Principles of Palliative and Supportive Care in Pancreatic Cancer: A Review

Abstract

Pancreatic adenocarcinoma (PDAC) is well known for its poor survival time. Clinical symptoms are painless jaundice or abdominal or back pain. Less specific symptoms often appear that make diagnosis difficult, e.g., weight loss, loss of appetite, nausea and vomiting, and general weakness. Only 10-20% of patients are diagnosed at an early stage. A cure is practically only possible with a radical surgical operation. In the case of locally advanced findings, neoadjuvant therapy is administered. Among the therapeutic options offered are chemotherapy, radiotherapy (including stereotactic radiotherapy-SBRT), targeted treatment, or immunotherapy. In the case of metastatic disease, of which more than half are present at diagnosis, the goal is to relieve the patient of problems. Metastatic PDAC can cause problems arising from the localization of distant metastases, but it also locally affects the organs it infiltrates. In our review article, we focus on the largest group of patients, those with locally advanced disease and metastatic disease-symptoms related to the infiltration or destruction of the pancreatic parenchyma and the growth of the tumor into the surrounding. Therefore, we deal with biliary or duodenal obstruction, gastric outlet syndrome, bleeding and thromboembolic diseases, pain, depression, and fatigue, as well as pancreatic exocrine insufficiency and malnutrition. Metastatic spread is most often to the liver, peritoneum, or lungs. The presented overview aims to offer current therapeutic options across disciplines. In accordance with modern oncology, a multidisciplinary approach with a procedure tailored to the specific patient remains the gold standard.

Keywords: palliative care; pancreatic adenocarcinoma; pancreatic cancer; supportive care.

Figure 1

EUS-guided biliary drainage methods: (1) antegrade stenting; (2) and (4) transmural stenting with two kinds of techniques: (2) hepaticogastrostomy (preferred bile duct segment 3 or left liver) and (4) choledochoduodenostomy; (3) the rendezvous technique [16].

Figure 2

Enteral stent. (A) Endoscope with guidewire through the stenosis; (B) stent in the correct position (Author: Prof. Tomas Hucl, Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic).

Figure 3

LAMS. (A) CT image; (B) EUS picture of LAMS opening; (C) endoscopic view (Author: Prof. Tomas Hucl, Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic).