We read with great in interest the review article on pancreatic adenocarcinoma. As mentioned by the authors this disease is characterised by its late presentation and poor prognosis with only 10-20 % amenable to resection. The vast majority of these patients with fall under the remit of palliative care and management of symptoms. Of these the treatment of pain is perhaps the most important and merits some attention. The article mentioned palliative interventions (surgical, endoscopic, radiotherapy, chemotherapy) that relieve biliary and duodenal obstruction which help alleviate pain to a degree. However multi modal analgesia is the cornerstone of the palliative process in a disease where 50 – 70 % of patients suffer from severe, difficult to treat pain.¹ This perhaps deserves more elaboration when discussing treatment.

Pancreatic pain is multifocal and thus requires a number of pharmacological and interventional modalities. Pain can be visceral, somatic or neuropathic depending on the stage of the disease, local infiltration, spread to surrounding structures, and perinueral invasion.

Pharmacotherapy should follow the WHO analgesic ladder starting with simple analgesics, weak opiates, progressing to strong opiates. Adjuvants such as antidepressants, anticonvulsants and corticosteroids can be added at any stage and are often useful due to the many pain generating foci mentioned above.

Pain often quickly increases in severity. Oral analgesic intake can become problematic as symptoms of nausea, vomiting and poor gastric emptying become more common with the rapid progression of the disease. Analgesia (opiates) may need to be given parenterally and in high doses this can lead to unacceptable side effects.

In this group of patients further interventional procedures may be indicated. Neurolytic Celiac Plexus block has been the subject of a recent Cochrane review¹ and at the very least provides patient satisfaction, much due to reduced consumption of opiates. In our practice we have certainly had great analgesic success with this procedure. This has been done blindly in the past, but more recently under guidance with CT, endoscopic ultrasound, and fluoroscopy. It is also important not to forget there is an opportunity to perform splanchnicectomy intraoperatively for those undergoing surgery.

In addition continuous epidural and intrathecal analgesia has been shown to be efficacious for refractory cancer pain. Again this will reduce the dose of systemic opiates and result in better analgesia.

Other strategies worthy of mention are also radiotherapy, chemotherapy, cognitive and behavioural therapy.

Adequate pain relief will have a significant effect on the quality of life of those with pancreatic carcinoma and should be at the forefront of our management strategy.

References

1) Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD007519. DOI: 10.1002/14651858.CD007519.pub2.

2) Mariam Hameed , Haroon Hameed, and Michael Erdek. Pain management in Pancreatic Cancer. Cancers 2011, 3, 43-60; doi:10.3390/cancers3010043

Competing interests: None declared