Nutrition for Patients With Pancreatic Cancer: Top Tips for Clinicians

Key Takeaways

• Early and routine malnutrition screening, prompt referral to an oncology registered dietitian, and ongoing nutritional assessment are essential to improving outcomes for patients with pancreatic cancer.
• Proactive management of treatment-related symptoms and recognition and optimization of pancreatic enzyme replacement therapy (PERT) for exocrine pancreatic insufficiency (EPI) can improve nutritional status, quality of life, and treatment adherence.
• Incorporating caregivers into nutrition education and supportive care discussions helps identify nutritional concerns earlier and supports patients throughout the continuum of care.

Amy Hacker-Prietz, DMSc, PA-C, a physician assistant in Radiation Oncology and coordinator of the Pancreas Multidisciplinary Clinic at Johns Hopkins University, discusses the importance of recognizing and addressing malnutrition in patients with pancreatic cancer. Drawing on a patient education initiative and insights from the Canopy Cancer Collective, she emphasizes early and consistent malnutrition screening, timely referral to oncology registered dietitians, proactive symptom management, and recognition and treatment of exocrine pancreatic insufficiency with pancreatic enzyme replacement therapy. She also highlights the critical role of caregiver engagement and supportive care throughout the treatment journey. For oncology advanced practice providers, integrating these evidence-informed nutrition strategies into routine practice can improve quality of life, reduce acute care utilization, and help patients remain on track with cancer treatment.

Transcript

Hi, I’m Amy Hacker-Prietz. I’m a physician assistant in Radiation Oncology, and I’m also the coordinator for the Pancreas Multidisciplinary Clinic at Johns Hopkins.

This article came about because of the high percentage of patients with pancreatic cancer who have malnutrition or are at risk for malnutrition at the time of diagnosis. We wanted to focus on how to recognize malnutrition, raise awareness of it, and provide practical tips on what to do about it. This paper is modeled after a patient education video we created on malnutrition in pancreatic cancer that was supported through a patient education grant from the 1440 Foundation.

We also have the privilege of being part of the Canopy Cancer Collective, a learning health network focused on pancreatic cancer. This network included a patient and caregiver focus group that highlighted the importance of whole-person care, including supportive care and nutrition. Patients and caregivers felt they were not consistently receiving this aspect of care, which prompted us to consider how we could improve early referral to a registered dietitian and ensure nutrition support throughout the continuum of care.

The biggest takeaway for advanced practice providers is to recognize malnutrition, recognize it early, assess it consistently throughout the patient’s care, and act on it.

Patients with pancreatic cancer develop malnutrition for many reasons. Symptoms that limit oral intake are often multifactorial. They also experience increased nutritional losses related to chemotherapy, radiation therapy, and surgery, which can result in nausea, diarrhea, and fatigue. Gastrointestinal complications from the disease itself, including pain, pancreatic enzyme insufficiency leading to malabsorption and diarrhea, and gastrointestinal obstruction, also contribute.

Recognizing malnutrition through early screening, educating patients about its importance, and routinely reassessing nutritional status are essential in this patient population. Partnering with an oncology registered dietitian is an important resource for both clinicians and patients.

The key is to screen every patient early and often at every visit. The Malnutrition Screening Tool is a simple, 3-question assessment that is easy to review with patients and helps identify those who are malnourished or at risk. Routine weight monitoring is also important to determine whether patients are staying on track. The goal is to keep patients feeling well, maintain treatment adherence, reduce hospitalizations, and decrease acute care utilization. Again, partnering with a registered dietitian is critical.

Every patient should be screened for nutritional status at every visit. The Malnutrition Screening Tool is simple, easy to administer, and helps identify patients who are malnourished or at risk for malnutrition. Routine weight checks help determine whether patients are maintaining their nutritional status. Our goals are to keep patients on treatment, improve quality of life, keep them out of the hospital, and reduce acute care utilization. Early and ongoing involvement of a registered dietitian is important.

Providers should routinely ask patients how much fluid they are consuming and educate them about their daily hydration needs. It is also important to account for additional fluid losses from nausea, vomiting, dehydration, fever, or bleeding. Vital signs should be reviewed carefully at every visit and compared with prior assessments to identify signs of dehydration.

Symptom management can be challenging, but routinely asking patients about their symptoms is essential. Ask what they are already doing to manage those symptoms, ensure they have appropriate medications available, and confirm they understand how and when to take them. Many patients have medications but are unsure how to use them appropriately. When symptoms are well managed, patients generally feel better and eat better.

Pain, nausea, vomiting, diarrhea, and fatigue can all reduce oral intake and contribute to malnutrition. Strategies such as eating smaller, more frequent meals, choosing lower-fiber foods when appropriate, and selecting foods that are easy to chew may also help when symptoms persist.

Exocrine pancreatic insufficiency (EPI) is highly treatable, so it is important to recognize it. Treating EPI improves nutrient absorption and can reduce many associated symptoms. Patients who experience fatty, floating, frequent stools, bloating, cramping, and ongoing weight loss should be evaluated for EPI. These symptoms can significantly impair nutrient absorption and contribute to malnutrition.

Patients should be screened for EPI, and pancreatic enzyme replacement therapy (PERT) should be initiated when appropriate. Ongoing assessment is also necessary to ensure PERT dosing is optimized.

Engaging caregivers in routine discussions and nutrition education is extremely important. Caregivers often serve as an extra set of ears and can reinforce information that patients may not fully retain. They are also the individuals who observe patients every day and often recognize declining nutritional intake before anyone else. Listen to caregivers, involve them in discussions, and include them as part of the care team.

Caregivers can support nutrition by encouraging shared meals, keeping snacks readily available, offering smaller portions, and helping patients maintain social engagement around eating. It is also important to remind caregivers not to become discouraged or take changes in eating habits personally. Patient and caregiver support groups may also be beneficial.

Recognizing and educating patients about malnutrition, ensuring they receive pancreatic enzyme replacement therapy when indicated, and raising awareness about these issues can be transformative. Introducing these concepts early and helping patients understand how nutrition affects their care can improve outcomes.

Pancreatic enzyme replacement therapy is one area where there remains a lack of understanding. Incorporating it into standard practice and optimizing dosing are very important. Many clinicians are not fully aware of appropriate dosing strategies, and EPI remains underrecognized and undertreated. This is a major contributor to malnutrition in patients with pancreatic cancer.

In addition to chemotherapy, radiation therapy, and surgery, it is important to focus on whole-person care and supportive care. These aspects are often overlooked because of the emphasis on cancer-directed treatment. Ensuring patients receive appropriate supportive care helps them feel better, improves quality of life, and ultimately helps them remain on track with their cancer treatment.