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Case history

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Image not available. Ronald was an 82-year-old retired taxi driver with a past medical history of mild chronic obstructive pulmonary disease (COPD), hypertension and ischaemic heart disease. He had been diagnosed with type 2 diabetes 6 months ago and started on oral hypoglycaemic agents. His medications at that point were salbutamol and tiotropium inhalers, ramipril, simvastatin, bisoprolol, glyceryl trinitrate spray, aspirin, metformin and gliclazide. Ronald developed epigastric pain and anorexia 3 months after the diagnosis of diabetes was made. The pain progressively worsened, and he lost more than 5 kg in weight. He had recently become acutely jaundiced and was admitted to hospital for investigations, which revealed a 3 cm tumour in the head of his pancreas causing common bile duct obstruction and multiple liver metastases. A liver biopsy confirmed the diagnosis of metastatic adenocarcinoma of the pancreas. He underwent endoscopic retrograde cholangiopancreatography and biliary stenting, which resolved the jaundice; his pain was controlled by a combination of paracetamol, modified-release morphine and gabapentin. Ronald's appetite improved considerably after commencing low-dose dexamethasone, which was prescribed with lansoprazole for gastric protection. Despite his comorbidities and resultant polypharmacy, his performance status (PS) was 1.

Ronald was offered palliative chemotherapy with single-agent gemcitabine.

What are the aims of anticancer treatment in this patient?

What is the evidence base for the different treatment options for metastatic pancreatic cancer in older patients?

Is there an evidence base for selecting different treatment options on the basis of age or comorbidities?

What could have been done to improve the patient's tolerance of anticancer treatment?

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What are the aims of anticancer treatment in this patient?

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Ronald's prognosis was a matter of months and the goals of his treatment were to maximize his quality of life and minimize his disease-related symptoms whilst supporting him and his family with advance care planning. Using the Comprehensive Geriatric Assessment framework, areas where more assessment and intervention were required were identified and the appropriate interventions put in place.1 In optimizing quality of life and function for Ronald it was important to establish the details of his social circumstances and his hopes and fears for the coming months. As Ronald was independent, review by the community physiotherapists and occupational therapists to maintain his independence and safety in the home were arranged. The aim of such assessments was to identify any visual or hearing deficits and minimize the risk of falls, and it was hoped the measures would reduce social isolation and the risk of depression. These initial assessments formed the basis of the developing care plan for Ronald and served to inform advance care decisions about where he would like to be as his condition deteriorated, and what factors were most important to him in his decision making.

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What is the evidence base for the different treatment options for metastatic pancreatic cancer in older patients?

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Pancreatic cancer is the third most common cause of ...

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