Improving Survival Rates for Pancreatic Cancer with William Hawkins, M.D.

Pancreatic cancer is among the deadliest of cancers. But in the last few decades, far more people are surviving this disease. In this episode, William Hawkins, M.D., a surgical oncologist at MUSC Health, explains why pancreatic cancer is so difficult to treat while also providing hope for those who may be undergoing treatment. Hawkins also highlights the role of cancer research in saving lives, including cutting-edge therapies being developed at MUSC. As the new deputy director of MUSC Hollings Cancer Center, Hawkins aims to bring more research developments to patients through translational science and clinical trials.

"When I started my career, the survival rate (for pancreatic cancer) was 4 percent. Survival rate, just announced by the American Cancer Society, is 13 percent. So, more than tripled the survival...which is just amazing. It's a lot of progress. There's a lot of new drugs. There's a lot of hope that immunotherapy can be harnessed for this disease."
— William Hawkins, M.D.,
Deputy Director, MUSC Hollings Cancer Center
Surgical Oncologist, MUSC Health

Topics Covered in This Show

• After a long career at some of the leading medical centers across the country, Dr. Hawkins recently joined MUSC Hollings Cancer Center as deputy director. In this role, he plans to help bring scientific advances in MUSC's laboratories to patients with all types of cancer.
• Only about 12 percent of people diagnosed with pancreatic cancer survive more than five years. Dr. Hawkins says the main reason pancreatic cancer is so deadly is because it's so difficult to diagnose early. Symptoms like jaundice and weight loss don't appear until the cancer has already advanced. Additionally, surgery is only effective if the cancer is caught early and hasn't spread.
• Dr. Hawkins and other scientists have learned that cancer isn't a single disease. Every pancreatic cancer is unique. Personalizing treatment to an individual's specific cancer will provide more effective treatment. Along with personalized medicine, Dr. Hawkins highlights two promising areas of cancer research at MUSC Health: immunotherapy and metabolism.
• In Dr. Hawkins' experience, patients can be hesitant about the idea of a clinical trial. They don't want to feel like experiments. He stresses that highly vetted and careful teams lead clinical trials and may benefit patients when nothing else can.
• Dr. Hawkins talks about the multidisciplinary science team at MUSC Health that's developing the latest medical advances. In his lab, for example, experts in statistics, metabolism, immunology, animal modeling, artificial intelligence and public health come together to make new discoveries.
• Hollings Cancer Center also takes a team approach to treating patients. Patients who've been diagnosed with pancreatic cancer will meet with a team of doctors to review the patient's case and create a treatment plan.
• The number one thing anyone can do to prevent pancreatic cancer is to avoid tobacco products. Other prevention strategies should focus on a healthy diet and exercise routine. Dr. Hawkins urges everyone to pay attention to their bodies and symptoms and to go to a doctor if something doesn't feel right.
• Only about 10 percent of pancreatic cancer is inherited. Dr. Hawkins recommends genetic testing if any family members have had pancreatic cancer at a young age or if multiple types of cancer run in your family.

Read the Transcript

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Pancreatic cancer is one of the most challenging cancers to treat and one of the deadliest. Dr. William Hawkins, a surgical oncologist at MUSC Health and the new deputy director of Hollings Cancer Center, has dedicated his career to this challenge. Dr. Hawkins joins us today to talk about the difficult reality of this disease, as well as the advances in research and treatment that are giving him and others hope. Welcome to the show, Dr. Hawkins.

[00:00:45] William Hawkins, M.D.: It is such a pleasure to be here.

[00:00:47] Erin Spain, MS: You've led an impressive career treating and researching pancreatic cancer at some of the top medical centers across the country. What's most exciting to you about MUSC Health and its mission?

[00:00:58] William Hawkins, M.D.: My experience is it's all about the people. And I just left one of the best jobs in the world to come and work with these people. And I did that because I found a group of really caring people making cutting-edge progress. We have some wonderful science going on in laboratories, but it really is an art form to get that science from the laboratory, get it into the clinic where it's going to benefit patients. And if you can do that, you're helping people here in South Carolina, but you're really helping people globally. And so I just thought there was so much opportunity here that this looked like a wonderful new challenge for me to improve on clinical trials, and to improve on what I call translational science.

