Evidence Based Update on the Management of Advanced Pancreatic Cancer Helen Brown Palliative Care Dietitian Nurse Maude Hospice Palliative Care Service
Background 2011 getting referrals for weight loss in pancreatic cancer Undiagnosed malabsorption Usually not on Creon Journal club
Pancreatic Cancer 4th most common cause of death in malignancy Incidence is equal in both sexes. Peak incidence in the sixth and seventh decades of life. Pancreatic cancer is unique compared to other cancers as weight loss and malabsorption are present in 80 – 90% of patients at time of diagnosis (J Support Oncol 2008, 6.393-396)
Symptoms of Malabsorption Patients may suffer: Indigestion Cramping after meals, Pain Large amounts of wind Foul smelling pale stools / may float and be hard to flush – Loose stools (Steatorrhea)
Negative impact on physical and psychological health
Function of Pancreatic Juices Contain enzymes that help breakdown dietary fats, protein and carbohydrates. Healthy pancreas secretes approx. 1 – 2 litres of digestive juices per day into the duodenum. Helps neutralize stomach acid as it enters the small intestine. Prevents bacterial overgrowth of intestine
Pancreatic Enzymes Lipase:
Works with bile to break down fat molecules Deficiency:
Breaks down proteins. Helps prevent bacterial overgrowth of the gut Deficiency:
- lack of fat soluble vitamins (A, D, E & K) - Steatorrhea.
- allergies due to incomplete digestion of proteins. - Increased risk of intestinal infections.
Pancreatic Enzymes Amylase: Breaks down carbohydrates into sugars. Also found in saliva. Deficiency: - Diarrhoea due to the effects of undigested starch in the colon.
Prescribed Pancreatic Enzymes Most common – Creon Forte (25,000), Creon 10,000 Dose is determined by amount of fat in a meal. The enteric coated beads within the capsules are pH sensitive, ideal environment in the duodenum pH of the duodenum is generally 6 – 7.
Guidelines for taking pancreatic enzymes Recommended initial dose is 40-50,000 IU for a meal and 25, 000 IU for a snack. Enzymes should be taken with every meal and snack that contains fat, esp. meat, dairy, bread and desserts. Grazing is not advisable for these patients.
Guidelines for taking pancreatic enzymes Ideal regime is to split the dose and take 1 capsule at the start of a meal and 2nd half way through 1 capsule at the beginning of a snack Capsule can be opened and sprinkled Patients should not be encouraged to restrict fat Consider Protein pump inhibitors (Omeprazole)
Side Effects of Pancreatic Enzymes: Constipation - may need to review bowel medication regimes - e.g. discontinue loperamide, commence a bowel regime
If dose too high – nausea, – abdominal cramps
Studies to Date PERT 1: (complete and published) Retrospective audit palliative care case notes pts with pancreatic cancer Jan 2010 to July 2012 -Patient demographics -Weight -Interventions -Documentation of symptoms of malabsorption -Current management including PERT
Preliminary Findings: 130 patients 71 male 59 female
Fig 1. The age categories for patients with metastatic pancreatic cancer
45 40 35 30 25 Female
Male 15 10 5 0 85
Preliminary Findings 56 patients had surgical/gastro interventions 74 had supportive care only
Fig 3. Different tumour sites in the patients with metastatic pancreatic cancer 90 80 70 60 50 40 30 20 10 0 Head
Tail Tumour Site
Fig 4. Number of patients with metastatic pancreatic cancer prescribed pancreatic enzyme replacement 100 90
80 70 60 50 40 30
10 0 Y
N PERT prescribed
Symptoms of Malabsorption 93 patients (72%) had documented symptoms of malabsorption Of these 93 patients
86% abdominal pain 18% wind 19% bloating 24% diarrhoea
PERT 2 (complete and submitted for publication) Prospective study of pts routinely prescribed PERT Education on function and use of PERT Weight monitored QOL measured using EORTC QLQ – C30 & PAN 26 before commencing PERT Nutritional assessment from dietitian Regular monitoring and support Dose reviewed
Results Between June 2013 and May 2015 97 patients were assessed by Dietitian: 44 consented to the study 29 completed all study assessments. Average age 69.8 years 66% female 2 participants had undergone surgery, 6 undergone biliary stenting.
Further Results Significant improvements in – Pain – Shortness of breath – Bowel habit – Digestive symptoms – Bloating
PERT 4: (recruiting) Qualitative study Gooden published study looking at unmet psychosocial need in those with PC but all the patients could talk about was digestive symptoms! Aim is to explore patient experiences of PERT and other interventions that have improved quality of life 5 interviews completed
Acknowledgements Dr Amanda Landers, Palliative Care Specialist, Nurse Maude. Dr Matthew Strother, Medical Oncologist, Christchurch Hospital. Gill Coe, Research Officer, Research Institute, Nurse Maude. Dr Wendy Muircroft, Palliative Care Specialist.