When Jim Smith, M.D., a physician and professor at Creighton University School of Medicine in Omaha, Nebraska, was diagnosed with metastatic pancreatic cancer more than two years ago, he believed his prospects for the future were dim.
The advanced stage of the cancer, which appeared to have spread to Jim's spleen and lungs, excluded him from having surgery to treat it. And while chemotherapy was an option, the nature of the disease was such that, even with chemotherapy, the cancer would likely claim Jim's life in less than a year.
"I remember having some difficult conversations," says Jim, who is married and has two daughters. "I didn't want heroics. If my time had come, it was important for me to move on and not pose a burden to my family."
Jim's wife of 14 years, Melanie, was not ready to accept that approach. "She said, 'We're going to live our lives with optimism and hope,'" Jim says.
With Melanie's strong encouragement, Jim requested an appointment for a second opinion at Mayo Clinic, which was studying a biopsy sample of Jim's tumor cells that'd been sent by his Omaha team. "At the time, we didn't know where the primary origin (of the cancer) was and wondered if there were some other therapies that could be used," Jim says.
In December 2017, Jim and Melanie drove to Mayo Clinic in Rochester, where Jim met medical oncologist Keith Bible, M.D., Ph.D. During the appointment, Jim was given an alternate take on the cancer — one that ultimately resulted in him receiving an aggressive surgery that removed the cancer from his body and provided him years, rather than months, of survival.
"We can't be cured of our human existence. We can't be here forever," Jim says. "But one thing that pops up for me is that (the treatment) was life-extending. It is not the norm that people with pancreatic cancer live for two years — and even less common that they are alive and doing as well as I feel like I'm doing."
Before Jim came to Mayo Clinic, his care team in Nebraska had discovered that the tumor that began in Jim's pancreas had invaded the uppermost portion of Jim's small intestine, or duodenum. The tumor was causing internal bleeding that was difficult to stop. Imaging also revealed the presence of nodule-like growths in his lungs and spleen — another indication the cancer had spread beyond his pancreas. Under the direction of his Omaha team, Jim started receiving chemotherapy.
At Mayo Clinic, however, Jim learned his diagnosis wasn't as clear-cut as he had previously believed. "There were a few little intriguing aspects of my condition," Jim says. "One of them was that pancreatic cancer can go anywhere, but it commonly goes to the liver. My liver seemed to be uninvolved."
"(My care team) said: 'You might have stage 4 disease, but that doesn't mean you can't have surgery. We're going to figure out the most important thing for you.'"Jim Smith, M.D.
The areas that did appear to be directly involved were reexamined by Jim's Mayo team. "The lesions in the spleen and lung were not consistent with my expectation of what would be typical in metastatic disease," Dr. Bible says. Small nodules identified in imaging looked more like signs of a respiratory illness, which implied the cancer had not spread beyond the primary site in Jim's upper digestive system.
This discovery allowed Jim to be considered for a surgery to address the most dangerous aspect of the cancer. "There was imminent threat from the local process involving the intestine that had great potential to cause him to bleed to death," Dr. Bible says.
During Jim's meeting with him, Dr. Bible requested a consult with Mayo hepatobiliary and pancreatic surgeon David Nagorney, M.D. The following morning at Jim's appointment, Dr. Nagorney lent his expertise to the conversation around Jim's treatment.
"The two of them, and some advanced-practice nurses and fellows, were all in the room talking about me, with me, and about how the future might look," Jim says. "They never called me stage 4 anything. They called me Jim, and said, 'What you have is specific to you.' They said: 'You might have stage 4 disease, but that doesn't mean you can't have surgery. We're going to figure out the most important thing for you.'"
Jim learned from his team that if he wanted to survive even a few months, surgery was necessary to remove his tumor and stop the bleeding. "They told me the good news is that I'm not going to die of pancreatic cancer. The bad news is that I was going to starve to death before the cancer could get me," says Jim, who shed 40 pounds from his 170-pound frame over the course of four months. "They said I would live longer if I had a Whipple surgery. And I said I appreciated the clarity because that helped."
In late January 2018, one month after his first appointments with Drs. Bible and Nagorney, Jim returned to Mayo Clinic for the Whipple procedure. Also called a pancreaticoduodenectomy, the surgery involves removing the head of the pancreas, the duodenum, the gallbladder and bile duct, and then reconfiguring the upper digestive system. In Jim's case, the spleen also was removed.
"I had surgery early in the week, and my goal was to be out by Sunday morning, so I could drive back to Omaha and watch the Super Bowl," Jim says.
"The rest of the story has been like a miracle."Jim Smith, M.D.
A few days after his operation, Jim's team informed him that his cancer was identified as an anaplastic pancreatic cancer. "Pancreatic cancers are pretty common and are one of the more lethal cancers in the U.S., but these undifferentiated, or anaplastic, pancreatic cancers are distinctly rare," Dr. Bible says. "This is a super high-risk, very aggressive pancreatic cancer."
Despite its severity, the entire tumor was successfully removed during surgery, and the tumor margins were clear of cancer cells. Tests also showed that Jim's lymph nodes and spleen were not affected by the disease.
To Jim's delight, he was released from the hospital in time for Melanie to drive them back home for the big game.
Jim returned to Mayo Clinic for follow-up appointments after surgery. During one of those visits, he underwent a lung biopsy. The biopsy came back negative for cancer. The abdominal areas where the tumor had been removed also came back negative for recurrence.
"The rest of the story has been like a miracle," Jim says.
Jim's outcome would have been impossible without collaboration — involving both his oncologist in Omaha and his team at Mayo Clinic. "It required a surgeon willing to commit to a very aggressive approach in a very hostile tumor environment," Dr. Bible says. "It required a change in the way we looked at his cancer — to view it as treatable with curative intervention, as opposed to viewing it as a lost cause from the outset."
Jim's outcome also depended on insight into the nature and behavior of aggressive, advanced-stage cancer. "It required recognition that the appearance of the lesions in the spleen and in the lungs didn't match expectation for metastatic disease," Dr. Bible says. "This recognition is something that we have as a potential benefit at Mayo Clinic because we are a high-volume center, and because we see a lot of rare cancers."
Jim will continue to have follow-up imaging and appointments to check for cancer recurrence. And while he doesn't know whether the cancer will come back, Jim deeply appreciates the care he received at Mayo Clinic that gave him the best chance to overcome his daunting diagnosis.
"In my almost 30 years out of training, I've been in different clinical, administrative and leadership positions, and we always talk about Mayo Clinic and the Mayo Model of Care in terms of quality, efficiency and international recognition," Jim says. "I understood those in terms of the practice of medicine and the administration of medical care, but not as a patient."
He continues: "To experience Mayo Clinic as a vulnerable patient with this catastrophic, life-altering, potentially life-ending diagnosis, I found that, all of the sudden, I understood what people mean when they talk about the Mayo model. Whether it's the legacy of the Mayo brothers or the sisters at Saint Marys, or the quality of care that the system continues to offer, it was the right place to be."