An internationally renowned pancreatic surgeon, surgical oncologist, and cancer researcher, Christopher Wolfgang, MD, PhD, joined NYU Langone Health last January. He is chief of the new Division of Hepatobiliary and Pancreatic Surgery in the Department of Surgery, having previously served as chief of hepatobiliary and pancreatic surgery and vice chair for surgical oncology at Johns Hopkins Medicine.
Specializing in technically challenging cases, he has performed more than 1,200 Whipple procedures, a complicated, high-risk surgical technique. It involves removing the head of the pancreas, part of the small intestine, the gallbladder, and the bile duct to preserve shared blood vessels, and then rebuilding a functional digestive system. A luminary in the field of pancreatic cancer, his practice draws patients from around the world whose tumors have been previously deemed inoperable.
You grew up on a farm in Pennsylvania. When you went off to college, you set out to study agriculture with the expectation that one day you would run the family business. What made you change course so dramatically?
My dad sent me to Penn State to study agricultural business. It was a big deal. I was the first Wolfgang in my immediate family to go to college. But I wasn’t all that interested in the subject matter. I really wanted to study science and medicine. When I came home with a GPA of 1.86 in my first year, my parents gave me an ultimatum. They said, “Chris, you can study what you want, but you need to turn your grades around, or we’ll pull you out of college.” I dove into science, and my grades soared after that. I loved the farm, and I always will. It’s a part of our family. But my passion is medicine.
A quarter of patients with pancreatic cancer die within a month of being diagnosed, and three-quarters will die within a year. What drew you to a field with such discouraging numbers?
When I began my training as a physician–scientist, I knew I wanted to concentrate my efforts in an area where I could make the biggest impact. I’m naturally drawn to and driven by difficult challenges. Pancreatic cancer has dismal survival rates and receives much less attention than other cancers. It’s also one of the most difficult cancers to treat surgically. So, of course, it was a natural fit.
You’ve performed more than 1,200 Whipple procedures, a demanding, high-stakes surgery to excise cancer from the pancreas. How did you develop a level of skill that attracts patients from around the globe?
There’s a saying, “Jack of all trades, master of none.” My philosophy is “Pick one or two things, and be the best at them.” I’m like that with everything. Some people wonder how I can do the same operation over and over again. It’s because every time I finish a surgery, I’m a little bit better. Even after nearly two decades in the operating room, I still feel like I’m a better surgeon than I was a month ago.
“The majority of my patients have been told surgery is not an option. It’s extraordinary when you can say, ‘I think we can take your tumor out,’ or ‘We can give you a shot at a cure.’”
Because I take on some of the most challenging, so-called “unresectable” cases, the majority of my patients have been told surgery is not an option and that their tumors can’t be removed. I think about that as I’m finishing an operation and sending the tumor to the pathology lab. That feeling of accomplishment and knowing you have changed someone’s life never gets old. It’s extraordinary when you can say, “I think we can take your tumor out,” or “We can give you a shot at a cure.”
NYU Langone has one of the lowest mortality rates for the Whipple procedure. Why?
Studies show that patients with pancreatic cancer experience higher survival rates and fewer complications when they seek care at a health system that performs at least 10 to 20 Whipple procedures a year. This year alone, NYU Langone is projected to complete well over 125 Whipple procedures.
It’s not only the experience of the surgeons and what we do in the operating room that matters, it’s the entire team—from anesthesia to nursing to the recovery room. We have the best of the best, and we all work together as one team to provide excellent patient care. We’ve assembled a multidisciplinary clinic that provides personalized medicine based on the very latest understanding of the molecular biology of the patient’s tumor. We offer clinical trials, and our innovative research translates into clinical advances. Like Vince Lombardi once said, in the process of chasing perfection, we will catch excellence.
You had a distinguished 15-year tenure at Johns Hopkins. Why join NYU Langone’s Perlmutter Cancer Center?
Even though the standard of care for pancreatic cancer is great, the vast majority of patients still die. We won’t turn that around unless we have a future-forward approach to research and treatment of the disease. At NYU Langone, pushing the envelope is part of the culture. I want to invent the future and set the world standard for pancreatic and hepatobiliary surgery, research, and innovation.
