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The pancreas makes the enzymes that digest food, and a cancer in it, or the operation to remove it, leaves most patients unable to absorb what they eat. Capsules replacing those enzymes are cheap and recommended, yet UK records show only one patient in five was prescribed them. The proposal is to prescribe by default at diagnosis, publish each hospital's rate, and run the trial never done.
Traverso and Longmire recorded in 1980 that every one of their 18 pylorus-preserving patients had marked pancreatic insufficiency and needed intensive enzyme replacement. Roberts 2019, in 4,554 UK primary care patients with pancreatic adenocarcinoma, found enzyme replacement prescribed to 21.7 percent, and in 807 propensity-matched pairs an adjusted survival time ratio of 2.62 (95 percent confidence interval 2.27 to 3.02), consistent across surgery and chemotherapy subgroups. NICE NG85 (2018) recommends enteric-coated pancreatin for unresectable disease and after resection, and the National Pancreatic Cancer Audit now reports prescribing as a performance indicator in England (the Wales data item was unavailable in the first report). The proposal has three parts: an opt-out prescription at diagnosis in every pancreatic multidisciplinary team, with dose titration by a dietitian; publication of the audit indicator by trust; and a pragmatic randomised or stepped-wedge trial of default prescribing against usual care with survival, weight and chemotherapy delivery as outcomes, since the survival association is observational and confounded by fitness. The UK figures and the audit's recommendations are on the UK and NHS page.
Enzyme replacement is cheap, guideline-recommended (NICE NG85) and under-prescribed; the National Pancreatic Cancer Audit now reports the prescribing rate as a performance indicator, which the UK and NHS page tracks.
The pylorus-preserving Whipple became the standard variant, and the 1980 follow-up is an early record of the exocrine insufficiency that still goes untreated in most patients today.
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