Cancer Therapy, Palliative
Palliative cancer therapy is treatment specifically directed to help improve the symptoms associated with terminal cancer.
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 remaining duration of life. Treatment usually involves a combination of modalities (multimodality approach) and numerous specialists are typically involved in the treatment planning process. Therapeutic planning usually involves meticulous coordination with the treatment team.
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. Radiotherapy for terminal cancer patients can also alleviate pain, bleeding, and obstruction of neighboring areas. 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 are usually 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 to reduce these symptoms.
Surgery for the purpose of 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 can also 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 capabilities for performing daily tasks and hence impair quality of life. These complications may negatively impact the patient's psychological well being.
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 chemotherapy) and diagnostic procedures (i.e., biopsy).
Patients are typically informed that their diagnosis is terminal and treatments are directed to improve quality of life for the remaining time and 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, acetaminophin, or nonsteroidal anti-inflammatory medications 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.
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.
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.
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Laith Farid Gulli, M.D.
Nicole Mallory, M.S.
Opioids—Narcotic pain killing medication.
World Health Organization (WHO)—An international organization concerned with world health and welfare.