Symptom Management in Cancer

Symptom Management in Cancer

Pain Management in Cancer

·        Principles of symptom control:

o   Evaluation: identify each problem/pain and make sure it‟s managed

o   Explanation

o   Individualised treatment

o   Monitoring progress

o   Attention to detail

o   Anticipate problems

·        Common problems:

o   Physical symptoms: pain, anorexia, nausea, insomnia etc 

o   Compounded by anger, losses, fear, financial insecurity, anxiety, isolation, bewildered by treatment. Always consider emotional, intellectual and spiritual components

·        Causes of pain:

o   Destructive/obstructive effects of the cancer

o   Debility: pressure sores, constipation

o   Due to treatment

·        WHO analgesic ladder:

o   Step 1: mild pain.  Paracetamol, aspirin, NSAIDs

o   Step 2: moderate pain.  Codeine, Tramadol (not subsidised, plus combination drugs:

§  Paradex (Digesic): dextropropoxyphene plus paracetamol

§  Panadine: codeine plus paracetamol

o  Step 3: severe pain:

§  Morphine: 

·        Actions: analgesia, respiratory depression, drowsiness, vomiting, miosis, convulsions, euphoria or Dysphoria, smooth muscle stimulation (® GI muscle spasm, bilary and renal tract spasm) 

·        Rapid acting oral: morphine elixir (10 mg 4 hourly) or Sevredol tablet (10 or 20 mg): maximum effect after 2 hours 

·        Longer acting: MST (duration 8 – 12 hours) or Kapanol (24 hour slow release)

·        PR: rapid acting suppositories or MST

·        Parenterally: IM (onset in 10 – 15 minutes, lasts 4 hours), SC, IV

·        Bioavailability: half parenteral dose over oral

·        Anticipate constipation

·        Signs of morphine overdose: RR < 12, if RR < 8 then Naloxone

§  Methadone (difficult titrating the dose) 

§  Fentanyl: less constipation than morphine, but not subsidised, transdermal fentanyl patches lasting 72 hours are well suited to patients with stable pain and low to medium opiod requirements

o  Adjuvants at any stage: TCAs, anticonvulsants, steroids, muscle relaxants, antiarrhythmics

·        Anticipate pain and give regular analgesia, plus PRN medication for acute-on-chronic pain („breakthrough‟ pain)

·        Enhance coping skills:

o  Listen and acknowledge the symptoms

o  Explanation, information

o  Shared decision making

o  Calm supportive environment

o  Complementary therapies: relaxation, art therapy, music, OT diversional therapy

o  Spiritual support, counselling

o  Treat anxiety, depression

o  Support the family

Management of Nausea

·        Identify the right pathway and treat it specifically:

·        “Drugs of choice”:

o  H1 antagonist: cyclizine

o  D2 antagonist: Haloperidol

o  Prokinetic: Oral domperidone, iv metoclopramide (also has anti-D2 effect)

·        Chemical cause (stimulation of chemoreceptor trigger zone by uraemia, opioid induced, hypercalcaemia, toxins): stimulates dopamine receptors. Haloperidol is a dopamine antagonist, as is chlorpromazine, metoclopramide and cisapride

·        Mechanical cause (squashed stomach, delayed emptying, regurgitation): Metoclopramide and domperidone ® prokinetic action

·        Emetogenic chemotherapy: stimulates release of serotonin in the gut: 5HT3 antagonists are used (ondansetron, granisetron, tropisetron)

·        Vestibular and ­ICP: use antihistamines eg cyclizine

·        Non-drug therapy: prophylactic treatment of constipation, keep away from sight or small of food; small, frequent, attractive meals, relaxation therapy, acupressure

Management of Breathlessness

·        Due to effusion, anaemia, mass or irritant effect, anxiety, fatigue. Compounded by fear of fighting to breath. Can also be PE (but don‟t anticoagulate them – it‟s better to die from a clot than a bleed)

·        Low dose morphine ® ¯irritant respiratory reflexes

·        Anxiolytics for panic (eg lorazepam for intermittent breathlessness, diazepam for chronic)

·        Steroids for anti-inflammatory effect

·        Nebulised saline: shift sticky secretions, humidify dry airways

·        Oxygen if symptomatic hypoxia – but commits the patient to the equipment

·        Advice from physio, especially re controlling expiration

·        Fan on face, open window

Management of Cachexia

·        = Marked weight loss and muscle wasting, especially in advanced GI and lung cancers

·        Due to ­metabolic rate and ¯food intake, plus abnormal metabolism and cytokine production

·        May also see altered taste sensation, loose dentures causing difficulty eating, oedema due to hypo-albuminaemia, pressure sores over bony prominences, etc

·        Body changes may generate feelings of fear, isolation or difficulty with relationships

·        Management:

o   Dietary supplements and NG feeding are unlikely to achieve anything. Patients should eat and drink as they wish

o   Corticosteroids in a reducing protocol may help (as well as reducing tumour oedema)

o   Relining dentures

o   General support: education, new clothes, aides to maintain independence