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Living with pancreatic cancer.

Management

Pain Management

Identification, assessment and treatment of pancreatic cancer pain is vital to quality of life. Each person’s response to pain is unique and dependent on different physical and psychological factors. It is important for the pancreatic cancer patient to discuss their treatment options, for pain management, with their healthcare team. A referral for a pain management specialist is strongly suggested. 

Remember: Successful treatment of pain in pancreatic cancer patients is achievable. 


What Causes Pain for People with Pancreatic Cancer?

Tumours often grow rapidly and can cause swelling and inflammation within the body. These rapidly growing tumours can cause tumour-obstructing flow (of bile or pancreas enzymes or the bowel contents) or by invading nearby nerves or other structures. 

Pain can also be caused by side effects from chemotherapy, radiation, surgery or other treatments.

Often abdominal pain is the first symptom of pancreatic cancer. This mid-abdominal pain often radiates to the back area. When pain is not treated properly it can have significant negative effects on the patient and can lead to anxiety and depression.

Treatment of Pain - The Four P’s

When considering pain management, it is important to take a thorough look at the individual and assess all areas of that patient's life, while considering all options of pain management. One can do this by considering the “Four P’s": 

• Physical Treatment - heat, ice, rest, TENS (Transcutaneous electrical nerve stimulation is a method of pain relief involving the use of a mild electrical current), acupuncture, diet

• Psychology Treatment - meditation, mindfulness, Qi Gong, Yoga and Cognitive Behaviour Therapy (CBT)

• Pharmaceutical - Medications

• Pins (Needles) - Injections and Coeliac Plexus Block


Medication Details

"Over the Counter Drugs"

  • Acetaminophen (Tylenol)
  • Ibuprofen (Advil or Motrin)
  • Naproxen (Aleve)
  • Topical creams such as Diclofenac (Voltaran). Used when a patient is undergoing radiation. 

First Line Prescription Medications
(These medications can take 3-6 weeks to work)

  • Tricyclics (“Old Antidepressants”) - Nortriptyline (Aventyl), Amitriptyline (Elavil)
  • Gabapentin Family- Gabapentin (Neurontin), Pregabelin (Lyrica)
  • “New Antidepressants”- Duloxetine, Venlafaxine
  • “Almost Opioids”- Tramadol, Tramacet, Tapentadol (Nucynta)

Opioids 

  • Weak - Codeine (Tylenol #3)
  • Strong - Morphine, Oxycodone, Hydromorphone, Methadone

When used responsibly, opioids are often have positive results. They are fast acting and effective for most cancer patients, however they can cause constipation and drowsiness.

Cannabinoids 

  • THC  
  • CBD  

There are medical prescriptions called Sativex Spray (50:50 THC: CBD) and Nabilone (Synthetic THC). 

Non prescriptions include medical access programs in Canada, or provincial distributors.

Coeliac Plexus Block 

A Coeliac Plexus Block can be used when patients experience belly and back pain. A needle is placed in the mid back to the nerves from the pancreas. It can be done by a pain specialist or a radiologist.

This is a permanent nerve block which usually lasts around six months. It can be repeated if it wears off. A rare but serious risk of the procedure is accidental flow of the medicine into the spinal cord causing paralysis.

The Coeliac Plexus Block is roughly 80% effective in relieving pain and works for 80% of patients. 


Additional Options for Pain Management

1. Placement of a Stent -  Some pain may be relieved by repairing the obstruction in the bowel or a bile duct. A stent can be placed in the bowel or bile duct. It will relieve jaundice and/or vomiting. 

2. Radiation and Steroids- Tumours can cause swelling and grow very rapidly causing inflammation and swelling around the site. Steroids and/or radiation may be used to reduce the tumour, swelling and discomfort. 

3. Palliative Surgery - Patients who are not curable may be offered palliative surgery which removes part of the pancreas and connects the bowel around the obstruction. Additionally, some of the tumour will be removed, to relieve some pain and discomfort.

4. Radiation and Steroids 

Remember that Pancreatic Cancer Pain Can Be Managed

Remember, patients have the right to receive the best pain control treatment options available. Good pain control allows you to focus on your life and do the things you want to be able to do. Make sure that your health care team listens to you and takes your concerns seriously.

  1. Ask for a referral to see a pain management specialist. 
  2. Talk honestly about the pain. Patients are the only ones who know what they are feeling and how it is affecting their life.
  3. Do not wait until the pain is unbearable before discussing options with your health care team. Pain is easier to control when it is mild. Stay ahead of your pain. Do not try to hold off between doses, follow the dose schedule given to you by your doctor.

Video Resources

Mental Health

Content coming soon.

Video Resources

Nutrition and Enzymes

Nutritional care, including supplemental pancreatic enzymes, improves pancreatic cancer patient outcomes and is critical for quality of life. 

