reason, when it is detected, it is often already in an advanced stage. Despite not having a high incidence in the population, it has a high mortality rate, with patient survival at five years between 7% and 10% (for men and women, respectively), according to the Spanish Society of Medical Oncology (SEOM). Surgical treatment is the only radical option, although it always needs to be accompanied by chemotherapy, with three possible scenarios depending on the extent of the tumour: resectable pancreatic cancer, where the tumour can be surgically removed because it has not affected important nearby blood vessels; borderline resectable pancreatic cancer, which has focal contact with some surrounding vessels; and locally advanced pancreatic cancer, the most difficult subtype to manage, as it more extensively affects abdominal veins and arteries.

The Vall d'Hebron University Hospital has surpassed one hundred patients operated on for borderline resectable pancreatic cancer and locally advanced pancreatic cancer since June 2018: the resectability rate for these patients is 73% once they reach the operating room, meaning 85% of patients with borderline resectable pancreatic cancer and 54% of those with locally advanced cancer are operated on.

"We have performed more than a hundred interventions for the most complex pancreatic cancer cases in just five years. This achievement is possible thanks to the work of a multidisciplinary team where excellent care is combined with the advances made by professionals dedicated to research to find new treatments so that patients reach the operating room in the best possible condition, allowing us to operate on them. Additionally, the fruits of this research return to the patient if they need them in the future," explains Dr. Elizabeth Pando, a surgeon in the Pancreatic Surgery Unit of the Hepatobiliopancreatic Surgery and Transplant Service and the principal investigator of the Hepatobiliopancreatic (HBP) Surgery and Liver Transplantation group in the Liver and Digestive Diseases Area of the Vall d'Hebron Research Institute (VHIR). The advanced pancreatic cancer program began in 2018 with the incorporation of clinical trials in this area, as well as training sessions by Vall d'Hebron professionals at prestigious specialized centres, which have enabled the incorporation of innovative surgical techniques.

In this regard, Dr. Teresa Macarulla, head of Oncology for the Upper Gastrointestinal and Endocrine Tumours Group at the Vall d'Hebron Institute of Oncology (VHIO), emphasizes the impact of new advances in systemic chemotherapy treatments that allow for disease control or, in the best cases, tumour reduction, which increases the options for future surgical salvage or control of relapses if they occur.

Since 2018, Vall d'Hebron has had a multidisciplinary group specifically dedicated to Pancreatic Cancer, which assesses the clinical situation of patients individually and allows for a comprehensive approach. This group comprises professionals from Hepatobiliopancreatic Surgery and Transplantation; Medical Oncology; Digestive Endoscopy; Gastroenterology and Digestive System; Radiology; Interventional Radiology; Pathology; Nutrition; and Radiation Oncology.

More than 700 patients evaluated by the Multidisciplinary Pancreatic Cancer Committee

The Multidisciplinary Pancreatic Cancer Committee has evaluated a total of 701 patients since its creation, with between 50% and 60% of the cases seeking a second opinion from other centres. Of the total number of patients operated on for pancreatic pathology at Vall d'Hebron between 2019 and 2023, 39.1% did not belong to the hospital's area of influence: 34.33% were from other parts of Catalonia, and 4.78% from the rest of the country, while 60.9% belonged to Vall d'Hebron's area of influence. In cases of malignant pathology, this percentage increases, and patients came from outside the area in 45.5% of cases: 39.15% (92 patients) came from other parts of Catalonia and 6.38% (15 patients) from the rest of the country. "We have become a reference centre for patients seeking a second opinion on surgical intervention, as most of them cannot be operated on in their original centre. Despite this, pancreatic cancer remains a very aggressive disease and presents a very difficult scenario for patients and their families, which is why all our efforts are dedicated to our patients, to give them a chance to prolong their survival," explains Dr. Elizabeth Pando.

These advances in favour of the patients would not be possible without the multidisciplinary involvement of the professionals who are part of their management. To carry out these interventions, the support of various expert professionals is required, such as anaesthetists experienced in managing highly complex patients or liver transplant professionals. The role of surgical nurses during the intervention is also essential—often working with biological grafts and vascular prostheses—and to overcome complications if they arise. In the diagnostic, staging, and follow-up processes, as well as in managing possible complications, the participation of radiologists is crucial.

Leaders in research

The Vall d'Hebron Barcelona Hospital Campus is also at the forefront of pancreatic cancer research through the Hepatobiliopancreatic Surgery (HBP) and Liver Transplantation group at VHIR and the Upper Gastrointestinal and Endocrine Tumours Group at VHIO. Already in 2018, Vall d'Hebron was the only centre in the country selected for the PELICAN clinical trial, an international, multicentre study to evaluate the effectiveness of the first intraoperative radio frequency in a locally advanced pancreatic adenocarcinoma in the country. Four years later, Vall d'Hebron included the first patient to treat locally advanced pancreatic cancer with nanoparticles. Currently, there are also several lines of basic research in pancreatic cancer by VHIO.

Currently, there are two standard chemotherapy treatment lines for pancreatic cancer, and research is underway to increase this therapeutic arsenal, in addition to adding immunotherapy or immunomodulatory treatments so that the body itself helps fight the tumour. In this regard, the results of the phase 1b/2 OPTIMIZE-1 clinical trial have recently been published, evaluating the efficacy of a new combination of immunotherapy and chemotherapy for patients with metastatic cancer. "We have observed an objective response rate of 40%, along with a median response duration of 12.5 months and a median overall survival of 14.3 months. These are promising results that open the door to investigating this combination in a phase 3 clinical trial to validate its efficacy in a larger number of patients," states Dr. Teresa Macarulla, who has led this study.