Leading surgeon helps pancreatic cancer patients overcome obstacles
An internationally renowned pancreatic surgeon, surgical oncologist and cancer researcher Christopher Wolfgang, MD, PhD, joined NYU Langone Health in January. He is head of the new Hepatobiliary and Pancreatic Surgery Division in the Department of Surgery, after serving as Chief of Hepatobiliary and Pancreatic Surgery and Vice President of Surgical Oncology at Johns Hopkins Medicine.
Specializing in technically difficult cases, he has performed over 1,200 Whipple procedures, a complicated and high-risk surgical technique. This involves removing the head of the pancreas, part of the small intestine, gallbladder, and bile duct to preserve shared blood vessels, and then rebuilding a functioning digestive system. A luminary in the field of pancreatic cancer, his practice attracts patients from around the world whose tumors have previously been deemed inoperable.
You grew up on a farm in Pennsylvania. When you went to college, you started studying agriculture in the hopes of someday running the family business. What made you change course so drastically?
My father sent me to Penn State to study agricultural business. It was a big deal. I was the first Wolfgang in my immediate family to go to college. But I was not at all interested in the subject. I really wanted to study science and medicine. When I came home with a GPA of 1.86 in the first year, my parents gave me an ultimatum. They said, “Chris, you can study whatever you want, but you have to change your grades, or we’ll take you out of college.” I dove into science, and my grades skyrocketed after that. I loved the farm, and will always love it. It’s a part of our family. But my passion is medicine.
One quarter of pancreatic cancer patients die within one month of diagnosis and three quarters will die within one year. What drew you to a field with such overwhelming numbers?
When I started my training as a doctor-researcher, I knew I wanted to focus my efforts in an area where I could have the greatest impact. I am naturally drawn to and motivated by difficult challenges. Pancreatic cancer has dismal survival rates and receives far less attention than other cancers. It is also one of the most difficult cancers to treat surgically. So, of course, it was a natural fit.
You’ve performed over 1,200 Whipple procedures, a demanding, high-stakes surgery to excise pancreatic cancer. How did you develop a level of competence that attracts patients from all over the world?
There is a saying: “German for all trades, master of nothing. My philosophy is “Pick a thing or two and be the best at it.” I am like that with everything. Some people wonder how I can do the same operation over and over again. It’s because every time I complete an operation, I get a little better. Even after almost two decades in the operating room, I still feel like a better surgeon than a month ago.
“The majority of my patients have learned that surgery is not an option. It’s amazing when you can say, “I think we can get your tumor removed” or “We can give you a chance to be cured.” “
Because I deal with some of the more difficult, so-called “unresectable” cases, the majority of my patients have learned that surgery is not an option and that their tumors cannot be removed. I think about it as I finish an operation and send the tumor to the pathology lab. That sense of accomplishment and knowing that you’ve changed someone’s life never gets old. It’s amazing when you can say, “I think we can get your tumor removed” or “We can give you a chance to be cured.”
NYU Langone has one of the lowest death rates for the Whipple procedure. Why?
Studies show that pancreatic cancer patients have higher survival rates and fewer complications when they see a healthcare system that performs at least 10-20 Whipple procedures per year. This year alone, NYU Langone is expected to perform over 125 Whipple procedures.
It’s not just the surgeons’ experience and what we do in the operating room that matters, it’s the whole team, from anesthesia to nursing to the recovery room. We have the best and we all work together as one team to provide excellent patient care. We have assembled a multidisciplinary clinic that offers personalized medicine based on the very latest knowledge of the molecular biology of the patient’s tumor. We offer clinical trials and our innovative research translates into clinical advances. As Vince Lombardi once said, by pursuing perfection, we will catch excellence.
You spent 15 years with Johns Hopkins. Why join the NYU Langone Perlmutter Cancer Center?
Even though the standard of care for pancreatic cancer is excellent, the vast majority of patients still die. We will not turn the situation around unless we have a forward-looking approach to finding and treating the disease. At NYU Langone, pushing boundaries is part of the culture. I want to invent the future and set the global standard for pancreatic and hepatobiliary surgery, research and innovation.
