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Living with pancreatic cancer.

Pancreatic Cancer Management

Managing Pancreatic Cancer Pain

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

Managing Mental Health with Pancreatic Cancer

Craig's Cause Pancreatic Cancer Society strongly recommends that all patients work with a healthcare team who care for the patient's physical needs and mental and emotional needs.

A cancer diagnosis can be difficult and stressful, affecting more than just the body – it can affect emotional/mental health, relationships with friends and family, work and finances. Feelings may become confusing and/or overwhelming. 

It is important to understand that if left untreated depression and anxiety can impair quality of life (QOL) in pancreatic cancer patients. Additionally, depression and anxiety can have an adverse impact on the patient’s ability to make treatment decisions and follow through with treatment recommendations.

If you would like assistance finding support services please contact us at 1 (877) 212-9582 or info@craigscause.ca


Depression

Depression is a serious illness which can negatively affect the way you feel, think and act. It can cause patients to feel sad and they may no longer participate and experience activities that they once enjoyed. Depression can lead to a variety of emotional challenges which decreases a patient's ability to function at work or at home. Research has found high rates of depression and anxiety in cancer patients, compared to the general population. Research also suggests that pancreatic cancer patients have a greater incidence of depression, which can impact a patients quality of life. 

Patients should be aware that as many as 50% of pancreatic cancer patients will experience depression, compared to 30% of other cancer patients. Some researchers have suggested that depression in pancreatic cancer may be due to biological processes inherent in the pathophysiology of pancreatic cancer and the tumor itself.

Recognizing Depression

Recognizing and diagnosing depression in cancer patients requires special attention because physical symptoms, such as fatigue and weight loss, are common in cancer patients however these symptoms can also be signs of depression. 

Therefore, the focus ought to be on the psychological symptoms of depression, such as hopelessness, loss of interest or pleasure in activities (i.e. anhedonia), and suicidal thoughts, which are dependable diagnostic markers for depression in pancreatic cancer patients.

 Symptoms of Depression:

• Depressed mood or irritability most of the day, nearly every day, as indicated by either a subjective report (e.g. I feel sad or empty) or observation made by others (e.g. my husband appears tearful).
• Loss of interest or pleasure in usual activities (i.e. anhedonia)
• Change in appetite
• Significant change in body weight (> 5%)
• Difficulty sleeping (insomnia or hypersomnia)
• Restlessness or feeling “slowed down”
• Fatigue or loss of energy
• Feelings of guilt, worthlessness or helplessness
• Diminished ability to think or concentrate, or more indecisiveness
• Thoughts of death or suicide


Anxiety

Like depression, anxiety can be a serious diagnosis when it impacts the way a patient thinks, behaves and interferes with the patient’s daily life.

Patients diagnosed with anxiety may experience chronic, daily worry about the future, real or imagined. Anxiety can also present as short, intense bouts of worry such as with a panic attack. 

Both chronic worry and feelings of terror can cause patients to avoid situations or places which make them feel anxious. This avoidance often strengthens the worry or fear. 

Anxiety May Be Related to Fears About:

• Upcoming test results
• Undergoing treatment
• Experiencing treatment-related side effects
• Having the cancer spread (i.e. metastasize)
• Having the cancer return after treatment (i.e. reoccurrence). Anxiety about reoccurrence is a significant issue for cancer survivors.

Symptoms of Anxiety:

• Excessive worry
• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling or staying asleep, unsatisfying sleep)

Symptoms of a Panic Attack:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed, or faint
• Chills or heat sensations
• Numbness or tingling sensations (paresthesia)
• Feelings of unreality (derealization) or being detached from oneself (depersonalization)
• Fear of losing control or “going crazy”
• Fear of dying

Cancer-related Post-traumatic Stress Disorder (PTSD)

Although many people may think of military combat when they think of Post-traumatic Stress Disorder (PTSD), it can also apply to cancer survivors. The definition of a “traumatic” event includes experiencing a life-threatening illness, such as cancer. Patients with a history of cancer are considered to be at risk for PTSD.

Symptoms of cancer-related Post-traumatic Stress Disorder may include:

• Recurrent, involuntary intrusive distressing memories about the cancer and cancer treatment;
• Recurrent, involuntary intrusive distressing dreams about the cancer and cancer treatment;
• Dissociative reactions (i.e. flashbacks) in which the individual feels as though they are reliving part of their cancer or treatment experience;
• Intense or prolonged psychological distress when exposed to triggers that remind the patient of their cancer or treatment (e.g. anxiety when entering a hospital);
• Intense physical distress when exposed to triggers that remind the patient of their cancer and cancer treatment (e.g. feeling nauseous when entering a hospital);
• Making efforts to avoid thinking or talking about cancer and/or triggers that remind the patient of their cancer and cancer treatment;
• Feeling emotionally numb toward family members and friends; PTSD is a concern particularly because it may result in patients avoiding medical care and follow-up. 

Having a good support system, including a good relationship with medical staff, could help reduce the risk of developing PTSD symptoms after cancer.

Management of Mental Health

The management of a patient's mental health is an important aspect of comprehensive cancer treatment. 

Depression and anxiety are highly treatable mental health conditions. They are typically responsive to psychological therapy and/or medication. Although mental health issues often go unrecognized and untreated, studies suggest that cancer patients are quite receptive to receiving mental health support. 

A combination of Cognitive-Behavioural Therapy (CBT), supportive psycho- therapy, and/or medication has been found to play a significant role in managing cancer-related depression and anxiety. CBT may include: reframing thoughts, relaxation strategies, and visualization exercises.

Relaxation strategies include deep breathing exercises. Visualization exercises may involve picturing a favourite place, a relaxing scene, or may involve picturing the cancer being eradicated in your mind’s eye. Studies suggest that regardless of the method of delivery (e.g. individual, group, face-to-face, telephone, or online), the most effective psychosocial intervention for cancer patients focus on the same basic elements: providing education, stress management, Cognitive-Behavioural Therapy (CBT), and support.

Mindfulness-based treatments may also be helpful for pancreatic cancer patients. These types of  treatments focus on learning acceptance, living according to your values, staying attuned to what is happening in the present moment, and meditation exercises. For patients with cancer-related PTSD symptoms, Cognitive-Behavioural Therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR) are helpful treatments.


Additional Coping Strategies Can Include: 

• Remember that it is normal to feel emotionally distressed
• Talk to your family and friends about your thoughts and feelings
• Educate yourself about pancreatic cancer and prepare questions to ask your  doctor (see section of booklet on Questions to Ask)
• Engage in pleasant, fun activities and hobbies (e.g. music, sports, art, yoga, etc.)
• Practice deep breathing and relaxation techniques
• Keep a journal of your thoughts and feelings
• Exercise (if approved by your doctor)
• Follow proper nutrition guidelines
• Get plenty of rest/sleep
• Attend a support group if available (Support4Caregivers is a monthly support network)
• See a mental health professional (e.g. psychologist) to talk about your thoughts and feelings
• Talk to your doctor about how to manage depression and anxiety and other mental health issues


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