Estimation of symptoms burden in advanced pancreatic cancer patient and impact of palliative care intervention on it

Introduction

Pancreatic cancer is a highly lethal disease, with 80% of cases presenting as metastatic or locally advanced at diagnosis, making curative treatment difficult. Despite advancements in diagnostics and therapies, survival rates remain poor (1). GLOBOCAN (2022) reported 0.51 million new cases and 0.4 million deaths annually, ranking pancreatic cancer as the 6^th leading cause of cancer-related deaths worldwide. The 5-year survival rate is only 10%, with most patients having metastatic or unresectable disease at diagnosis (2).

Patients with pancreatic cancer experience a high symptom burden due to bile duct obstruction and tumour progression. Common symptoms include jaundice, abdominal pain, anorexia, dark urine and weight loss. These symptoms, along with fatigue and pain, contribute to psychological distress, depression, and social isolation. Obstructive jaundice may lead to infections, prolonged hospital stays, and delayed treatment, thereby increasing anxiety for patients and caregivers (1).

Surgical resection is often not an option due to vascular involvement, and one-third of patients have locally advanced disease at diagnosis. Chemotherapy is the standard treatment for metastatic disease, though survival remains modest. Median survival is 22–26 months after surgery and 11–15 months with chemotherapy (3).

Palliative care plays a crucial role in managing symptoms, providing pain relief, emotional support, and improving quality of life (QOL). Studies indicate that patients with pancreatic cancer experience poor QOL among all cancer types, with marked deterioration in physical, psychological, and social domains. American Society of Clinical Oncology (ASCO) (2020) guidelines recommend (4):

• Early palliative care consultation to assess symptoms, psychological distress, and social support;
• Aggressive pain management to enhance patient comfort.

Involvement of palliative care specialists alongside oncologists, gastroenterologists, with participation from patients and their family members, helps to tailor the right treatment for the right patient in the right setting. The palliative care triangle model aids in evaluating risks and benefits while considering patient and family values (5,6).

QOL is multifaceted, taking into account how one feels about their physical, psychological, social, and spiritual well-being. When compared to patients with other cancers, QOL is lower in people with pancreatic cancer (4). According to multiple studies, patients with pancreatic cancer reported declines in QOL across all facets of life, with psychological distress being the worst of all malignancies. By including the emotional and spiritual facets of patient care, palliative care strives to provide treatment that goes beyond the conventional goals of relieving medical symptoms and ensuring survival. In contrast to normal treatment alone, early involvement with palliative care leads to enhanced QOL (7).

Despite the high burden of pancreatic cancer in India, very few studies are available to evaluate symptom frequency and severity with validated tools, integration of palliative care and its outcomes, and end-of-life experiences in this population. Addressing this gap is important for guiding evidence-based integration of palliative care into standard oncology practice and for shaping health policies tailored to the Indian healthcare setting for the betterment of patients suffering from this type of disease.

The present study was conducted:

• To estimate the severity of various symptoms in advanced pancreatic cancer patients;
• To determine the impact of palliative care intervention on symptom burden.

We present this article in accordance with the STROBE reporting checklist (available at https://apc.amegroups.com/article/view/10.21037/apc-25-15/rc).

Methods

This study was conducted at the Department of Palliative Medicine of Gujarat Cancer and Research Institute, State Cancer Institute in Western India, providing comprehensive cancer care to a diverse population of rural and urban regions of the country. This was a prospective analytical study that included 61 patients from January to December 2024. Sample size was calculated with consideration of precision level ±5, confidence level 95%, and estimated proportion 0.5. The study has a power of 80%.

Patient selection criteria

Patients aged ≥18 years with histologically confirmed advanced pancreatic cancer (stage III or IV), receiving palliative care, and able to attend biweekly follow-up visits were considered eligible. Exclusion criteria included lack of informed consent, inability to communicate due to language limitations, concurrent participation in another clinical study, psychiatric disorders interfering with comprehension of study questionnaires, or the presence of a second primary malignancy, and not having a previous palliative care visit or pain clinic consultation.

Data collection

All patients who presented during the study period and fulfilled the inclusion and exclusion criteria were recruited consecutively, after taking informed consent. Demographic variables such as age, gender, weight, education, and socioeconomic status were collected, along with clinical details including prior treatments (surgery, chemotherapy, and radiotherapy) and comorbidities like hypertension, diabetes mellitus, asthma, etc. were noted.

