Chapter 143: Principles of Palliative Care for Patients with Pancreatic Adenocarcinoma

INTRODUCTION

Palliative care is an approach to care that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and assessment and treatment of pain and other problems—physical, psychosocial, and spiritual.¹ As with many health care disciplines, there are both medical and surgical components to palliative care. Palliative medical care employs expertise on the assessment and management of problems including pain, cachexia, delirium, fatigue, dyspnea, and end-of-life issues. Although palliative care has long been demonstrated to improve symptom control and quality of life, recent evidence suggests it may also be associated with longer survival.^2,3 Therefore, the American Society of Clinical Oncology has recently issued a statement suggesting that palliative care should be considered early in patients with metastatic disease and/or high symptom burden.⁴ Palliative surgery is defined as surgery for which the major intent is alleviation of symptoms and improving patient's quality of life.⁵

The need for palliative surgery in cancer patients is frequent. Palliative surgery comprises approximately 20% of surgical practice and over 1000 procedures per year at major cancer centers.^6,7 In addition, almost half of all inpatient consultations at cancer centers meet the criteria for palliative care.⁸ Although formal training in palliative surgery is infrequently provided during surgical residency, palliative surgeries are among the most high-risk surgical procedures performed and require some of the most time-intensive preoperative discussions. Surgical decision-making and risk assessment are critical as morbidity and mortality rates for palliative surgical procedures are commonly estimated at 30% and 10%, respectively. The risk–benefit ratio is often narrow and the considerable risks of surgery must be balanced against the prognosis and estimated remaining length of life.

Pancreatic cancer represents the 12th most common cancer type but the 4th most common cause of cancer death in the United States.⁹ An individual's lifetime risk of developing pancreatic cancer is approximately 1.5%. The majority of patients with pancreatic cancer are diagnosed with unresectable or metastatic disease at presentation, and the 5-year survival rate of pancreatic cancer is only 6%.¹⁰ In addition, curative-intent pancreatic resection only offers an expected long-term survival rate of approximately 20%.⁹ In light of the dismal rate of cure for pancreatic cancer surgery, a nihilistic approach would be to consider all pancreatic cancer surgery primarily palliative. However, as defined above, palliative surgery is defined as surgery in patients with advanced or incurable malignancy with the intent of improving quality of life or symptoms. Although improved quality of life may lead to improved length of life, all surgeries performed with an intent to cure, including for patients with resectable pancreatic cancer, are by definition excluded from classification as palliative surgery.

The more complex concept of preemptive palliation must also be addressed in discussions of palliative surgery for pancreatic cancer, as ...