NCLEX Review Guide: Pancreatic Cancer

Disease Overview

• Pancreatic adenocarcinoma is the most common type, originating in the ductal epithelium with extremely poor prognosis due to late detection.
• Most tumors occur in the head of the pancreas, causing obstruction of bile ducts and resulting in jaundice as an early symptom.
• Rapid metastasis occurs to liver, lungs, and peritoneum due to the pancreas's rich blood supply and lymphatic drainage.

Major Risk Factors

• Smoking is the #1 modifiable risk factor, increasing risk 2-3 times compared to non-smokers.
• Chronic pancreatitis, diabetes mellitus (especially new-onset in adults >50), and family history significantly increase risk.
• Obesity, high-fat diet, and excessive alcohol consumption are additional modifiable risk factors.

Classic Triad of Symptoms

• Painless jaundice occurs when tumor obstructs the common bile duct, causing progressive yellowing of skin and sclera.
• Severe epigastric pain radiating to the back that worsens when lying flat and improves when leaning forward or sitting up.
• Unexplained weight loss (>10% body weight) occurs due to malabsorption, decreased appetite, and tumor cachexia.

Additional Signs & Symptoms

• New-onset diabetes in adults >50 years may be the first sign of pancreatic cancer in 10-15% of patients.
• Courvoisier's sign: palpable, non-tender gallbladder in presence of jaundice suggests malignant obstruction.
• Steatorrhea (fatty, foul-smelling stools) due to pancreatic enzyme deficiency and fat malabsorption.
• Thrombophlebitis or blood clots may occur due to hypercoagulable state associated with cancer.

Laboratory Tests

• Elevated bilirubin, alkaline phosphatase, and ALT/AST indicate biliary obstruction and liver involvement.
• CA 19-9 tumor marker is elevated in 80% of patients but is not diagnostic alone due to false positives in benign conditions.
• Decreased albumin and prealbumin reflect poor nutritional status and protein synthesis.

Imaging Studies

• CT scan with contrast is the gold standard for diagnosis, staging, and assessing resectability.
• ERCP (Endoscopic Retrograde Cholangiopancreatography) allows direct visualization and tissue biopsy of pancreatic ducts.
• EUS (Endoscopic Ultrasound) provides detailed images of pancreatic tissue and can guide fine-needle aspiration biopsy.

Surgical Interventions

1. Whipple procedure (pancreaticoduodenectomy) removes head of pancreas, duodenum, gallbladder, and part of stomach.
2. Post-operative monitoring includes assessment for pancreatic fistula, bleeding, and delayed gastric emptying.
3. Pancreatic enzyme replacement therapy is required lifelong after pancreatic resection to prevent malabsorption.

Chemotherapy & Radiation

• FOLFIRINOX or gemcitabine-based regimens are first-line treatments for metastatic disease.
• Radiation therapy may be used for locally advanced disease or as adjuvant treatment post-surgery.
• Monitor for chemotherapy side effects including neuropathy, fatigue, nausea, and myelosuppression.

Nursing Priorities

• Pain management is crucial - use multimodal approach including opioids, nerve blocks, and positioning.
• Nutritional support with high-calorie, high-protein diet and pancreatic enzyme supplementation with meals.
• Monitor blood glucose closely as diabetes management becomes more complex with pancreatic dysfunction.
• Provide emotional support and facilitate advance directive discussions due to poor prognosis.

Common Complications

• Biliary obstruction requires ERCP with stent placement to relieve jaundice and prevent cholangitis.
• Gastric outlet obstruction may necessitate gastrojejunostomy or gastric stenting for symptom relief.
• Pancreatic insufficiency leads to diabetes and malabsorption requiring enzyme replacement and blood glucose monitoring.

Palliative Care Focus

• Pain control using WHO pain ladder: start with non-opioids, progress to weak then strong opioids as needed.
• Celiac plexus block may provide significant pain relief for patients with uncontrolled abdominal pain.
• Nutritional counseling focuses on small, frequent meals with enzyme supplementation and fat-soluble vitamin replacement.
• Psychosocial support includes grief counseling, spiritual care, and assistance with end-of-life planning.