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In an effort to improve outcomes and deliver the highest quality of care to patients with pancreatic cancer, Duke Cancer Institute launched a multidisciplinary Pancreatic Cancer Center that prioritizes thorough surveillance of high-risk patients, stays at the forefront of clinical trials, and considers the role of comorbidities.
Though pancreatic cancer makes up only 3.3% of new cancer cases, it is the cause of 8.4% of all cancer deaths, and the third-leading cause of cancer-related deaths in the United States. Difficult to detect, pancreatic cancer is often diagnosed at a later stage when the cancer has metastasized, by which point the 5-year relative survival rate declines significantly. This rate, stalled at 13% for several years, suggests that pancreatic cancer may become the second-leading cause of cancer-related deaths by 2030.
One of the chief reasons behind this dismal prognosis is the fact that pancreatic cancer lacks a standard screening strategy, which is key to early treatment. Improving patient outcomes for this lethal form of cancer requires a thoughtful, proactive approach that prioritizes thorough surveillance of high-risk patients, stays at the forefront of clinical trials, and considers the role of comorbidities.
Recognizing the threat this disease poses, ACCC Program Member Duke Cancer Institute (DCI) launched a multidisciplinary Pancreatic Cancer Center (PCC) dedicated to delivering the highest level of care for all patients at risk for and with pancreatic cancer. To learn more about the development of the center and its ambitions for the future, ACCCBuzz spoke with Niharika Mettu, MD, PhD, a medical oncologist and clinical trialist at DCI, co-director of the Phase I and Immunotherapy Program, and leader of clinical trials at the DCI PCC; and Afreen Shariff, MD, an endocrinologist and director of the Duke Onco-Endocrinology Program at DCI, and the associate director for the Cancer Therapy Toxicity Program at the Center for Cancer Immunotherapy at DCI. Both are appointed as Associate Professors of Medicine at Duke University School of Medicine.
With a focus on prevention, early detection, and treatment, the DCI PCC is committed to improving health outcomes and helping patients live longer and live better. In practice, this translates to a robust surveillance program for all patients who are at a particularly high risk of developing pancreatic cancer, such as those with multiple first-degree relatives with a history of the disease.
“We do not screen the general population for pancreatic cancer,” said Dr. Mettu. “We do not have the equivalent of a screening colonoscopy to identify pancreatic cancer at an early stage and intervene.” However, those patients identified as high risk—typically followed by the gastrointestinal department at Duke—are put on a surveillance program, which alternates between MRIs and endoscopic ultrasounds.
Duke is in a relatively unique position with clinical trial recruitment compared to many other cancer programs in the nation, in that patients—especially those with pancreatic cancer—actively seek out trials at Duke. One of the goals of the PCC is to build a robust clinical trial portfolio to offer patients, regardless of their disease stage. Of course, not every single patient will be a candidate for a trial, due to factors such as comorbidities or long travel distances. But offering several trials to patients, whether their cancer is resectable, borderline resectable, locally advanced, or metastatic, would be a significant achievement.
Secondly, Dr. Mettu voiced a desire to focus on novel therapies. “We don’t want to only use regimens that are 10 years old,” she said. “We want to be pushing the horizons of the field, investigating targeted therapies like KRAS inhibitors or immunotherapy in pancreatic cancer treatment. We want to position ourselves not just for what comes next, but for what comes after next.”
The pancreas is the insulin factory in the body, which makes diabetes a common comorbidity for patients with pancreatic cancer. According to Dr. Shariff, about 30% to 50% of these patients already have diabetes at the time of diagnosis, while about 40% develop new-onset diabetes afterward—a condition often referred to as Type 3c (pancreatogenic) diabetes, which remains underrecognized and undertreated.
