Pancreatic enzyme replacement therapy (PERT) for malabsorption in patients with metastatic pancreatic cancer

Landers, Amanda; Muircroft, Wendy; Brown, Helen

doi:10.1136/bmjspcare-2014-000694

Cited by 46 publications

(40 citation statements)

References 20 publications

(20 reference statements)

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“…This was confirmed in a survey conducted on members of the Dutch and German patient associations for pancreatic disorders, that clearly showed that most patients suffering from PEI after pancreatic surgery are undertreated even in countries with well-organized health care systems [41]. In an Australian retrospective study on 129 patients with metastatic pancreatic cancer and symptoms that could be attributable to malabsorption, only 21% patients were prescribed PERT [42]. Another study highlighted a clear clinical gap in managing PEI in patients with supportive care for pancreatic cancer [43].…”

Section: Pancreatic Enzyme Replacement Therapy (Pert)mentioning

confidence: 88%

Pancreatic Exocrine Insufficiency in Pancreatic Cancer

et al. 2017

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Cancer patients experience weight loss for a variety of reasons, commencing with the tumor’s metabolism (Warburg effect) and proceeding via cachexia to loss of appetite. In pancreatic cancer, several other factors are involved, including a loss of appetite with a particular aversion to meat and the incapacity of the pancreatic gland to function normally when a tumor is present in the pancreatic head. Pancreatic exocrine insufficiency is characterized by a deficiency of the enzymes secreted from the pancreas due to the obstructive tumor, resulting in maldigestion. This, in turn, contributes to malnutrition, specifically a lack of fat-soluble vitamins, antioxidants, and other micronutrients. Patients with pancreatic cancer and pancreatic exocrine insufficiency have, overall, an extremely poor prognosis with regard to surgical outcome and overall survival. Therefore, it is crucial to be aware of the mechanisms involved in the disease, to be able to diagnose pancreatic exocrine insufficiency early on, and to treat malnutrition appropriately, for example, with pancreatic enzymes.

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Section: Pancreatic Enzyme Replacement Therapy (Pert)mentioning

confidence: 88%

Pancreatic Exocrine Insufficiency in Pancreatic Cancer

et al. 2017

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“…Despite these benefits, evidence suggests that clinicians are not initiating treatment often enough, nor replacing enzymes adequately. A recent study showed that only 21% of patients with pancreatic cancer received PERT, despite 70% reporting symptoms consistent with fat maldigestion[ 28 ]. A Northern European cross sectional survey of patients receiving PERT found 68% had steatorrhoea and 39% had weight loss.…”

Section: Management Of Pancreatic Exocrine Insufficiencymentioning

confidence: 99%

Challenges in the management of pancreatic exocrine insufficiency

Shandro

Nagarajah

Poullis

2018

WJGPT

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Pancreatic exocrine insufficiency (PEI) occurs when the insufficient secretion or function of pancreatic enzymes leads to maldigestion, most commonly as a result of chronic pancreatitis and pancreatic cancer. The condition is associated with significant morbidity and reductions in quality of life, even in milder forms. The challenges in approaching this condition include the non-specific presentation of mild to moderate PEI, and the lack of a convenient, accurate diagnostic test in this cohort. Classical symptoms appear late in the disease, and the diagnosis should be considered before steatorrhoea develops. Direct pancreatic function tests are the reference standard for diagnosis, but are invasive and not widely available. The faecal elastase-1 (FE-1) stool test is widely available and has been shown to be as effective as the 13C-mixed triglyceride breath test in more advanced disease. We recommend a pragmatic diagnostic approach that combines clinical history, assessment of nutritional status and measurement of FE-1. The critical first step is to consider the diagnosis. Once the diagnosis is confirmed, pancreatic enzyme replacement therapy should be initiated. The variety of enzyme preparations and recommended dosing regimens can present a challenge when selecting an adequate initial dose. Non-response should be actively sought and addressed in a systematic manner. This article discusses these challenges, and presents a practical approach to the diagnosis and management of PEI.

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“…In addition, PERT was associated with significant improvement in fat and protein digestion in patients with a partial/total pancreatic resection [ 28 ]. Of note, a recent study reported low rates of PERT prescription (21%) in patients with metastatic pancreatic cancer, in which the vast majority of patients had tumors of the pancreatic head and were likely to have had a blocked pancreatic duct [ 29 ].…”

Section: Introductionmentioning

confidence: 99%

Impact of the treatment of pancreatic exocrine insufficiency on survival of patients with unresectable pancreatic cancer: a retrospective analysis

et al. 2018

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BackgroundMalnutrition and weight loss are commonly observed in patients with pancreatic cancer and contribute to poor survival. Pancreatic exocrine insufficiency (PEI), which can be caused by ductal obstruction by a tumor, causes maldigestion and malabsorption of nutrients, thus contributing to malnutrition in these patients. In this study, we evaluated the effects of pancreatic enzyme replacement therapy (PERT) on survival in patients with unresectable pancreatic cancer.MethodsA retrospective analysis was conducted on a database of patients with unresectable, pathologically confirmed pancreatic cancer. All patients were evaluated for palliative chemotherapy and received the optimal palliative care. Patients were divided into two groups: Group 1 received standard therapy; Group 2 underwent additional evaluation of the pancreatic function and therapy with PERT, if needed. Survival (median and 95% confidence interval [CI]) was analyzed using Kaplan–Meier and Cox regression; groups were compared using the log-rank test.ResultsOverall, 160 patients with unresectable pancreatic cancer were included in the analysis (mean age: 70.5 years [range 28–100]; gender: 57.5% male; tumor stage: 78.7% Stage IV). Eighty-six patients (53.75%) were in Group 1 and 74 (46.25%) were in Group 2. Age, gender, tumor size, location and stage, weight loss, and serum CA 19–9 were similar between groups. Ninety-three (58.1%) patients received palliative chemotherapy; 46.5% in Group 1 and 71.6% in Group 2 (P < 0.001). Forty-nine (66.2%) patients in Group 2 and none in Group 1 received PERT. Survival in Group 2 (189 days, 95% CI 167.0–211.0 days) was significantly longer than in Group 1 (95.0 days, 95% CI 75.4–114.6 days) (HR 2.117, 95% CI 1.493–3.002; P < 0.001). Chemotherapy and PERT were significantly and independently associated with longer survival in a model controlled by age and tumor stage. In patients with significant weight loss at diagnosis (> 10% bodyweight within 6 months), PERT was associated with longer survival (HR 2.52, 95% CI 1.55–4.11; P < 0.001).ConclusionsIn patients with unresectable pancreatic cancer, PERT in patients with PEI was associated with longer survival compared with those not receiving PERT, especially in those experiencing significant weight loss. This finding should guide future prospective clinical trials of similar interventions.

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Pancreatic enzyme replacement therapy (PERT) for malabsorption in patients with metastatic pancreatic cancer

Abstract: Guidelines recommending empiric treatment of PERT in patients with metastatic PC are not currently being utilised.

Cited by 46 publications

References 20 publications

Pancreatic Exocrine Insufficiency in Pancreatic Cancer

Pancreatic Exocrine Insufficiency in Pancreatic Cancer

Challenges in the management of pancreatic exocrine insufficiency

Impact of the treatment of pancreatic exocrine insufficiency on survival of patients with unresectable pancreatic cancer: a retrospective analysis

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