Prospective Observational Study of Prevalence, Assessment and Treatment of Pancreatic Exocrine Insufficiency in Patients with Inoperable Pancreatic Malignancy (PANcreatic Cancer Dietary Assessment—PanDA)

Abstract

Introduction: Pancreatic exocrine insufficiency (PEI) in patients with advanced pancreatic cancer (aPC) is well documented, but there is no consensus regarding optimal screening. Methods and analysis: Patients diagnosed with aPC referred for palliative therapy were prospectively recruited. A full dietetic assessment (including Mid-Upper Arm Circumference (MUAC), handgrip and stair-climb test), nutritional blood panel, faecal elastase (FE-1) and 13C-mixed triglyceride breath tests were performed. Primary objective: prevalence of dietitian-assessed PEI (demographic cohort (De-ch)); design (diagnostic cohort (Di-ch)) and validation (follow-up cohort (Fol-ch)) of a PEI screening tool. Logistic and Cox regressions were used for statistical analysis. Results: Between 1 July 2018 and 30 October 2020, 112 patients were recruited (50 (De-ch), 25 (Di-ch) and 37 (Fol-ch)). Prevalence of PEI (De-ch) was 64.0% (flatus (84.0%), weight loss (84.0%), abdominal discomfort (50.0%) and steatorrhea (48.0%)). The derived PEI screening panel (Di-ch) included FE-1 (normal/missing (0 points); low (1 point)) and MUAC (normal/missing (>percentile 25) (0 points); low (2 points)) and identified patients at high-risk (2–3 total points) of PEI [vs. low-medium risk (0–1 total points)]. When patients from the De-ch and Di-ch were analysed together, those classified by the screening panel as “high-risk” had shorter overall survival (multivariable Hazard Ratio (mHR) 1.86 (95% CI 1.03–3.36); p-value 0.040). The screening panel was tested in the Fol-ch; 78.4% patients classified as “high-risk”, of whom 89.6% had dietitian-confirmed PEI. The panel was feasible for use in clinical practice (64.8% patients completed all assessments), with high acceptability (87.5% would repeat it). Most patients (91.3%) recommended dietetic input for all patients with aPC. Conclusions: PEI is present in most patients with aPC; early dietetic input provides a holistic nutritional overview, including, but not limited to, PEI. This proposed screening panel may help to prioritise those at higher risk of PEI, requiring urgent dietitian input. Its prognostic role needs further validation.

Nutritional status in advanced pancreatic cancer

“…больных РПЖ исследование на уровень фекальной эластазы проводилось только 1,9%, заместительную ферментную терапию (ЗФТ) получали только 22%, а в адекватной дозе -только 5,5% из них [10]. Следовательно, экзокринная недостаточность не выявляется и не корректируется в достаточном объеме [11,12], хотя лечение экзокринной недостаточности является доказанным фактором, способствующим увеличению срока жизни больных РПЖ [13][14][15][16].…”

Utilising Pancreatic Exocrine Insufficiency in the Detection of Resectable Pancreatic Ductal Adenocarcinoma

“…Most of the studies using the 13 C-MTGBT have been conducted over a 360-min window [10]; however, it remains a valid test in as little as 240 min, with a cumulative percentage dose recovered of 13 CO 2 of 18.9% accepted as the cutoff for establishing a diagnosis of PEI [11]. The 13 C-MTGBT has been used to establish PEI in unresectable PDAC [12], and to demonstrate an improvement in exocrine pancreatic function following decompression of the biliary system in obstructions caused by inoperable PDAC [13], although it has not been used to evaluate whether PEI is a feature of resectable PDAC. An alternative breath test using 13 C-trioctanion has been used to establish PEI in those about to undergo pancreatic resection [14], but the 13 C-MTGBT is considered a better test than the 13 C-trioctanion test due to the way it is hydrolysed by pancreatic lipase [15].…”