Content Reviewers:Antonella Melani, MD, Lisa Miklush, PhD, RNC, CNS, Ashley Mauldin MSN, APRN, FNP-BC, Gabrielle Proper, RN, BScN, MN
Now, let’s quickly review some anatomy and physiology. The pancreas is located in the abdomen, right behind the stomach, and it consists of four main parts, the head, neck, body, and tail. Now, the pancreas is a mixed exocrine and endocrine organ. Its exocrine glands produce digestive enzymes like amylase and lipase, which are released through the pancreatic duct into the duodenum; while its endocrine glands produce hormones like insulin and glucagon, which are released into the blood to help regulate our metabolism and blood glucose.
Okay, so pancreatic cancer can rarely arise from endocrine glands, called neuroendocrine tumors; and more commonly from exocrine glands, which is called pancreatic adenocarcinoma. So, pancreatic adenocarcinoma occurs when a cell from the exocrine pancreas acquires mutations, which can arise due to a variety of risk factors. Modifiable risk factors include smoking, excessive alcohol consumption, chronic pancreatitis, diabetes mellitus, obesity, and diet high in processed meat; while non-modifiable risk factors include older age, being assigned male at birth, family history, and genetic predisposition due to inherited gene mutations like BRCA or PALB2.
Once a pancreatic cell becomes mutated and cancerous, it starts dividing uncontrollably, forming a tumor mass. Most often, tumors originate in the head of the pancreas, and less frequently, in the body or tail of the pancreas. Now, as the tumor keeps growing, new blood vessels also develop via angiogenesis to supply it. Eventually, cancerous cells start invading neighboring tissues, such as the bile duct, duodenum, or stomach; and may even spread to nearby lymph nodes or metastasize to more distant organs, such as the liver.
Initially, clients with pancreatic cancer may experience symptoms like fatigue and weight loss, as well as nausea, vomiting, and epigastric pain that radiates to the back. In addition, the tumor can interfere with the exocrine function of pancreatic enzyme secretion, leading to malabsorption and diarrhea. The tumor may also interfere with the endocrine function of the pancreas, so clients may develop new-onset diabetes mellitus.
Additional symptoms may vary depending on the tumor location. Tumors that originate in the head or neck of the pancreas can obstruct the bile duct, so the gallbladder can’t secrete bile into the duodenum.
Now, bile is essential to digest and absorb fats from food; so biliary obstruction can lead to fat malabsorption and steatorrhea, meaning foul-smelling greasy stools. As bile builds up in the bile duct, it’s main component, bilirubin, can spill over into blood, leading to obstructive jaundice or yellowing of the skin, sclera, and mucous membranes, as well as pale stools, and dark urine. The buildup of bile can also result in an enlarged, palpable, nontender gallbladder.
On the flip side, tumors arising in the body or tail of the pancreas generally don’t cause biliary obstruction, and clients tend to develop symptoms later, when their cancer is quite advanced.
Diagnosis of pancreatic cancer involves history and physical assessment, as well as additional diagnostic tests. Laboratory test results are generally non-specific, and may show elevated blood levels of amylase and lipase, as well as tumor markers like CA 19-9 and CEA. In clients with obstructive jaundice, laboratory tests can also show elevated blood levels of bilirubin and alkaline phosphatase or ALP. Imaging tests like abdominal ultrasound, CT scan, MRI, and endoscopic scans can be used to stage the tumor by defining the location, and look for lymph node involvement or metastasis. Once a suspicious lesion is found on imaging, a biopsy is needed to confirm the diagnosis.
Treatment for pancreatic cancer depends on its aggressiveness and extension. Unfortunately, most clients with pancreatic cancer have a poor prognosis, since it’s often pretty advanced at the time of diagnosis. For localized tumors, the treatment of choice is surgical resection. A major surgical procedure, called a Whipple procedure or pancreaticoduodenectomy, can be performed to remove tumors involving the head of the pancreas. Some clients may require a partial or total pancreatectomy, where part or all the pancreas is surgically removed. Additionally, chemotherapy can be given as a neoadjuvant therapy, used to shrink the tumor before surgery, as well as for adjuvant therapy after surgery. On the other hand, for clients with unresectable or metastatic tumors, as well as those who can’t have surgery, treatment can involve a combination of chemotherapy and palliative care, which can include opioid analgesics and antiemetics, in order to decrease their symptoms and improve their quality of life.
Alright, let’s talk about nursing care for a client with pancreatic cancer. The goals of nursing care are to manage symptoms, monitor for complications related to treatments, and provide supportive care to promote quality of life.