[00:01:42] Erin Spain, MS: Well, we're glad you're here. I want to dig into pancreatic cancer a little bit, but first give us some background. Talk about the role of the pancreas. What does it do?

[00:01:51] William Hawkins, M.D.: Yeah, the pancreas is an interesting organ. It makes about 11 hormones that we know of — insulin and glucagon — and it helps regulate your digestion and your sugar. And it also has this function where it helps break down food you eat, like fats and proteins, so it makes enzymes to do that. So the pancreas is really a critical organ for your daily life and function, but it is also the center of diseases. Like in pediatrics, it can cause Type 1 diabetes. As adults, if we don't take care of ourselves, you can get insulin resistance and Type 2 diabetes. It's also subject to become cancerous. But the pancreas is just this essential organ that helps us get through our daily lives, with every meal we eat and every hour of the day. When you feel hangry, that's your pancreas telling you you're hangry.

[00:02:38] Erin Spain, MS: And unfortunately, it is an organ that doesn't really show a lot of symptoms when disease is present. Tell me about that.

[00:02:47] William Hawkins, M.D.: Unfortunately, it's pretty secretive about its diseases until it gets kind of advanced. If you take diabetes as an example, by the time kids present with Type 1 diabetes, it's because 90 percent of the insulin cells have been already knocked out of commission. When somebody presents with pancreatic cancer, it's usually because the disease has grown into something else that causes trouble. So, for example, it wraps itself around the bile duct and you turn jaundice because it's blocking the flow of bile from the liver. So you can get this really orangey, yellowish color to your skin, dark urine. Sometimes people have weight loss because it's blocking that duct for digestion so that your enzymes don't get to your food. So you could be eating quite well, but not really getting the nutrition out of your food. But unfortunately, it's an area of active research, trying to get early detection like we have for breast cancer, you know, with mammography or we have with colon cancer by getting your colon scope. We don't have that yet for pancreas cancer, so we hope to catch it before it's symptomatic.

[00:03:49] Erin Spain, MS: Only about 12 percent of the people diagnosed with pancreatic cancer survive more than five years. And a lot of people know this cancer is very deadly. We don't have a good way to detect it. What are some other reasons why it's so deadly?

[00:04:03] William Hawkins, M.D.: We have scientific evidence to back this up, that the pancreas is so essential to your life that, as you've evolved evolutionarily, your body has developed a way of ignoring your pancreas. Because if you imagine, you know, it's only been since the 1940s or '50s where if you develop diabetes, you live, right? So if you develop immune disease against your pancreas in the old days, you either didn't get nutrition or you didn't regulate your blood sugar, and you were shortly lived.

So, similarly to how a woman does not detect or destroy a fetus if she's pregnant. That's an amazing thing if you think about it, right? Because you have this immune system. If you transplant an organ and we don't give you immune suppression, you're going to destroy it. But similarly, if you see an organ, you get an organ disease.

You get autoimmune disease, that sort of stuff. If you see your pancreas, you die. And so it's kind of an immune privilege site, which makes the cancer sneak up on you.

Most of the time, when it presents, it's present because it made itself known. By the time it makes itself known, it's already spread. So even very small pancreas cancers have already spread the majority of the time. So when your doctors do recommend surgery, it's usually because it's small, we found it before it spread anywhere, and then surgery can work. Even then, when we think it's contained, most of the patients who undergo surgery still recur because there's been some microscopic spread that we don't know about yet.

[00:05:30] Erin Spain, MS: Well, there is some hope out there. The five-year survival rate has tripled since you started your career. How does your approach as a surgeon-scientist help you stay motivated or hopeful?

