Dr. Jonathan Sham
When John Nowoj was diagnosed with locally advanced pancreatic cancer in August 2019, he was told the cancer was inoperable. Nowoj, 57, began pursuing his only treatment option: chemotherapy to be followed by radiation, which could shrink but not eradicate the tumor. Then an unexpected development completely changed the outlook.
A new surgeon at Seattle Cancer Care Alliance (SCCA), Dr. Jonathan Sham, was offering a rare type of pancreatic surgery that could be appropriate for Nowoj’s cancer.
Dr. Sham, a surgical oncologist who specializes in pancreatic cancer, told Nowoj he may be eligible for a modified Appleby procedure, a highly technical and rarely utilized surgery that Dr. Sham learned how to perform at The Johns Hopkins Hospital, where he’d trained in both Complex Surgical Oncology and Hepatopancreatobiliary Surgery. The surgical technique was originally developed decades ago by a Canadian surgeon, Dr. Appleby, for gastric cancer, but in the past several years, a modified version has been gaining traction as an option for locally advanced pancreatic tumors that involve the celiac axis — the major blood vessels that feed the stomach, liver and spleen.
It’s a complex surgery that can last up to eight hours as the surgeon carefully removes the cancer and main blood vessels in such a way that enables the body to reverse blood flow in the remaining vessels to nourish the vital organs such as the stomach and liver. Done incorrectly, the blood flow doesn’t redirect, damaging organs and potentially leading to complications or death.
The surgery is appropriate for just a sliver of pancreatic cancer patients. Only about 25% of patients qualify for any type of surgery because the tumor must be localized, with no spread to other areas, and it must not involve certain blood vessels. “Most patients are not eligible for surgery because it has already spread by the time they’re diagnosed,” said Dr. Sham.
Of those patients eligible for more common surgeries — such as the Whipple procedure or distal pancreatectomy — just 1 to 2 percent may benefit from the modified Appleby procedure, although that percentage could climb. “Now that the field is moving in this direction, the number may go up as chemotherapy improves and more people qualify,” said Dr. Sham.
As chemotherapy options expand and become more effective, the availability of the modified Appleby procedure at SCCA highlights new options for a cancer that is notoriously difficult to treat. “Without effective chemotherapy, I can’t do the surgery,” said Dr. Sham. “Advances in both surgical technique and chemotherapies allow us to offer options to patients that previously were not available.”
Dr. Sham operated on Nowoj in February 2020. Nowoj’s surgery was the first modified Appleby procedure performed at UW Medicine, where SCCA physicians operate. At Nowoj’s first follow-up visit a few weeks later, Dr. Sham told him he looked great and had weathered the surgery exceptionally well. “Everything we could have taken out, we did,” Dr. Sham told Nowoj.
Dr. Andrew Coveler, Nowoj’s medical oncologist and director of SCCA’s Pancreas Cancer Specialty Clinic, reinforced to Nowoj that the multidisciplinary nature of the clinic would ensure he would continue to receive state-of-the-art care. “It really is a team approach here,” Dr. Coveler said. “It’s not just one person making a decision. We have surgeons, radiologists, oncologists — everyone in the room. It makes the difference between having no hope versus having hope.”
Nowoj credits the multidisciplinary approach with making a difference in his care. “The team of Dr. Coveler and Dr. Sham are phenomenal and put me in the best position to beat this cancer,” Nowoj said.
Patients diagnosed with pancreas cancer often feel hopeless; even after chemotherapy and radiation, recurrence is likely. But as chemotherapies become more effective and are coupled with surgeries such as the Appleby, SCCA’s multidisciplinary team sees hope for long-term control or even cure.
Nowoj glanced at his wife. “That is amazing,” he said. “It’s incredible.”