Jose G. Veliz, M.D. M.S.A.
Medical Director
Palomar Pain Management Center
Pomerado Pain Management Center

Posted December 2, 2008

PAIN AND PANCREATIC CANCER

Approximately 45% of patients with pancreatic cancer develop severe pain. Additionally, anxiety and depression are more common in cancer patients with severe pain.

Despite the fact that 90% of patients with cancer obtain relief with oral analgesics, pain is the aspect of cancer that is most feared.

Pancreatic cancer results in pain due to the fact that the pancreas is in close proximity to the liver, stomach, duodenum, jejunum, and transverse colon. Pain, from pancreatic cancer, may also be felt at distant sites due to the fact that the pancreas is innervated (supplied) by nerves from the parasympathetic and sympathetic nervous systems. Pain may occur in the upper, central aspect of the abdomen (mid epigastric and left epigastric) as well as in the left rib cage (intercostal space). Pancreatic cancer commonly spreads to the liver which results in pain in the right upper aspect of the abdomen. There can also be pain referred to the right shoulder or neck without tumor invasion of these areas. This is due to the complex nerve supply (innervation) of the pancreas and neighboring structures.

Medications for pain secondary to pancreatic cancer include opioids, antidepressants, anticonvulsants, and corticosteroids. These can be prescribed by oncologists, pain management specialists and primary care physicians. As the illness progresses, around the clock opioid dosing along with rescue doses will be needed. Early side effects of opioid medication include nausea, sedation and respiratory depression. Patients usually become tolerant to these three side effects. Unfortunately, constipation is a side effect with which tolerance does not occur. Aggressive preventive measures to avoid constipation will be needed and this should be discussed with your doctor.

A celiac plexus nerve block can be used as an adjunct to medication management. Rare complications include paraplegia, pneumothorax, and gangrene of the bowel. Respiratory depression may occur if the pain relief is quick and dramatic and the patient is on high doses of opioids. The celiac plexus nerve block should be performed with CT scan (computerized tomography) guidance.

For severe abdominal pain, secondary to pancreatic cancer, intraspinal drug delivery can also be extremely effective. This can be delivered in either the intrathecal or epidural spaces. For a permanent intraspinal drug delivery system, the intrathecal space is used, while the epidural space is used as a temporary measure.

Radiotherapy is occasionally used as a means to decrease pain in pancreatic cancer. Although controlled, randomized trials have not been performed, radiotherapy is sporadically used in combination with celiac plexus nerve blocks and/or opioids.

Reference: Brescia F. Palliative Care and Pancreatic Cancer. Cancer Control 11 (1): 39-45, 2004. © 2004 H. Lee Moffitt Cancer Center and Research Institute, Inc.