[00:05:41] William Hawkins, M.D.: I said to my wife, the day it really stops bothering me to lose a patient is the day I go into another profession. You know, you get so attached to your patients. You get so entangled in their lives that ,you know, you really want to help. But like you said, you know, if all I did was surgery for the pancreas, knowing that the surgery cure rate is about 20, 25 percent, it would mean I lose 80 percent of my patients all the time for the rest of my life. So it's helpful to the patients to know there's new things out there and it's helpful for the doctors to know that we're going to do better in the future.

And like you said, when I started my career, the survival rate was 4 percent. Survival rate, announced by the American Cancer Society, is 13 percent so more than tripled the survival. And when we say five years, we mean cure, because most people who recur, they die within two years. Eighty percent of people die within two years, so it's very rare if you've made it five years that you're going to get pancreas cancer again.

Cure rates are 13 percent, which is just amazing. It's a lot of progress. There's a lot of new drugs. There's a lot of hope that immunotherapy can be harnessed for this disease. I think this opens the window to talk maybe a little bit about clinical trials. A lot of times, patients are afraid of the word "clinical trial," because they feel like they don't really want to be experimented on. So I just want to put a plug in for if that opportunity comes your way to understand how highly vetted and thoughtful the doctors are in putting those together.

They must go through multiple committees, and, most of the time, it is vetted in such a way that there is what we call equipoise, or we have a question, we don't know what the best answer is, so we're going to do a trial to figure it out. We might have a new drug, everything else has failed, let's try it out. This is a huge opportunity. You know, if you're out there and you've had pancreas cancer and you think there's no options, you know, to get a second opinion because there are options.

We test everybody's genetics today, look at particular individual opportunities in an individual cancer. When I started my career, we didn't have personalized medicine. Now we have 10 or 15 different, novel opportunities. Each one is less than two or three percent of pancreas cancers, but, together, we got 10 or 15 percent of pancreas cancers covered with a novel therapeutic. Things are really changing, and they're changing in a hurry.

[00:07:57] Erin Spain, MS: And here at MUSC Health Hollings Cancer Center, you mentioned this is something that you want to do is build out even more opportunities for clinical trials. Tell me about what approach you're going to be taking, especially in your new role here as deputy director of MUSC's Hollings Cancer Center.

[00:08:12] William Hawkins, M.D.: So, I think there are two huge opportunities, and I'm going to talk generally about cancer. One of the things that we're learning is that cancer is not one disease. Even if you're talking about pancreas cancer, it's not one pancreas cancer. Once you get into the genetic analysis of pancreas cancer, we learn that pancreas cancer is messed up in hundreds of different unique ways. And so, if you can find those unique ways and personalize your treatment to that individual cancer, you're going to do much better.

But this is not unique to pancreas cancer. I mean, when I started my career, breast cancer was breast cancer was breast cancer, right? Now everybody, even commonly, knows there's triple-negative breast cancers, there's estrogen-positive breast cancer. So breast cancer comes in many flavors, and so do most cancers.

And so by learning, by doing discovery and learning about these, we open up opportunities for individualized or customized personal care.

The second thing or major opportunity for cancer discovery and improvement is immunotherapy. It's worked really well for diseases where the mutational burden has been really high. So things like melanoma, where the sun causes the cancer and you have all this sun damage, so the cancer looks a little bit more foreign than a cancer that develops on the inside of your body, like a pancreas, or the inside of your brain, like a neuro cancer. But as we learn to harness the immune system, we're bringing those from the rare cures. So when immunotherapy works, immunotherapy can not only get rid of cancer cells, but it does so often in a less toxic way than a drug. Just like it's trained to pick out that needle in a haystack that is a virus in your body, it can pick out the small changes that are cancer. So really big opportunities to expand immunotherapy across the board for all cancers.

And the last sort of major opportunity in cancer is metabolism. So the more we learn about cancer, the more we learn, the reason it grows so disorganized, the reason it grows so much faster than your normal cells, is because it cheats on metabolism. It steals, borrows, it tries to get to the next division by cheating its neighbors and stealing stuff. But we're going to get that little camera out on the front porch next time it steals and say, Oh, this is what you're after. And so that's kind of what we're doing. We're looking at how each individual cancer cheats on that. And then you say, well, if you're normal, you may have other pathways, but if you're cheating on this pathway, you've sort of given up the ability to go around it in some ways. And so we can poison that metabolism in the cheaters.