The following parameters were measured.

• Bothersome symptoms at day zero (baseline) were recorded and described as a percentage;
• Performance status was assessed using the Palliative Performance Scale (PPS) at baseline and every 4 weeks until 24 weeks or death, whichever occurred earlier;
• Symptom burden was evaluated with the Edmonton Symptom Assessment Scale-revised with constipation and sleep disturbance (ESAS-r CSS) at baseline and at every 4-week follow-up until 24 weeks or death;
• The impact of palliative care interventions was measured using the Palliative Outcome Scale (POS) at baseline and every 4 weeks until 24 weeks or death;
• Data on hospital admissions, emergency room visits, and intensive care unit (ICU) admissions in the last 30 days of life were recorded;
• The frequency of symptoms in the last three days of life and the place of death (home, hospital, or hospice) were documented via tele-consultation.

PPS

The PPS uses five observer-rated parameters (ambulation, activity, self-care, intake, and level of consciousness), scores from 0 to 100 in 10% increments. It is a reliable and valid tool for measuring performance status in cancer patients, with categories ranging from 0 (deceased) to 100 (full function without limitation) (8).

ESAS-r CSS

The ESAS is a validated, self-reported tool assessing 10 common symptoms, each rated on an 11-point (0–10) numerical rating scale. The revised version (ESAS-r) incorporates changes in wording, sequence, and format. The ESAS-r CSS further adds two items (constipation and sleep disturbance). In this study, we used the ESAS-r CSS combined with an additional spiritual well-being domain (9).

POS

The POS is a validated tool to assess physical, psychological, and existential aspects of QOL. It consists of 10 questions covering pain, anxiety, family stress, information sharing, support, self-worth, value of life, time wasted, and personal matters. Each question is rated from 0 (not a problem) to 4 (overwhelming problem), with a total score out of 40; higher scores indicate poorer QOL (10).

Palliative interventions

Palliative care interventions were provided according to the physical and psychological needs of each patient. Symptom management followed standard guidelines, tailored to individual requirements.

• Pain: managed according to World Health Organization (WHO) analgesic ladder;
• Nausea and vomiting: metoclopramide 10 mg orally (PO) or intravenous (IV), haloperidol 0.5 mg PO or IV at bedtime (HS);
• Ascites: furosemide (20 mg) + spironolactone (50 mg) once daily (OD) or twice daily (BID), drainage of ascitic fluid when required;
• Depression and anxiety: amitriptyline 12.5–25 mg HS, alprazolam 0.25–0.5 mg HS as needed, behavioural therapy, psychotherapy;
• Shortness of breath: morphine 5 mg 6 hourly PO, drainage of pleural fluid when indicated, non-pharmacological interventions such as adequate ventilation, positioning;
• Fatigue: psychosocial interaction, nutritional therapy and exercise as tolerated;
• Anorexia and weight loss: dietary counselling, protein supplement;
• Sleep disturbance: lorazepam 1 mg PO HS as needed;
• Constipation: diet modification, lactulose syrup 20 mL PO HS, liquid paraffin 30 mL HS, suppository bisacodyl and phosphate enema if required.

Data and statistical analysis

Patients’ characteristics such as age were recorded as mean ± standard deviation (SD) and range, while gender, co-morbidity, and treatment history were reported as percentages.

Palliative performance score recorded as mean ± SD.

Severity of symptoms was measured with ESAS-r CSS and reported as mean ± SD. To identify statistical significance for the severity of symptoms, we used repeated measures analysis of variance (ANOVA) test. P values were calculated to assess the impact of palliative care interventions (two-tailed P<0.05 considered statistically significant).

Bothersome symptoms at day zero (baseline) were recorded and described as a percentage.

Outcome of the palliative care intervention was recorded using POS at baseline and at 4-week follow-up. For post-palliative care intervention, we used the average score of all 4-week follow-up data. Data were reported as mean ± SD. To know the statistical significance between pre- and post-POS, we used a paired t-test.

Statistical analysis was done using the www.socscistatistics.com software.

