By Debra Melani
Bonnie Dahl knows chance and circumstance played key roles in halting her pancreatic cancer, one of the deadliest and most insidious forms of the disease.
Chance came when a keen radiologist spotted the tiny cyst on the CT scan her doctor had ordered of the longtime Boulder businesswoman’s lungs, not her pancreas.
Circumstance took over when Dahl called her brother, who was being treated for head and neck cancer at the University of Colorado Anschutz Medical Campus, before she booked an appointment with the local surgeon her gastroenterologist recommended.
Today, after months of treatment at the CU Anschutz Medical Campus, Dahl’s tests show no signs of the disease, and her doctors say chances of the highly recurring cancer sneaking back unseen are lower than average.
“Going through such a serious cancer, I know how fortunate I was,” says Dahl, who in January celebrated a year since her last chemotherapy treatment. “I know that not everybody has these outcomes. But it’s how you deal with it along the journey that is key.”
Following her intuition to get a second opinion is something almost all doctors recommend when facing serious diagnoses. Her brother’s physician assistant at CU Anschutz was a longtime friend of Dahl’s daughter and had worked at one of Dahl’s stores in Boulder as a teenager. “She called me and said, ‘Bonnie, [your brother] just told me about your diagnosis,’” recalls Dahl, describing a nagging cough that had been diagnosed as post-nasal drip. “She said, ‘You have to go to Anschutz. We have the two top surgeons in the world for pancreatic cancer.’”
After more research and recommendations, Dahl quickly found herself meeting with her care team at CU Anschutz, which included one of those top surgeons, Marco Del Chiaro, MD, professor and division chief of surgical oncology at the CU School of Medicine.
“I was really excited, because I just had this sense of things going in the right direction,” Dahl says. “I knew I was in good hands.”
The team had already set Dahl’s treatment plan after reviewing her case with the CU Cancer Center tumor board – a rare entity that involves up to 25 multidisciplinary specialists who meet weekly, evaluating and monitoring every patient case based on tumor type.
Choosing the CU Cancer Center, a National Pancreas Foundation Academic Center of Excellence, makes a difference for most patients, Del Chiaro says.
“It’s been demonstrated that when you go to a high-volume, integrated center that specializes in a particular cancer, your results are better,” says Del Chiaro, an international leader in highly complex pancreatic surgery.
Due to the integrated approach and advanced surgical techniques, Del Chiaro and his team can operate on more of its pancreatic cancer patients, nearly double the national average, a key to improved outcomes.
Cancer care goes well beyond surgery, and for Dahl, her medical oncologist’s advanced, evidence-based treatment plan played as vital a role.
Dahl’s protocol included four sessions of a powerful chemotherapy drug before surgery and then eight more after the operation.
The chemotherapy, called FOLFIRINOX, was once limited to patients with cancers that had spread beyond the pancreas.
“But we are using it now in the neoadjuvant (before surgery) setting because the data show it provides better outcomes,” says Alexis Leal, MD, an assistant professor of medical oncology and CU Cancer Center member.
Using chemotherapy before surgery, Leal says, helps shrink tumors to make them easier to remove surgically. Also, the pre-surgical use allows doctors to observe tumor biology so that they can determine responsiveness to chemotherapy and utilize the proper post-surgical chemotherapy regimen. It also helps prevent spread of cancer cells outside of the pancreas.
For Dahl, the outcome was “stellar,” Del Chiaro said, with final pathology after surgery showing no signs of cancer cells remaining. Generally, only 3% to 5% of patients have such results, he says.
Continuing with the aggressive, post-surgery chemotherapy plan, even in cases like Dahl’s, remains critical, Leal says, especially with pancreatic cancer, when cancer cells might have escaped through the blood stream and be lurking elsewhere. The rationale is that the drug will seek out and kill any remaining cells, she says.
In the largest study of its kind released late last year, Del Chiaro and colleagues confirmed improved outcomes for patients who received chemotherapy pre- and post-pancreatic surgery compared with patients who did not.
“I went through the entire protocol of somebody who’s stage 3,” Dahl said. “So, I did not get a pass at all – except that I caught it early.”
Dahl’s case was a lucky catch, because it resulted from a friend pushing her to see a doctor for a persistent, unrelated cough, Leal says. With no viable screening method for pancreatic cancer, the disease often goes undetected until later stages, a large reason it ranks as third-deadliest cancer in the country behind lung and colon cancer.
Dahl’s cancer stemmed from a precancerous pancreatic cyst called an intraductal papillary mucinous neoplasm (IPMN), Del Chiaro says.
Not all these pancreatic cysts become cancerous. In fact, studies suggest they are present in a large percentage of the population.
At CU Anschutz, Dahl was able to get care at specialty clinic dedicated solely to pancreatic cysts, run by Del Chiaro and colleagues.
“It’s something really unique,” Leal says. “I don’t know of other cancer centers having this. Not uncommonly, we get referrals from primary care physicians, surgeons, and other doctors for patients that had these cysts incidentally picked up on scans.”
CU Anschutz patients with IPMNs are rigorously surveilled for life, with highly specialized cystic experts monitoring and discussing each patient’s case to determine when and if surgical removal is necessary.
“We’re going to keep a close eye on Bonnie,” Leal says. “It’s unlikely that something would be missed in the future.”
In addition to the expert clinical care Dahl received, her outlook made an important contribution to her recovery. “She is so positive,” Leal says, adding that no matter how rough the chemotherapy would get, Dahl would report: “I’m doing great!”
The petite Dahl, who says she is “5 foot tall on a good day,” fell to a low of 88 pounds over the course of her care, but never complained, Leal says.
“She was an unwavering force. It brings tears to my eyes,” Leal says, adding that Dahl’s dedication to world travel left a mark on her caregivers. “She was always planning trips and vacations in between her chemotherapy cycles,” Leal says. Dahl’s excursions included a women’s trip to Greece mid-treatment and a family vacation to Sri Lanka after her last chemotherapy session.
“Another great thing about CU Anschutz is that they want you to live and to lead a normal life when you can during treatment,” Dahl says. “They are the first to say: If you’re up for travel, do it. I appreciate that. I don’t think you get that from other institutions.”
“This is why we’re doing this,” Leal tells her patients. "We’re doing this so you can live your life. Patients of mine that have that positive way of being and relating just do well. We love Bonnie. She’s a force to be reckoned with. I think that really served her well.”