Cancer therapy, palliative

Definition

Palliative cancer therapy is treatment specifically designed to help improve symptoms at the end of life associated with advanced and/or terminal cancer. Palliative care has evolved to become an integral component of cancer care and is typically provided by a team of multidisciplinary health care professionals.

Demographics

Currently, it is estimated that approximately 40% of patients diagnosed with cancer-about 550,000 people per year in the United States-will die from their cancer.


The end-of-life care of many of these patients will be delivered by professionals skilled in hospice or palliative cancer care.

Description

Palliative care is directed at improving symptoms associated with advanced and incurable cancer. The five major precepts of palliative care, which were delineated as part of the Robert Wood Johnson Foundationfunded Last Acts campaign to improve quality of care at the end of life, include:

Palliative care can include surgery, radiation therapy, chemotherapy, hormone therapy, and other specialized therapies, as well as treatment of symptoms resulting from cancer, and providing relief from 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 typically incorporates an emphasis on the patient's family.



Causes and symptoms

Some signs of advanced cancer include extreme fatigue and weakness that is progressive, unexplained weight loss, pain, and shortness of breath, especially if the cancer has spread to the lungs.

There is the potential for a wide range of symptoms as the cancer progresses to the advanced or terminal phase. These symptoms include pain, myoclonus, dyspnea, anxiety, delirium, and noisy breathing or "rattle" among a variety of other symptoms.

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 1 to 10, 1 is rated as no pain while 10 is severe) or by 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 chemotherapy) and diagnostic procedures (i.e., biopsy).

Diagnosis

Patients typically are informed that their diagnosis is terminal and treatments are directed to improve quality of life and ease suffering at the end of life.

Examination

The physician may perform a physical examination to help confirm advanced cancer based on the signs and symptoms the patient is experiencing. Results of this physical exam may include evidence of fluid in the lungs or abdominal area. An enlarged liver may be palpated by the physician, or external lumps that are comprised of tumor may be able to be seen and palpated on various areas of the body.

Tests

Blood test results that may confirm advanced cancer include elevated levels of tumor markers in the blood, elevated liver function tests and liver enzymes, and elevated or decreased white blood cells, red blood cells, and/or platelets, among other findings.

Imaging tests such as x rays and CT, MRI, PET, bone, and ultrasound scans may be conducted to determine the location and spread of the cancer.

A comprehensive palliative care assessment should be conducted to evaluate the following:

  • benefits and risks associated with continuing treatments and therapies directed at controlling the cancer
  • physical symptoms and problems such as pain, anorexia, dyspnea, nausea/vomiting, constipation, fatigue, weakness, alterations with sleep, and delirium, as well as other problems
  • psychosocial symptoms and problems including spiritual needs
  • the patient's and family's goals and wishes related to end-of-life care
  • educational level to determine information needs and requirements
  • the impact of cultural beliefs on preferences related to end-of-life care

Treatment

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. A combination of radiation therapy and bisphosphanates offers 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 breathing, constipation, dehydration, agitation, and delirium. The palliative treatment-planning goal focuses on reducing these symptoms.

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 such as 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.

Prognosis

Palliative cancer care is typically offered to patients with six months to one year of life expectancy.

prevention

Currently, the only way to prevent a cancer from spreading and developing into an advanced or incurable cancer is to detect the cancer prior to metastatic spread and to initiate treatment for the cancer as soon as possible after diagnosis.