Frequency of emergency visits to the hospital, hospital admission and ICU admissions in the last 30 days of life was measured in percentage.

The frequency of common bothersome symptoms in last 3 days of life was documented retrospectively via structured tele-consultation with the primary caregiver. Caregivers were asked to report symptoms experienced during the final 3 days prior to death according to question number 11 of POS. Also, the place of death (home, hospital or hospice) was recorded in percentage.

Ethical statement

The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the Institutional Review Committee of Gujarat Cancer and Research Institute (No. 2025/P-81). Informed consent was obtained from all individual participants included in the study.

Results

A total of 67 patients had visited the palliative medicine department, of which 6 patients were excluded from the study as they had previously visited the palliative medicine OPD or pain clinic at another centre. The remaining 61 patients were included in this study.

Demographic characteristics

• Age: the mean age of the study population was 58±9.32 years (range, 35–81 years).
• Gender: the cohort included 17 females (27%) and 44 males (73%).
• Comorbidities: 18 patients (29%) had hypertension, 9 (14%) had diabetes, and 12 (19%) had both hypertension and diabetes. Five patients (8%) had asthma, 4 (6%) had chronic obstructive pulmonary disease (COPD), 3 (4%) had a history of stroke, and 3 (4%) were on treatment for hypothyroidism.
• Treatment history: 11 patients (18%) had undergone surgery, 7 (11%) underwent surgery followed by chemotherapy, 7 (11%) received only chemotherapy, and 6 (10%) received only radiotherapy. Thirty patients (49%) were on supportive care (Table 1).

  Table 1

  Data of demographic

  
  

  Characteristics	Values
  Age (years)
  Range	35–81
  Mean ± SD	58±9.32
  Gender, n [%]
  Male	44 [73]
  Female	17 [27]
  Co-morbidity, n [%]
  Hypertension	18 [29]
  Diabetes	9 [14]
  Hypertension and diabetes	12 [19]
  Hypothyroid	3 [4]
  Stroke	3 [4]
  Asthma	5 [8]
  COPD	4 [6]
  Treatment, n [%]
  Surgery	11 [18]
  Chemotherapy	7 [11]
  Surgery and chemotherapy	7 [11]
  Radiotherapy	6 [10]
  Supportive care	30 [49]

  COPD, chronic obstructive pulmonary disease; SD, standard deviation.

PPS over time

Out of 61 patients, 2 (3%) died before 8th week of follow-up, 17 (27%) died before 12th week, and 33 (54%) died before 16th week. At 24th week, only two patients remained alive.

The mean PPS at baseline was 63.63±7.42 [95% confidence interval (CI), 61.73–65.53]. It improved to 74.00±7.90 (95% CI, 71.98–76.02) at 4th week, then declined to 68.29±12.88 (95% CI, 64.93–71.65) at 8th week, 60.76±9.99 (95% CI, 57.72–63.80) at 12th week, and 58.35±8.30 (95% CI, 55.13–61.57) at 16th week. At 24th week, the mean PPS of the two surviving patients was 47.00±6.00 (95% CI, −6.91 to 100.91) (Figure 1).

Figure 1 Data of total number of patients, number of patients in each follow-up along with PPS. PPS, Palliative Performance Scale.

Symptom severity (ESAS-r CSS)

Symptom severity was assessed at baseline and during follow-up using the ESAS-r CSS (Table 2).

