Welcome to Partners in Pancreatic Cancer. My name is Dr. Jeff Gudin and I am the Director of Pain Management and Palliative Care at the Englewood Hospital and Medical Center in New Jersey. I am also clinical instructor of anesthesiology at the Icahn School of Medicine at Mount Sinai. I am often asked, “Which is the best pain management strategy for patients with pancreatic cancer?” We have a number of treatment options available to us. We have nonopioids like NSAIDs and acetaminophen; we have opioid analgesics like the morphine class of drugs, both immediate-release, extended-release, and rapid-onset; and then we have interventional pain management techniques such as celiac plexus block. And when all else fails, there are implantable device strategies like intrathecal drug delivery systems, though oftentimes clinicians wonder which of these strategies is best. When I talk about the management of pancreatic cancer, I usually say, like most other disease states, it is a step-ladder approach. We often start with the least invasive option first, and that is usually oral analgesics. But let’s face it, by the time patients with pancreatic cancer present, pain is usually one of their symptoms. So we progress to the opioid management strategy, starting with immediate-release agents like morphine sulfate immediate-release or hydromorphone, and then we will escalate their doses and continue the immediate-release strategy as needed. If their pain becomes around-the-clock, then we add in an around-the-clock or extended-release long-acting opioid agent. And if they have bouts of breakthrough pain, these rapid paroxysms of pain, we might use one of the newer rapid-onset fentanyl-like products.
Now what happens if patients fail medication management? Then we have a number of interventional tools at our fingertips. It turns out that celiac plexus block is quite effective in controlling the pain for most patients with advanced pancreatic cancer. This involves placing a needle around a plexus of nerves in the abdomen; it actually wraps almost around the aorta at the level of T12 or L1. This can be done from a posterior approach, which is how I learned to do it, under fluoroscopic guidance, or the newer approach that we are using is under CT guidance from an anterior approach. Usually I have the radiologist help me place the needle around the celiac access close to the aorta; we inject a little bit of contrast dye and we watch that dye spread around the celiac plexus before we inject either our local anesthetic as a test dose, or more often our neurolytic, like alcohol or phenol, for the definitive process.
The efficacy of celiac plexus blocks for pancreatic cancer pain is fairly good. Some studies in the literature quote up to 50% of patients will get complete relief. And if you look at the range, it is probably 40-90% of patients get some type of relief. Clearly, there are adverse effects associated with putting a needle in around a plexus of spinally originated nerves, but this is not the forum to talk about those. It is usually an accepted risk profile because patients are really suffering with pain. And if the strategy like celiac plexus block is not effective, that is when we consider the implanted device therapies like intrathecal morphine delivery pumps. Those systems can be expensive and usually we usually try to use a risk-benefit or a time-benefit ratio here. Because of their expense, we usually look to see that the patient has at least a 3-6 month life expectancy before we implant one of those types of devices.
We appreciate you viewing this activity. For additional resources, please be sure to view the other educational activities on PartnersinPancreaticCancer.com. I am Dr. Jeff Gudin, thank you so much.