Therefore, proactive blood sugar management and diabetes support throughout treatment are central to the delivery of high-quality pancreatic cancer care. “The most important metric we’re tracking is whether we are preventing delays in surgery and treatment,” said Dr. Shariff. “If a pancreatectomy is necessary, is high blood sugar standing in the way? Are we ensuring [HbA1c’s] are lowering appropriately to prevent poor outcomes in surgery or the next chemotherapy treatment?”
As a result, a chief goal of the DCI PCC is to more quickly identify patients with pancreatic cancer in the system who also have diabetes. According to Dr. Shariff, internal review revealed that as many as 70% to 80% of patients with cancer at Duke lacked a formal diagnosis of diabetes, despite many of them having a blood sugar over 300mg/dL—far beyond the threshold for diagnosis—because it was not properly documented.
This distinction is especially important in pancreatic cancer because many treatment options include steroids like dexamethasone that accompany chemotherapy, which can cause high blood sugar by worsening insulin resistance in a patient who is already insulin-deficient. “That’s the more difficult metric to track, but we want to know how many patients we [Duke’s Onco-Endocrinology Program] are touching that we didn’t touch before,” said Dr. Shariff. These findings highlighted a broader systems gap, one that ultimately helped shape Duke’s Onco-Endocrinology partnership with the DCI PCC.
Undoubtedly, the future of cancer care will rely on precision—both in treatment and in collaboration among providers. Since 2015, Duke Onco-Endocrinology has bridged gaps among oncology, primary care, and endocrinology by supporting patients through precancer treatment planning, adverse effects (AEs) during active treatment, and management of endocrine conditions during survivorship. From managing postradiation or postchemotherapy AEs to diabetes and immune-related AEs, Dr. Shariff’s team is dedicated to handling anything that impacts the endocrine system in patients with cancer.
“We noticed that patients’ treatments were being held due to the development of an adverse event,” explained Dr. Shariff. “Even though they qualified for very effective treatments, they were unable to continue them because they were waiting for an endocrinologist or cardiologist to intervene.” This process can take months at most institutions.
“Our goal is to enable safer cancer treatments and improve outcomes by supporting and collaborating with our oncologists,” she said. The program has been offering electronic direct-to-provider e-consultations (recommendations within 48-72 hours) for patients with cancer at Duke since 2020, and has a streamlined referral pathway for patients to see the Onco-Endocrinology team within 1 to 4 weeks. But these services still could not address patients with a blood glucose (BG) level over 300mg/dL whose diabetes was unrecognized.
Dr. Shariff, along with the DCI Center for Onco-Primary Care, developed a back-end electronic medical record–based alert system that detects every patient at DCI locations who is on active cancer treatment and has a BG greater than 300 mg/dL—dubbed the Sugar High Program. The alert remains silent for 1 week, allowing time for the oncology team to act on the elevated BG. If a referral or e-consultation is not signed within that week, Dr. Shariff’s team receives the alert. This step acts as a trigger to ensure that patients receive timely intervention.
The Sugar High Program serves as a safety net that catches patients whose high glucose levels may have been missed by their oncology and primary care teams. Due to the nature of pancreatic cancer and its close relationship to diabetes, for this population, the alert threshold is reduced accordingly to a blood sugar of 250 mg/dL. This automated, proactive identification of patients’ needs is pivotal in reducing treatment delays and ensuring their safety at every turn. A few days or a week can mean a lot to a patient with cancer—that’s enough time to necessitate hospitalization or withholding of treatment. Identifying AEs and comorbidities more quickly can transform patient outcomes.
At Duke, multidisciplinary collaboration is central to pancreatic cancer care. Creating a centralized hub has allowed the institute to concentrate its resources on pursuing a single goal, creating a structure where, at its core, everyone involved is laser-focused on improving patient outcomes.
“The DCI PCC represents a beautiful marriage of quality resources and services that are aligned for patient safety,” said Dr. Shariff. “Our patients are getting younger. They want to live full lives after treatment, and they should. Ensuring that patients are safe during treatment must be at the core of how we practice today.”
