pancreatic cancer

Cancer of pancreas, pancreatic carcinoma Oncology A 'silent' cancer that rarely causes early Sx unless it blocks the common bile duct and bile cannot pass into the digestive system, causing jaundice Epidemiology 5^th leading cause of CA death–US; 11^th most common CA; 24,000 deaths/yr–US Incidence 9/105 5-yr survival, ± 5% Risk factors ♂, black, smoking, ↓ consumption of fruits, vegetables, ↑ meats, alcohol, chronic pancreatitis Pancreatic cancer stages I CA confined to the pancreas, or direct extension to duodenum, bile duct, peripancreatic tissues II CA extends directly to the stomach, spleen, colon, or adjacent large vessels III Any direct tumor size with positive lymph nodes IV Any known metastasis, eg to liver or lungs

pancreatic cancer

Carcinoma of the pancreas. The American Cancer Society estimated there would be 37,700 new cases of the disease in the U.S. in 2008, with 34,300 deaths caused by the illness that year. Although the causes of pancreatic cancer are unknown, it has been found in more men than women, more blacks than whites, more smokers than nonsmokers, and more patients with a history of chronic pancreatitis and diabetes mellitus than without. When cancer occurs in the head of the pancreas, where it may obstruct the bile ducts and cause jaundice, the disease is most likely to be diagnosed at an early stage, when it may be most responsive to therapy. Surgical excision of the tumor and treatment with chemotherapy or radiotherapy may prolong survival in some patients. Only 4% of victims of pancreatic cancer survive 5 years. Synonym: carcinoma of the pancreas; cancer of the pancreaspancreatic carcinomaSee also: cancer

Pancreatic Cancer

DRG Category:	436
Mean LOS:	5.2 days
Description:	MEDICAL: Malignancy of Hepatobiliary System or Pancreas With CC

Pancreatic cancer is currently the fourth-most common cause of cancer-related deaths in the United States. Pancreatic cancer includes carcinomas of the head of the pancreas, the ampulla of Vater, the common bile duct, and the duodenum. Approximately 45,000 people in the United States are diagnosed each year. The survival rate of pancreatic cancer is low; about 23% of patients survive 1 year after diagnosis, and fewer than 5% of persons with the disease are alive 5 years after diagnosis.

Tumors can develop in both the exocrine and the endocrine tissue of the pancreas, although 95% arise from the exocrine parenchyma (functional tissue) and are referred to as adenocarcinomas. The remaining 5% of pancreatic tumors develop from endocrine cells of the pancreas; they are named according to the hormone they produce (i.e., insulinomas, glucagonomas). Adenocarcinoma of the ductal origin is the most common exocrine cell type (75% to 92%), and it occurs most frequently in the head of the pancreas. Pancreatic adenocarcinoma grows rapidly, spreading to the stomach, duodenum, gallbladder, liver, and intestine by direct extension and invasion of lymphatic and vascular systems. Further metastatic spread to the lung, peritoneum, and spleen can occur. Metastatic tumors from cancers in the lung, breast, thyroid, or kidney or skin melanoma have been found in the pancreas.

Causes

Although the exact cause is unknown, associations with cigarette smoking (incidence is more than twice as high for smokers as nonsmokers); diets high in fat, meat, dehydrated foods, fried foods, refined sugars, soybeans, and nitrosamines; and diabetes mellitus and chronic pancreatitis have been suggested as possible causes. Persons who have occupational exposure to gasoline derivatives, naphthylamine, and benzidine are considered to be at higher risk. High coffee consumption and alcohol intake have been implicated; however, many believe a direct effect of these substances on the development of pancreatic cancer is questionable.

Genetic considerations

Pancreatic cancer can be seen in several familial cancer syndromes and hereditary pancreatitis. There have also been families with isolated heritable pancreatic cancer that is transmitted in an autosomal dominant fashion, showing early onset and a penetrance greater than 80%. Heritable (germline) mutations in BRCA2 are the most common seen in familial pancreatic cancer.

Gender, ethnic/racial, and life span considerations

Pancreatic carcinoma can occur in persons of all ages but is rare before age 45. Its peak incidence is between the ages of 60 and 70. The incidence in men and women is now equal and is attributed to the increase in smoking among women. Pancreatic cancer occurs 50% more frequently among African Americans than among European Americans, with the highest incidence in the United States among Korean Americans and people who immigrated from Eastern Europe.