• Pain: mean score 5.8±1.3 (95% CI, 5.47–6.13) at baseline, reduced to 2.5±0.8 (95% CI, 2.26–2.74) at 4th week and 1.2±0.5 (95% CI, 1.11–1.29) at 12th week (P<0.001);
• Drowsiness: improved from 0.9±1.1 (95% CI, 0.70–1.10) at baseline to 0.6±0.7 (95% CI, 0.48–0.72) at 4th week but increased to 2.0±1.7 (95% CI, 1.60–2.40) at 12th week (P=0.02);
• Nausea: decreased from 2.4±2.1 (95% CI, 2.02–2.78) at baseline to 0.6±0.7 (95% CI, 0.48–0.72) at 4th week but increased again to 2.1±1.3 (95% CI, 1.79–2.41) at 12th week (P<0.001);
• Depression: reduced from 3.9±1.2 (95% CI, 1.07–1.53) at baseline to 0.3±0.8 (95% CI, 0.18–0.42) at 4th week, remained low at 0.7±1.1 (95% CI, 0.42–0.98) at 12th week (P=0.006);
• Anxiety: declined from 3.7±1.6 (95% CI, 3.42–3.98) at baseline to 1.0±1.4 (95% CI, 0.68–1.32) at 4th week but rose to 2.6±2.3 (95% CI, 1.91–3.29) at 12th week (P<0.001);
• Overall well-being: improved initially from 2.8±1.8 (95% CI, 2.51–3.09) at baseline to 2.2±1.3 (95% CI, 1.94–2.46) at 4th week but worsened to 3.5±1.9 (95% CI, 3.10–3.90) at 12th week (P=0.005);
• Constipation: improved from 1.4±2.1 (95% CI, 1.02–1.78) at baseline to 0.4±1.0 (95% CI, 0.23–0.57) at 4th week, increasing again to 1.5±1.1 (95% CI, 1.23–1.77) at 12th week (P=0.02);
• Sleep disturbance: improved consistently from 3.0±1.5 (95% CI, 2.74–3.26) at baseline to 1.0±1.2 (95% CI, 0.76–1.24) at 4th week and 1.2±1.2 (95% CI, 0.94–1.46) at 12th week (P<0.001).

Symptoms such as tiredness, loss of appetite, shortness of breath, and spiritual well-being were not improved (Table 2).

Bothersome symptoms at baseline

At baseline, pain and diminished overall well-being were present in all 61 patients (100%). Anxiety was reported by 41 patients (68%), sleep disturbance by 40 patients (65%), and loss of appetite by 35 patients (57%) (Figure 2).

Figure 2 Bothersome symptoms in percentage (%) at baseline of patients.

POS

The impact of palliative care was measured using POS (maximum score: 40; higher scores indicate poorer QOL). The mean pre-intervention POS score, recorded at the first palliative care consultation, was 19.28±2.15. After intervention, the mean POS score decreased to 11.34±3.54 (Table 3).

Emergency visits, hospital admissions, and ICU admissions

Out of the 61 patients with complete follow-up data, 13 patients (22%) required one emergency room visit, and 37 patients (62%) required hospital admission during the last 30 days of life. No patient required ICU admission (Table 4).

Frequency of symptoms in the last 3 days of life

In the last 3 days of life, symptom frequency was assessed using POS question 11. The most common symptoms were fatigue (37 patients, 62%), generalised weakness (33 patients, 55%), and diminished overall well-being (32 patients, 54%). Other symptoms, such as pain, anorexia, constipation, and drowsiness, were reported less frequently (Figure 3).

Figure 3 Frequency of symptom in last three days of life in percentage (%) of patients.

Place of death

Out of 61 patients, 44 (75%) died with dignity at home, 14 (24%) died at the hospital, and one patient died in hospice (Figure 4).

Figure 4 Data of death of place of patients.

Discussion

Patients with advanced pancreatic cancer face a high symptom burden and poor survival outcomes despite advances in oncological treatments. In our study, pain, loss of appetite, fatigue, and impaired overall well-being were the most common symptoms, consistent with prior literature. Importantly, palliative care interventions significantly improved pain, depression, anxiety, sleep disturbance, and overall QOL, highlighting the essential role of palliative care in this patient population (11).

Gaidhani et al. conducted an epidemiological review of pancreatic cancer in the Indian population and reported that the risk of pancreatic cancer increases with age. Patients under 30 years are unlikely to develop pancreatic cancer, whereas those over 55 years are at higher risk. Similarly, in our study, the mean age of the study population was 58 years. Male patients are more prone to pancreatic cancer than females due to multiple risk factors; in our cohort, 44 of 61 patients (73%) were male (12).

Our findings align with those of Labori et al., who reported pain, fatigue, and appetite loss as the most prevalent symptoms in inoperable pancreatic cancer patients using a modified ESAS tool (13). Similarly, Tang et al., in an integrative review of 16 studies, identified fatigue, appetite loss, and diminished well-being as key concerns (14). This convergence of evidence underscores the global relevance of our observations.

