Why is PERT inconsistently prescribed?

 

Pancreatic exocrine insufficiency (PEI) is a common feature of pancreatic cancer. PEI is due to blockage or scarring of the pancreatic duct preventing pancreatic enzymes entering the small intestine to digest food (malabsorption). The difficulties in digestion may result in significant weight loss and symptoms such as abdominal pain, diarrhoea, and bloating. These symptoms can be detrimental to a patient’s quality of life, causing unnecessary physical and psychological distress.

PEI can be treated using pancreatic enzyme replacement therapy (PERT). This medication is safe, well tolerated and effective at improving the symptoms of malabsorption. There is also evidence to suggest that may improve survival. The use of PERT is recommended for people with pancreatic cancer in multiple international guidelines. Despite this, it is inconsistently prescribed, which means many patients may be missing out on treatment. However, high-quality evidence for the use of PERT in this population is lacking.

The Aotearoa Australia Pancreatic Enzyme Replacement Therapy Research Group (ASPERT) is a multi-disciplinary team interested in this area of medicine. ASPERT has recently published a systematic review titled “The Impact of Pancreatic Enzyme Replacement Therapy on Patients with Advanced Pancreatic Adenocarcinoma”. The purpose of the review was to explore the impact that PERT has on people with advanced pancreatic cancer.

Twelve studies met the inclusion criteria for the review, four of which were randomised controlled trials, with a mixture of qualitative and cross-sectional studies also included. The studies reviewed suggest that PERT is safe and beneficial for people with pancreatic cancer. However, there is a lack of knowledge amongst both people with pancreatic cancer and their health care professionals about the use of PERT, which may be contributing to inconsistent prescribing.

With only four randomised control trials meeting inclusion criteria, this review highlighted that there is a lack of high-quality evidence for the use of PERT in this population. Given the absence of progression in the treatment for patients with pancreatic cancer it is critical that high-quality trials are conducted in order to guide the use of PERT.

This study laid the foundation for further research to be conducted in the area. As a result of this review, the ASPERT group has conducted two population surveys across Australasia. The first titled “The experience of taking pancreatic enzyme replacement therapy in inoperable pancreatic cancer” and the second titled “The experience of prescribing pancreatic enzyme replacement therapy in inoperable pancreatic cancer and post-pancreaticoduodenectomy: a clinician survey”. The results of this research will enable us to better understand the patient experience of using PERT, and the clinician's experience of prescribing it in New Zealand and Australia.

The  10-minute pancreatic cancer treatment clinician survey is open across Australia and New Zealand until 30 September 2022. Visit the ASPERT study website to find out more and access the survey.

 

Charlotte Cahill is a Research Assistant for the ASPERT Research Group. She has a Bachelor of Science with a major in Anatomy from the University of Otago and is enrolled as a medical student at the University of Otago.