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
Pancreas
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)
 Weight loss
 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:
Protease:
 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
20
Male
15
10
5
0
<56
56-65
66-75
Age Category (yrs)
76-85
>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
Body
Tail
Tumour Site
Other
unk
Fig 4. Number of patients with metastatic pancreatic cancer prescribed pancreatic
enzyme replacement
100
90
69%
80
70
60
50
40
30
21%
20
9%
10
0
Y
N
PERT prescribed
ND
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.