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Palliative Management of the Patient With Advanced Pancreatic Cancer

Palliative Management of the Patient With Advanced Pancreatic Cancer

ABSTRACT: For the patient with advanced pancreatic cancer, curative strategies may not be appropriate, and palliative symptom management may be the best approach to patient care. Oncologists, who have been trained to concentrate on curing cancer, must shift focus when caring for these patients and consider palliative treatment strategies. Pancreatic cancer patients are multisymptomatic and may require treatment for such conditions as pain, bowel obstruction, anorexia, early satiety, cachexia, nausea and vomiting, constipation, diarrhea, ascites, and dyspnea, among others. These patients may be most effectively managed in a hospice care center, which can provide comprehensive care. Alternatively, new programs, such as the Cleveland Clinic Palliative Care Program, provide a unique setting for the patient with advanced cancer that integrates the qualities of hospice care into the acute medical care system. [ONCOLOGY 10(Suppl):40-44, 1996]

Introduction

In the United States, the care of cancer patients is a critical
issue that impacts on both the medical community and society in
general. The scope of this issue continues to expand due to a
number of factors, including the aging of the US population and
the increasing incidence of specific cancers.

It has been estimated that in 1996, 1,359,150 people will be diagnosed
with cancer in the United States and 554,740 will die of this
disease [1]. Thus, despite the continuing emergence of new cancer
therapies, about half of all cancer patients will die of their
disease. This suggests that many patients with advanced cancer
will require treatment strategies focusing on symptom management,
because curative strategies may not benefit them [2]. This approach
will require a shift in the focus of cancer research to include
studies of palliative treatment in addition to new curative regimens.
Oncologists, who have been trained to concentrate on curing cancer,
will be required to integrate palliative treatment strategies
into patient management. These changes are likely to be affected
by the increasing role of health economics in the treatment decision-making
process [3].

Issues Associated with Palliative Therapy

Challenges for the Oncologist

Current approaches to palliative treatment for patients with advanced
cancer are fraught with deficiencies [4]. Many physicians fail
to appreciate the impact of symptoms on the patient's quality
of life or may lack an understanding of how to treat the whole
patient rather than just the tumor. These problems reflect a void
in the oncology training curriculum [2,5]. For example, although
pain is a dominant cancer symptom, pain control has only recently
been included in the Medical Oncology Board examinations [4].
Furthermore, uniform clinical practice protocols for palliative
treatment are lacking. Although some institutions have begun to
develop these protocols, most cancer centers have not instituted
systematic approaches to palliative patient management [2]. For
a list of the most commom symptoms in advanced cancer patients,
see Table 1 [6].

Due to the aging of the US population, oncologists will be increasingly
faced with managing cancer patients who have a variety of other
age-associated illnesses, including osteoarthritis, diabetes,
and congestive heart failure. Oncologists will require training
not only in the appropriate use of palliative treatment regimens
but also in the treatment of patients with advanced cancer who
have multiple diseases and associated symptoms. Overall, the clinical
role of the oncologist must encompass preventive oncology, diagnostic
evaluation, communication, antitumor therapies, symptom control,
optimization of social supports, and care of the dying patient
[2].

Measuring the Efficacy of Palliative Interventions

Measuring tumor response is a well-established means of determining
the efficacy of cancer therapy. Unfortunately, there is no gold
standard quality-of-life measurement to assess the efficacy of
palliative interventions. Various tools have been developed to
permit the systematic, reproducible assessment of patients' quality
of life (Table 2) [7]. Although these assessment tools can provide
useful information for the oncology researcher, the implementation
of these tools in clinical practice has been difficult. For example,
the instrument may not ask questions specific to the patient's
particular cancer, or it may be too detailed for the patient [6].
Thus, at present, the practicing oncologist should rely on communication
with patients to determine the efficacy of palliative treatment
regimens.

Palliative Management of Advanced Pancreatic
Cancer

While palliative interventions should be considered for all patients
with advanced cancer, advanced pancreatic cancer provides a distinct
challenge for the oncologist. The nonspecific and vague symptoms
associated with pancreatic cancer contribute to a delay in diagnosis,
and most patients are diagnosed at an advanced stage [8,9]. In
its advanced stages, pancreatic cancer is associated with a plethora
of symptoms that require treatment. In addition, a small number
of patients have histories of substance abuse that must be considered,
but this does not preclude adequate palliation [10,11].

