PERT in Unresectable Pancreatic Cancer

November is Pancreatic Cancer Awareness Month. For the past two years, a global initiative, coined the Demand Better campaign, has empowered the pancreatic cancer community to “Demand Better” for patients and their survival. The only chance for a cure is surgery, for which only 10% to 20% of diagnosed patients qualify. This month, I’m going to Demand Better by educating colleagues about the use of pancreatic enzyme replacement therapy (PERT) in unresectable (ie, inoperable) pancreatic cancer patients who have exocrine pancreatic insufficiency (EPI), a common complication.

RDs’ knowledge of PERT is particularly important given the rising rates and severity of pancreatic cancer; despite recent advances in detection and management, pancreatic cancer continues to be one of the deadliest cancers, with only 24% of patients surviving past one year and 9% surviving longer than five years. By 2030, pancreatic cancer is expected to surpass colorectal cancer as the second deadliest cancer.

These patients present challenging dilemmas for RDs, as they deal with poor quality of life, failure to thrive, and significant weight loss due to disease-related symptoms such as abdominal pain, diarrhea, and bowel irregularities. How can dietitians help the 80% to 90% of patients with unresectable pancreatic cancer who choose to go up against all odds and undergo multiagent chemotherapy drug regimens in a deconditioned, malnourished state? RDs can improve symptom control by demanding better nutrition. Nutritional counseling often focuses on dietary strategies to alleviate symptoms and improve overall nutritional intake.

EPI is the inability to properly digest food due to a lack of digestive enzymes made in pancreas. Symptoms may include frequent diarrhea or loose stools; weight loss; steatorrhea (due to excess fat content, stools are loose, floating, oily, fatty, foul-smelling, and hard to flush); gas and bloating; and abdominal pain. These may be present in varying degrees in patients.

Causes of EPI in unresectable pancreatic cancer include tumor damage to the pancreatic parenchyma and narrowing or obstruction of the pancreatic duct. Important predictors of EPI include localization of the tumor to the pancreatic head, significant destruction of normal tissue, degree of ductal obstruction, postcibal (occurring after eating) asynchrony, coexisting chronic pancreatitis, and fibrosis/scarring.

In PERT, patients take digestive enzymes containing lipase, amylase, and protease, usually in tablet form, to replace those the pancreas no longer makes or releases due to EPI. The 2019 National Comprehensive Cancer Network guidelines recommend PERT be given to pancreatic cancer patients with symptoms of EPI. This means patients can avoid fecal fat testing, requiring them to consume 50 to 150 g of fat per day and collect stool samples for two to three days. Dietitians can screen for EPI by asking patients what specific symptoms they’re experiencing (ie, diarrhea, bloating/gas particularly after meals). Several recent studies have shown that the use of pancreatic enzymes in unresectable pancreatic cancer helps symptom control of pancreatic, abdominal, and hepatic pain, in addition to improving quality of life and weight. One study showed improved survival in pancreatic cancer patients on enzymes vs those who were not.

Correct dosing of pancreatic enzymes involves a learning curve that must be addressed. Often, patients on PERT are underdosed, leading them to see no benefit and quit taking enzymes. Dietitians should discuss pancreatic enzymes with patients and assess whether their current dose appropriate for their weight and dietary intake. Larger, higher fat meals may require additional enzymes, and taking enzymes throughout the meal also may help with symptom control. Often, pancreatic enzyme manufacturers will provide dosing charts to help providers prescribe the correct weight-based dose. Practitioners may need to increase the dose if symptoms aren’t fully controlled, which they can determine through routine follow-up. Changing pancreatic enzyme brands also may help if one brand of PERT doesn’t offer relief. RDs should educate and help physicians identify and dose patients correctly.

Join me to sign the pledge to Demand Better. Let’s challenge our profession to Demand Better when caring for this population and make a difference by improving symptom control in EPI.

— Whitney B. Christie, MS, RD, CSO, CNSC, is a board-certified specialist in oncology nutrition and certified nutrition support clinician. Her approach to caring for cancer patients is individualized, which she feels can help support the best possible treatment outcomes and positively impact qualify of life during one of the most difficult times in their lives. She lives in King George, Virginia, with her husband and two children.

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