Vol. 10 Issue 23
The Learning Scope
Patients with the disease face an uphill battle, but healthcare providers seek improved methods for early detection and treatment
This offering expires in 2 years: October 27, 2010
The goal of this continuing education offering is to provide nurses current information on caring for patients with pancreatic cancer. After reading this article, you will be able to:
1. Discuss the often late onset of signs and symptoms of pancreatic cancer and explain the mechanism by which they develop.
2. Describe management strategies available for the patient with pancreatic cancer.
3. List five postoperative nursing interventions to prevent complications after pancreatic resection.
You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
Mr. H is a 67-year-old male who presented to his physician with a new onset of jaundice. He had been self-treating what he thought was "back strain" for several months with NSAIDs. His past medical history is significant for type 2 diabetes mellitus. Mr. H's evaluation included CT scan of the abdomen, which revealed pancreatic head enlargement with dilatation of the pancreatic duct.
During his diagnostic evaluation, Mr. H developed nausea and vomiting presumed secondary to duodenal obstruction from a tumor of the head of the pancreas, most likely an adenocarcinoma.
Mr. H is one of approximately 31,000 people in the U.S. diagnosed with pancreatic cancer each year. Cancer of the pancreas is the fourth leading cause of cancer in the U.S. The morbidity rate is high; more than 30,000 deaths in this country occur each year as a result of the disease.
These statistics are dismal because pancreatic cancer produces few symptoms until it has invaded nearby organs. Unlike some cancers, there is no reliable screening method for its early diagnosis.
The pancreas, a vascular organ located behind the stomach in the retroperitoneum, is responsible for many important functions, including the production and secretion of the endocrine hormones insulin and glucagon. The pancreas also is an exocrine gland producing the pancreatic enzymes amylase, lipase and trypsin, which aid in the digestion of carbohydrates, fats and proteins.
The risk factors for pancreatic adenocarcinoma include:
- age over 60;
- male gender;
- tobacco use;
- ethnicity (black);
- inherited susceptibility;
- type 2 diabetes mellitus; and
Possible risk factors include:
- physical inactivity;
- some pesticides; and
- high carbohydrate/sugar intake.
When pancreatic function goes awry with the onset of a cancerous or precancerous lesion, several signs and symptoms develop.
The invasion or obstruction of adjacent organs by a tumor also may result in some of the clinical sequelae associated with pancreatic cancer.
Making the Diagnosis
The clinical findings in patients with the disease depend highly upon the location of the lesion. Most patients report vague symptoms early in the course of the disease that they may ignore or self-treat. Most patients with head of the pancreas, ampullary or distal bile duct adenocarcinoma have the classic symptoms of jaundice, pruritus, acholic (pale, lacking bile pigment) stool and tea-colored urine. Vague upper abdominal pain radiating to the back is another common symptom. Fatigue, anorexia, malaise, weight loss, nausea and vomiting also have been reported.
Diagnostic interventions patients undergo once a suspicion of pancreatic cancer has surfaced include:
- right upper-quadrant ultrasound;
- magnetic resonance cholangiopancreato-graphy (MRCP);
- endoscopic retrograde cholangiopancreato-graphy (ERCP);
- percutaneous transhepatic cholangiography; and
- positron emission tomography (PET)(diagnostic use of this test has not yet been established).
Preoperative staging is integral to determining the prognosis and forming a management plan for patients. This staging is accomplished by performing a spiral CT scan and endoscopic ultrasound, which also can provide tissue diagnosis by fine-needle aspiration. Invasive imaging studies are not routinely performed. Tumors are staged according to their size, extent, lymph node involvement and the presence of metastases.
A large percentage (80-85 percent) of patients with adenocarcinoma of the pancreas have unresectable disease at the time a diagnosis is made. The management plan for these patients is to ease their symptoms and enhance their quality of life by alleviating pain, gastric outlet obstruction and obstructive jaundice. This objective is accomplished nonoperatively, either by percutaneous or endoscopic techniques; for example, the endoscopic placement of duodenal stents for duodenal obstruction. Biliary stents can be placed endoscopically or percutaneously to drain ducts obstructed by tumor.
Pain can be managed by the use of opioids and/or other analgesics. Another pain management technique is an ultrasound or CT-guided celiac plexus nerve block to more specifically target the neurologic pain caused by pancreatic cancer.
