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Symptom management: An important part of cancer care

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ABSTRACTPhysicians can do a better job of palliating symptoms and improving the quality of life of cancer patients if they understand the principles of symptom management. We review the general principles of symptom management for fatigue, anorexia, constipation, dyspnea, nausea, and vomiting.

KEY POINTS

  • Patients with advanced cancer typically suffer from multiple concurrent symptoms, which they rate as moderate or severe.
  • The principles of symptom management include taking an aggressive detailed approach, prioritizing, and identifying symptom pathophysiology.
  • Prescribed regimens should be specific and simple; physicians should consider the patient’s age and fragility, the cost of the treatment, and anticipated drug side effects.
  • To ensure optimal palliation with the fewest possible adverse effects, reassess frequently, make one change at a time, and use rescue doses.


 

References

Cancer patients experience many distressing symptoms during the course of their illness. In addition to pain, they commonly suffer from fatigue, anorexia, constipation, dyspnea, nausea, and vomiting.1

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Although it is important to diagnose and manage the cancer itself, it is also the physician’s duty to recognize and effectively treat associated symptoms, regardless of the outcome of the underlying disease.

Some of the symptoms are due to the underlying disease, but some are iatrogenic, as many medical interventions have predictable adverse effects, such as nausea and vomiting with chemotherapy or constipation with opioids.

Symptoms of advanced cancer become chronic, and patients usually rate them as moderate or severe.1 Unrelieved suffering causes demoralization and may quickly impair quality of life.2

Understanding the principles of symptom management may help optimize palliation and improve quality of life. In this paper, we outline an approach to the management of cancer-related symptoms.

A HEAVY BURDEN OF SYMPTOMS

In patients with advanced cancer, the prevalence rates of various symptoms are approximately as follows1,3:

  • Pain 89%
  • Fatigue 69%
  • Weakness 66%
  • Anorexia 66%
  • Lack of energy 61%
  • Nausea 60%
  • Dry mouth 57%
  • Constipation 52%
  • Early satiety 51%
  • Dyspnea 50%
  • Vomiting 30%.
Data from Homsi J, et al. Symptom evaluation in palliative medicine: patient report vs systematic assessment. Support Care Cancer 2006; 14:444–453.

Figure 1.

Furthermore, patients with advanced cancer typically have multiple concurrent symptoms. In a survey of patients in a palliative medicine service at our hospital,4 we found that the median number of symptoms per patient was 10 (range 0–25) (Figure 1).

PRINCIPLES OF SYMPTOM MANAGEMENT

Show an interest in the patient’s symptoms. Many patients with advanced cancer believe that suffering is an inevitable part of the disease or of its treatment.

Ask patients about their symptoms in a positive and detailed fashion, starting with open-ended questions and following up with specific questions. Patients may underreport their symptoms or may not mention them if not asked directly. In the survey of palliative care patients at our hospital mentioned above,4 the median number of volunteered symptoms was only 1 (range 0–6), whereas a median of 10 were found by systematic assessment.

The examiner should clarify when necessary and recognize that a layperson’s language may not directly translate to medical language. For example, a patient may not understand the term “anorexia.” Furthermore, “loss of appetite” may mean nausea, vomiting, constipation, or early satiety. “Numbness” may mean a loss of sensation or a pins-and-needles sensation. Symptoms should also be quantified using a consistent measure (ie, numerical or categorical) to facilitate monitoring.

Prioritize the symptoms. Advanced cancer is accompanied by multiple symptoms. Assess which ones are most bothersome, and where therapy should be directed first.

Try to understand the pathophysiology behind the symptom. When possible, choose a drug treatment that targets the likely underlying cause. Nausea and vomiting, for example, can be secondary to gastric outlet obstruction, hypercalcemia, increased intracranial pressure, esophagitis, opioid use, or constipation.

Be specific about the drug, dosing, timing, and route, and keep it simple. If a regimen is cumbersome, compliance suffers. It is better to start one medication for the most bothersome symptom or symptoms and make some progress than it is to overwhelm the patient with a complex list of drugs. Sustained-release formulations are often useful. It is unrealistic to expect most patients to take a medication every 4 hours around the clock. Try the most cost-effective remedies first, and attempt to use one drug that may address multiple symptoms. For example, dexamethasone may have positive effects on energy, pain, and appetite.

Use ‘rescue dosing.’ Rescue drugs are important for expected symptom exacerbations in those on sustained medication. This approach increases efficacy and minimizes adverse effects. In most cases, the rescue medication should be the same as the regularly scheduled one. For example, a prescription to treat nausea may read “metoclopramide (Reglan) 10 mg by mouth before meals and at bedtime and every 4 hours as needed to treat nausea or vomiting.”

Consider the patient’s age and fragility, the cost of the drug, and anticipated adverse effects. Oral or transdermal preparations are preferable to parenteral ones with regard to convenience and compliance, although many transdermal preparations are costly. If parenteral dosing is necessary, the subcutaneous route is an alternative to the intravenous route.

Discontinue drugs that are ineffective or unnecessary. This may help compliance and diminish adverse effects.

Make one change at a time so the response to that change is clear. Titrate one drug to its effective dose, to its maximum dose, or to a level of intolerability before considering another. If one drug of a class is ineffective, another drug in the same class may work.

Reassess often. A follow-up phone call or office visit in 1 to 2 weeks is appropriate. The symptoms of advanced cancer are often progressive, so regular evaluation is important, even if symptoms are controlled on stable drug regimens. Instructions should be both verbal and written and should be communicated to patients and any involved caregiver to ensure compliance. Have a “plan B” if the first plan is ineffective.

Figure 2. During the course of progressive cancer, proportionally more attention is directed to relieving symptoms and less to treating the underlying disease.

A challenging and important part of symptom management is to assess the goals of care. Every intervention is not appropriate for every patient. Which therapies are used depends on the stage of the disease, the available disease-modifying treatments, and the patient’s condition and preferences. Patients and their loved ones should be engaged in discussions about goals of care early in the disease and should be included in medical decision-making. Both curative treatment and palliative treatment are important, but palliation plays a bigger role towards the later stages of advanced cancer (Figure 2).

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