Global health considerations

The global incidence of pancreatic cancer is approximately 4 cases per 100,000 individuals per year. The overall incidence of pancreatic cancer is five to six times higher in developed than in developing nations. India in particular has a low incidence.

Assessment

History

Cancer of the pancreas has been called a “silent” disease; one reason for the poor survival rate is that cancer is often not detected during its early stages because of its insidious onset. The signs and symptoms are vague and frequently disregarded or they are attributed to some minor ailment. Abdominal pain is a common sign of advanced pancreatic cancer. Cancer of the body of the pancreas impinges on the celiac ganglion, causing pain. Unplanned weight loss and epigastric pain that may radiate to the back are common complaints. Ask the patient to describe the type and intensity of the pain and also aggravating and relieving factors. Patients often report a dull intermittent pain that has become more intense. Eating and activity often precipitate pain, whereas lying supine or sitting up and bending forward may offer relief. Question the patient as to the presence of any nausea and vomiting (especially that worsens after eating), anorexia, flatulence, diarrhea, constipation, or unusual fatigue.

Physical examination

The diagnosis of pancreatic cancer based on symptoms is difficult because early symptoms are vague and nonspecific. Symptoms may include weight loss, anorexia, fatigue, and epigastric pain. Inspect the patient for the presence and extent of jaundice, which is the presenting symptom in 80% to 90% of patients with cancer of the pancreatic head. The jaundice may have preceded or followed the onset of pain, but it usually progresses along a distinctive pattern: beginning on the mucous membranes, then on the palms of the hands, and finally becoming generalized. If the cancer blocks the release of pancreatic juices into the intestines, the patient may have difficulty digesting fatty foods; this will result in pale, bulky, greasy stools that tend to float in the toilet. Assess for the presence of pruritus and dark urine, which is caused by a buildup of bilirubin in the skin and blood, respectively.

Early tumors usually cannot be palpated, but auscultate, palpate, and percuss the abdomen. If the tumor involves the body and tail of the pancreas, an abdominal bruit may be heard in the left upper quadrant (indicating involvement of the splenic artery) and a large, hard mass may be palpated in the subumbilical or left hypochondrial region. Note the presence of liver or spleen enlargement. Dullness on percussion may indicate the presence of ascites or gallbladder enlargement.

Psychosocial

Assess for the presence of irritability, depression, and personality changes. The sudden onset of characteristic symptoms can precipitate these emotional responses. Families and patients often display profound grief and disbelief upon receiving the diagnosis of pancreatic cancer and a poor prognosis. Assess the specific feelings and fears of the patient and family as well as the support systems available and previous coping strategies.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Computed tomography (CT) scan	Normal structure of the pancreas and surrounding organs and structures	Identifies size and location of tumors	Provides detailed images with multiple cross-sections of the pancreas
Magnetic resonance imaging	Normal structure of the pancreas and surrounding organs, structures, and vessels	Identifies size and location of tumors; determines if vessels are compressed by tumor	Uses radio waves and strong magnets; computer translates pattern of radio waves into detailed images
Abdominal sonogram (ultrasound)	Normal structure of the pancreas	Although CT is more accurate in locating tumors, may be used to rule out pancreatic pseudocysts	Creates oscilloscopic picture from echoes of high-frequency sound waves passing over pancreatic area
Tumor marker antigen; CA 19-9	< 37 AU/mL	Elevated > 1,000 AU/mL indicates metastasis	Elevated levels occur in 80% of patients with late-stage pancreatic cancer; also used after treatment to determine effectiveness or reoccurrence

Other Tests: Upper gastrointestinal (GI) series, positron emission tomography, biopsy of pancreatic tissue, angiography, endoscopic retrograde cholangiopancreatography

Primary nursing diagnosis

Diagnosis

Pain (chronic and acute) related to the effects of tumor invasion and surgical incision

Outcomes

Comfort level; Pain control behavior; Pain: Disruptive effects; Pain level

Interventions

Pain management; Analgesic administration; Positioning; Teaching: Prescribed activity/exercise; Teaching: Procedure/treatment; Teaching: Prescribed medication

