Rasmussen College Pancreatic Cancer Advances in Treatment Assignment Treatment options for acute and chronic diseases continue to advance in efforts to cur

Rasmussen College Pancreatic Cancer Advances in Treatment Assignment Treatment options for acute and chronic diseases continue to advance in efforts to cure diseases or manage symptoms and improve quality of life. While working in healthcare, it is important to be able to research treatment options to understand the different treatments or questions patients may need to consider.Select 1 disease directly related to one of the body systems reviewed in this module. Research and select a peer reviewed article written within the past 5 years discussing treatment options for the selected disease and write a 1-page (minimum) Annotated Bibliography. For annotated bibliographies, use standard APA format for the citations, then add a brief entry, including:2 to 4 sentences to summarize the main idea(s) of the source including a brief summary of the disease and treatment option(s).1 or 2 sentences to assess and evaluate the source including if this information is reliable and discuss if the source is objective or biased.1 or 2 sentences to reflect on the source including how this information can benefit a patient and your understanding of the selected disease.Use APA formatting for your citations and references. For more information on APA, navigate to the Resources tab in this course.Pancreatic CancerFull Text AvailableQuick LessonSchub T; Pravikoff D; CINAHL Nursing Guide, EBSCO Publishing, 2018 Jul 06 (Quick Lesson), Database: Nursing Reference Center PlusSubjects: Pancreatic NeoplasmsAdd to folderHTML Full Text PDF Full TextSave PDF to Cloud QUICK
LESSON
Pancreatic Cancer
Description/Etiology
Pancreatic cancer (PC) is difficult to diagnose in its early stages and is almost always
fatal. The characteristics and clinical manifestations of PC depend on whether the tumor
is located in the head, body, or tail of the pancreas, and if exocrine or endocrine gland
tissue is involved. Exocrine cells and ducts compose most of the pancreas, producing
digestive enzymes and carrying them to the small intestine. Exocrine PC is the most
common type of PC, accounting for 95% of PC cases, with adenocarcinoma representing
95% of exocrine tumors. Endocrine cells represent a very small portion of the pancreas,
are grouped in clusters called islets, and release the hormones insulin and glucagon into
the blood. Endocrine tumors are uncommon, are classified as functioning (i.e., producing
hormones [e.g., insulin, glucagon]) and nonfunctioning, and have a much better prognosis
than pancreatic adenocarcinoma.
The exact etiology of most cases of PC is unknown, but some are believed to result at least
in part from inherited or acquired genetic mutations. Patients with PC often already have
metastatic disease at the time of diagnosis, not only because malignant cells travel easily
throughout the peritoneal cavity, but because the initial clinical manifestations of PC are
nonspecific and diagnosis is often delayed. There is no effective screening test for PC. PC
usually first metastasizes to the regional lymph nodes, then to the liver and, on occasion, to
the lungs. PC can also directly invade surrounding organs (e.g., duodenum, stomach, colon)
and metastasize to any surface in the abdominal cavity via peritoneal spread.
ICD-9
157.9
ICD-10
C25
Authors
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Mary Woten, RN, BSN
Cinahl Information Systems, Glendale, CA
Reviewers
Morgan Nicole Holle, RN, BSN, OCN
Cinahl Information Systems, Glendale, CA
Obiamaka Oji, DNP, APRN, FNP-BC
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Pravikoff, RN, PhD, FAAN
Cinahl Information Systems, Glendale, CA
PC is staged using the tumor, node, metastasis (TNM) staging system. Treatment and
prognosis vary according to tumor type and stage. If the tumor is resectable, surgery is
standard treatment for both exocrine and endocrine PC. Neoadjuvant chemotherapy with
radiation therapy prior to surgery can be beneficial in patients with PC, particularly in those
with borderline resectable tumors. Resection is most often curative in patients with PC in
the head of the pancreas; these patients are more likely to be diagnosed early because of
the close proximity of the malignancy to the bile duct causes earlier onset of symptoms
(e.g., pruritus, urine darkening, stool changes. Surgical intervention for PC in other parts
of the pancreas can be attempted if complete tumor removal is considered possible; these
surgical procedures are pancreaticoduodenectomy (also called the Whipple procedure; i.e.,
removal of the head and body of the pancreas, gallbladder, and part of the stomach, small
intestine, common bile duct, and lymph nodes; surgically connecting the bile duct to the
duodenum), distal pancreatectomy (i.e., removal of the tail and/or body of the pancreas
and/or spleen), and total pancreatectomy (i.e., removal of the entire pancreas and spleen).