The World Pancreatic Cancer Coalition recommends that everyone diagnosed with pancreatic cancer has their nutritional needs assessed by someone with nutritional expertise, is offered information about diet and nutrition, and has access to pancreatic enzymes. 

Individuals living with pancreatic cancer often struggle with maintaining a healthy appetite and weight, as a result of their pancreas being compromised by a cancer diagnosis. This is called Pancreatic Exocrine Insufficiency (PEI). PEI means that the pancreas is not:

  • Providing the proper enzymes to breakdown food and provide nutrients to the body
  • Providing the necessary hormones to regulate blood sugar, which can result in diabetes

Because the pancreas is struggling to provide the enzymes required to breakdown food and to regulate sugars, patients struggle with:

  • Diarrhea
  • Nausea and vomiting
  • Greasy, pale, smelly and floating stool
  • Fatigue
  • Anemia 
  • Decreased appetite
  • Abdominal discomfort, bloating and gas
  • Weight loss

NOTE
Medications, pain, depression and anxiety can also impact appetite and proper nutrition. Because of this, it is imperative that patients are referred to specialists trained in working with pancreatic cancer patients. These specialists should include:

  • a nutritionist
  • a pain management specialist
  • a psychologist/social worker

Nutritional Guidelines

Purchasing, preparing, eating food and personal lifestyle may look very different, once diagnosed with pancreatic cancer.  The good news? With adjustments to your food and lifestyle, patients should start to feel better.  

Eat multiple, small meals per day (6 - 8 meals)

Patients are encouraged to eat several small meals a day for a variety of reasons, some of which are:

  • It will give the small intestine, time to absorb more nutrients, which will feed the body and provide it with energy and strength
  • Large meals can leave a patient feeling full and nauseated

Chew Slowly

When patients chew slowly they are ensuring that their body:

  • Has time to start and slowly digest food, at a comfortable pace
  • Won’t feel as much discomfort, during the digestion of food

Stay Hydrated

Drink at least 6-8 cups (1500-2000ml) of water a day. Patients are encouraged to avoid caffeinated products as they can cause dehydration. 

Avoid (or limit) Fatty Foods

Fatty foods include:

  • Processed foods
  • Fast food (and food with added oil)
  • Red meats
  • Dairy - cheese, whole or 2% milk, butter, margarine, sour cream, cream cheese and salad dressings
  • Rich desserts (and any dessert high in sugar)

Use Healthy Fats.

Although it is important to consume fat to absorb important vitamins, patients should understand that there are bad fats and good fats. Patients should avoid processed foods and red meats. However, good fats need to be consumed, such as:

  • Nuts
  • Seeds
  • Olives 
  • Fatty fish

Use Less Fibre

Fibre is part of a healthy diet, however, patients diagnosed with pancreatic cancer may find that foods high in fibre can make food move through the intestine more quickly, therefore the intake of whole grain breads, raw vegetables and nuts should be limited.

Easy fibre foods to digest include:

  • Oat fiber
  • High pectin foods (apples, applesauce, peaches, strawberries, oranges, green beans, carrots, tomatoes, potatoes, bananas, raspberries, blackberries, apricots, peas, sweet potato)     

Avoid Gassy Foods
There are several types of foods which can cause gas and discomfort as a result. Vegetables in the cabbage and onion family, beans, corn, pop corn, carbonated drinks and even gum can cause gas. 

High-Calorie Foods

These foods can help patients with weight gain and provide energy. 

Physical Activity

Patients are encouraged to engage in some form of physical activity daily. 

Avoid Alcohol and Drugs

Avoid these as much as possible. 

Smoking

Quit

Vitamins

Doctors may also prescribe vitamin replacements for vitamins A, D, K and E. 

Anti nausea, anti diarrhea medication

Patients must talk to their physician, who is a part of their treatment team. 

Pancreatic Enzyme Replacement Therapy (PERT)

This is an effective treatment using mediation called pancrelipase (Cotazym®, Creon®, Pancrease® MT) medications.  These medications help patients break down their food, digest their food and absorb the nutrients in their food. These enzymes are taken during meals or snacks. They travel with food, past the stomach until they reach the small intestine.

Here they will release digestive enzymes which will aid in the absorption of important nutrients. Some important points to note:

  • Treatment varies from patient to patient, diet, fat intake and size of meal and snack.
  • Patients need to work with their health care team to establish and individualize dosage.

Recipes

Changes in grocery lists, food preparation and consumption can be challenging and intimidating for many. The following cook book was developed by Celgene, in consultation with Pancreatic Cancer Action Network to assist patients and families in meal planning.

CLICK HERE for a downloadable recipe book called Cooking. Comfort. Care. to assist in menu planning. 

Additional Resources

Canadian Society of Intestinal Research

Canadian Digestive Health Foundation

Video Resources