Pancreatic Cancer Nutrition (Week 8 Lecture 2)

Question 1

What is PDAC, PEI and PERT?

Answer 1

• pancreatic adenocarcinoma
• pancreatic exocrine insufficiency
• Pancreatic Enzyme Replacement Therapy

Question 2

Prevalence of malnutrition in PDAC

Answer 2

> 80% of PDAC pts have significant weight loss with severe malnutrition and cancer cachexia at diagnosis.

Question 3

What factors play into malnutrition?

Answer 3

psychological factors, metabolic factors, gastrointestinal factors
* sarcopenia
* cachexia
* ↓ immune competence and QOL
* ↑ infections, stress, treatment toxicity and mortality

Question 4

Describe sarcopenia and potential outcomes

Answer 4

• can occur concurrently with obesity
• ↑ incidence of chemo related toxicity
• shorter time to tumour progression
• physical disability
• poor surgical outcomes
• ↓ survival

Question 5

2 main pancreatic functions

Answer 5

• Exocrine: produce and secrete digestive enzymes/juices (protease, amylase, lipase, water and bicarbonate)
• Endocrine: produce and secrete hormones for digestion (insulin, glucagon, gastrin and amylin)

Question 6

Describe pancreatic cancer

Answer 6

95% of pancreatic cancers are exocrine tumours, with 90% being adenocarcinoma (PDAC), originating from ductal tissue (originates in head from ductal tissue)
* Important to consider location of tumour, ductal dilation, state of remaining pancreas and overall tumour burden (head will have biggest impact, rest of pancreas is atrophic)

Question 7

What are the main types of pancreatic cancer?

Answer 7

2 main types of PDAC:
1. Unresectable/metastatic - too much vascularizationfrom the malignancy and unable to remove
* Palliative bypass (may be deemed this for years)
2. Curative/Surgical:
* Whipple (classic or pylorus preserving-head of pancreas, gallbladder, duodenum is removed and liver, and stomach attached to the jejunum. So can still have some pancreas left)
* Total Pancreatectomy (acute type of diabetes)
* Distal pancreatectomy (just tail removed and then most of exocrine remains)

Question 8

Describe PEI

Answer 8

A condition caused by reduced or inappropriate secretion or function of pancreatic juices and its digestive enzymes causing maldigestion
* lipase in particular, protease, amylase and likely bicarbonate
* Can be caused by decreased production of pancreatic enzymes, blockage due to mass, or surgery/removal of enzyme producing cells

Question 9

Prevalence of PEI

Answer 9

• 90 - 100% locally advanced or metastatic pancreatic cancer (exocrine insufficiency). Increased risk factors, head localized, larger size, ductal obstruction, coexistent chronic pancreatitis
• Post-operative PDAC patients: 80-90% of Whipple pts, 20-50% distal pancreatectomy, 100% total pancreatectomy.

Question 10

What are some outcomes of PEI?

Answer 10

Impact of PEI in pts with PDAC is associated with malnutrition, sarcopenia, fat degradation, longer hospital stays, increased risk of complication, reduced response to treatment, decrease QOL, increase risk of morbidity and mortality in both unresectable and resectable pts.
* Associated with decreased QOL, nutrition, post-op survival and cancer related outcomes.
* Post PEI may impede ECOG and ability to initiate adjuvant chemotherapy

Question 11

Abdominal symptoms of PEI

Answer 11

• Diarrhea
• Steatorrhea (oily, pale, floating)
• Fecal urgency
• Bloating, gas, foul smelling
• Reflux
• Cramping abdominal pain or gurgling post intake (57%)

Question 12

Endocrine symptoms of PEI

Answer 12

• Hypoglycemia
• Decreased insulin requirements for pre-cancer diabetics

Question 13

nutrition symptoms of PEI

Answer 13

• Unexplained weight loss (even if still eating)
• Sarcopenia
• Weakness, fatigue
• Food avoidance (due to fear of digestive symptoms)
• Vitamin deficiency - fat soluble vitamins

Question 14

What is the treatment for PEI?

Answer 14

Pancreatic enzyme replacement therapy (PERT) are prescribed by the doctor, with/without help of specialized dietitian, exact dosing is still not well established. Should be defined based on improvement of identified PEI symptoms.
* Pancreatic enzymes used commonly: Creon (10, 25, 35), Cotazym ECS (8, 20)
* enterically-coated needed for oral use (other than post gastrectomy); need coating to prevent degradation
* Each pancreatic enzyme capsule contains combination of lipase, protease, amylase

Question 15

How is PERT dosing determined?

Answer 15

PERTdosing recommendations primarily based on CF population but assume pancreatic patients will need more; for CF based on kg BW x units of lipase per meal or with a total daily limit.
* 500-2500 units of lipase per kg/meal or 10,000 units per kg/day
* Use half calculated meal dose for snacks
* Risk associated with exceeding, constipation
* Starting dose for pancreatic patients is 40,000 – 50,000 USP/meal, 25,000 USP/snack
* Start conservatively and increase slowly

Question 16

Outcome of PERT

Answer 16

• Side effects when starting enzymes: bloating, cramping, fullness, nausea, hyperglycemia
• Evaluating response to enzymes should be routine → signs of PEI symptoms
• PERT will cause large volume soft stools. Pt must be aware of this
• Dietary fat restriction is not indicated or recommended

Question 17

How is PERT taken?

Answer 17

PERT is needed with all solids or liquids that contain complex carbohydrates, fat or protein. They should be taken right before onset of intake.
* Do not need to be taken with sugar only (refined CHO) foods: popsicle, hard candy, fruit juice, pop
* Slightly higher doses may be needed with foods that are high in fat/protein or larger meals/snacks, start by adding 1-2 for meal, 1 for snack.
* Patients need education before initiating this treatment!

Question 18

Assessing and adjusting PERT

Answer 18

• Follow up: Follow up on enzyme therapy initiation within ~ 2 weeks of start (my current practice). Assess for symptom improvement, review titration and dose up if indicated.
• Increase: Enzyme doses may need to increase with disease progression or organ atrophy. Important patient understands dose may need to change.
• Switch: If started on low concentration PERT, once dose range established can switch to higher concentration to reduce number of capsules needed. I leave this to patient choice.

Question 19

How to ensure patients are taking PERT properly

Answer 19

• Timing: right before starting oral intake, can try up to 30min prior. Effective for up to 1hr. If out for social style meals that have multiple courses or take >1hr, multiple smaller doses will be needed.
• Frequency (all meals/snacks), often patients miss doses with snack, liquids

Question 20

How to adjust PERT if it was effective then symptoms return

Answer 20

If patient had been finding effective, then PEI symptoms return or new upper GI symptoms of GERD or burping, consider adding PPI. This is related likely to bicarbonate secretion dysfunction.
* If ongoing weight loss despite PERT and PPI, ensure blood supar is assessed and monitored