Like many southeast Wisconsin residents, Richard and Cynthia Drewek love escaping to their cottage up north to boat, fish and relax. Married since 1977, the high school sweethearts were enjoying time on the lake in July 2019 before their cottage narrowly escaped damage from an EF1 tornado. Little did they know, they would have to weather a different kind of storm soon after.
“We hid in the back of our cottage because we don’t have a basement,” Cynthia said. “90 mile per hour shear winds were crashing into our cottage, and you could see the white chute of the tornado out on the lake. Luckily, we got through that pretty unscathed, but that’s also when Rick got sick.”
Richard was fatigued, itchy, developed jaundice and quickly lost about six pounds. Once the Wisconsin National Guard cleared the roads from storm damage, the Dreweks drove immediately to their primary care doctor in Glendale, who referred Richard to a GI specialist. After diagnostic tests and imaging showed a potentially cancerous tumor on Richard’s pancreas, he was referred to the pancreatic cancer specialists with the Froedtert & the Medical College of Wisconsin Cancer Network for diagnosis confirmation and focused care.
Pancreatic Cancer Confirmation at Froedtert Hospital
At Froedtert Hospital, Richard had a pancreas protocol CT scan and an endoscopic retrograde cholangiopancreatography with both a biopsy and metal stent placement, as well as a positron emission tomography scan. The results from these procedures were reviewed by physicians within a multidisciplinary tumor board meeting who concluded that Richard had borderline resectable pancreatic cancer, meaning the cancer could still be potentially removed with surgery. Richard’s team also determined that the best treatment course would consist of chemotherapy within a clinical trial, radiation therapy and, ultimately, surgery.
“Our cancer tumor boards are absolutely critical, not only for coming to a consensus on the diagnosis and treatment plan, but for monitoring people as they go through their health care journey,” said Kathleen Christians, MD, surgical oncologist at Froedtert Hospital. “With Richard, different experts, all specializing in pancreatic cancer, sat together to review his disease nuances, and we monitored him as a group to see if treatment was working.”
Chemotherapy Within a Clinical Trial
The first step in Richard’s treatment course was chemotherapy. As the only academic medical center in eastern Wisconsin, Froedtert Hospital has the expertise and resources to conduct clinical research trials to find innovative treatments. The trial Richard participated in was developed by the pancreatic cancer team at Froedtert Hospital and is the only location in the U.S. to offer it. The goal is to understand if standard chemotherapy before surgery can be delivered more effectively.
“Pancreatic cancers are notoriously difficult to treat because it can be challenging for clinicians to understand when there is a treatment response,” said Susan Tsai, MD, MHS, surgical oncologist and principal investigator of this trial. “Historically, a patient continues on a treatment to keep their disease stable until there’s an obvious disease progression, and then they’ll switch treatments. In this trial, we are using blood biomarkers to identify treatment responses instead of waiting for disease progression to occur. If two months go by and we don’t see a robust positive patient response, we’ll switch to a different chemotherapy drug.”
When asked if he’d like to participate in the trial, Richard said yes, citing that it could help future cancer patients. The first chemotherapy drug combination he received was FOLFIRINOX, which was administered eight separate times through an IV port in his chest at the hospital. As an outpatient chemotherapy treatment, a part of the drug combination diffused slowly throughout Richard’s body over the next 48 hours while he was at home. This proved to be the only pre-radiation chemotherapy Richard needed, as his blood biomarkers showed he was having a positive response at the two-month checkpoint and at the end of his four-month treatment course.
“On a one to 10 scale, with 10 being the most potent, I was somewhere between an eight and a 10 of the potency of the chemo treatment,” Richard said. “They wanted to start me out high and see if I could handle it. I was actually fine, very mobile and still active throughout the chemo process. I really didn’t experience a lot of symptoms compared to what other people experience.”
Following the FOLFIRINOX treatment course, Richard required radiation therapy to further shrink the size of his cancerous tumor. Getting one session per weekday, he visited Froedtert Hospital for 28 sessions of intensity-modulated radiation therapy (IMRT) with William Hall, MD, radiation oncologist and co-investigator of Richard’s clinical trial. Richard would also simultaneously receive a low dose of another chemotherapy drug, gemcitabine, once a week to boost the effectiveness of the radiation.
“IMRT with daily image guidance is a highly advanced form of radiation that directs multiple different radiation beams from many different angles at the exact area where the tumor is,” Dr. Hall said. “This technique keeps the high radiation dose within the vicinity of the tumor, avoiding affecting normal organs and other areas where the tumor isn’t.”
Compared to his four-month chemotherapy treatment course, radiation therapy proved to be a bit tougher on Richard, who needed a month to regain his strength following his last radiation therapy session. He kept in touch with his doctors through MyChart while he exercised and drank protein shakes.
“They tasted like liquid chalk,” Richard said. “My doctors told me that losing some strength can happen to people sometimes after treatment. Luckily, through exercising and eating right, I got stronger and stronger before getting the ‘OK’ for the operation.”
Surgery and Recovery During the COVID-19 Pandemic
With his strength regained and tumor biomarkers down, Dr. Christians performed a five-hour surgery to remove Richard’s cancerous tumor on March 9, 2020. This surgery, known as a Whipple procedure, removes the entire head of the pancreas, the lower part of the bile duct, the gallbladder, parts of the stomach and all the lymph nodes in the area. The remaining parts of the pancreas, bile duct and stomach are then rejoined to the bowel.
"I wasn’t scared going into surgery,” Richard said. “I just had so much confidence in Dr. Christians that I felt the outcome was going to be positive, and it was.”
At a time when COVID-19 cases in Wisconsin were beginning to spike and many other institutions paused all nonemergent surgeries, Richard’s surgery proceeded as usual with safety precautions that included appropriate PPE, face masks, hand washing and limited postoperative visitation.
“Richard came in and trusted us to keep him safe,” Dr. Christians said. “Despite all of the COVID-19-related adversity and a borderline resectable tumor, he had an excellent outcome.”
Following the successful surgery, Richard had a shorter-than-average, seven-day hospital stay. He and Cynthia navigated around COVID-19 in the months following his surgery for his follow-up care at Froedtert Hospital.
“When I went home after surgery, they told me not to do any heavy lifting or be too active,” Richard said. “That, of course, was pretty easy with the quarantine due to COVID-19 anyhow.”
All of Richard’s postoperative scans have been coming back clean with no evidence of cancer. The Dreweks couldn’t be happier with the care they received from the Froedtert & MCW Cancer Network – from the oncologists to the nurses, dietitians and radiation therapists – that has allowed them to once again return up north.
“This is the place we love to come to,” Cynthia said, speaking from the cottage. “We’re so glad that we are here, and Rick is well. We thank Froedtert for their compassionate, respectful and kind care, and we thank God for it all working out.”
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I'm close to someone who works on this trial. This type of cancer generally has a poor prognosis, so it's wonderful to read of Richard's success story. It's a tribute to all the hard work put in by the doctors, nurses, aids, and researchers. This kind of work takes its toll on all involved, and a bit of positivity can go a long way for everyone who does this kind of work.