Pancreatic cancer is the fourth leading cause of cancer mortality in the United States. Individuals with pancreatic cancer are often present with non-specific symptoms which may contribute to the delay of proper diagnosis. Symptoms may include weight loss, nausea, abdominal discomfort and upper and/or lower back pains. Often times, pancreatic cancer is detected in its later stages and pain management becomes a factor in maintaining the quality of life for pancreatic cancer survivors.
Conservative Pain Management
1) Non-Opioids: NSAIDS (non-steroidal anti-inflammatory), Acetaminophen, and Anticonvulsants. Some non-opioid medications are available over the counter however most used for individuals with pancreatic cancer require a doctor's prescription.
NSAIDS: There are several types of anti-inflammatories available. Most often prescribed are Vioxx and Celebrex as they have fewer gastrointestinal side effects.
Acetaminophen: Often times alone is not strong enough for the treatment of pancreatic cancer pain. Acetaminophen can be used in combination with narcotic pain medication for mild to moderate pain (i.e. Percocet).
Anticonvulsants: Anti-seizure medications such as Neurontin are sometimes used to treat nerve pain and can be effective, especially if the tumor is compressing nerve ganglia.
2) Narcotic/Opioid Pain Medications are available by doctor's prescription and are the main methods of medical management of pain for individuals with pancreatic cancer. There are several types and brands of narcotic medications. Some of the drugs commonly prescribed are: Morphine (oral or patient controlled analgesia/PCA), Oxycodone, Percocet, Methadone and Fentanyl (Patch). Finding a dosage that helps to manage pain with minimal side effects can be challenging and often takes a period of trial and error. Common side effects are dizziness, drowsiness, nausea, vomiting, loss of appetite, constipation and at higher dosages altered mental status and hallucination. Where nausea is a factor and patients are unable to take pills orally, medication can be administered via a patch on the skin.
Surgical Pain Management
1) Whipple Resection: If detected early on, the pancreatic tumor may be removed surgically. Individuals who are candidates for surgical removal of the tumor usually have a better prognosis for a longer survival with fewer complications involving severe pain.
2) Palliative Double By-pass (Roux-en-Y Procedure): When surgical resection of the pancreas is not a viable option and the individual suffers from bile and/or intestinal obstruction due to the tumor compressing it, this surgical procedure re-routes the flow of bile and stomach contents to the intestines. This procedure may alleviate jaundice, nausea, stomach pains and vomiting.
3) Celiac Nerve block: If the pancreatic tumor is pressing on the nerves (the celiac plexus) that are near the spine, it may cause severe, intense abdominal and/or back pains. A celiac nerve block, usually done under anesthesia, involves the injecting of alcohol into/around the celiac ganglia, and may help to temporarily decrease nerve pain and therefore decrease the need for narcotic drugs.
Pain is very subjective and can be difficult to manage in patients with pancreatic cancer. It is helpful to use quantitative data such as visual analog scales or numerical pain intensity scales to monitor the efficacy of drugs and/or surgical interventions. Consistent daily and sometimes hourly tracking of pain levels and side effects can help a patient determine which drugs/interventions or combination of drugs allow for the best quality of living. Caregiver support and assistance in documentation of drug delivery and patient's response in a written log are also helpful. This article is dedicated to my father, a six month survivor.
