Pain affects approximately 80% of patients with pancreatic cancer, with half requiring strong opioid analgesia, namely, morphine-based drugs on step 3 of the WHO analgesic ladder.
The presence of pain is associated with reduced survival.
Dr Andreas Koulouris and colleagues from the United Kingdom reviews the literature regarding pain: prevalence, mechanisms, pharmacological, and endoscopic treatments and identifies areas for research to develop individualized patient pain management pathways.
The online literature review was conducted through PubMed, Clinical Key, Uptodate, and NICE Evidence.
|Case series report pancreatic duct stenting gives effective analgesia|
|Digestive Diseases & Sciences|
The team found 2 principal mechanisms for pain, involving pancreatic duct obstruction and pancreatic neuropathy which, respectively, activate mechanical and chemical nociceptors.
In pancreatic neuropathy, the research team reports several histological, molecular, and immunological changes occur which correlate with pain including transient receptor potential cation channel activation and mast cell infiltration.
The researchers note that current pain management is empirical rather etiology-based, and is informed by the WHO analgesic ladder for first-line therapies, and then endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in patients with resistant pain.
For EUS-CPN, there is only one clinical trial reporting a benefit, which has limited generalizability.
Case series report pancreatic duct stenting gives effective analgesia, but there are no clinical trials.
Dr Koulouris' team comments, "Progress in understanding the mechanisms for pain and when this occurs in the natural history, together with assessing new therapies both pharmacological and endoscopic, will enable individualized care and may improve patients’ quality of life and survival."