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Review
. 2020 Jan 22;12(2):275.
doi: 10.3390/cancers12020275.

Pancreatic Enzyme Replacement Therapy in Pancreatic Cancer

Raffaele Pezzilli  1 , Riccardo Caccialanza  2 , Gabriele Capurso  3 , Oronzo Brunetti  4 , Michele Milella  5   6 , Massimo Falconi  7
Affiliations
Review

Pancreatic Enzyme Replacement Therapy in Pancreatic Cancer

Raffaele Pezzilli et al. Cancers (Basel). .

Abstract

Pancreatic cancer is an aggressive malignancy and the seventh leading cause of global cancer deaths in industrialised countries. More than 80% of patients suffer from significant weight loss at diagnosis and over time tend to develop severe cachexia. A major cause of weight loss is malnutrition. Patients may experience pancreatic exocrine insufficiency (PEI) before diagnosis, during nonsurgical treatment, and/or following surgery. PEI is difficult to diagnose because testing is cumbersome. Consequently, PEI is often detected clinically, especially in non-specialised centres, and treated empirically. In this position paper, we review the current literature on nutritional support and pancreatic enzyme replacement therapy (PERT) in patients with operable and non-operable pancreatic cancer. To increase awareness on the importance of PERT in pancreatic patients, we provide recommendations based on literature evidence, and when data were lacking, based on our own clinical experience.

Keywords: chemotherapy; nutritional support; pancreatic cancer; pancreatic enzyme replacement therapy; pancreatic exocrine insufficiency; pancreatic resection.

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Conflict of interest statement

Raffaele Pezzilli is a paid consultant for Mylan Italia S.r.l. Capurso is a paid consultant for Mylan Italia S.r.l. Riccardo Caccialanza received personal fees, speakers’ honoraria, research grants from, or participated on advisory boards for: Akern, Angelini, Baxter Healthcare, B. Braun, Boehringer Ingelheim, Eli Lilly, Fresenius Kabi, Nestlè Health Science, Mylan and Nutricia. Oronzo Brunetti is a paid consultant for Mylan Italia S.r.l. Michele Milella received speakers’ honoraria from and participated on advisory boards for: EUSA Pharma, Pfizer, MSD, AstraZeneca, Merck-Serono and Mylan. Massimo Falconi received speakers’ honoraria and research grants from, or participated on advisory boards for: J&J, Novartis, Ipsen, AAA, Mylan and Celgene. The funder had no role in the writing of the manuscript, or in the decision to publish the results.

Figures

Figure 1
Figure 1
Factors contributing to malnutrition in pancreatic cancer patients. IL: interleukin; PEI: pancreatic exocrine insufficiency; and TNF-α: tumour necrosis factor alpha. Warburg effect: See the text for an explanation.
Figure 2
Figure 2
Panels A and B represent examples of Fagan nomograms showing how the probability of diagnosing pancreatic exocrine insufficiency (PEI) by means of faecal elastase 1 (FE-1) dosage can vary in different scenarios, depending on its prevalence and on the accuracy of the test. On the left: Data from 40 operated patients, with a pre-test probability of having PEI of 67%. The FE-1 test has a sensitivity of 91%, a specificity of 35% and a positive likelihood ratio (+LR) of 1.4. The post-test probability increases only moderately to 74% (blue line) [27]. The negative likelihood ratio (−LR) of 0.26 suggests that, in the case of normal FE-1 levels, the post-test probability of PEI would be as low as 35% (red line). On the right (panel B): The case of 15 unoperated, locally advanced pancreatic cancer patients, with a pre-test probability of 87%. In this case, the post-test probability would only increase to 90% when FE-1 levels are reduced (blue line), but would decrease to 0% (red line) in the case of normal values (sensitivity 100%, specificity 22%, +LR 1.28, −LR 0) [41].
Figure 3
Figure 3
Pragmatic approach to testing and treating pancreatic exocrine insufficiency (PEI) in patients with pancreatic cancer.
See this image and copyright information in PMC

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