Adjuvant postoperative chemotherapy can increase survival by up to 3 months; adjuvant
radiation therapy is not of benefit for most patients. Surgical intervention for palliation
to relieve bile duct blockage has been widely replaced by endoscopic metal or plastic
stent placement. Radiation therapy, chemotherapy (e.g., gemcitabine for exocrine PC;
streptozotocin for both functioning and nonfunctioning types of endocrine PC), or both can
be used to treat nonresectable PC or as adjuvant treatment to surgery. Pain management,
nutritional support, and other palliative care interventions are essential to improve quality of
life (QOL), and referral to hospice is usual.
July 6, 2018
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or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Facts and Figures
PC is the tenth most common cancer diagnosed in the United States but the fourth leading cause of cancer death, accounting
for 7% of all cancer-related deaths (Dragovich et al., 2017). The American Cancer Society (ACS) estimates that55,440 new
cases of PC will be diagnosed and 44,330 people will die of the disease in the U.S. in 2018 (ACS, 2018). In most countries,
the incidence of PC is 8–12 cases per 100,000 per year. Approximately 75% of PCs occur in the head or neck of the pancreas,
15–20% occur in the body of the pancreas, and 5–10% occur in the tail of the pancreas. The median age at diagnosis of PC
is 69 years in Whites and 65 years in Blacks. At diagnosis, 20% of patients have localized, potentially resectable disease,
40% have locally advanced disease, and40% have distant metastases at the time of diagnosis. The overall median survival is
4–6 months; survival is lower in patients with significant weight loss, lower performance status, and metastasis to the liver.
Patients who have undergone successful resection have a median survival of 12-19 months, and a 5-year survival of 15-20%.
(Dragovich et al., 2017)
Risk Factors
Smoking appears to be the most prominent risk factor for PC; risk for developing PC is increased at least 2-fold in current
smokers and 30% of PCs are thought to be related to smoking. Chronic pancreatitis confers a 26-fold increased risk for PC.
Between 5% and 10% of patients with PC have a family history of the disease. Additional risk factors include older age; male
gender; being a Black person living in the U.S.; diabetes mellitus (DM); low vitamin D levels; a diet high in fat and/or meat;
using smokeless tobacco; inherited genetic mutations such as family syndromes involving BRCA2, p16, or PRSS1 mutations;
exposure to maternal smoking in utero or as a young child; overweight and obesity; physical inactivity; consumption of 3 or
more alcoholic beverages per day; sarcoidosis; chronic hepatitis; infection with Helicobacter pylori; and occupational exposure
to certain chemicals (e.g., beta-naphthylamine,benzidine).
Signs and Symptoms/Clinical Presentation
The clinical presentation of patients with PC can include jaundice, pruritus, upper abdominal and/or back pain,
nausea/vomiting, loss of appetite, severe weight loss, weakness, fatigue, sleep disturbance,and an impaired sense of
well-being.Additionally, endocrine tumors can cause obstructive symptoms, gastrointestinal tract bleeding, or abdominal
masses; functioning endocrine tumors hypersecrete insulin or glucagon and can cause hypoglycemia, glucose intolerance,
hypokalemia, and Cushing’s syndrome. Patients can also demonstrate anxiety and depression.
