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What is Supportive Care?
CONTROLLING SIDE EFFECTS | Pain | Nutrition | Nausea | Constipation
Some of the most common side effects of pancreatic cancer are nausea, vomiting, and pain. Supportive care provided by the
healthcare team can help ease and even eliminate these problems, thus increasing the patient’s quality of life. Supportive care in patients with cancer is the use of medications to prevent or counteract the unwanted side effects of cancer or of cancer
treatments.
Palliative Care Service at Jefferson: Learn More
 To palliate means to provide comfort. Palliative Care focuses on promoting quality of life for patients.
We specialize in relieving symptoms of your illness and easing fears and anxieties. In addition, our staff can help you make
decisions about your medical care.
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PAIN
Causes of Pain
Pain is the body’s way of indicating to the brain that something is wrong. Pain may be acute or chronic. Acute pain usually is short-lived, may be the result of an injury, and subsides when the injury heals. Chronic pain occurs over a long period of time and ranges from mild to severe. 1,2
Pain from cancer may be chronic and may be caused by the tumor when it presses on organs, nerves, or bone; blocks blood or
lymph vessels; or blocks a hollow organ such as the intestines. Other causes are infection, constipation,indigestion, and
immobility. Cancer treatments also may cause pain. 1,2
| PATIENTS WHO HAVE CANCER DO NOT HAVE TO SUFFER WITH PAIN 1,2 |
As a patient with cancer, you do not have to suffer with pain. In the mid-1990s, the American College of Physicians said that
“Most cancer pain can be eliminated, and all cancer pain can be controlled.” If your pain relief is inadequate, tell your
healthcare providers.
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Ways of Controlling Pain
Patients who have cancer do not have to endure pain. They are entitled to and should receive aggressive pain management. In
fact, management of chronic pain in patients who have cancer is essential. Chronic pain may limit basic activities such as
dressing, eating, and walking, and even may result in anxiety and depression. Chronic pain may disrupt sleep and curb the
appetite, weakening the body’s immune defenses, which fight infection and disease, and interfering with healing. 1,2
The goals of management of pain from pancreatic cancer are to 3:
- Control pain
- Prevent or minimize side effects
- Enhance quality of life
| MYTHS ABOUT PAIN 1,2 |
Myth : Pain in the early stages of cancer will always get worse.
Truth : Treatment intended to eliminate or reduce the size of tumors may relieve or eliminate pain.
Myth : There is nothing that can be done about pain caused by cancer.
Truth : There are very effective treatments available to control pain. Tell your doctor if you have pain, and seek appropriate
treatment.
Myth : Patients who take strong pain medications will become addicted.
Truth : The risk of addiction to the strongest of painkillers, opioids, is low. Patients with cancer who take opioids to relieve
pain usually can take a high dose, can take it often, and can remain on these medications for a long time if need be.
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For patients who have pain, the healthcare provider should 3:
- Understand the causes of the pain
- Perform a comprehensive pain assessment
- Select the most appropriate medications and non drug interventions
- Evaluate the response to treatment for pain
Assessment of Pain
When assessing pain, your doctor will ask lots of questions 2,3:
- Onset:
- When did the pain begin?
- How often does it occur?
- Location: Where is the pain?
- Quality: What does it feel like?
- Intensity
- Numerical rating scale: 0 (no pain) to 10 (worst pain)
- Verbal descriptor scale: mild, moderate, severe
- Aggravating and relieving factors:
- What makes the pain better?
- What makes the pain worse?
- What are the effects of your pain on you? For example, lack of sleep, fatigue, irritability, depression
You can help your doctor assess your pain by clearly communicating what your pain feels like and by keeping a pain log ( Box 10-1 ).
| Box 10-1 |
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ASSESSING YOUR PAIN 2-3
To clearly communicate what your pain feels like, you can use some of these descriptive words:
- Dull, sharp, achy, sore
- Radiating, spreading
- Penetrating, piercing
- Cold, numbing; hot, burning
- Exhausting, tiring
- Beating, pounding, throbbing, pulsing
You also can keep a pain log. Keep a record of the date, time, and severity of your pain from 0 (no pain) to 10 (worst pain).
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Treatment for Pain
Pain Medications. Once the doctor knows the severity of the pain, a treatment can be chosen. Most doctors use a pain treatment approach developed
by the World Health Organization (WHO) called the WHO Three-Step Analgesic Ladder ( Table 10-1 ). 4 An analgesic is a medication whose primary purpose is to relieve pain.
Mild pain may be treated with acetaminophen (Tylenol®) or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen (Motrin®, Advil®) or naproxen (Naprosyn®, Anaprox®, Aleve®). Check with your doctor before taking aspirin,
because it can thin the blood and thus may not be safe for use by patients who have cancer. For pain that is not relieved
by NSAIDs, more potent drugs called opioids are used. These drugs are the very strongest pain relievers available 3 and are some of the best medicines for controlling pain. Some mild opioids are codeine, hydrocodone, and oxycodone. Some
strong opioids are morphine, fentanyl, and hydromorphone. 2 Sometimes combinations of these drugs are used.
Opioids have different side effects than NSAIDs ( Box 10-2 ). Always discuss any side effects you may have with your doctor.
