20: PanCan

Question 1

Majority of Pancreatic Cancers involve what type of pancreatic cells? What type of cancer are majority of those cases?

Answer 1

93% are exocrine tumors
95% of all exocrine tumors are pancreatic adenocarcinomas

Question 2

What is the overall survival rate of PanCan (adenocarcinoma) in 5 years and by staging?

Answer 2

9%

If resectable (localized) – 34%
If regional at diagnosis – 12%
If met – 3%

Question 3

What are the risk factors for PanCan?

Answer 3

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)

Question 4

What lab value is elevated in PanCan, though not technically a tumor-specific marker? How can it be used during treatment?

Answer 4

Carbohydrate antigen 19-9 (CA 19-9)
Can be followed to see if responding to treatment

Question 5

What are the basics for treatment (modality)?

Answer 5

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).

Question 6

What are some of the common chemos used for treatment?

Answer 6

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

Question 7

What is a common targeted therapy used for treatment?

Answer 7

Erlotinib (Tarceva)

Question 8

What is a common immunotherapy used for treatment?

Answer 8

Pembrolizumab (Keytruda)

Question 9

What are possible radiation therapy side effects?

Answer 9

anorexia, N/V/D, fatigue, wt loss, develop/worsening EPI — because of GI tract getting direct treatment

Question 10

What are the two main types of surgery for PanCan?

What are 3 other, less common, surgeries?

Answer 10

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)

Question 11

What are the morbidity concerns for surgical patients?

Answer 11

Reported at 30-60%

Infectious – pneumonia, abscess, cholangitis, wound, UTI
Noninfectious – bile leak, pancreatic fistula or leak

Question 12

What is the primary concern with nutrition assessment for these patients?

Answer 12

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.

Question 13

What the two types of PD surgery? What’s the difference?

What are the main possible nutrition impact symptoms for each?

Answer 13

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

Question 14

What are the possible nutrition impact symptoms for a Total Pancreatomy?

Answer 14

Definite: EPI and Diabetes —- often more fragile than your most brittle type 1
Possible: dumping, delayed emptying, and lactose intolerance

Question 15

What are the possible nutrition impact symptoms for a distal Pancreatomy?

Answer 15

possible EPI and DM

Question 16

What are common symptoms at the time of diagnosis for PanCan?

Answer 16

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

Question 17

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?

Answer 17

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.

Question 18

What are clinical tests for PEI/EPI and is it worth it?

Answer 18

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

Question 19

What does PERT (pancreatic enzyme replacement therapy) show to have improvements on?

Answer 19

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

Question 20

What is the most common way to dose PERT? What is the standard starting dose?

What is the 2nd method and standard starting dose?

Answer 20

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

Question 21

What is the limit for PERT per day and per meal?

Answer 21

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

Question 22

What does PERT require in its environment to work and what does that possibly mean for the patient?

Answer 22

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

Question 23

What is a significant barrier for PERT for patients?

Answer 23

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

Question 24

What type of TF formula would be needed for a PanCan patient needing feedings?

Answer 24

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)

Question 25

What are Diet modifications for patients needing PERT (have EPI/PEI)? Or had surgery?

Answer 25

At risk for micronutrient deficiencies – enzymes are needed to help absorb some and there is the potential loss of intrinsic factor from surgery.

Shouldn’t need to restrict fat if PERT is adequate – though some with severe steatorrhea may want to limit to 75 g fat/day

If having issues getting enough calories, use MCT oil to increase fat, but without needing PERT

Question 26

PanCan increases the risk of DM. What are some MNT concerns for DM management specific to this population?

Answer 26

1 – high percentage of patients that were non diabetic prior to diagnosis, will be from treatment or surgery.
2 – It’s important to note that current DM patients maybe see improvement, remain stable or get worse with DM – it’s very varied
3 – treatment can make things worse.

So, best to be aggressive with meidcation/insulin management of sugars and be less strict on diet while under treatment. Aim for A1c of 8%. Should still be encouraged to avoid refined CHO, consume meals/snacks at regular intervals and have a mix of protein/fat/CHO at all eating times.