Procedures such as staging laparoscopy may be useful in directing the course of further interventions by accurately determining a tumor's surgical resectability. Appropriate patients can then undergo a planned surgical intervention. Patients with an unresectable tumor will avoid the higher complication rate of a laparotomy and choose an endoscopic or percutaneous technique.
Surgery is the only potentially curable intervention. However, only a small percentage of those with pancreatic cancer (10-20 percent) are candidates for surgical resection of the tumor.
Patients with a potentially resectable pancreatic or periampullary tumor will undergo a pancreaticoduodenectomy.
Two operative procedures accomplish this goal. One is the classic Whipple procedure, developed by surgeons Walther Kausch and Allan Whipple, and the other is the pylorus-preserving pancreaticoduodenectomy.
The classic Whipple procedure consists of the removal of the pancreatic head, duodenum, common bile duct, gallbladder, distal portion of the stomach and the adjacent lymph nodes.
The organ-preserving alternative to the classic Whipple procedure, the pylorus-preserving pancreaticoduodenectomy, includes the same resections but leaves a functional pylorus at the gastric outlet and anastomoses are made to the jejunum. The use of this procedure is an effort to reduce complications such as dumping syndrome, reflux of stomach contents and weight loss. More randomized controlled trials are needed to confirm these advantages.
Advances in surgical techniques and postoperative care of patients after pancreatic resection have improved outcomes and decreased the morbidity and mortality for patients with pancreatic cancer. High-volume centers that perform many of these procedures have gone to great lengths to improve care for patients and prevent complications, including pancreatic fistula formation, intra-abdominal fistula, sepsis and delayed gastric emptying.
Mr. H underwent a pylorus-preserving Whipple. He was admitted to the ICU for 2 days postoperatively. His nursing care was focused on recovery from general anesthesia and management of postoperative and cancer-related pain with opiates and nonpharmacologic measures, such as repositioning. In the immediate postop period, patient-controlled analgesia is the frequent choice for optimal pain management, converting to oral narcotics when the patient tolerates oral intake.
Aggressive pulmonary care was needed to prevent atelectasis, retained secretions and pneumonia. Pulmonary complications were thwarted by early and progressive ambulation. Ambulation, as well as sequential compression devices and anticoagulation, are important adjuncts in the prevention of venous thromboembolism in these high-risk patients.
In addition, nurses closely monitor for the onset of postoperative bleeding by assessing effluent from postoperative (frequently two Jackson Pratt) drains for blood, trending vital signs and watching hematocrit levels.
Anastomotic breakdown with leakage of biliary fluid is another complication that warrants aggressive assessment.
This dreaded complication is heralded by the onset of fever, abdominal pain and drainage of bile from postoperative drains.
Mr. H's initial postoperative period was complicated by early hypotension managed with volume resuscitation. This hypotension was unrelated to bleeding and the remainder of his course was uneventful. Mr. H was maintained NPO for 2 days postoperatively and had a nasogastric tube in place until the first postoperative day.
On his second day postop, Mr. H was placed on a clear liquid diet and was then gradually advanced until he was tolerating a regular diet. Mr. H also began oral pancreatic enzyme supplementation. His drains were discontinued as the effluent amount decreased, and his urinary catheter was discontinued as well.
He was discharged on postoperative day 6 once his discharge plan for medications, activity and follow-up were reviewed. He had been evaluated by medical oncology and radiation oncology and was to have this plan developed on an outpatient basis.
Mr. H had a tumor of the head of the pancreas. Should his tumor have been located in the body or the tail of the pancreas, he may have undergone a distal pancreatectomy. In this procedure, the involved segment (tail of the pancreas and a portion of the body) is removed, along with the surrounding lymph nodes and possibly the spleen. The postoperative nursing management for patients undergoing this procedure mirrors that already described for those status post-Whipple procedure.
A total pancreatectomy is not routinely used in the management of pancreatic cancer.
This procedure is only indicated for a tumor whose boundaries extend over the entire pancreas or where multiple tumors exist throughout the organ.