[00:10:44] Erin Spain, MS: And this, in fact, is work that is happening in your lab right now with targets of metabolism and the immune system. Tell me about your lab and the people that you're working with to really push this work forward.

[00:10:56] William Hawkins, M.D.: Science doesn't happen the way it used to, with one guy sitting around scratching his head. Science is really a team sport now. Nobody can know it all. I mean, we have people working in statistics.

We have people working in animal models. We have people working in artificial intelligence, you know, doing computer-generated prediction of what's going to bind where, for example, within a structure. So we can invent drugs that have never been thought of before. We can find opportunities that have never been thought of before. And we can build resources that allow us to test things in an accelerated time.

So, you know, I've been biobanking specimens from surgeries and stuff for 20 years. So we can pull those out of the freezer and say, "Hey, we got a new idea. Do we have any cancers in there that might respond to this new idea?" And test it in an accelerated way. So this takes a whole team of scientists. It takes people who have expertise in immunology and in metabolism and animal modeling and statistics and in public health. And together we work as a team to propose new ideas. And it can be quite a joy. And the fact that it's hard only makes it better.

[00:12:04] Erin Spain, MS: In your lab, are you able to test existing drugs and immunotherapies on some of these samples that you've banked over the years as new things come along? Is that one approach you're taking?

[00:12:13] William Hawkins, M.D.: Absolutely. So repurposing old drugs, repurposing drugs that were meant for something else. You know, one of our successful trials was repurposing a drug which was made for osteoporosis. We learned this little interesting tidbit that in order for a cancer to spread, it needs to send a signal from the tumor to the bone marrow. A signal in the bone marrow needs to go out and set up a receiving line for where the tumor lands. If it doesn't set up the receiving line when the tumor lands there, it can't set up successfully. So this is a whole new window of opportunity. So actually, we found that an osteoporosis drug, which traps calcium and certain cells in the bloodstream can actually inhibit the spread of metastasis to a small extent. It slows it down. These are little nuances that can allow discovery to move forward.

[00:13:03] Erin Spain, MS: Now this is really fascinating information, and I think it might be helpful for patients and families who are listening to understand that when they come to MUSC Hollings Cancer Center, there are options, that there are things on the table to try and discover. Can you talk to me a little bit about what people might encounter if they come and they see you and they have this diagnosis.

[00:13:24] William Hawkins, M.D.: From the patient perspective, when I meet somebody for the first time, or whether I'm meeting somebody after they've seen other doctors, is to take a step back, get the whole story, find out what's been tried, find out what's been successful, find out what's failed and, then, gather information. A true second opinion, or even a true first opinion, doesn't happen until you get what I call primary data. If you just believe what everybody's told you, you might miss something. So, you know, we collect the outside path report. We look at the genetic analysis that's been done. Because let's say you're three years into your journey. We might know about two more genes. Sometimes things are worth repeating.

And then we have a team approach. After your cancer is evaluated, you're usually presented, a what we call a multidisciplinary conference, where we have radiologists, medical oncologists, gastroenterologists, surgeons, all in a room, and we review your case, so we don't leave any stones unturned.
And then we recommend a treatment plan. And a lot of the time, that treatment plan is here at Hollings, but I can tell you the ethical people I work for sometimes will say, "Hey, you know, we can't do every trial. You need to go to the NCI or you need to go to some other place because, you know, they have something open that's particular for you." And so we sometimes keep the patients, we sometimes send the patients, but whatever it is, we're here to help.

[00:14:45] Erin Spain, MS: Oh, that's fantastic. And I want to talk a little bit about preventing cancer. And this is difficult because we all know we need to be taking care of ourselves, but there are certain things that you can do to decrease your chances of developing pancreatic cancer. Can you talk about those a little bit?

