Pain management in pancreatic cancer: time to change our strategy!

Pain affects 70-80% of patients with pancreatic adenocarcinoma and remains inadequately controlled in more than half of cases. Beyond its impact on quality of life, pain is now recognized as an independent prognostic factor, reflecting the unique neurobiological features of this malignancy. Perineural invasion drives a bidirectional dialogue between cancer cells and the peripheral nervous system, in which neurotrophic factors, neuropeptides, and immune mediators fuel both nociception and tumour progression. Current pain management relies on the WHO analgesic ladder supplemented by adjuvant agents (gabapentinoids, duloxetine, corticosteroids) and interventional procedures including celiac plexus neurolysis, intrathecal opioid delivery, and palliative radiotherapy. Recent advances, notably celiac plexus radiosurgery and evidence favouring early neurolysis, challenge the prevailing reactive approach. This review examines the pathophysiology of pancreatic cancer pain, critically appraises available treatments, identifies gaps in current evidence, and argues for a proactive, multimodal strategy initiated at diagnosis rather than reserved for refractory disease.