My philosophy of taking calculated risks; pursuing pioneering, groundbreaking solutions; and constantly challenging the status quo aligns with that of NYU Langone’s leadership. To paraphrase Wayne Gretzky, it’s not knowing where the puck is, but where it’s headed. That means doing certain things that in the beginning may seem unconventional, but leadership understands that investing in innovation now is going to change the future.
How do you see the future unfolding for pancreatic cancer?
Two of the biggest things that need to happen to dramatically move the needle are early detection and improved systemic control. My colleague Diane M. Simeone, MD, director of NYU Langone’s Pancreatic Cancer Center, is focused on early detection. Of the 60,000 cases of pancreatic cancer diagnosed annually, 80 percent are ineligible for surgery because the cancer is too advanced. Dr. Simeone’s work will shift that percentage.
However, we must also crack the biology of the disease. Even among the 20 percent of patients eligible for surgery, the tumor will rebound in 80 percent of those cases. The cancer is systemic, so invariably it spreads beyond the surgical site. The only way we’re going to cure this disease is to eradicate it systemically.
To that end, my research focuses on circulating tumor cells—what we call the seeds of metastasis—and how the cancer spreads. Even if we remove a tumor, we can still find these little seeds circulating throughout the body. If chemotherapy doesn’t kill them all, the disease rebounds. So understanding the biology of systemic disease is one of the most important next steps in curing more people.
How long does it take for pancreatic cancer to metastasize?
Research shows that a tumor growing in the pancreas can take 12 to 15 years before it becomes invasive. If we can find and remove premalignant tumors within that window, we can potentially cure pancreatic cancer with surgery alone. The problem is that many early tumors are invisible. We can’t see them on scans. We are developing ways to detect them in the blood, a diagnostic technique called liquid biopsy. The tumors that can be detected on scans are called cystic neoplasms. Most of these lesions are benign, but 3 to 5 percent will undergo malignant transformation. The challenge with these types of tumors is determining which ones to watch and which ones to surgically remove. So that’s another big area of research.
Are there particular risk factors for pancreatic cancer?
Most cases of pancreatic cancer are sporadic, meaning that they’re caused by bad luck. Like all cancers, pancreatic cancer is driven by genes, but the mutations occur in the adult cells of the pancreas, not in the sex cells that pass on genes from generation to generation. For example, as far as I know, I wasn’t born with a mutation that predisposes me to pancreatic cancer, but I may acquire one.
“I’m optimistic and upbeat by nature. If I’m watching a game and my team’s down by 40 points, I’m always thinking, ‘The game isn’t over yet.’ That’s the same attitude I have with my patients. We’re always thinking of ways to beat the cancer.”
Germline mutations that create familial clustering occur in less than 10 percent of cases. To get a better understanding of them, Perlmutter Cancer Center is running a research project to sequence the DNA of patients with pancreatic cancer, and then analyze those sequences for germline mutations. The other roughly 90 percent of pancreatic cancer cases arise randomly, or they’re driven by hidden environmental exposures. For example, the incidence of pancreatic cancer is higher in the West Virginia coal region near where I grew up. So learning more about environmental drivers is also key.
You’ve said that the single most important thing you can do for a patient, aside from providing great clinical care, is to offer hope. What has convinced you of this?
I develop a relationship with each and every one of my patients. I’m their physician for life. I answer their emails. We talk on the phone. Even patients now 15 years out will still see me once a year. These relationships are extremely meaningful to me.
I’m also optimistic and upbeat by nature. If I’m watching a game and my team’s down by 40 points, I’m always thinking, “The game isn’t over yet.” I’m on the edge of my seat until the very end. That’s the same attitude I have with my patients. We never throw in the towel. We’re always thinking of ways to beat the cancer. We never give up.
At the same time, I’m also realistic. When I see my patients for the first time, we chat for an hour. It’s my opportunity to explain where we stand, and prepare them for the hard road ahead. I tell them that the odds are stacked against us, but that together, we’re going to fight nonetheless. I’m with them. I’ve mastered the technical aspects of my job. I have deep knowledge of the disease, and I know when and how to operate.
But one of my most rewarding roles is cheerleading for my patients. If you take a 100 people with localized pancreatic cancer, 5 years from now, 80 of those people won’t be here. But here’s the thing. We don’t know if you’re going to be one of those 80 or one of those 20. I tell my patients, “Right now, I have no reason to think that you won’t be one of those 20. We’re going to fight the fight and help get you through it every step of the way.”