Cancer Therapy, Palliative

Cancer Therapy, Palliative

 

Definition

Palliative cancer therapy is treatment specifically directed to help improve the symptoms associated with terminal cancer.

Purpose

Palliative care is directed to improving symptoms associated with incurable cancer. Care can include surgery, radiation therapy, chemotherapy, symptomatic treatments resulting from cancer, and side effects of treatment. The primary objective of palliative care is to improve the quality of the remainder of a patient's life. Treatment usually involves a combination of modalities (multimodality approach) and numerous specialists typically are involved in the treatment planning process. Therapeutic planning usually involves careful coordination with the treatment team. The approach to palliative care also involves easing psychosocial problems and an emphasis on the patient's family.
Surgery can be utilized for palliation after careful evaluation and planning. The use of surgery in these cases may reduce the tumor bulk and help improve the quality of life by relieving pain, alleviating obstruction, or controlling bleeding. Radiation therapy for terminal cancer patients can also alleviate pain, bleeding, and obstruction of neighboring areas. New research in 2003 showed that using a combination of radiation therapy bisphosphanates helped offer palliative relief to patients with metastatic bone disease (metastatic disease is cancer that has spread beyond the original site or organ to other areas of the body). Chemotherapy may be helpful to reduce tumor size and provide some reduction to metastatic disease. Long-term chemotherapy patients develop drug resistance, a situation that renders chemotherapeutic treatments ineffective. If this occurs, patients usually are given a second line medication or, if admission criteria are met, they may participate in an experimental research protocol. Palliative treatments and terminal cancer in combination can cause many symptoms that can become problematic. These symptoms commonly include pain, nausea, vomiting, difficulty in breathing, constipation, dehydration, agitation, and delirium. The palliative treatment-planning goal focuses on reducing these symptoms.

Precautions

Surgery for tumor removal, biopsy, or size reduction is associated with postoperative pain and local nerve damage, which may be both severe and difficult to alleviate. Chemotherapy and radiation therapy also can produce nerve damage and severe pain. Additionally, patients with malignant cancer are susceptible to infections like herpes, pneumonia, urinary tract infections, and wound abscess, all of which can cause severe pain. Pain associated with cancer and/or treatments can significantly impair the patient's abilities to perform daily tasks and hence impair quality of life. These complications may negatively impact the patient's psychological well-being.

Description

Pain is one of the common symptoms associated with cancer. Approximately 75% of terminal cancer patients have pain. Pain is a subjective symptom and thus it cannot be measured using technological approaches. Pain can be assessed using numeric scales (from one to 10, one is rated as no pain while 10 is severe) or rating specific facial expressions associated with various levels of pain. The majority of cancer patients experience pain as a result of tumor mass that compresses neighboring nerves, bone, or soft tissues, or from direct nerve injury (neuropathic pain). Pain can occur from affected nerves in the ribs, muscles, and internal structures such as the abdomen (cramping type pain associated with obstruction). Many patients also experience various types of pain as a direct result of follow-up tests, treatments (surgery, radiation, and chemo-therapy) and diagnostic procedures (i.e., biopsy).

Preparation

Patients typically are informed that their diagnosis is terminal and treatments are directed to improve quality of life an ease suffering for the remaining time. Treatment also is aimed to minimize emotional suffering associated with pain.
A careful history is necessary to assess duration, severity, and location of pain. A physical examination may verify the presence of pain. Imaging analysis may further confirm the presence of potential causes of pain. The World Health Organization (WHO) recommends an analgesic ladder. This treatment approach provides medication selections based on previous analgesic use and severity of pain. The ladder starts with the use of non-opioid (non-morphine) drugs such as aspirin, acetaminophen, or non-steroidal anti-inflammatory medications (NSAIDs) for control of mild pain. Chronic pain must be treated with constant and consistently administered medication(s). The "take as needed" approach is not advised. Supplemental doses may be recommended in addition to the standard dose for circumstances that may worsen pain. Opioids (i.e., morphine and codeine) are the medications of choice for moderate to severe pain. Doses are adjusted to produce maximum pain relief while minimizing side effects. These medications are conveniently administered orally. Administering steroids can help reduce nausea and vomiting. Delirium and anxiety may be improved by psychoactive medications.

Aftercare

Care for palliation is continuous and consistent for the remainder of life. Patients who have less than six months of life remaining may choose a hospice to stop treatment and control pain. Nutritional care is an important part of palliative care, since many patients suffer malnourishing effects of radiation and chemotherapy and those who can maintain pleasure from food should. A proper diet can offset effects of the many medications patients on palliative care may receive.

Risks

Patients taking opioids for pain relief can develop tolerance and dependence. Tolerance develops when a patient requires increasing amounts of medication to produce pain reduction. Dependence shows characteristic withdrawal symptoms if medications are abruptly stopped. These symptoms can be avoided by tapering down doses in the event that these medications should be stopped.

Key terms

Opioids — Narcotic pain killing medications.
World Health Organization (WHO) — An international organization concerned with world health and welfare.

Resources

Books

Abeloff, Martin D., et al. Clinical Oncology. 2nd ed. Churchill Livingstone, Inc, 2000.
Goroll, Allan H., et al., editors. Primary Care Medicine. 4th ed. Lippincott, Williams & Wilkins. 2000.
Washington Manual of Medical Therapeutics. 30th ed. Washington University School of Medicine, Department of Medicine, 2001.

Periodicals

"Bisphosphanates, Radiation Therapy Can be Used for Metastatic Bone Disease." Cancer Weekly October 28, 2003: 112.
Cimino, James E. "The Role of Nutrition in Hospice and Palliative Care of the Cancer Patient." Topics in Clinical Nutrition July-September 2003: 154-158.
Mercadante, S., F. Fulfaro, and A. Casuccio. "The Impact of Home Palliative Care on Symptoms in Advanced Cancer Patients." Support Care Cancer July 2000.

Organizations

American Cancer Society. http://www.cancer.org.
American Pain Society. 〈http://www.ampiansoc.org〉.
National Cancer Institute. 〈http://cnetdb.nci.nih.gov/cancerlit.shtml〉.

Other

"Improving Palliative Care for Cancer." Report and Booklet. Institute of Medicine, 2001. http://www.nap.edu/catalog/10790/html.
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