Ronnie, a 68-year-old patient with stage IV pancreatic ductal adenocarcinoma, recently started palliative FOLFIRINOX chemotherapy, a regimen consisting of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin, every two weeks. During his toxicity evaluation, prior to starting his second cycle, he describes a few concerning symptoms that have been ongoing for several weeks, including unintentional weight loss of 15 kg over the last two months, significant bloating after meals, and frequent flatulence with oily stools that are difficult to flush.
What Would You Do?
Pancreatic exocrine insufficiency (PEI) is a phenomenon that patients with pancreatic tumors frequently experience, especially those with tumors in the head or uncinate process of the pancreas.
A normally functioning pancreas releases enzymes into the pancreas ducts in response to food in the stomach as part of the gastropancreatic reflex. The enzymes flow toward the ampulla of Vater and are expelled into the duodenum to assist with food breakdown and nutrient absorption. However, pancreatic tumors obstruct the ducts and inhibit adequate flow of enzyme expulsion.
PEI can often go unnoticed for an extended period of time. However, when enzyme insufficiency reaches a significant level, patients can experience malnutrition, weight loss, bloating, flatulence, and steatorrhea.
The most effective treatment for PEI is pancreatic enzyme replacement therapy (PERT), which is administered as enteric-coated capsules with meals to simulate normal pancreatic function and assist with food breakdown and absorption. When used correctly and under the close guidance of a clinician, PERT has been shown to improve quality of life and survival of patients with pancreatic cancer.
Depending on capsule concentration, patients often require several capsules with each meal and with snacks. Rather than taking all the capsules prior to or following a meal, patients should take the capsules throughout the meal, especially if they are only able to eat small, frequent meals because of early satiety.
Patients do not need to dramatically alter their diet while on PERT, but they should aim for a well-balanced diet with sufficient protein. Dosing for PERT is highly individualized and dependent on the patient’s response to therapy. Nurses should routinely assess for signs of improvement or worsening PEI in patients receiving PERT.
PERT can be financially toxic for patients. Nurses should collaborate with the interdisciplinary team to explore options for copay assistance or more affordable formulations. Ensuring appropriate use of PERT and limiting overuse can also assist with financial toxicity.
PEI is widely underreported and undertreated in patients with pancreatic cancer. Nurses serve a pivotal role in the recognition and management of patients with PEI.
Clinicians and nurses must frequently assess for PEI in patients with pancreatic cancer, intervene as soon as possible, and educate and provide guidance to patients receiving PERT to ensure its effectiveness. Education should include reviewing the dose, frequency, and strategies for taking the prescribed pancreatic enzymes. Pancreatic cancer is a complex disease, but by advocating for patients and removing barriers to appropriate care, nurses can help improve their quality of life.
You carefully document Ronnie’s symptoms and, in collaboration with his provider, you start him on PERT. During the toxicity evaluation, you educate Ronnie on the dose and frequency and instruct him about when to contact the care team while taking PERT. One week later, you call Ronnie to assess his symptoms. He notes a decrease in frequency of loose stools and less bloating with meals. You advise him to continue on the same dose of PERT and plan for continued weekly follow-ups for the first month of therapy.