Pancreatic cancer secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

## Overview

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Secondary prevention of pancreatic cancer involves proper diet based on American Cancer Society (ACS) guidelines and palliative therapy for patients. Malabsorption may arise when pancreatic duct obstruction leads to exocrine pancreatic insufficiency. The diet proposed for pancreatic cancer patients is based on ACS guidelines and advocates administration of pancreatic enzyme replacement therapy, avoidance of high-protein/high-fat diets, individualized dietary prescriptions from a registered dietitian and dietary supplementation with omega-3 fatty acids. Palliative therapy is considered as an important part of secondary prevention and includes adequate analgesia, treatment of jaundice and duodenal obstruction, arising as complications of surgery.

## Secondary prevention

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### Diet

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Diet supplementation is an important component in the management of patients after pancreatic surgery due to the development of exocrine pancreatic insufficiency:[1][2][3][4][5][6][7][8][9][10][11][12][13]

* Exocrine pancreatic insufficiency due to pancreatic duct obstruction by the tumor may lead to malabsorption.
* Malabsorption in patients presents with anorexia, weight loss, and diarrhea.
* The diet proposed for pancreatic cancer patients is based on American Cancer Society (ACS) guidelines
* Pancreatic enzyme replacement therapy
* Avoidance of high-protein/high-fat diet
* Individualized dietary prescriptions from a registered dietitian
* Supplementation with omega-3 fatty acids

### Palliative Therapy

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Palliative therapy in patients with pancreatic cancer mainly involves the management of symptoms arising as a result of complications of surgery or chemoradiation therapy:[14][15][16][17][18][19][20]

#### Pain:

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* There are various techniques for pain management as palliative therapy in patients with advanced stage of pancreatic cancer:
* Narcotic analgesics
* Narcotic analgesics\+ tricyclic antidepressants/ antiemetics
* Radiation therapy

* Surgical techniques used to treat pain in advanced pancreatic cancer cases include:
* Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction
* Neurolysis of the celiac ganglia by many approaches:
* Intraoperative
* Transgastric
* Transthoracic
* Transabdominal

#### Jaundice:

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* Obstructive jaundice can present with features of cholangitis:
* Fever and chills
* Nausea, vomiting
* Clay-colored stools
* Dark urine
* Yellowish discoloration of skin
* Pruritus
* Right upper quadrant pain
* Anorexia
* Preferred treatment in patients: Endoscopic decompression with stent placement in patients with biliary obstruction.
* Techniques of biliary decompression:
* Cholecystojejunostomy
* Choledochojejunostomy

* Types of stents:
* Metal- costly, longer lifespan
* Plastic- cheaper, need replacement every three months

#### Duodenal obstruction

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* Preferred treatment:
* Endoscopic stenting of duodenal obstruction
* Gastrojejunostomy

