20: PanCan Flashcards
Majority of Pancreatic Cancers involve what type of pancreatic cells? What type of cancer are majority of those cases?
93% are exocrine tumors
95% of all exocrine tumors are pancreatic adenocarcinomas
What is the overall survival rate of PanCan (adenocarcinoma) in 5 years and by staging?
9%
If resectable (localized) – 34%
If regional at diagnosis – 12%
If met – 3%
What are the risk factors for PanCan?
family history
smoking
obesity and abd adiposity
chronic pancreatitis
Diabetes
heavy drinking (more than 3 drinks/day)–evidence is limited by suggestive
a diet high in total fat/sat fat, red/processed meats, or food/beverages containing fructose (limited but suggestive)
What lab value is elevated in PanCan, though not technically a tumor-specific marker? How can it be used during treatment?
Carbohydrate antigen 19-9 (CA 19-9)
Can be followed to see if responding to treatment
What are the basics for treatment (modality)?
Systemic therapy will be used for all patients, but when depends on staging. If resectable, might be used as neoadjuvant and postop to help shrink/clear margins. If non-resectable, typically main/only course of treatment offered, usually palliative.
Radiation is often used if needing to clear margins after surgery or help reduce pre-op. Not always a part of treatment, however. Usually given at same time as chemo.
Surgery is best method for curative intent. Staging will determine if chemo is needed prior (or after).
What are some of the common chemos used for treatment?
First/2nd line therapy with good performance will usually get FOLFIRINOX (5-FU, leucovorin, oxaliplatin, and irinotecan) or GA (Gemcitabine and abraxane)
First/2nd line for those with poor performance status: GX (Gemcitabine and Xeloda) or GEM-E (Gemcitabine and erlotinib/Tarcava).
Might also see XELOX, FOLFIRI, FOLFOX, GemCis, GTX
What is a common targeted therapy used for treatment?
Erlotinib (Tarceva)
What is a common immunotherapy used for treatment?
Pembrolizumab (Keytruda)
What are possible radiation therapy side effects?
anorexia, N/V/D, fatigue, wt loss, develop/worsening EPI — because of GI tract getting direct treatment
What are the two main types of surgery for PanCan?
What are 3 other, less common, surgeries?
Main: Pancreaticoduodenectomy (PD)–commonly called Whipple and distal Pancreatectomy
Less Common: Total Pancreatectomy, central pancreatectomy, and enucleation (Total Pan but taken in one whole piece)
What are the morbidity concerns for surgical patients?
Reported at 30-60%
Infectious – pneumonia, abscess, cholangitis, wound, UTI
Noninfectious – bile leak, pancreatic fistula or leak
What is the primary concern with nutrition assessment for these patients?
Weight loss/malnutrition — occurs in 50-90% of patients, correlated with shorter progression-free survival, decreased chemo response, decreased QOL/performance status, and greater surgical morbidity/mortality.
What the two types of PD surgery? What’s the difference?
What are the main possible nutrition impact symptoms for each?
PD (Whipple) and PPPD (pylorus-preserving Whipple)
Standard Whipple resects: head of pancreas, duodenum, gallbladder(maybe), distal stomach and part of common bile duct
PPPD: all the same except leaves the stomach alone, thus preserving the pylorus – eliminates dumping syndrome as a side effect
Both have EPI, delayed gastric emptying, lactose intolerance and diabetes as possible side effects — standard whipple also has dumping as possible side effect
What are the possible nutrition impact symptoms for a Total Pancreatomy?
Definite: EPI and Diabetes —- often more fragile than your most brittle type 1
Possible: dumping, delayed emptying, and lactose intolerance
What are the possible nutrition impact symptoms for a distal Pancreatomy?
possible EPI and DM
What are common symptoms at the time of diagnosis for PanCan?
Jaundice or light-colored(clay) stools, dark urine, yellow/itchy skin - 51-75% - blocked bile duct
Pain - 72-80% - tumor involving/invading nerves, blocked digestive tract, EPI
Wt loss - 70-80% - cancer cachexia, malabsorption
Decreased appetite - 28-48% - cancer cachexia, jaundice
malabsorption - 50-94% - blocked pancreatic duct, EPI, blocked bile duct
Delayed gastric emptying/outlet obstruction - 2-38% - partial/full blockage of duodenum
Ascites (within 0-2 months of diagnosis) - 22% - cancer spread to peritoneum, portal vein HTN, hepatic insufficiency, blockage of lymph system
How often to EPI/PEI (Exocrine Insufficiency) occur in PanCan? What are the signs/symptoms?
What sign/symptom can get thrown off by pain meds?
50-94% of patients develop PEI/EPI during the course of the disease
Abd bloating
cramping after meals
excessive gas (burping, flatulence)
indigestion
stool changes: fatty/oily (frothy/foamy), frequency, floating, light-colored or yellow, loose
foul-smelling gas/stools — lingers past normal in the air
unexplained wt loss
frequency of and how loose stools are can get disrupted by pain meds since they can cause constipation.
What are clinical tests for PEI/EPI and is it worth it?
Coefficient of fat absorption
fecal chymotrypsin level
fecal elastase 1
fecal fat excretion
urinary paraaminobenzoid acid excretion rate
carbon 13-labled mixed triglyceride breath test
No — these are often less sensitive and can cause underdiagnosing/treating. Best to use Functional test – screen with questions and trial enzyme replacement (PERT) if felt warranted
What does PERT (pancreatic enzyme replacement therapy) show to have improvements on?
Symptomatic concerns — the gas/smell/floating stools, etc
Even without those, shown to help body weight, stool frequency, total calorie intake, and total protein intake
What is the most common way to dose PERT? What is the standard starting dose?
What is the 2nd method and standard starting dose?
Meal-based dosing —
20,000-75,000 per meal or 5000-50,000 per snack is starting standard dose
Body Weight Dosing—
500 units per kg or body weight per meal and 250 units pre snack
What is the limit for PERT per day and per meal?
10,000 lipase units per kg of body weight or 2,500 lipase units per kg body weight per meal up to 4 times/day
example: PT weighs 150# or 68.2kg. Max would be 682,000 lipase units/day or 170,500 units per meal
If you used Creon 36,000/Zenpep 40,000, that would mean taking more than 4/meal (4.7 (C)/4.2 (Z) would be max) or more than 17 (Z)-18(C)/day
What does PERT require in its environment to work and what does that possibly mean for the patient?
It requires a basic environment and for bile acids to transport fatty acids into the bloodstream
A patient may need to take either a histamine H2-receptor antagonist (ranitidine/Zantac or famotidine/Pepcid) or a PPI (pantoprazole/Protonix or omeprazole/Prilosec) may be used because bicarb production and transport to the small intestine could be impaired
What is a significant barrier for PERT for patients?
Cost! There are some general resources (CancerCare, NeedyMeds, Medicine Assistance Tool) and drug specific ones too (AbbVie/Creon, Vivus/Pancreaze, Chiesi CareDirect/Pertzye, and Allergan/Zenpep)
Work with financial counseling/pharmacy to see what they know if you are uncertain — it’s better to try for assistance with the meds vs having a patient try OTC supplement versions
What type of TF formula would be needed for a PanCan patient needing feedings?
A semi-elemental formula with high in medium-chain triglycerides (MCTs) to minimize issues with need for PERT. Traditional PERT can be given every 3 hours during continuous feeds or delivered with each feed if gravity/bolus (if has a large-bore G-tube).
However, there is now some enzymes that can be connected to the feeding tube — formula goes through the adapter with the enzymes and then into the tube (Relizorb)
