2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

A Myriad of Symptoms: New Approaches to
Optimizing Palliative Care of Patients with
Advanced Pancreatic Cancer
Overview: Patients with advanced pancreatic cancer (APC)
require early and frequent palliative interventions to achieve
optimal quality of life for the duration of illness. Evidencebased
supportive treatments exist to maximize quality of life
for any patient, whether receiving chemotherapy or not. This
article provides a comprehensive review of symptoms with
current treatment recommendations and directions for future
development. Celiac plexus neurolysis improves pain in the
majority of patients with APC and should be moved earlier in
the analgesic paradigm. Malignant bowel obstruction can be
palliated quickly with optimal management via gastric decompression,
octreotide, parenteral opioids, and standing antiemetics.
Recommendations are provided for best treatment of
malignant gastroparesis, gastric outlet obstruction, and
chemotherapy-induced nausea and vomiting in this popula-
PATIENTS WITH advanced pancreatic cancer (APC)
require early and frequent palliative interventions to
achieve optimal quality of life for the duration of illness.
Despite recent notable advances in multidisciplinary antineoplastic
therapy, the majority of patients with APC ultimately
die after facing numerous physical and emotional
hurdles. 1,2 As a physician caring for these patients, there
are opportunities to relieve suffering from predictable complications
of pancreatic cancer. Evidence-based supportive
treatments exist to maximize quality of life for any patient,
whether receiving chemotherapy or not. This article provides
a comprehensive review of symptoms facing patients
wtih APC with current treatment recommendations and
directions for future development.
Pain
Pain from cancer in the pancreas is often constant and
severe, felt predominantly in the midback and epigastrium.
Noxious sensory input from inflamed pancreatic tissue and
direct neural invasion is transmitted via the celiac plexus as
pain. 3 Opioids and adjuvant medications remain standard of
care for analgesia; however, the titration of opioids can be
limited by systemic toxicities and may not adequately address
the pain. Successful locoregional intervention minimizes
systemic opioid requirements early in the disease. 3
In the majority of patients, celiac plexus neurolysis (CPN)
has been shown to provide effective pain relief simultaneous
with reduction in systemic opioids. 3,4 An injection of either
ethanol or phenol destroys afferent nerve fibers 3,4 and disrupts
pain signals for an average of 3 months, though
sometimes permanently. CPN can be performed with equivalent
efficacy surgically, percutaneously under radiologic
guidance, or endoscopically via ultrasound. 3 The most common
risks include transient hypotension, constipation, or
diarrhea; no serious adverse events were noted in a metaanalysis.
3 More than 80% of patients note significantly
improved analgesia after CPN in blinded or sham studies. 3,4
To evaluate both effect and timing of CPN in pancreatic
cancer, Wyse and colleagues performed a double-blind, randomized
controlled trial of patients found to have inoperable
By Lauren A. Wiebe, MD
tion. Malignant ascites can be treated initially with diuretics
and sodium-restriction in patients with an exudative process;
however, an indwelling catheter is recommended for patients
with recurrent ascites, particularly because of carcinomatosis
or a refractory process. With exocrine insufficiency contributing
to weight loss, pancreatic enzyme replacement is essential
to improve nourishment in the majority of patients. Presently,
megestrol acetate is the only U.S. Food and Drug Administration
(FDA)-approved therapy for the anorexia-cachexia syndrome,
although future developments are promising. Finally,
patients with advanced pancreatic cancer should be screened
and treated early for depression as a common comorbid
diagnosis. Early palliative care consultation also helps address
the existential and psychosocial concerns of patients
facing death from pancreatic cancer in a holistic manner.
pancreatic cancer at time of diagnostic endoscopic ultrasound
(EUS). The 96 participants were randomized to either
CPN or usual medical management at time of EUS diagnosis.
Persistently increasing pain scores were noted in the
control group during the study; however, patients who
underwent neurolysis reported improvements in analgesia
both 1 and 3 months later with a statistically significant
decrease of 49% in mean pain score. 4
The study from Wyse and colleagues adds to the body of
evidence supporting early CPN for patients with pancreatic
cancer. 3 Optimal timing would be at moment of diagnosis if
a patient reports abdominal pain attributable to inoperable
pancreatic cancer.
Because these investigators took a detailed pain history
before diagnostic EUS/endoscopic retrograde cholangiopancreatography
(ERCP), patients were able to benefit from
CPN with early, lasting pain relief. 4 For patients undergoing
surgical exploration, CPN should be considered intraoperatively
for early, seamless analgesia once a diagnosis
is secured. With recurrent pain, repeat CPN is indicated
and effective, particularly if a patient had benefit from prior
neurolysis. 3
Nausea and Vomiting
Nausea or vomiting in a patient with APC can arise from
multiple etiologies. With new onset, a patient should be
evaluated for potentially reversible causes, some of which
are discussed later in this article. While receiving antineoplastic
therapy, adequate support with antiemetics should
be provided per the guidelines of the American Society of
Clinical Oncology (ASCO) or the National Cancer Care
Network (NCCN), available online. As FOLFIRINOX is
From the Department of Hematology and Oncology, The Medical College of Wisconsin,
Froedtert Memorial Hospital.
Author’s disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests to Lauren Wiebe, MD, Department of Hematology and Oncology,
The Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226; email:
laurenwiebe@gmail.com.
© 2012 by American Society of Clinical Oncology.
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