[00:15:02] William Hawkins, M.D.: The single most controllable thing that we have is to avoid tobacco products. Tobacco is just really bad. And, I sometimes joke around with the patients. What happened? You didn't get the memo? They put it on the pack now. You know, it's like people know, but it's hard.

And that's part of what addiction is about. So avoiding even getting started. We have kids today starting on vaping. If you get hooked on those products early on, we have some really, really impressive smoking cessation programs here. So that is controllable. The other controllable thing that we have is to take care of yourself and eat right. Diets high in fats lead to digestive cancers like colon cancer and that sort of stuff.

So I'm not saying to have an unrealistic expectation of diet, but you can eat healthier. And you can exercise and control your weight. And that's been shown to reduce

GI cancers as well. And then pay attention to your body and symptoms. Patients know sometimes something's not right, and they wait forever to go see the doctor.

[00:16:03] William Hawkins, M.D.: And I can't tell you how many patients I've had with pancreatic cancer, just as an example, who, for the first time in their lives at 50 or 60 years of age, had depression. And you know, maybe they were treated for depression, but their body knew something was wrong. They weren't presenting in the usual window of time. If you have, all of a sudden, diabetes, but you're not at that age and you're not overweight, get it checked out. What I'm saying is: listen to your bodies, get regular health checkups, get some regular exercise, take care of yourselves. And then the rest of it: we have to take care of our planet. We're doing some things as a society and population that our grandchildren are going to pay for.

[00:16:44] Erin Spain, MS: There's environmental factors, there's your personal health. Is there also a genetic component that you know of to pancreatic cancer?

[00:16:52] William Hawkins, M.D.: Absolutely. Know your family history. I have what you call the worriers. They have a couple of family members who got cancer, but maybe they were, you know, grandma was 97, and she got cancer. Am I at risk? You know, if people get cancers in their 80s or 70s or 80s and 90s, that's probably not a risk factor. But if you're that type of person who goes out there and, say, you know, my mom had cancer at 40 and my sister had cancer at 35. Here I am at 33.

Should I get a colonoscopy? Well, yeah, absolutely.

So we should start treating people or screening people about 10 years earlier than their youngest sibling or family member got cancer. That's one of the things we're learning. And it's more of a general rule: breast cancer, colon cancer, pancreatic cancer. But if you have young family members who have cancers or multiple types of cancer in your family, genetic tests are easy to get today. And if you do find you're at risk, then there are lots of things we can watch and lots of things we can do to keep you safe.

[00:17:49] Erin Spain, MS: Are there some inherited mutations that we know of that are associated with pancreatic cancer?

[00:17:54] William Hawkins, M.D.: There are. Actually, the most common one that most patients know about is if you have the breast-cancer-associated, the BRCA gene, that also increased your risk for pancreas cancer. And some families have more pronounced pancreas cancer than others, but that's actually the most common genetic risk for pancreas cancer. And there are many, many others, but if you learn about them, it's worth screening. About only 10 percent of pancreatic cancer is inherited.

[00:18:17] Erin Spain, MS: You mentioned a lot of things that we can do to improve our health and our lifestyles. One question we ask everyone who comes on this show is: what do you do to optimize your health and live well?

[00:18:28] William Hawkins, M.D.: I do what's recommended, right? So I am 55 years of age. So I started — you know we now recommend starting at 45 — but I started at 50 when that was the recommendation, but I got my colonoscopies. I've had two every five years. I've had my prostate screened by the blood test for PSA. I exercise three to four times a week, and my wife and I try to eat healthy. Although I grew up in a meat and potatoes family, we have a couple nights a week where we eat vegetarian and, you know, try to take care of ourselves. We just moved to Mount Pleasant. We rode down and around over the Isle of Palms and over the Sullivan Bridge, did a nice 20-mile bike ride over the weekend and try and stay fit.

[00:19:06] Erin Spain, MS: Dr. William Hawkins. We appreciate your time.

[00:19:09] William Hawkins, M.D.: Thank you. It's been a pleasure to be here.

[00:19:11] Erin Spain, MS: For more information on this podcast, check out Advance.MUSCHealth.org.