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Palliative care vs. aggressive treatment: IMPERATIVE study insights for advanced pancreatic cancer

Managing advanced pancreatic cancer is complicated, given the grim survival outlook. Choosing between palliative care and aggressive treatment is a common dilemma faced by both patients and medical professionals. In an attempt to provide clarity, the IMPERATIVE case-crossover study was conducted.

This blog explores the study's findings and their clinical implications for patients battling metastatic and locally advanced pancreatic cancer.

First, let’s recap some basics of pancreatic cancer!

Pancreatic cancer is a type of cancer that originates in the pancreas. It is considered one of the most aggressive human malignancies. Its symptoms are not obvious in the early stages which complicates the diagnosis. In as much as half of the patients, the disease spreads (metastasized) to other parts of the body at the time of diagnosis [1].

What are the challenges in care for pancreatic cancer patients?

The current management of pancreatic cancer consists of:

  • Surgical resection of the tumor

  • Radiation therapy

  • Chemotherapy drugs such as capecitabine, fluorouracil (5-FU), and gemcitabine [2]

However, these options are not as effective due to the highly aggressive nature of the disease. Targeted drugs and immunotherapy are being investigated for their potential role in the deadly disease but so far, they have not resulted in a substantial clinical benefit.

Advanced pancreatic cancer

Not only the survival time is short, but patients also suffer from the burden of cancer-associated symptoms that significantly decrease their quality of life. In the present scenario, palliative care becomes an important approach. Palliative care is a multidisciplinary approach that aims to improve the quality of life and emotional well-being of the patient by focusing on symptom management. It also encompasses end-of-life planning for patients with terminal illnesses.

Despite a need for early palliative care, its benefit and uptake in this population are not fully quantified. To address this shortcoming, an observational study was performed to evaluate the benefit of early palliative care alongside standard care in improving the quality of life of patients with locally advanced and metastatic pancreatic cancer.

How was the study conducted?

The IMPERATIVE case‑crossover study was conducted in the province of Manitoba, Canada [3]. It enrolled newly diagnosed locally advanced or metastatic pancreatic cancer patients over the age of 18 years from ambulatory clinics at a tertiary cancer center. Eligible patients were identified by gastrointestinal medical oncologists.

Patients received a palliative care consultation within two weeks of enrollment. They had follow-up visits every two weeks for the initial month, then extended to every four weeks until week 16. After that, follow-up visits were scheduled as needed.

The main focus of the study was to assess the change in the quality of life using the Functional Assessment of Cancer Therapy - hepatobiliary (FACT-Hep) questionnaire. The FACT-Hep score is a measurement of quality of life specifically related to hepatobiliary (liver and bile duct) cancer. It can range from 0 to a higher value. A higher FACT-Hep score indicates a better quality of life, while a lower score suggests poor quality of life.

The FACT-Hep score was taken between the baseline (BL) and week 16. A protocol amendment was made during the COVID-19 pandemic to allow for in-person, videoconference, or telephone follow-up visits. Questionnaires could be completed on paper, over the telephone, or returned via mail.

What was the outcome?

According to the results of the IMPERATIVE case‑crossover study, the average FACT-Hep score at baseline was 118.8, which increased to 125.7 at week 16 [4]. The mean change observed was 6.89. Following palliative care interventions, patients with metastatic disease showed a significant improvement in QOL, with a mean change of 15.3. Usually, a change of 8 to 9 points in the FACT-hep score is considered clinically meaningful in terms of emotional well-being and overall quality of life of the patients [5].

What are its implications?

The results of the IMPERATIVE case‑crossover study suggest that palliative care should be initiated early in the management of metastatic and locally advanced pancreatic cancer. It should be preferred over more aggressive treatment options due to its ability to improve QOL and symptom burden.


1. E. P. Weledji, G. Enoworock, M. Mokake, and M. Sinju, “How Grim is Pancreatic Cancer?,” Oncol Rev, vol. 10, no. 1, p. 294, Jul. 2016, doi: 10.4081/oncol.2016.294.

2. H. M. Kolbeinsson, S. Chandana, G. P. Wright, and M. Chung, “Pancreatic Cancer: A Review of Current Treatment and Novel Therapies,” J Invest Surg, vol. 36, no. 1, p. 2129884, Dec. 2023, doi: 10.1080/08941939.2022.2129884.

3.Early Palliative Care on Quality of Life of Patients With Advanced Pancreas Cancer - Full Text View -” (accessed Jul. 08, 2023).

4. C. A. Kim 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, vol. 31, no. 4, p. 250, Apr. 2023, doi: 10.1007/s00520-023-07709-3.

5. J. L. Steel, D. T. Eton, D. Cella, M. C. Olek, and B. I. Carr, “Clinically meaningful changes in health-related quality of life in patients diagnosed with hepatobiliary carcinoma,” Annals of Oncology, vol. 17, no. 2, pp. 304–312, Feb. 2006, doi: 10.1093/annonc/mdj072.



IIT Guwahati
University of Manchester
Rhenix Lifesciences
American university of Sharjah
IIT Delhi
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