My philosophy of taking calculated risks; seek pioneering and revolutionary solutions; and constantly questioning the status quo aligns with that of NYU Langone management. To paraphrase Wayne Gretzky, it’s not about where the puck is, but where it is heading. It means doing some things that at first may seem unconventional, but leadership understands that investing in innovation now will change the future.
How do you see the future of pancreatic cancer?
Two of the most important things that must happen to move the needle significantly are early detection and improved systemic control. My colleague Diane M. Simeone, MD, director of the Pancreatic Cancer Center at NYU Langone, focuses on early detection. Of the 60,000 cases of pancreatic cancer diagnosed each year, 80 percent are not eligible for surgery because the cancer is too advanced. Dr Simeone’s work will change this percentage.
However, we also need to break the biology of the disease. Even among the 20 percent of patients eligible for surgery, the tumor will rebound in 80 percent of these cases. Cancer is systemic, so it invariably spreads beyond the surgical site. The only way to cure this disease is to eradicate it systemically.
To that end, my research focuses on circulating tumor cells – what we call the seeds of metastases – and how cancer spreads. Even if we remove a tumor, we can still find these little seeds circulating throughout the body. If chemotherapy doesn’t kill them all, the disease rebounds. Understanding the biology of systemic disease is therefore one of the most important next steps in curing more people.
How long does it take for pancreatic cancer to metastasize?
Research shows that a tumor that develops in the pancreas can take 12 to 15 years to become invasive. If we can find and eliminate precancerous tumors within this window, we can potentially cure pancreatic cancer with surgery alone. The problem is that many early tumors are invisible. We cannot see them on the scans. We’re developing ways to find them in the blood, a diagnostic technique called a liquid biopsy. Tumors that can be detected on scans are called cystic neoplasms. Most of these lesions are benign, but 3-5% will undergo malignant transformation. The challenge with these types of tumors is figuring out which ones to watch for and which to remove surgically. So that’s another big area of research.
Are there any particular risk factors for pancreatic cancer?
Most cases of pancreatic cancer are sporadic, which means they are caused by bad luck. Like all cancers, pancreatic cancer is induced by genes, but mutations occur in the adult cells of the pancreas, not in the sex cells which pass genes on from generation to generation. For example, as far as I know, I was not born with a mutation that predisposes me to pancreatic cancer, but I can get one.
“I am an optimist and optimist by nature. If I watch a game and my team loses 40 points, I always think to myself: “The game is not over yet. It’s the same attitude I have with my patients. We are always thinking about ways to beat cancer.
Germline mutations that create family reunification occur in less than 10 percent of cases. To better understand them, the Perlmutter Cancer Center is conducting a research project to sequence the DNA of patients with pancreatic cancer, then analyze these sequences for germline mutations. The other 90% of pancreatic cancer cases occur randomly or are due to hidden environmental exposures. For example, the incidence of pancreatic cancer is highest in the coal region of West Virginia, near where I grew up. It is therefore also essential to learn more about environmental factors.
You said the most important thing you can do for a patient, in addition to providing excellent clinical care, is to offer hope. What convinced you of this?
I develop a relationship with each of my patients. I am their doctor for life. I answer their emails. We are talking on the phone. Even patients who are now 15 years late will still see me once a year. These relationships are extremely important to me.
I am also an optimist and optimist by nature. If I watch a game and my team loses 40 points, I always think to myself: “The game is not over yet. I’m on the edge of my seat until the very end. It’s the same attitude I have with my patients. We never throw in the towel. We are always thinking about ways to beat cancer. We never give up.
At the same time, I am also a realist. When I see my patients for the first time, we chat for an hour. This is an opportunity for me to explain where we are and to prepare them for the hard road ahead. I tell them the odds are against us, but together we will fight anyway. I am with them. I master the technical aspects of my work. I have extensive knowledge of the disease and know when and how to operate.
But one of my most rewarding roles is as a cheerleader for my patients. If you take 100 people with localized pancreatic cancer, in 5 years 80 of those people won’t be here. But here’s the thing. We don’t know if you’re going to be in those 80s or 20s. I tell my patients, “Right now, I have no reason to believe that you won’t be in these 20. Go fight. and help you get through it every step of the way.