Assessment
› Physical Findings of Particular Interest
• Dark-colored urine, clay-colored stools, and yellow skin and sclera indicate jaundice
• Physical examination of the abdomen can reveal tenderness and/or a well-defined mass in the subumbilical or left
hypochondrial region; ascites and enlargement of the liver, gallbladder, and/or spleen can be present
› Laboratory Tests
• Tumor markers CA 19-9 and carcinoembryonic antigen (CEA) are elevated in advanced PC; a CA 19-9 value > 100 U/
mL strongly indicates PC, and levels are monitored for response during treatment; genetic testing can reveal PC-related
mutation
• Serum levels of bilirubin, alkaline phosphatase, and gamma-glutamyltranspeptidase (GGT) are significantly elevated in
patients with obstructive jaundice
• Serum levels of albumin and/or cholesterol can indicate malnutrition; liver, kidney, and/or bone marrow function tests can
reveal underlying abnormalities
• Glucosuria, hyperglycemia, and impaired glucose tolerance can be present
• Histologic analysis of biopsied tumor specimen confirms the diagnosis
› Other Diagnostic Tests/Studies
• Multiphase thin-cut spiral CT scan with radiocontrast will show abnormalities that indicate PC; CT scan can provide
information that assists with biopsy, staging, and identification of metastasis; endoscopic ultrasound identifies smaller
tumors than CT scan and can also be helpful in identifying area(s) for biopsy and in staging
• Endoscopic retrograde cholangiopancreatography (ERCP) will identify bile/pancreatic duct obstruction in jaundiced
patients and resolve obstruction by stent placement
• MRI or PET scan will identify metastasis; angiography will identify vascular abnormalities that prohibit surgical resection
Treatment Goals
› Provide Symptomatic Relief and Reduce Risk of Treatment-RelatedComplications
• Monitor all physiologic systems for underlying conditions and PC complications; frequently assess for pain, pruritus, and
other discomfort; provide prescribed treatment
–For information about management of pain (which can be severe and debilitating) in patients with PC, see Quick Lesson
About … Pancreatic Cancer and Pain
• Promote optimum hydration and nutrition; give prescribed parenteral fluids, enteral feedings, and pancreatic enzymes, as
ordered
• Follow facility pre- and post-treatment protocols if patient becomes a candidate for surgery, radiation therapy, and/or
chemotherapy; reinforce pre- and post-treatment education and verify completion of facility informed consent documents;
closely monitor the patient post-treatment for adverse effects and complications (see Red Flags , below)
› Educate and Promote Emotional Well-Being
• Assess the anxiety level and coping ability of the patient and family; educate and encourage discussion about the disease
process, treatment options, and end-of-life issues, as appropriate
• Request referral to a dietitian for nutrition evaluation/education; to a mental health clinician for counseling on coping
strategies; and to a social worker for identification of resources for in-homeservices, hospice, Internet information, and
support groups
Food for Thought
› Carcinogenesis of PC begins roughly 10 years prior to the onset of symptoms
› Among the potential PC treatment strategies under investigation is the use of nanotechnology to improve drug delivery
› Vitamin intake—particularly of Vitamins D and B12—may decrease risk for PC (Liu et al, 2018)
› Early diagnosis and treatment of PC are associated with improved prognosis, but early diagnosis is difficult and there
is currently a lack of biomarkers available to aid in the identification of patients with early-stage PC. Researchers in a
recent study identified 38 microRNAs (i.e., short, noncoding RNAs that play important roles in cancer development and
metastasis) in whole blood that are significantly dysregulated in patients with PC, and they constructed 2 diagnostic panels
of microRNAs that can have the potential to identify patients with early-stage PC. Additional research is needed to confirm
the diagnostic utility of these panels (Schultz et al., 2014)
› Researchers found that serum tumor marker levels of CA 19-9, lactic dehydrogenase (LDH) and CEA had significant
prognostic roles on survival in patients diagnosed with metastatic PC receiving gemcitabine-basedchemotherapy (Tas et al.,
2014)
› In a 2014 study, researchers concluded that baseline hemoglobin-a1c levels are significantly higher in patients diagnosed
with pancreatic ductal adenocarcinoma versus benign pancreatic disease and seem to affect overall survival (Fan et al., 2014)
Red Flags
› Pancreaticoduodenectomy carries a significant risk for complications, including leaking from new surgical connections,
delayed gastric emptying, bleeding, and infection. Surgery for PC should be performed only in facilities that perform at least
15-20 procedures annually
› Monitor patients with endocrine PC for hyperinsulinism that leads to severe hypoglycemia, and immediately administer
prescribed oral or parenteral glucose
What Do I Need to Tell the Patient/Patient’s Family?
