Y A L E S C H O O L O F M E D I C I N E. This is a CME accredited activity. The presenters and there are no conflicts of interest.

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Felicia Ray
5 years ago
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1 This is a CME accredited activity. The presenters and there are no conflicts of interest.

2 Pain in Pancreatic Cancer More than 50% of patients with pancreatic cancer suffer from abdominal and back pain Third most common symptom when tumor is in head of pancreas and second most common symptom when tumor is in the body or tail. Pancreatic cancer involves visceral, somatic and neuropathic components, the main therapeutic approach is a multimodal analgesia

3 Pancreatic Cancer Pain Management Figure 1 World J Gastrointest Oncol Aug 15; 8(8):

4 Medical Approach Opioids (most cancer related pain is controlled by pharmacological oral treatments Morphine (step 3 opioid)- is the first line medical therapy for pancreatic cancer. Randomized controlled study showed similar analgesia provided with oral morphine and oxycodone for pancreatic cancer (Mercadante S et al 2010) Transdermal fentanyl patches can be used for patients whose opiod requirements are stable.

5 Medical Approach Multidimensional pain mechanisms Gabapentin and pregabalin effectiveness demonstrated in cancer-related neuropathic pain. Corticosteroids adjuvant for visceral pain

6 Chemotherapy and radiation therapy Chemotherapy Gemcitabine and FOLFIRINOX showed better quality of life and pain control in management of metastatic pancreatic cancer. Radiotherapy particularly effective in controlling and relieving pain caused by large tumors compressing other organs or structures

7 Adverse Effects of opioids Drowsiness Delirium Dry mouth Anorexia Constipation Nausea/vomiting

8 How can we enhance pain control yet decrease risk of drug induced adverse effects?

9 Advanced Endoscopy Approach: Pancreatic Ductal Stenting Occlusion of pancreatic duct blocks flow of digestive enzymes leading to increased interstitial and intraductal pressures Duct stenting involves deep cannulation of the major PD and insertion of guidewire across the stricture. Dilation is then performed with either a catheter or a balloon followed by stent insertion. The most recent case series performed PD stenting in 20 patients with typical obstructive pain and documented decreases in the (VAS) pain score compared to pre treatment Four other case series have reported total pain resolution between 41 and 87% of patients. Risks include pancreatitis, cholangitis, ductal rupture, stent migration

10 Advanced Endoscopy Approach: Celiac Plexus Neurolysis (CPN) The celiac plexus plays a vital role in the transmission of the pain sensation originating from most of the abdominal viscera CPN- prolonged interruption of the plexus by injection of alcohol. EUS permits direct access to the celiac plexus Avoids paraplegia and pneumothorax risk (1-2% percutaneous approach) Meta-analysis have reported CPN effectiveness in controlling pain in 70-90% of patients. Randomized controlled trial compared pain control in pancreatic cancer patients with early administration of EUS-CPN at diagnosis versus conventional drug therapy- evidence of superiority of CPN in pain relief and some evidence of lower use of morphine Self limited complications such as transient diarrhea (10-30%) and orthostatic hypotension due to splanchnic blood pooling (10-60%)

11 Advanced Endoscopy Approach: EUS Celiac Plexus Block

12 Considerations for treatment Corticoids gastric bleeding Opioids- patients with long-term constipation or ileus Pancreatic cancer patients higher risk of thrombosis

13 Nutritional Considerations in Pancreas Cancer Disease and treatment cause significant nutritional impairment that impacts quality of life with more than 80% reporting weight loss at time of diagnosis and 1/3 of patients having lost greater than 10% of their bodyweight before diagnosis Endocrine and Exocrine function of the pancreas are often affected Common symptoms include anorexia, hyperglycemia, steatorrhea, weight loss, cachexia and malabsorption Chemotherapy can further these symptoms with increased diarrhea, nausea and vomiting. Resection can amplify the endocrine and exocrine deficits

14 Implications Cachexia and malnutrition leads to skeletal muscles wasting and fat degradation, longer hospital stays, increased risk of complications, reduced response to treatment, shorter survival time, reduced quality of life and increased morbidity and mortality.

15 Nutritional Support Enteral Nutrition (EN) vs Parenteral Nutrition (PN) Oral nutrition is preferred TPN (total parental nutrition) is associated with more complications, weight loss, constipation, further inability to tolerate oral nutrition Supplementation with protein and energy dense nutrition supplements + fatty acids improves outcomes and does not inhibit meal intake

16 Other Supplementation Fish Oil Supplemented with EN or TPN as eicosapentaenoic acid (EPA) ranged 2.2g/day to 6g/day Increase weight gain and reported quality of life L-carnitine Decreased weight loss, increased BMI and improved quality of life compared to placebo

17 Medical management Antiemetics Anti diarrheal agents Appetite stimulants Pancreatic enzyme supplementation

18 Advanced Endoscopy Approach: Duodenal stenting for obstruction caused by tumor

19 References Bauer, J., Capra, S., Battistutta, D., Davidson, W., & Ash, S. (2005). Compliance with Nutrition Prescription Improves the Outcomes in Patients with Unresectable Pancreatic Cancer. Clinical Nutrition 24; Davidson, W., Ash, S., Capra, S., Bauer, J.; Cancer Cachexia Study Group. (2004). Weight stabilisation is associated with improved survival duration and quality of life in unresectable pancreatic cancer. Clinical Nutrition;23: Ferrucci, L., Bell, D., Thornton, J., Black, G., McCorkle, R., Heimburger, D., Saif, M,. (2011). Nutritional status of patients with locally advanced pancreatic cancer: a pilot study. Support Care Cancer. 219: Gartner, S., Kruger, J., Aghdassi, A., Steveling, A., Simon, P., Lerch, M., & Mayerle, J. (2016 May) Nutrition in Pancreatic Cancer: A Review. Gastrointestinal Tumors 2(4): Gilliland, T., et al. (2017). Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection. Nutrients 9 (243). Koulouris, A.I., Banim, P. & Hart, A.R. Dig Dis Sci (2017) 62: doi.org/ /s z

20 References Lahoud, M. J., Kourie, H. R., Antoun, J., El Osta, L., & Ghosn, M. (2016). Road map for pain management in pancreatic cancer: A review. World Journal of Gastrointestinal Oncology, 8(8), Mercadante S., Tirelli W. David F, Arcara C, Fulfaro F, Casuccio A, Gebbia V. (2010). Morphine versus oxycodone in pancreatic cancer pain: a randomized controlled study. Clin J Pain 2010; 26: Richter, E., Denecke, A., Klapdor, S., & Klapdor, R. (2012). Parenteral nutrition support for patients with pancreatic cancer - improvement of the nutritional status and the therapeutic outcome. Anticancer Research. 32: Soweid, A. M., & Azar, C. (2010). Endoscopic ultrasound-guided celiac plexus neurolysis. World Journal of Gastrointestinal Endoscopy, 2(6),

Pancreatic cancer Palliative Care

Pancreatic cancer Palliative Care Snežana Bošnjak Institute for Oncology and Radiology of Serbia Dept. Supportive Oncology & Pall Care Serbia, Belgrade Pancreatic Cancer: Palliative Care Abdominal / epigastric