Tung et al. performed a population-based study of 2,623 patients with non-curable pancreatic adenocarcinoma from 2010 to 2016 to assess changes in pain scores following interventions such as opioids, radiotherapy, and nerve blocks. Using the ESAS scale, they reported that 61.8% of patients had high baseline pain scores (>4), and 62.1% experienced significant improvement after treatment (15). In our study, the mean baseline pain score was 5.8±1.3, which improved significantly following palliative care interventions, in line with their findings.

Bye et al. conducted a prospective descriptive study in advanced pancreatic cancer patients and reported that dysphagia, nausea, xerostomia, and altered taste and smell directly reduced food intake, while discomfort and psychological issues indirectly contributed by reducing appetite and motivation to eat. They noted that nausea, indigestion, and altered bowel habits improved with palliative care (16). Similarly, our study found significant improvement in nausea and vomiting with intervention.

However, symptoms such as fatigue and loss of appetite remain more difficult to control in pancreatic cancer. Labori et al. observed that these were among the most distressing symptoms in their prospective study of advanced pancreatic cancer patients (13). In our study, loss of appetite and fatigue worsened over time. The mean baseline score for loss of appetite was 3.0, which increased to 5.0 at the 20th week of follow-up, while fatigue increased from 1.3 at baseline to 3.5. The persistence of fatigue and appetite loss despite palliative care may be partly explained by systemic inflammation and cancer-related cachexia. Recent evidence demonstrated that inflammatory markers, such as the Systemic Inflammation Response Index, together with weight loss, are strong prognostic factors in metastatic pancreatic cancer. This highlights the complex metabolic and inflammatory pathways underlying these symptoms, which are less responsive to conventional palliative interventions (17).

Di Marco et al. reported that fatigue is one of the most common symptoms in patients with pancreatic carcinoma, with 94% of patients experiencing fatigue of mild to moderate severity. They also demonstrated the impact of fatigue on general activity, mood, walking ability, relationships, and overall enjoyment of life (18). In our study, fatigue was also the most frequently reported symptom in the last 3 days of life, observed in 37 patients (60%).

In our study, depression and anxiety were frequent at baseline in patients with advanced pancreatic cancer but improved significantly with palliative care interventions and regular follow-up. This underscores the effectiveness of early psychosocial support in reducing psychological distress. Our findings match those of Dengsø et al., who reported a markedly increased risk of antidepressant and anxiolytic use among pancreatic cancer patients compared with matched controls, particularly in younger individuals, those with advanced disease, and those not undergoing surgery (19). Similarly, Kelsen et al. demonstrated a strong association between uncontrolled pain, depression, and poorer QOL. Together, these studies highlight that psychological distress in pancreatic cancer is both common and clinically significant (20). The improvement we observed suggests that integrating palliative care early into oncology practice can help address this unmet need, aligning care with global evidence while demonstrating feasibility in the Indian setting.

Moningi et al. evaluated the relationship between symptom burden, QOL, and performance status in pancreatic cancer patients. They used Eastern Cooperative Oncology Group (ECOG) and Karnofsky performance status (KPS) to measure performance status and found that patients with higher symptom burden had poorer performance. Pain, anorexia, altered bowel habits, and cachexia were among the most common symptoms (11). In our study, the baseline mean PPS was 63.63. We observed initial improvement with palliative care interventions; however, PPS declined after the 8th week, likely due to disease progression and worsening symptoms such as anorexia, pain, and constipation.

Kim et al. conducted a prospective crossover study in 40 pancreatic cancer patients to evaluate the effect of early palliative care on symptom burden and QOL. Using ESAS-r, they calculated the Total Symptom Distress Score (TSDS), which decreased from 26 at baseline to 18.6 at week 16, suggesting significant improvement with early palliative care. Similarly, in our study, early palliative care interventions improved symptom burden and QOL (21).

Zimmermann et al. compared standard care with standard care plus early palliative care in a randomised trial of 461 patients with advanced solid tumours. The interventional arm included monthly palliative care consultations and access to palliative care specialists via telephone. They found a significant improvement in QOL after four months, with lower symptom burden, higher satisfaction, and reduced utilization of medical resources (22).

