Palliative Care in Pancreatic Cancer

Frank J. Brescia, MD, MA, FACP

Disclosures

Cancer Control. 2004;11(1) 

In This Article

Abstract and Introduction

Abstract

Background: Pancreatic cancer is a formidable health problem, representing the 10th most common malignancy in the United States and the 4th most common cause of all cancer deaths. The overall 5-year survival rate is 4%, making this disease a model tumor in which to address the specialized care issues of palliative medicine.
Methods: General considerations in both medical decision-making and symptom management are reviewed. Treatment of patients with locally unresectable, recurrent, or metastatic disease is individualized, based on considerations that include patient age, patient wishes, family influence, insurance constraints, and geographic practice variations.
Results: Success in managing progressive symptoms is needed to palliate patients with advanced pancreatic cancer. Common problems include biliary obstruction, depression, pain, intestinal obstruction, and fatigue.
Conclusions: Relief of pain and suffering associated with critical illness is required in managing patients with cancer. Pancreatic cancer is a model illness that mandates this need.

Introduction

Pancreatic cancer is a formidable health problem with increasing incidence.[1] Although this tumor represents only 2% of new cancer diagnoses in both men and women and is the 10th most common malignancy in the United States, it is the fourth most common cause of all cancer deaths. Despite advances in the understanding of the pathology and biology of the disease, as well as improved diagnostic imaging and staging studies, the overall 5-year survival rate remains 4% for all stages and races.

Adenocarcinoma of the pancreas comprises 90% to 95% of all malignant tumors of the exocrine pancreas. It is one of the most lethal malignancies, and its geographic location within the body makes imaging studies and biopsy procedures more difficult compared with other tumors. There are no clear-cut high-risk populations to follow, even if effective screening procedures were available. More problematic is the reality that presenting symptoms are vague, diverse, and long-evolving before medical attention is sought.

The clinical presentation is often dramatic, with "painless" obstructive jaundice. There is often a history of mild but progressive discomfort or pain in the mid-abdomen, occasionally with radiation to the back, and usually noted worse at the end of the day.

Ten percent of patients have a new onset of diabetes. Others describe fatigue, anorexia, nonspecific gastrointestinal symptoms, weight loss, and depressed mood -- all of which can go unnoticed until there is an obvious need to seek medical care. Patients may require symptom relief before any treatment interventions can begin, and some patients move rapidly to a state where the options are aimed solely at comfort. Multiple complaints, poor performance status, and comorbid illness make definitive surgery a less likely option. Interestingly, long-standing symptoms, weight loss, and anemia are not negative predictors of survival by univariate analysis, if the patient is able to undergo a resection.[2] In a series of 13,560 patients with pancreatic cancer, a major predictor of survival was the ability to undergo a complete resection, whereby survival rates were 2-fold greater compared with palliative bypass procedures.[3] Yeo et al[4] reported that residual disease, manifested by positive vs negative margins, translates into a 5-year survival rate of 8% vs 26%. This disease is a model tumor to address the specialized care issues of supportive and palliative medicine.

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