The final clinical scenario in which a total pancreatectomy may be performed is when a pancreatic anastomosis is technically impossible. Patients who undergo this surgical intervention will have the additional postoperative challenge of insulin-dependent diabetes. Nurses caring for these individuals provide education about insulin administration, appropriate diet, glucose monitoring, signs and symptoms of hypo- and hyperglycemia, and many other elements for control of this condition.
Another critical component to caring for patients with pancreatic cancer is assessing and understanding the anxiety related to the diagnosis and prognosis of this disease. Nurses provide the patient and family with information, listen to concerns and answer questions honestly.
In our current information age, when patients can acquire information so readily, they may have fears and concerns regarding their prognosis and what the future holds for them. Patients may already know of the statistics and poor outcomes given the usually delayed diagnosis and interventions. Nurses play a major role in providing support to patients and their families during a difficult time. Nurses ensure patients and families are provided with needed resources such as written materials, Web sites and appropriate support groups that will aid in coping with the many lifestyle changes that occur whether the patient has had curative or palliative interventions.
Treatments such as chemotherapy, radiation therapy, immunotherapy and antihormonals, which are commonly used in the treatment of other cancers, have not been shown as effective in the management of the aggressive tumors of the pancreas.
Neoadjuvant therapy (administered before surgery) may be used in some cases to attempt to downsize a tumor to enhance resectability. There have been no large randomized controlled studies in the use of neoadjuvant therapy in pancreatic cancer. However, current evidence suggests adjuvant (after surgery) external beam radiotherapy and chemotherapy are beneficial after resection of pancreatic cancer in those with non-metastatic disease. The current standard treatment regimen is 5-FU. This therapy may be enhanced by the use of gemcitabine, or gemcitabine may substitute the 5-FU for greater efficacy.
Adjuvant and neoadjuvant chemotherapies should be reserved for patients who have a reasonable expectation for improved survival with the treatment. This recommendation is so important given the significant potential adverse effects of nausea, vomiting, fatigue, malaise, diarrhea, diminished appetite and neutropenia, which increases the risk of infection.
Survival of patients after they have undergone resection is dependent on the site of the tumor and the stage of the disease. Factors associated with improved survival include negative resection margins, tumors of less than 3 cm, negative lymph nodes, blood loss less than 750 mL, no need for blood transfusion and the use of postoperative chemoradiation. In the case of patients with advanced pancreatic cancer, for whom palliative chemotherapy is the treatment of choice, gemcitabine is used. This drug, approved by the FDA due to its ability to relieve tumor-related symptoms, has been shown to significantly improve overall survival when compared to 5-FU.
Research & Trends
Much research is currently under way exploring the molecular and genetic basis of pancreatic cancer and this research may offer hope in the future of an improved rate of cure (the current overall 5-year survival is approximately 4 percent).
Trials are currently under way examining the use of immune-based therapies. Immunotherapy utilizes vaccination to stimulate the immune response, recruiting and activating T-cells that recognize tumor-specific antigens and yield an antitumor effect.
These and many other therapies currently being studied give us a glimpse into the future in our fight against pancreatic cancer.
Pancreatic cancer is a difficult entity to identify as well as treat. It is, in fact, one of the most difficult challenges in surgery and oncology. Currently, there is no panacea for earlier diagnosis or management, although surgical resection, when appropriate, offers the best chance for long-term survival. Patients with the disease face an uphill battle, which healthcare providers and researchers are striving to make easier with improved methods for early detection, prevention, diagnosis, treatment and follow-up. n
Diener, M.K., et al. (2007). A systematic review and meta-analysis of pylorus-preserving classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Annals of Surgery, 245(2), 187-200.
Schnelldorfer, T., et al. (2008). Long-term survival after pancreatoduodenectomy for pancreatic adenocarcinoma: Is cure possible? Annals of Surgery, 247(3), 456-462.
Schulick, R.D., & Cameron, J.L. (2007). Pancreatic and periampullary cancer. In C.J. Yeo, (Ed.), Shackelford's surgery of the alimentary tract (6th ed.). Philadelphia: Saunders Elsevier.
Willett, C.G., Czito, B.G., & Bendel, J.C. (2007). Adjuvant therapy of pancreatic cancer. The Cancer Journal, 13(3), 185-191.
Eleanor L. Fitzpatrick is a clinical nurse specialist in surgical critical care at Thomas Jefferson University Hospital, Philadelphia.