Supportive care of the patient with locally advanced or metastatic exocrine pancreatic cancer
- Carlos Fernandez-del Castillo, MD
Carlos Fernandez-del Castillo, MD
- Professor of Surgery
- Harvard Medical School
- Ramon E Jimenez, MD
Ramon E Jimenez, MD
- Assistant Professor of Surgery
- University of Connecticut Medical School
- Section Editors
- J Thomas Lamont, MD
J Thomas Lamont, MD
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — Anorectal Disorders and Misc. Lower GI Disease
- Section Editor — Nutrition, Malabsorption, and Misc. Upper GI Disease
- Professor of Medicine
- Harvard Medical School
- Richard M Goldberg, MD
Richard M Goldberg, MD
- Section Editor — Gastrointestinal Cancer
- Director of the West Virginia University Cancer Institute and the Mary Babb Randolph Cancer Center
- Professor of Medicine
- Laurence S. & Jean J. DeLynn Chair of Oncology
Approximately 53,070 people develop cancer of the exocrine pancreas each year in the United States, and almost all are expected to die from the disease . The majority of these tumors (85 percent) are adenocarcinomas arising from the ductal epithelium. (See "Pathology of exocrine pancreatic neoplasms".)
Surgical resection offers the only chance of cure. However, only 15 to 20 percent of patients have resectable disease at initial diagnosis; the majority have either locally advanced or metastatic cancer. The median survival for patients with untreated, locally advanced, unresectable pancreatic cancer is 8 to 12 months and only three to six months for those with metastatic disease at presentation. For patients with metastatic disease, systemic chemotherapy can improve survival but not generally beyond 12 months. (See "Chemotherapy for advanced exocrine pancreatic cancer".)
Throughout the course of the disease, most patients suffer significant symptom burden, and they are frequent users of the emergency department. Typical patients will require numerous interventions targeting multiple issues, including pain, anorexia and weight loss, depression and anxiety, biliary obstruction, gastric outlet obstruction, ascites, and venous thromboembolism.
This topic review will summarize an approach to these issues. A discussion on antitumor therapies for management of patients with localized pancreatic cancer (surgery, adjuvant and neoadjuvant therapy) and locally advanced pancreatic cancer (who may be eligible for chemotherapy and radiation-based therapy), and chemotherapy for advanced disease are presented separately. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis" and "Treatment for potentially resectable exocrine pancreatic cancer" and "Initial chemotherapy and radiation for nonmetastatic locally advanced unresectable and borderline resectable exocrine pancreatic cancer" and "Chemotherapy for advanced exocrine pancreatic cancer".)
IMPORTANCE OF PALLIATIVE CARE
All patients with newly diagnosed pancreatic cancer should have a full assessment of symptom burden, psychological status, and social supports as early as possible [2-5]. Many patients with locally advanced or metastatic disease will benefit from formal palliative care consultation and services. Early referral and initiation of palliative care services improves clinical and quality of care outcomes, and may prolong survival.
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- IMPORTANCE OF PALLIATIVE CARE
- MANAGEMENT OF SPECIFIC SYMPTOMS
- - Celiac plexus neurolysis and radiation therapy
- - Surgical options
- - Stents
- Plastic versus metal stents
- Covered versus uncovered stents
- Percutaneous versus endoscopically placed stents
- Gastric outlet obstruction
- - Prevention
- - Treatment
- Delayed gastric emptying
- Depression and anxiety
- Venous thromboembolism
- - Prophylaxis
- Ambulatory patients
- Hospitalized patients
- Choice of agent
- - Treatment
- Anorexia, cachexia, and weight loss
- - Cancer-related anorexia-cachexia syndrome
- - Pancreatic exocrine insufficiency
- Role of dietary modification
- SUMMARY AND RECOMMENDATIONS