Planning and implementation

Collaborative

Surgery, radiotherapy, and chemotherapy are the major treatment modalities for pancreatic cancer. A distal pancreatectomy, used more often with islet cell tumors than with exocrine cancer, removes only the tail of the pancreas or the tail and part of the body. The spleen is also removed. A total pancreatectomy or a pancreatoduodenectomy (Whipple procedure) is used when cure is the objective. In a total pancreatectomy, the entire pancreas and spleen are removed. The Whipple procedure involves removal of the head of the pancreas, distal stomach, gallbladder, pancreas, spleen, duodenum, proximal jejunum, and regional lymph nodes. The procedure induces exocrine insufficiency and insulin-dependent diabetes. A pancreatojejunostomy, hepaticojejunostomy, and gastrojejunostomy are performed with the Whipple procedure to reconstruct the GI system. A vagotomy is usually done in both procedures to decrease the risk of peptic ulcer. A stent may be used for bile duct obstruction.

Careful postoperative management is essential for providing comfort and reducing surgical mortality. Observe vital signs, prothrombin times, drainage from drains, and wounds for signs of infection, hemorrhage, or fistula formation. Report immediately any evidence of increasing abdominal distention; shock; hematemesis, bloody stools; or bloody, gastric, or bile-colored drainage from incision sites. Vitamin K injections and blood components may be needed.

Monitor GI drainage from the nasogastric (NG) or gastrostomy tubes carefully. These tubes are strategically placed during surgery to decompress the stomach and prevent stress on the anastomosis sites. Maintain the tube’s patency by preventing kinks or dislodgment; maintain suction at the prescribed level (usually low continuous suction for an NG tube). Secure gastrostomy tubes in a dependent position. Monitor the color, consistency, and amount of drainage from each tube. The presence of serosanguineous drainage is expected, but clear, bile-tinged drainage or frank blood could indicate disruption of an anastomosis site and should be reported immediately. Do not irrigate the NG or gastrostomy tube without specific orders. When irrigation is ordered, gently instill 10 to 20 mL of normal saline solution to remove an obstruction.

Because postoperative nutritional requirements for adequate tissue healing is approximately 3,000 calories per day, parenteral hyperalimentation is often ordered. Monitor the blood and urine glucose levels every 6 hours and administer insulin as needed. Once oral food and fluids are allowed, the patient is placed on a bland, low-fat, high-carbohydrate, high-protein diet. Administer pancreatic enzyme supplements (pancrelipase [Viokase, Cotazym] and lipase for metabolism of long-chain triglycerides) with each meal and snack. Observe and report any evidence of diarrhea or frothy, floating, foul-smelling stools (an indication of steatorrhea) because an adjustment in the enzyme replacement therapy may be needed.

A combination of adjuvant chemotherapy and radiation therapy with surgery may increase survival time 6 to 11 months. Most patients receive chemotherapy and radiation therapy on an outpatient basis. Palliative surgical procedures can be used to relieve the obstructive jaundice, duodenal obstruction, and severe back pain that are characteristic of advanced disease.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Chemotherapy	Varies with drug	Gemcitabine; fluorouracil (5-FU); cisplatin; irinotecan, paclitaxel; capecitabine; oxaliplatin; streptozocin	Kills cancer cells
Pancreatic enzyme supplements	Varies with drug	Pancrelipase; lipase	Aid in digestion of proteins, carbohydrates, and fats

Other Drugs: Narcotic analgesics delivered via a patient-controlled analgesic device or an epidural catheter are usually ordered postoperatively. Monitor the patient’s response to these devices and encourage their usage to maintain pain at a tolerable level. Administer prophylactic antibiotics as ordered.

Independent

Provide emotional support and information as treatment goals and options are explored. Patients who are newly diagnosed with pancreatic cancer are often in shock, especially when the disease is diagnosed in the advanced stages. Encourage the patient and family to verbalize their feelings surrounding the diagnosis and impending death. Allow for the time needed to adjust to the diagnosis, while helping the patient and family begin the grieving process. Assist in the identification of tasks to be completed before death, such as making a will; seeing specific relatives and friends; or attending an approaching wedding, birthday, or anniversary celebration. Urge the patient to verbalize specific funeral requests to family members.

Help family members identify the extent of physical home care that is realistically required by the patient. Arrange for visits by a home health agency. Suggest that the family seek supportive counseling (hospice, grief counselor) and, if necessary, make the initial contact for them. Local units of the American Cancer Society offer assistance with home care supplies and support groups for patients and families.