Rugno et al. performed an integrative review and concluded that the POS is a practical and multidimensional tool for evaluating palliative care outcomes, suitable for routine clinical use. In our study, the mean POS score decreased significantly from 19.28 at baseline to 11.34 after palliative care intervention, highlighting improved QOL (23).

End-of-life outcomes in our cohort further emphasise the value of palliative care. The majority of patients (75%) died at home, while 24% died in hospital and only 1% in hospice, with none of patient required ICU admission. Only 22% of patients required an emergency visit, and 37% required hospitalisation in the last 30 days of life. These findings suggest that timely palliative care interventions not only help in controlling distressing symptoms but also facilitate home-based care and reduce the need for acute hospital services in the terminal phase.

Our results are consistent with those of Michael et al., who demonstrated that early palliative care referral was associated with fewer emergency visits and hospitalisations in the last month of life (24). Similarly, Miinalainen et al. reported that late referrals often led to increased utilization of hospital services near the end of life, whereas timely referrals allowed patients to remain at home (25). Ekström et al. also showed that patients referred to specialised palliative care were significantly more likely to die at home rather than in hospital, thereby aligning the place of death with patient and family preferences (26). Taken together, these findings highlight that palliative care has an important role not only in symptom relief but also in optimizing end-of-life care trajectories. By reducing unnecessary hospital utilization and supporting home deaths, palliative care aligns treatment with the values of dignity, comfort, and patient-centred decision-making.

Strengths and limitations

The strengths of our study include prospective design, use of validated tools (PPS, ESAS-r CSS, POS), and serial follow-up of patients. Limitations include this was a single-center study with a relatively small sample size (n=61), which may limit statistical power and generalizability of the findings. As such, our results should be interpreted with caution and considered exploratory. The frequency of bothersome symptoms in the last 3 days of life was reported by caregivers through telephonic consultation after the patient’s death, which may be influenced by recall bias.

Recommendation

• In an Indian setting, there is a need for a larger multi-centric study;
• Two-arm comprehensive study with a large sample size;
• To implement ASCO guidelines 2020 recommendation of early palliative care consultation to assess symptoms, psychological distress, and social support.

Conclusions

We conclude that advanced pancreatic cancer patients suffer from various distressing symptoms that significantly impair the QOL. Early palliative care integration can improve symptom burden, reduce unnecessary hospital visits, and ultimately be helpful in better QOL. Policymakers should prioritise policies that strengthen palliative care services and early involvement of palliative medicine specialist into standard cancer care treatment.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://apc.amegroups.com/article/view/10.21037/apc-25-15/rc

Data Sharing Statement: Available at https://apc.amegroups.com/article/view/10.21037/apc-25-15/dss

