Management of Advanced Pancreatic Cancer

Pain Management

• The National Comprehensive Cancer Network and the American Cancer Society recommend celiac plexus blocks for pain management in pancreatic cancer, with the strongest evidence supporting this use, and the European Society for Medical Oncology (ESMO) guidelines recommend celiac plexus block for persistent pain in pancreatic cancer patients with adequate performance status 1, 2, 3, 4
• A progressive analgesic ladder approach should be used for patients with pancreatic mass pain, starting with non-opioids (paracetamol/acetaminophen and/or NSAIDs) for mild pain, adding tramadol if non-opioids provide insufficient relief, and progressing to morphine (preferred) or fentanyl for severe pain, as recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology 5, 6, 7
• Consider gabapentin, pregabalin, nortriptyline, or duloxetine for neuropathic pain management, which can be used alongside analgesics to target nerve pain specifically, as recommended by the American Society of Clinical Oncology 5
• Neurolytic celiac plexus block is recommended for patients with refractory pain, providing effective palliation in approximately 70-80% of patients, and is most effective when used early rather than late in disease course, as recommended by the American Society of Clinical Oncology, the European Society for Gastrointestinal Endoscopy, and the Asian EUS Group consensus guidelines 5, 8, 7, 3, 9, 10, 11
• Consider thoracoscopic splanchnicectomy for patients who fail celiac plexus block, and hypofractionated radiotherapy for pain control, as recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology 5, 8, 6, 7

Palliative Care

• Assess pain at every visit, and continuously reassess and adjust pain management, as recommended by the American Society of Clinical Oncology 5
• Consider early palliative care consultation to optimize pain management strategies, and address psychological components, such as depression and anxiety, which can exacerbate pain perception, as recommended by the European Society for Medical Oncology and the American Society of Clinical Oncology 5, 8, 7
• Ensure adequate biliary drainage for patients with biliary obstruction, and consider self-expanding metal stents for permanent biliary drainage, as recommended by the American Society of Clinical Oncology 5

Gastrointestinal Management

• Consider expandable metal stent placement for patients with gastric outlet obstruction, and endoscopic placement of an expandable metal stent over surgery for gastric outlet/duodenal obstruction, as recommended by the European Society for Medical Oncology 3, 7, 6
• Recognize symptoms of gastric outlet/duodenal obstruction, including early satiety, nausea, postprandial vomiting, and weight loss, as described by the American Society of Clinical Oncology 5
• The median duration of stent patency is approximately 6 months, according to the American Society of Clinical Oncology, and metal stents are preferred for patients with life expectancy >3 months, while plastic stents can be considered for patients expected to survive <3 months, as recommended by the European Society for Medical Oncology 1, 5

Nutritional Support

• Consult with a nutritionist/dietician to assess dietary intake and need for nutritional support, and consider pancreatic enzyme replacement therapy for management of exocrine insufficiency symptoms, as recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology 3, 5, 7, 11