Following any surgical procedure, direct care toward preventing the associated complications. Use the sterile technique when changing dressings and emptying wound drainage tubes. Place the patient in a semi-Fowler’s position to reduce stress on the incision and to optimize lung expansion. Help the patient turn over in bed and perform coughing, deep-breathing, and leg exercises every 2 hours to prevent skin breakdown and pulmonary and vascular stasis. Teach the patient to splint the abdominal incision with a pillow to minimize pain when turning or performing coughing and deep-breathing exercises. As soon as it is allowed, help the patient get out of bed and ambulate in hallways three to four times each day. Be alert for the sudden onset of chest pain or dyspnea (or both), which could indicate the presence of a pulmonary embolism.

As the disease progresses and pain increases, large doses of narcotic analgesics may be needed. Instruct the patient on the effective use of the pain scale and to request pain medication before the pain escalates to an intolerable level. Consider switching as-needed pain medication to an around-the-clock dosing schedule to keep pain under control. Encourage the patient and family to verbalize any concerns about the use of narcotics and stress that drug addiction is not a consideration.

Evidence-Based Practice and Health Policy

Risch, H.A., Yu, H., Lu, L., & Kidd, M.S. (2010). ABO blood group, Helicobacter pylori seropositivity, and risk of pancreatic cancer: A case-control study. Journal of the National Cancer Institute, 102(7), 502–505.

Investigators conducted a population-based study comparing 373 cases of patients with pancreatic cancer to 690 age and sex-matched control cases to examine differential cancer risks among patients with varying ABO blood group and Helicobacter pylori seropositivity.
Non-O blood type was associated with a 1.37 times increased risk of pancreatic cancer compared to O blood type (95% CI, 1.02 to 1.83; p = 0.034).
This risk increased to 1.88 times among cases of patients with non-O blood type who were also H. pylori seropositive when compared to the O blood type, H. pylori seronegative control cases (95% CI, 1.14 to 3.08; p = 0.013).
Non-O blood type cases who were also seropositive for CagA-negative H. pylori had the highest risk, which was 2.78 times that of the O blood type, H. pylori seronegative control cases (95% CI, 1.49 to 5.20; p = 0.0014).

Documentation guidelines

Response to the diagnosis of pancreatic cancer, the diagnostic tests, and recommended treatment regimen
Description of all dressings, wounds, and drainage collection devices: Location of drain, color and amount of drainage, appearance of incision, color and amount of GI drainage
Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, and condition of extremities
Response to pain medications, oral intake, and activity regimen
Presence of complications: Hemorrhage, infection, pulmonary congestion, activity intolerance, unrelieved discomfort, absence of return of bowel sounds and function, decrease in urinary output
Bowel pattern: Presence of constipation, diarrhea, steatorrhea

Discharge and home healthcare guidelines

Reinforce the need for small, frequent meals. Warn against overeating at any one meal, which places too great a demand on the pancreas, and stress limiting caffeine and alcohol. Instruct the patient to inspect her or his stools daily and report to the physician any signs of steatorrhea. Teach the patient and family the care related to surgically induced diabetes: symptoms and appropriate treatment for hypoglycemia and hyperglycemia, procedure for performing blood glucose monitoring, and administration of insulin injections. Teach the patient or significant other to change the dressing over the abdominal incision and empty the drains daily (if present).

Teach the patient care of skin in the external radiation field. Instruct the patient to do the following:

Wash the skin gently daily with mild soap, rinse with warm water, and pat the skin dry
Not wash off the dark ink markings outlining the radiation field
Avoid applying any lotions, perfumes, deodorants, or powder in the treatment area
Wear nonrestrictive, soft, cotton clothing directly over the treatment area
Protect the skin from sunlight and extreme cold

Patient discussion about pancreatic cancer

Q. Can any one give me information about Carcinoma of the pancreas? What is the prognosis for carcinoma of the pancreas? I want to know as much as I can information on carcinoma of the pancreas.A. I’m sorry to say that 95% people that have pancreatic carcinoma do not survive. Apparently the area around it and the pancreas itself is without sensory nerves. That means that when it starts to be painful – it’s much too late…this is a silent killer.
Sorry for the bad news…

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pancreatic cancer