Update: Strategies for managing pancreatic cancer pain

Contents

UPDATE AT A GLANCE

What is this update about?

This study reviewed pain management strategies for people with pancreatic cancer.

Why is this update important?

Pancreatic cancer, though relatively uncommon, is the third leading (and by 2030 is projected to be second leading) cause of cancer death in the U.S. That’s because it is often found after the disease has already progressed to an advanced stage. When advanced disease is found, treating the symptoms and delaying the spread of cancer, rather than curing it, is the main focus of healthcare providers.

Many people with pancreatic cancer experience cancer-related pain that decreases their quality of life and survival. The study authors cited a survey by the Pancreatic Cancer Action Network determined that 93 percent of patients experience pain related to their diagnosis, and 83 percent reported moderate to severe levels of pain. Pain leads to poor survival outcomes because patients in pain often eat less, get less sleep, are limited in their ability to work and socialize, and are less tolerant of chemotherapy.

One of the most common symptoms of pancreatic cancer is mid-abdominal or back pain. Unlike pain from other cancers, pancreatic pain typically persists at severe levels even when the disease responds well to treatment. Managing this pain is essential to the well-being and quality of life of people living with pancreatic cancer, yet few studies have investigated strategies for best mitigating pancreatic pain.

The causes of pancreatic cancer pain are complex, complicating pain management strategies. This review of the literature analyzed different strategies for pain management in patients with pancreatic cancer to better understand how well each approach reduces pain.

What causes pancreatic cancer pain?

• Nerve pressure: Some pancreatic tumors press against nerves near the pancreas and cause pain.  
• Nerve damage: Pancreatic tumors can invade the nerves surrounding the pancreas. About 70 percent of patients have pancreatic cancers with nerve involvement. Cancer that grows into the nerves can lead to inflammation and cause pain by physically disrupting nerve function.
• Blocking the pancreatic duct: Tumors may block the main pancreatic duct, which carries digestive enzymes from the pancreas to the small intestine. This results in decreased pancreatic enzymes that can disrupt food digestion and cause pressure in the pancreas.

Pain management strategies

Tumor-targeting therapies

• Chemotherapy: When pancreatic cancer is advanced and surgery to remove the cancer is not an option, chemotherapy may relieve cancer-related pain by shrinking the tumor. Combinations of chemotherapy drugs can preserve quality of life, increase survival and decrease pain for people with pancreatic cancer.
• Radiation therapy: Radiation therapy can reduce pain for people with advanced pancreatic cancer. Radiation therapy sessions can last a few minutes or up to 30 minutes. Typically, radiation therapy sessions are repeated 5 days a week for 2-5 weeks. In some studies, more than 60 percent of people reported reduced pain after radiation therapy, and about half reported no further pain.
  • Stereotactic body radiation therapy is a newer form of radiation therapy that more precisely delivers higher doses to specific areas of the body. These radiation sessions typically last 15-60 minutes and are repeated 1-5 times within a 2-week period; these are shorter treatment regimens than more conventional radiation therapy. In a recent review of pancreatic cancer patients, 80 percent experienced reduced pain with this type of therapy, and 54 percent reported that they no longer had pain.
     

Acetaminophen and nonsteroidal anti-inflammatory drugs

For many people, these common over-the-counter drugs are the first defense against cancer-related pain. However, taking these drugs for severe and persistent pain is not recommended. Long-term use at high doses is associated with liver damage, gastritis, ulcers and kidney damage. Additionally, using these medications alongside chemotherapy may increase the likelihood of harmful side effects.

Opioids

The vast majority of patients with pancreatic cancer are prescribed opioids for managing their pain. This class of drugs includes morphine, codeine, oxycodone and fentanyl, among others. Opioids activate the parts of the nervous system that regulate pain, mood, stress, gastrointestinal functions and breathing. They also cause the release of neurotransmitters in the brain that produce pleasure, creating feelings of euphoria.

While highly effective at relieving pain, opioids can cause a number of side effects and can be potentially addictive. Common side effects of opioid use include excessive drowsiness, itchy skin, bloating, nausea and constipation. Other more serious side effects may also occur, including respiratory problems, confusion and a risk of overdose. With careful monitoring and dosing, opioids have proven to reduce pain in patients with pancreatic cancer, improving their physical function, appetite, quality of life and overall survival.

One retrospective study showed that people with advanced pancreatic cancer who were prescribed a 60-day supply of opioids survived two months longer on average than patients who weren’t prescribed opioids, suggesting adequate pain management can improve both quality and quantity of time.

