What’s ahead for Justice Ginsburg?

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For Supreme Court Justice Ruth Bader Ginsburg, who has been diagnosed with pancreatic cancer, surgery was likely just the beginning of her treatment.

Because surgeons removed part of her pancreas, she now faces an increased risk of developing diabetes, particularly if there is a family history of the disease. If at least 75% of the pancreas was left behind, she has about a 5% to 10% chance of developing the disease, and it can most likely be controlled with oral medications, said Dr. Gagandeep Singh, director of the Liver and Pancreas Center at John Wayne Cancer Institute.

There is a good chance Ginsburg will also receive chemotherapy, particularly if the cancer is found to have spread to lymph nodes. ‘The No. 1 drug that is effective is Gemzar,’ known generically as gemcitabine, according to Dr. Glen Justice, director of Orange Coast Memorial Hospital’s Cancer Center in Fountain Valley. Physicians might combine it with 5-fluorouracil, Tarceva or oxaliplatin.

‘Those are the bread-and-butter drugs for treatment,’ he said.

Radiation is also an option, but it is controversial. Studies in Europe suggest that it has no benefit in pancreatic cancer post-surgically. Moreover, ‘it is almost impossible to use radiation in combination with gemcitabine,’ Singh said, because the drug acts as a radiosensitizer, increasing side effects from the radiation.

Both radiation and chemotherapy ‘can improve the long-term outcome but, at most, minimally,’ said Dr. Joshua Ellenhorn, chief of the division of general and oncologic surgery at the City of Hope National Medical Center.

Experts agree that there is almost certainly no link between the colon cancer Ginsburg suffered nine years ago and her new tumor. It is definitely not a metastasis. Some Ashkenazi Jews -- which Ginsburg is -- have a genetic abnormality that increases the risk of colon and pancreatic cancers. But if that were at the root of Ginsburg’s problem, Ellenhorn said, she probably would have developed the pancreatic tumor at a much earlier age.

-- Thomas H. Maugh II