## References

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1. ↑ Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM (2017). "Less common etiologies of exocrine pancreatic insufficiency". World J. Gastroenterol. 23 (39): 7059–7076. doi:10.3748/wjg.v23.i39.7059. PMC 5656454. PMID 29093615.
2. ↑ Nikfarjam M, Wilson JS, Smith RC (2017). "Diagnosis and management of pancreatic exocrine insufficiency". Med. J. Aust. 207 (4): 161–165. PMID 28814218.
3. ↑ Roberts KJ, Schrem H, Hodson J, Angelico R, Dasari B, Coldham CA, Marudanayagam R, Sutcliffe RP, Muiesan P, Isaac J, Mirza DF (2017). "Pancreas exocrine replacement therapy is associated with increased survival following pancreatoduodenectomy for periampullary malignancy". HPB (Oxford). 19 (10): 859–867. doi:10.1016/j.hpb.2017.05.009. PMID 28711377. Vancouver style error: initials (help)
4. ↑ Vujasinovic M, Valente R, Del Chiaro M, Permert J, Löhr JM (2017). "Pancreatic Exocrine Insufficiency in Pancreatic Cancer". Nutrients. 9 (3). doi:10.3390/nu9030183. PMC 5372846. PMID 28241470.
5. ↑ Saito T, Hirano K, Isayama H, Nakai Y, Saito K, Umefune G, Akiyama D, Watanabe T, Takagi K, Hamada T, Takahara N, Uchino R, Mizuno S, Kogure H, Matsubara S, Yamamoto N, Tada M, Koike K (2017). "The Role of Pancreatic Enzyme Replacement Therapy in Unresectable Pancreatic Cancer: A Prospective Cohort Study". Pancreas. 46 (3): 341–346. doi:10.1097/MPA.0000000000000767. PMID 28099252.
6. ↑ Bartel MJ, Asbun H, Stauffer J, Raimondo M (2015). "Pancreatic exocrine insufficiency in pancreatic cancer: A review of the literature". Dig Liver Dis. 47 (12): 1013–20. doi:10.1016/j.dld.2015.06.015. PMID 26211872.
7. ↑ Gheorghe C, Seicean A, Saftoiu A, Tantau M, Dumitru E, Jinga M, Negreanu L, Mateescu B, Gheorghe L, Ciocirlan M, Cijevschi C, Constantinescu G, Dima S, Diculescu M (2015). "Romanian guidelines on the diagnosis and treatment of exocrine pancreatic insufficiency". J Gastrointestin Liver Dis. 24 (1): 117–23. PMID 25822444.
8. ↑ Landers A, Muircroft W, Brown H (2016). "Pancreatic enzyme replacement therapy (PERT) for malabsorption in patients with metastatic pancreatic cancer". BMJ Support Palliat Care. 6 (1): 75–9. doi:10.1136/bmjspcare-2014-000694. PMID 25164613.
9. ↑ Berry AJ (2014). "Pancreatic enzyme replacement therapy during pancreatic insufficiency". Nutr Clin Pract. 29 (3): 312–21. doi:10.1177/0884533614527773. PMID 24687867.
10. ↑ Braddick JA, Flaherty AM (2013). "Management of pancreatic exocrine insufficiency". Oncol Nurs Forum. 40 (2): 116–9. doi:10.1188/13.ONF.116-119. PMID 23448736.
11. ↑ Sikkens EC, Cahen DL, van Eijck C, Kuipers EJ, Bruno MJ (2012). "The daily practice of pancreatic enzyme replacement therapy after pancreatic surgery: a northern European survey: enzyme replacement after surgery". J. Gastrointest. Surg. 16 (8): 1487–92. doi:10.1007/s11605-012-1927-1. PMC 3399077. PMID 22711213.
12. ↑ Domínguez-Muñoz JE (2011). "Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency: when is it indicated, what is the goal and how to do it?". Adv Med Sci. 56 (1): 1–5. doi:10.2478/v10039-011-0005-3. PMID 21450558.
13. ↑ Kushi LH, Doyle C, McCullough M, Rock CL, Demark-Wahnefried W, Bandera EV, Gapstur S, Patel AV, Andrews K, Gansler T (2012). "American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity". CA Cancer J Clin. 62 (1): 30–67. doi:10.3322/caac.20140. PMID 22237782.
14. ↑ Kulaylat AS, Mirkin KA, Hollenbeak CS, Wong J (2017). "Utilization and trends in palliative therapy for stage IV pancreatic adenocarcinoma patients: a U.S. population-based study". J Gastrointest Oncol. 8 (4): 710–720. doi:10.21037/jgo.2017.06.01. PMC 5582050. PMID 28890822.
15. ↑ Mastenbroek TC, Kramp-Hendriks BJ, Kallewaard JW, Vonk JM (2017). "Multimodal intrathecal analgesia in refractory cancer pain". Scand J Pain. 14: 39–43. doi:10.1016/j.sjpain.2016.10.002. PMID 28850428.
16. ↑ Schenker Y, Bahary N, Claxton R, Childers J, Chu E, Kavalieratos D, King L, Lembersky B, Tiver G, Arnold RM (2017). "A Pilot Trial of Early Specialty Palliative Care for Patients with Advanced Pancreatic Cancer: Challenges Encountered and Lessons Learned". J Palliat Med. doi:10.1089/jpm.2017.0113. PMID 28772092.
17. ↑ Ouyang H, Ma W, Liu F, Yue Z, Fang M, Quan M, Pan Z (2017). "Factors influencing survival of patients with pancreatic adenocarcinoma and synchronous liver metastases receiving palliative care". Pancreatology. 17 (5): 773–781. doi:10.1016/j.pan.2017.07.002. PMID 28734721.
18. ↑ Agarwal R, Epstein AS (2017). "Palliative care and advance care planning for pancreas and other cancers". Chin Clin Oncol. 6 (3): 32. doi:10.21037/cco.2017.06.16. PMID 28705009.
19. ↑ Laquente B, Calsina-Berna A, Carmona-Bayonas A, Jiménez-Fonseca P, Peiró I, Carrato A (2017). "Supportive care in pancreatic ductal adenocarcinoma". Clin Transl Oncol. doi:10.1007/s12094-017-1682-6. PMID 28612201.
20. ↑ Kayaalp C, Dogan MS, Ersan V (2017). "Surgery for intractable pain in a patient with chronic pancreatitis complicated with biliary obstruction, portal vein stenosis and mesenteric venous collaterals". Ann Hepatobiliary Pancreat Surg. 21 (2): 101–105. doi:10.14701/ahbps.2017.21.2.101. PMC 5449365. PMID 28567456.