Complications and Symptoms

The most common symptom associated with pancreatic cancer is pain,
which occurs in approximately 80% of patients [6,12]. Other symptoms
include anorexia, early satiety, xerostomia, sleep problems, weight
loss, fatigue, weakness, nausea, and constipation. In addition
to these symptoms, physical findings may include cachexia, a palpable
abdominal mass, ascites, and jaundice. Metastasis to other major
organs, such as the liver, lungs, lymph nodes, and bone, also
can occur [12].

Pain Management

According to the World Health Organization, 20% to 50% of patients
with cancer present with pain, approximately 33% experience pain
during treatment of their disease, and 75% to 90% of patients
with advanced or terminal cancer have pain [13]. The reasons for
this problem include societal barriers due to the perceived potential
for misuse of opioid analgesics, insufficient knowledge about
pain control measures among health-care providers, governmental
regulations, and health economics [4,14]. Physicians face a variety
of obstacles when treating the patient with cancer pain, including
complications from the side effects of other medications; metabolic
abnormalities, such as liver dysfunction; and homebound patients
with rapidly changing disease [15]. A critical component of pain
management is communication and trust between the physician and
the patient [16].

For the patient with advanced cancer, the goals of pain management
should be to permit an acceptable level of functioning and to
allow the patient to die as free of pain as possible [16]. Therapeutic
options to treat cancer pain include behavior modification, standard
drug therapy, experimental drugs or novel methods of drug administration,
and selective anesthetic and neurosurgical approaches.

General Guidelines for Using Analgesics--Analgesic drugs
can be divided into three categories: nonnarcotic analgesics (ie,
aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs)
that act on peripheral pain mechanisms; narcotic agonist and antagonist
drugs that interact with opiate receptors (morphine, hydromorphone,
methadone, levorphanol, oxymorphone, heroin, codeine, oxycodone);
and adjuvant analgesic drugs that produce analgesia in certain
pain states or potentiate opioid analgesics [16]. Unlike nonnarcotic
analgesics, the dose-response relationship of opioid agonists
is logarithmic, such that the increment in analgesia is linear
until loss of consciousness [17]. Unfortunately, many physicians
underuse opioids to treat cancer pain, probably because of controlled
substance regulations and/or concerns about sedation, respiratory
depression, tolerance, and addiction [11,18].

The optimal use of opioid analgesics requires maintaining a balance
between their benefits and toxicities. Side effects may include
nausea, vomiting, mental clouding, sedation, constipation, urinary
retention, and pruritus. Appropriate strategies to manage these
side effects should be anticipated for patients on opioids. Furthermore,
since opioids produce different responses in different individuals,
the analgesic regimen must be tailored to the patient's response,
in terms of both the drug's analgesic efficacy and its side effects.
It is important to note that it is rare for patients with cancer
pain to develop psychological dependence on these drugs [16].

Guidelines for Using Opioids in Pancreatic Cancer Patients--Pain
management in patients with pancreatic cancer is notoriously difficult.
There is a history of alcohol and/or benzodiazepine abuse in a
significant number of these patients. Because of this, their tolerance
to analgesic dosing is higher than in the typical cancer patient,
and the prescriber must be prepared to use higher doses of analgesics
than in patients with other common solid tumors.

No specific opiate appears to have superior activity in the setting
of pain related to pancreatic cancer. The principles and practice
of opiate use in this setting are similar to those in other situations,
with one exception: There is a much higher risk of small bowel
obstruction in patients with pancreatic cancer. Opiate-induced
bowel obstruction is a preventable complication in this setting,
but patients and their families must be warned specifically to
watch for symptoms suggestive of bowel obstruction and to call
the physician immediately should these be noted. Also, aggressive
use of laxatives is essential to prevent this complication.

A specific technique that is invaluable in patients with pancreatic
cancer is the continuous administration of subcutaneous opiate
infusions by means of a patient-controlled analgesia (PCA) pump.
This approach has the advantage of delivering analgesics reliably
in patients who have impaired gastrointestinal function and for
whom oral analgesics may not be the best choice. In addition,
in patients who develop a bowel obstruction, a PCA pump can ensure
optimal analgesia despite their inability to take liquids or food
by mouth.

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