Pain medications may be given in various ways. Most are taken orally, that is, by mouth, with good results. Other ways of
giving pain medications are subcutaneously (under the skin), through the skin using a transdermal patch, and rectally by the use of a suppository. Sometimes pain medications are given intravenously, that is, they are injected directly into a vein. Sometimes they are given intrathecally, that is, injected directly into the spinal canal.
| Box 10-2 |
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POSSIBLE SIDE EFFECTS OF OPIOIDS 5
- Constipation
- Sedation
- Nausea
- Vomiting
- Difficulty breathing
- Dry mouth
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- Difficulty urinating
- Rash
- Muscle tightness
- Confusion
- Problems thinking
- Problems sleeping
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Another method of delivering pain medication is patient-controlled analgesia (PCA). In PCA, the patient controls the amount of pain medicine that is used by pressing a button on a computerized pump connected
to a small tube in the body; patients cannot use more than the prescribed amount because the device is programmed for a maximum
dosage. 2,5 PCA is commonly used after pancreatic cancer surgery in the immediate postoperative period.
Adjuvant Drugs. Adjuvant drugs, which treat a variety of problems in addition to pain, are also commonly used to enhance the effectiveness
of pain medications. Adjuvant drugs often have a greater effect than either nonopioid or opioid pain medications alone. Some
provide pain relief by themselves. Typical adjuvant drugs include corticosteroids, anticonvulsants, tricyclic antidepressants, and antianxiety medications. 2,5
Other Pain Control Measures. Many nondrug therapies may be useful to help control cancer pain. Doctors may advise the use of heat therapy, cold therapy,
or physical therapy. Massage, hypnosis, acupuncture, coping skills, and emotional support and counseling also may be effective.
These techniques, and others, may be used in conjunction with pain medications. 3,5
For pain that does not respond to other measures, an alcohol nerve block may be performed. A local anesthetic is injected into the nerve root of the celiac plexus using ultrasound or computed tomography guidance. This procedure is performed by an anesthesia pain specialist in an outpatient
setting. The effects may last for 3 to 4 months. 3 Sometimes a skilled surgeon will perform a neuroablation in which part of the pain nerve fibers are cut or destroyed. 2 Radiation therapy can be used effectively to relieve pain by shrinking tumors. 3 (See Question 7 on Treatment.)
NUTRITION
Patients with pancreatic cancer may have lost weight before the diagnosis. In addition, treatments may make patients not feel
like eating. Good nutrition is essential to control weight loss, maintain strength, and promote healing. A diet high in calories
and protein can help keep up weight.
High-calorie foods are 6:
- Dairy products: whole milk, butter, cheese, yogurt, and ice cream
- Honey, jellies, and jams
- Granola and dried fruit
To these, add foods with protein 6:
- Nuts, seeds, wheat germ, and peanut butter
- Meat and fish
- Nutritional drinks such as Ensure®
Some, but not all, studies have suggested that fish oil supplements can be particularly helpful in maintaining body weight. 7
NAUSEA AND VOMITING
Nausea and vomiting are common side effects of treatments for pancreatic cancer and usually stop when treatment ends. 6 Pancreatic cancer itself also may cause nausea and vomiting, which may occur in the early stages, later stages, or not at
all.
Preventing nausea will help patients get the nutrition they need. Patients should eat foods that are easy to digest; avoid
fatty foods; eat small portions and frequently; avoid smells that bring on nausea; eat warm, not hot, food; rest after eating
to allow the food to digest; and wear loose-fitting clothing. If nausea persists, contact your doctor because antinausea medications
can be prescribed. 6
Vomiting can be controlled very effectively with the use of drugs called antiemetics. 6 Talk to your doctor if you experience vomiting after eating. If vomiting is severe or lasts for more than a few days, contact
your doctor.
CONSTIPATION
Constipation is a condition of the digestive system where a person experiences hard stools that are difficult to eliminate.
Constipation may be painful and, in severe cases, may lead to a blockage of the bowel.
For some people, it may be normal to have a bowel movement daily; for others, it may be normal to have a bowel movement only
three times each week. It is important to report any changes in bowel movements from your regular routine to a member of your
healthcare team.
Different things can cause constipation. It is a common side effect of pain medications (usually opioids). These medications
reduce the motility (movement) of the intestines, making it more difficult to move the bowels and resulting in hard, dry stools. 2 Your doctor may recommend that you begin taking a stool softener to help prevent constipation at the time that an opioid
is prescribed. Other problems associated with cancer and cancer treatments can contribute to constipation, for example, reduced
activity, poor appetite, and weakness. 2 If you have constipation, let your healthcare team know as soon as possible.
REFERENCES ! Click reference number to return to text.
1. Teeley P, Bashe P. The Complete Cancer Survival Guide. New York: Doubleday; 2000.
2. Eyre HJ, Lange DP, Morris LB. Informed Decisions: The Complete Book of Cancer Diagnosis, Treatment, and Recovery. 2nd ed.
American Cancer Society–Health Content Products. Atlanta, GA; 2002.
3. Johns Hopkins Pathology. Pancreas cancer. www.pathology.jhu.edu/pancreas. Accessed May 23, 2007.
4. Hill CS. Effective treatment of pain in the cancer patient. In: American Cancer Society Textbook of Clinical Oncology. Atlanta,
GA: American Cancer Society; 1995.
5. Clinical Practice Guideline for the Management of Cancer Pain. www.hospicepatients.org/clinicalpracticeguidelines1994.html.
Accessed April 17, 2007.
6. National Cancer Institute. Eating hints for cancer patients: before, during, and after treatment. www.cancer.gov/cancer topics/eatinghints/allpages.
Accessed April 17, 2007.
7. Jatoi A. Omega-3 fatty acid supplements for cancer-associated weight loss. Nutr Clin Pract. 2005;20:394-9.
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