In more than half of people diagnosed with pancreatic cancer, the disease has already advanced to stage 4 before they notice any symptoms. But for Rita Krueger, a bothersome symptom was the catalyst for her diagnosis.
A persistent, intense itching prompted Rita to make a doctor's appointment, and in short order, testing revealed that she had pancreatic cancer. The quick diagnosis didn't seem to matter much at first, however, then a surgeon told Rita to get her affairs in order.
But a second opinion and a more aggressive approach to treatment at Mayo Clinic turned that outlook around. Today, Rita is doing well, and she's eager tell others about her experience.
"I want to talk about this, so I can change people's lives in a positive way," Rita says. "Because pancreatic cancer can be so fatalistic, I want to give people hope and let them know that they have options."
When Rita went to see her primary care doctor in Lino Lakes, Minnesota, to find the cause of her itching, bloodwork showed that she had developed diabetes, and results of her liver tests were abnormal. Those findings, coupled with her skin discomfort, were ominous signs.
"Weight loss, itchy skin and new-onset diabetes — these are three red flags that you have pancreatic cancer," says Mark Truty, M.D., a Mayo Clinic hepatobiliary and pancreatic surgeon.
Rita's local doctor recommended she undergo an MRI. The imaging revealed a tumor in Rita's pancreas, and it showed that her intense itching was due to the fact that the tumor was blocking one of her bile ducts. At that point, Rita was referred to a surgeon for a consult.
When she walked into the surgeon's office in February 2018 to discuss options to remove the tumor, Rita says she was not prepared for the conversation that followed. "I expected him to tell me he was going to do the surgery, and I could move on with life," Rita says. "Instead, he assumed it was cancer and told me to get my affairs in order. I remember sitting in his office crying. That was the first fatalistic conversation anyone had had with me."
"I've been a very healthy person all my life, so this was a big shock."Rita Krueger
Rita underwent an endoscopy procedure to biopsy the tumor and place a stent in the blocked bile duct. Six days later, she received terrible news. "They confirmed I had pancreatic cancer," she recalls. "I've been a very healthy person all my life, so this was a big shock."
Rita and her husband, Jim, decided to go to Mayo Clinic in Rochester for a second opinion. On March 23, 2018, they met with Dr. Truty. A friend had told Rita about a high school classmate who Dr. Truty treated for pancreatic cancer and was cancer-free.
"I read that (Dr. Truty) had lost his father to this disease and made it his mission to help others have a better outcome. I felt like he was the dragon slayer of this disease," Rita says. "He was so confident, and he'd had such good success. I felt a peace and a confidence when I went to see him. I trusted him."
After meeting Rita and Jim, and reviewing her situation, Dr. Truty learned that Rita's tumor had grown outside of the pancreas, and it involved veins and arteries that supply and drain the pancreas and go to the liver. That made her condition complicated. But Dr. Truty had a plan.
"This would be a very complex surgery that would only be beneficial if we could remove the tumor and not leave cancer cells behind," Dr. Truty says. "Our approach was to do chemo first to kill the microscopic cancer cells that we know most people have circulating, but we can't see on any imaging."
Typically, patients with other types of cancer undergo a CT scan at the end of chemotherapy to determine if the tumor has shrunk. But that imaging isn't as helpful with pancreatic cancer. "One of the hallmarks of pancreatic cancer is that the cancer cells are embedded in a large amount of fibrosis, which makes penetration of the chemotherapy difficult," Dr. Truty says. "It also makes it difficult to discern the actual amount of living cancer. Therefore, CT scans aren't very predictive of whether the chemotherapy was beneficial or not, since the tumor doesn't always shrink."
"Because of this imaging, we're open to taking on more complex operations than might be the case at other centers."Mark Truty, M.D.
Because of that, Mayo Clinic employs positron emissions tomography (PET) scanning combined with MRI imaging to determine how active the cancer is prior to chemotherapy. The test is repeated afterward to see if the activity has significantly decreased. "This is not often performed elsewhere and has revolutionized how we run our practice," Dr. Truty says. "Because of this imaging, we're open to taking on more complex operations than might be the case at other centers."
In April 2018, Rita began a three-drug combination chemotherapy that is one of only two regimens that have significant benefit for pancreatic cancer. After two months, however, a tumor marker blood test, a CT scan and a PET scan all showed that the tumor had not responded to the treatment.
Dr. Truty put Rita on the second chemotherapy regimen. Several months later, tests showed no evidence of a response. He then recommended radiation therapy five days a week for five weeks, beginning in August. In mid-September, Dr. Truty repeated all the tests.
"Unfortunately, the tumor was the same size and just as active, despite all our efforts," Dr. Truty says. "I had an otherwise healthy and vibrant 53-year-old woman in front of me who was very scared and would require a significantly complicated operation. Statistically, however, it didn't seem like she would do well with surgery."
After extensive discussions with Dr. Truty about the risks and benefits, and after praying about it, Rita decided she would move forward with surgery.
Rita underwent the 10-hour procedure on Oct. 23, 2018. Dr. Truty took out her pancreas, duodenum, spleen and left adrenal gland. He also removed and reconstructed several blood vessels that were involved in the tumor mass.
Two days after the surgery, the pathology report showed stunning results. There was no cancer left in Rita's tumor.
Part of the reason for that was a condition that had previously remained hidden. "The whole time we were seeing the tumor not changing or responding, it was because she'd developed severe pancreatitis," Dr. Truty says. "A PET scan, despite its significant benefit in assessing response, can't perfectly differentiate between inflammation of the pancreas and cancer. This was a wonderful surprise. Immediately, she was catapulted into a much better than average outcome."
"I really feel grateful that I've been given a second chance. I don't think I would be alive today if I hadn't gone to Mayo."Rita Krueger
One of the major predictors of survival in people who undergo surgery after extensive chemotherapy is the amount of viable tumor found in the surgical specimen. People who have very little or no living cancer left in the tumor tend to do well long-term.
Rita was able to leave the hospital 19 days after surgery. In January 2019, she went back to her work as a software engineer full time. Because she had her pancreas removed, she now has to take insulin throughout the day. She also has to take pancreatic enzymes with her food to aid with digestion. But overall, she is doing well and feeling good.
"I really feel grateful that I've been given a second chance. I don't think I would be alive today if I hadn't gone to Mayo," Rita says. "Dr. Truty is a remarkable man and an innovative doctor who pushes the envelope. He and his team have given me a chance to be more intentional about how I live my life."
Dr. Truty credits Rita for being willing to persevere through all that was required to get her to that positive outcome. "She trusted me, and I trusted her. We both trusted our faith in order to make the right decision. We were on this journey together. And this was the right thing to do," Dr. Truty says. "I saw her two weeks ago, and all the scans looks pristine. She's getting back to life, and that's the whole point of this: to get some more time."
Watch this video to learn more about treatment for pancreatic cancer at Mayo Clinic: