Pancreatic Enzyme Replacement Therapy in Pancreatic Cancer

Abstract

Pancreatic cancer is an aggressive malignancy and the seventh leading cause of global cancer deaths in industrialised countries. More than 80% of patients suffer from significant weight loss at diagnosis and over time tend to develop severe cachexia. A major cause of weight loss is malnutrition. Patients may experience pancreatic exocrine insufficiency (PEI) before diagnosis, during nonsurgical treatment, and/or following surgery. PEI is difficult to diagnose because testing is cumbersome. Consequently, PEI is often detected clinically, especially in non-specialised centres, and treated empirically. In this position paper, we review the current literature on nutritional support and pancreatic enzyme replacement therapy (PERT) in patients with operable and non-operable pancreatic cancer. To increase awareness on the importance of PERT in pancreatic patients, we provide recommendations based on literature evidence, and when data were lacking, based on our own clinical experience.

Pancreatic exocrine insufficiency and pancreatic enzyme replacement therapy in patients with advanced pancreatic cancer: A systematic review and meta‐analysis

“…7,8 Malnutrition in APC is multifactorial, but PEI leading to maldigestion and secondary malnutrition plays a major role. 9,31 Patients with PEI reported the worst quality of life mainly due to difficulties managing gastrointestinal complaints, diet and digestion. 32 In the present study, PEI was diagnosed in over three out of four patients with APC, and there was a threefold increase in the prevalence of PEI in tumours located in the head of the pancreas compared to those located in the body-tail; 40% of those patients had severe PEI based on FE-1 levels.…”

“…Malnutrition, weight loss, sarcopenia and cachexia are related to chemotherapy‐induced toxicity and worsening of quality of life and survival in several reports 7,8 . Malnutrition in APC is multifactorial, but PEI leading to maldigestion and secondary malnutrition plays a major role 9,31 . Patients with PEI reported the worst quality of life mainly due to difficulties managing gastrointestinal complaints, diet and digestion 32 …”

Profiling of Adipose and Skeletal Muscle in Human Pancreatic Cancer Cachexia Reveals Distinct Gene Profiles with Convergent Pathways

“…The pathophysiology of PDAC cachexia involves a complex interplay between the host and tumor interactions which results in inflammation, malnutrition, anorexia, and neuroendocrine changes. These complex interactions lead to a series of metabolic changes including Warburg effect resulting in increased Cori cycle, lipolysis and decreased lipogenesis [ 9 , 10 , 11 ]. Studies using animal models have helped uncover many mechanisms that cause muscle and fat wasting [ 12 , 13 , 14 , 15 , 16 , 17 , 18 ], and newer animal models are constantly developed to study PDAC and understand cachexia mechanisms [ 19 , 20 ].…”

State of the Art in Exocrine Pancreatic Insufficiency

“…EPI is almost always produced by a pancreatic disease, with the most frequent cause being chronic pancreatitis in adults [ 10 , 11 ] and cystic fibrosis in children [ 4 ]. Other etiologies include acute pancreatitis [ 12 , 13 ], pancreatic tumors [ 14 ], diabetes mellitus [ 15 , 16 ], celiac disease, inflammatory bowel disease [ 17 , 18 ], gastrointestinal and pancreatic surgery [ 19 , 20 , 21 ], HIV and genetic and congenital factors. Some of these causes have are less frequent, and there is even debate around their true role in the etiology of EPI.…”