› Continued medical surveillance is essential, and end-of-life issues should be addressed
References
1. American Cancer Society. (2018). Pancreatic cancer. Retrieved May 29, 2018, from http://www.cancer.org/acs/groups/cid/documents/webcontent/003131-pdf.pdf (GI)
2. Dragovich, T., Erickson, R. A., Larson, C. R., & Shabahang, M. (2017, July 15). Pancreatic cancer. Medscape. Retrieved May 29, 2018, from
http://emedicine.medscape.com/article/280605-overview (GI)
3. Fan, K. Y., Dholakia, A. S., Wild, A. T., Su, Z., Hacker-Prietz, A., Kumar, R., … Herman, J. M. (2014). Baseline hemoglobin-a1c impacts clinical outcomes in patients with
pancreatic cancer. Journal of the National Comprehensive Cancer Network, 12(1), 50-57.
4. Ferri, F. F. (2018). Pancreatic cancer (exocrine). In F. F. Ferri (Ed.), 2018 Ferri’s clinical advisor: 5 books in 1 (pp. 941-942). Philadelphia, PA: Elsevier. (GI)
5. Karakas, Y., Lasin, S., & Yalcin, S. (2018). Recent advances in the management of pancreatic adenocarcinoma. Expert Review of Anticancer Therapy, 18(1), 51-62.
doi:10.1080/14737140.2018.1403319 (RV)
6. Liu, Y., Wang, X., Lu, S., & Liu, S. (2018). Vitamin intake and pancreatic cancer risk reduction: A meta-analysis of observational studies. Medicine (Baltimore), 97(13), e0114.
doi:10.1097/MD.0000000000010114 (M)
7. National Comprehensive Cancer Network. (2018). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Pancreatic adenocarcinoma. Version 1.2018—April 27
2018. Retrieved May 29, 2018, from http://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf (G)
8. National Institute for Health and Care Excellence. (2018). Pancreatic cancer in adults: Diagnosis and management. NICE guideline [NG85]. Retrieved May 29, 2018, from
https://www.nice.org.uk/guidance/ng85/resources/pancreatic-cancer-in-adults-diagnosis-and-management-pdf-1837696373701 (G)
9. Schultz, N. A., Dehlendorff, C., Jensen, B. V., Bjerregaard, J. K., Nielsen, K. R., Bojesen, S. E., … Johansen, J. S. (2014). MicroRNA biomarkers in whole blood for detection of
pancreatic cancer. JAMA: Journal of the American Medical Association, 311(4), 392-404. doi:10.1001/jama.2013.284664
10. Tang, C. C., von Ah, D., & Fulton, J. S. (2018). The symptom experience of patients with advanced pancreatic cancer: An integrative review. Cancer Nursing, 41(1), 33-44.
doi:10.1097/NCC.0000000000000463 (SR)
11. Tas, F., Karabulut, S., Ciftci, R., Sen, F., Sakar, B., Disci, R., & Duranyildiz, D. (2014). Serum levels of LDH, CEA, and CA-19-9 have prognostic roles on survival in patients
with metastatic pancreatic cancer receiving gemcitabine based chemotherapy. Cancer Chemotherapy & Pharmacology, 73(6), 1163-1171. doi:10.1007/s00280-014-2450-8

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