Peer Review File: Available at https://apc.amegroups.com/article/view/10.21037/apc-25-15/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apc.amegroups.com/article/view/10.21037/apc-25-15/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its subsequent amendments. Ethical approval was obtained from the Institutional Review Committee of Gujarat Cancer and Research Institute (No. 2025/P-81). Informed consent was obtained from all individual participants included in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Puckett Y, Garfield K. Pancreatic Cancer. Treasure Island (FL): StatPearls Publishing; 2025.
2. International Agency for Research on Cancer. Cancer Today (GLOBOCAN 2022). 2022. Available online: https://gco.iarc.fr/today
3. Bauer MR, Bright EE, MacDonald JJ, et al. Quality of Life in Patients With Pancreatic Cancer and Their Caregivers: A Systematic Review. Pancreas 2018;47:368-75. [Crossref] [PubMed]
4. Sohal DPS, Kennedy EB, Khorana A, et al. Metastatic Pancreatic Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 2018;36:2545-56. [Crossref] [PubMed]
5. Adiwinata R, Livina A, Waleleng BJ, et al. Palliative Management of Advanced Pancreatic Cancer: The Role of Gastroentero-hepatologist. Acta Med Indones 2020;52:185-91.
6. Perone JA, Riall TS, Olino K. Palliative Care for Pancreatic and Periampullary Cancer. Surg Clin North Am 2016;96:1415-30. [Crossref] [PubMed]
7. Rabow MW, Petzel MQB, Adkins SH. Symptom Management and Palliative Care in Pancreatic Cancer. Cancer J 2017;23:362-73. [Crossref] [PubMed]
8. Virik K, Glare P. Validation of the palliative performance scale for inpatients admitted to a palliative care unit in Sydney, Australia. J Pain Symptom Manage 2002;23:455-7. [Crossref] [PubMed]
9. Johnstone PAS, Lee J, Zhou JM, et al. A modified Edmonton Symptom Assessment Scale for symptom clusters in radiation oncology patients. Cancer Med 2017;6:2034-41. [Crossref] [PubMed]
10. Stevens AM, Gwilliam B, A'hern R, et al. Experience in the use of the palliative care outcome scale. Support Care Cancer 2005;13:1027-34. [Crossref] [PubMed]
11. Moningi S, Walker AJ, Hsu CC, et al. Correlation of clinical stage and performance status with quality of life in patients seen in a pancreas multidisciplinary clinic. J Oncol Pract 2015;11:e216-21. [Crossref] [PubMed]
12. Gaidhani RH, Balasubramaniam G. An epidemiological review of pancreatic cancer with special reference to India. Indian J Med Sci 2021;73:99-109.
13. Labori KJ, Hjermstad MJ, Wester T, et al. Symptom profiles and palliative care in advanced pancreatic cancer: a prospective study. Support Care Cancer 2006;14:1126-33. [Crossref] [PubMed]
14. Tang CC, Von Ah D, Fulton JS. The Symptom Experience of Patients With Advanced Pancreatic Cancer: An Integrative Review. Cancer Nurs 2018;41:33-44. [Crossref] [PubMed]
15. Tung S, Coburn NG, Davis LE, et al. Population-based study of the prevalence and management of self-reported high pain scores in patients with non-resected pancreatic adenocarcinoma. Br J Surg 2019;106:1666-75. [Crossref] [PubMed]
16. Bye A, Jordhøy MS, Skjegstad G, et al. Symptoms in advanced pancreatic cancer are of importance for energy intake. Support Care Cancer 2013;21:219-27. [Crossref] [PubMed]
17. Pacheco-Barcia V, Custodio-Cabello S, Carrasco-Valero F, et al. Systemic Inflammation Response Index and weight loss as prognostic factors in metastatic pancreatic cancer: A concept study from the PANTHEIA-SEOM trial. World J Gastrointest Oncol 2024;16:386-97. [Crossref] [PubMed]
18. Di Marco M, Rubbi I, Baldi A, et al. Evaluation of fatigue in patients with pancreatic cancer receiving chemotherapy treatment: a cross-sectional observational study. Acta Biomed 2018;89:18-27. [Crossref] [PubMed]
19. Dengsø KE, Andersen EW, Thomsen T, et al. Increased psychological symptom burden in patients with pancreatic cancer: A population-based cohort study. Pancreatology 2020;20:511-21. [Crossref] [PubMed]
20. Kelsen DP, Portenoy RK, Thaler HT, et al. Pain and depression in patients with newly diagnosed pancreas cancer. J Clin Oncol 1995;13:748-55. [Crossref] [PubMed]
21. Kim CA, Lelond S, Daeninck PJ, et al. The impact of early palliative care on the quality of life of patients with advanced pancreatic cancer: The IMPERATIVE case-crossover study. Support Care Cancer 2023;31:250. [Crossref] [PubMed]
22. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721-30. [Crossref] [PubMed]
23. Rugno FC, Carlo MM. The Palliative Outcome Scale (POS) applied to clinical practice and research: an integrative review. Rev Lat Am Enfermagem 2016;24:e2764. [Crossref] [PubMed]
24. Michael N, Beale G, O'Callaghan C, et al. Timing of palliative care referral and aggressive cancer care toward the end-of-life in pancreatic cancer: a retrospective, single-center observational study. BMC Palliat Care 2019;18:13. [Crossref] [PubMed]
25. Miinalainen S, Rissanen A, Leskela RL, et al. Effect of Palliative Care Decision on Use of Hospital Services in Pancreatic Cancer Patients: A Retrospective Study. Anticancer Res 2022;42:5457-63. [Crossref] [PubMed]
26. Ekström A, Brun E, Eberhard J, et al. Integration of Specialized Palliative Care with Oncological Treatment in Patients with Advanced Pancreatic Cancer. J Pancreat Cancer 2022;8:2-8. [Crossref] [PubMed]