Procedures for pain relief

• Celiac plexus neurolysis: This outpatient procedure, also known as CPN, relieves pain by destroying the celiac plexus, the bundle of the nerves behind the pancreas that most often relays pain. To perform this procedure, a healthcare provider injects the celiac plexus with alcohol (ethanol or phenol), which kills the nerves. CPN is commonly performed for advanced cancer patients whose pain has not responded well to medication. This procedure can reduce abdominal pain for 3-4 months. However, pain can return if the disease progresses to areas that are connected to other abdominal nerves. CPN usually decreases a person’s reliance on opioids for pain relief.
• Thoracoscopic splanchnicectomy: This minimally invasive procedure, known as TS, cuts the nerve branches connected to the pancreas to relieve pain. Pain relief can last up to several weeks and can reduce opioid use.

Pancreatic enzyme replacement therapy

When cancer cells block the main pancreatic duct, digestive enzymes from the pancreas can’t enter the small intestine. Low digestive enzyme levels prevent food from being completely digested and lead to abdominal pain and malnutrition. Pancreatic enzyme replacement therapy (PERT) can help reduce pain and improve the quality of life and nutrition for people with pancreatic cancer. However, a 2021 study found that out-of-pocket costs for Medicare beneficiaries averaged about $1,000 for a 30-day supply of PERT medication. The authors report that this prohibitively high cost, on top of the cost of cancer treatments and care, could be one reason why healthcare providers underprescribe this supportive care therapy for people with pancreatic cancer. Fortunately, some of these medications have recently become generic, offering a much more affordable option for patients.

Implanted pain pumps

Pain pumps are small containers of pain medication that can be implanted under the skin. They automatically dose and deliver pain medication (usually opioids) to the space surrounding the spinal cord. Opioids administered in this way reduce pain while using lower doses than medication taken by mouth, resulting in fewer side effects. Risks of this procedure include bleeding, infection, and, in rare cases, spinal fluid leakage. One observational study showed that implanted pain pumps reduced pain levels by 50 to 75 percent in patients with pancreatic cancer and that similar levels of pain reduction were sustained for up to three months.

Integrative therapies

• Acupuncture: In this ancient practice of Traditional Chinese Medicine, a skilled practitioner places extremely thin needles under the skin and gently moves them by hand or with electrical impulses. Some studies report that acupuncture reduced visceral pain by 30-50 percent, with pain relief beginning 24 hours after the procedure and lasting several hours to several days. A recent randomized controlled trial found that daily acupuncture for 3 days reduced pain intensity by 40% for people with pancreatic cancer, compared to individuals who received a fake acupuncture procedure.
• Transcutaneous electrical nerve stimulation (TENS): In this non-invasive, low-risk strategy, a healthcare provider places electrodes on the skin in the areas with pain. Low-voltage electrical impulses travel through the electrodes stimulate the nerve cells. Though scientists are unsure how it works, this stimulation decreases pain by blocking pain signals, changing a patient’s perception of their pain or stimulating the release of endorphins, the body’s pain-killing chemical. Studies show that TENS can reduce pain by 20-50% within 30 minutes of stimulation, and the effects can last 1 to several hours after the procedure. TENS is not recommended for people who are pregnant or who have a cardiac pacemaker.
• Marijuana and synthetic cannabinoids: Historically, people have used marijuana for its various mental and physical effects, including pain relief. Although studies have shown that both ingesting and inhaling cannabis can reduce chronic pain associated with nerve damage and arthritis and cancer in general, there is little data suggesting it reduces pain for patients with pancreatic cancer. Two synthetic cannabinoids have been approved by the U.S. Food and Drug Administration for treating chemotherapy-related nausea and vomiting, but these have not been effective in treating pain. Randomized controlled clinical trials are needed to understand how cannabis affects pain in people with cancer. Side effects of marijuana include decreased motor control, disorientation, anxiety and if smoked, smoking-related health consequences.

What does this mean for me?

If you have been diagnosed with advanced pancreatic cancer and are experiencing prolonged pain, you could benefit from one or more pain-relieving strategies discussed in this review. Relieving your pain should be a priority of your healthcare provider, given that properly managed pain has been linked to improved quality of life, improved response to anticancer treatment and prolonged survival. They might refer you to a pain or palliative care specialist who can help you decide which approach would work best for you.

Reference

Coveler AL, Mizrahi J, Eastman B, et al. Pancreas cancer-associated pain management. The Oncologist 2021; 26: Issue number 6. Published online May 12, 2021.

Disclosure: FORCE receives funding from industry sponsors, including companies that manufacture cancer drugs, tests and devices. All XRAYS articles are written independently of any sponsor and are reviewed by members of our Scientific Advisory Board prior to publication to assure scientific integrity.

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