After completing treatment and if have no evidence of disease, then aim for under 7% for A1c – give a full DM education, this will help with compliance and better outcomes overall.

Not in book, but from experience: Total Panc patients are the worst DM patients you can have. Endocrinology needs to be involved with their care from inpatient right after postop and have CLOSE management. Standard levels of fasting Glucose don’t apply. My endos often have them aim for staying around 150. The reason is they can drop dangerously low VERY quickly and often don’t feel it. I’ve had a walking/talking patient in clinic with a glucose of 32. Diet wise, its consistency and making sure they don’t skip out on CHO.

Question 27

What are the common reasons for a gastric outlet obstruction or small bowel obstruction in PanCan?

What are the treatments?

Answer 27

Gastric – also a duodenal obstruction, is typically late-onset side effect - tumor growth/mets
SBO – blockage in intestine past the ligament of Treintz may occur as a result of peritoneal disease mets

gastric bypass or endocopy/stent if able. Usually depends on survivorship/life expectancy. If neither are an option, a G-tube might be placed for drainage and J-tube for feeding

Question 28

What are the common reasons for a gastric outlet obstruction or small bowel obstruction in PanCan?

What are the treatments?

Answer 28

Gastric – also a duodenal obstruction, is typically late-onset side effect - tumor growth/mets
SBO – blockage in intestine past the ligament of Treintz may occur as a result of peritoneal disease mets

gastric bypass or endoscopy/stent if able. Usually depends on survivorship/life expectancy. If neither are an option, a G-tube might be placed for drainage and J-tube for feeding

Question 29

What is the diet for a duodenal stent?

Answer 29

**Little published guidelines

First liquids, before transitioning to soft/low-fiber diet. Chew food very well, drinking plenty of liquids with meals.

Question 30

Ascites is also common with PanCan. What are the dietary recommendations?

Answer 30

Similar to delayed gastric emptying, but there is no evidence regarding effectiveness of sodium restriction for cancer-related ascites. In practice, still recommended and is found to be beneficial for patients who have high (>1g/dL) serum-ascites albumin gradient (SAAG)

Question 31

What is the post-op Diet plan (per MD Anderson) – PD/PPPD/Total?

Answer 31

Early oral feeding can be beneficial.

Low in insoluble fiber/fat/refined CHO – around day 4 postop
transition to low fiber/low fat diet for 1-2 weeks post op
after 4-8 weeks postop, absence of enduring side effects or surgical complications, transition back to regular diet
long term: may be best to avoid high-fat foods and and limiting fat intake to 75 g/d

Question 32

How frequent is PEI/EPI and malabsorption in post-op patients?

Answer 32

50-100% after PD/PPPD and 0-42% after a distal. Obviously 100% in total.

Of note, fecal elastase is not recommended as a gold standard–can still have normal levels and have EPI.

Question 33

How frequently does chyle leak occur with surgery? Define it.

Answer 33

up to 10% following all types; 12.5% after PD.

Output of milky-colored fluid from drain, drain site or wound on or after postop day 3 with triglyceride content of 110 ml/dL or higher. Generally recognized at a median of 5-6 days postop. Drainage has a median of 14 days.

Question 34

What is the MNT for a chyle leak?

Answer 34

fat-free diet (limiting to 0.5 g fat/serving)
OR Low-fat diet
OR diet supplemented with MCTs
OR low-fat, high MCT EN formula
OR NPO/clear liquid with PN
OR a combo above

Maintained for 7-10 days can be stopped when drainage volume decreases

Question 35

What labs should be reviewed surgery and when/how frequently?

Answer 35

CBC, Vit B12, Methylmalonic acid, Foldate, Ferritin, Total Iron binding capacity, Iron, Copper, Zinc, Selenium, Vitamin A, serum retinol, vitamin E, Vit D, A1c, Mg

Within 1 year of surgical resection or sooner if showing signs/symptoms of malabsorption — if normal done annually, if abnormal, done every 3 months