Advanced cancer is associated with symptoms that negatively affect the quality of life of patients and their families. One significant effect is the change cancer evokes in the nociceptive system. The patient's pain threshold may change to the point where stimuli not previously considered painful (eg, touching, coughing, and walking) are now perceived as painful, and painful stimuli evoke an exaggerated perception of pain. About 75% of patients with advanced cancer experience moderate to severe pain.
Many patients suffer gastrointestinal problems such as nausea, vomiting, and constipation. About 85% experience anorexia and cachexia. Others, especially those with lung cancer or distention of the abdomen, suffer respiratory problems such as dyspnea. Urinary problems also can occur. Other patients may experience changes in mentation. The great majority suffer from intense fatigue. More than 90% of patients say they feel significant tiredness unrelieved by napping or resting. All of these symptoms take a toll on both patients and caregivers.
Definition and Role of Supportive Care
Members of the National Institutes of Health Pain and Palliative Care Working Group (NIH-PPCWG) describe palliative care (supportive care) as the collaborative effort of an interdisciplinary team with expertise to address the physical, social, psychosocial, and spiritual needs of patients and their families. Palliative (supportive) care focuses on minimizing suffering and optimizing quality of life. Supportive care must start with the onset of serious and/or progressive illness, and should continue until the illness is cured, the symptoms have subsided, or the patient dies.
At the time of diagnosis, major efforts are focused on curing the disease if cure is indeed possible. However, the physical, psychological, and emotional needs of patients and caregivers still must be addressed through supportive care. If the patient is cured or goes into remission, and has no bothersome symptoms, supportive care abates. If the disease recurs and the patient moves from a curable illness to a progressive or terminal illness, then supportive care increases and antineoplastic therapy decreases.
Supportive care focuses on controlling symptoms, and controlling severe pain and other symptoms not only improves quality of life, but can also prolong life. The care team should explain to the patient why symptoms occur and discuss the care plan for dealing with them. This effort requires an interactive relationship between physicians, nurses, other healthcare professionals, patients, and family. This interaction also can help the care team individualize treatment for each patient.
Each symptom must be assessed and aggressively treated, bearing in mind that treatment of one symptom can cause other symptoms. Pain, for instance, is a symptom for many cancer patients. The cancer itself can cause soft-tissue/bone, visceral, or neuropathic pain, but pain can also arise from cancer therapy, debility, immobility, and concurrent chronic disorders. Treatment of pain with opioids may cause constipation that then must be properly treated with laxatives. Other symptoms such as dysphagia, dyspepsia, nausea, and vomiting can interfere with patients' ability to eat, leading to cachexia and fatigue.
Some patients also experience respiratory symptoms. Dyspnea can arise from a number of conditions, including effusion, obstructions, abdominal distention, pneumonectomy, fibrosis, atelectasis, infection, anemia, and general weakness. Cough can be caused by intrathoracic cancer, chronic bronchitis, chest infections, and smoking. Hiccuping can be caused by irritation of the diaphragm or phrenic nerve, gastric distention, uremia, infections, or tumors of the central nervous system.
Urinary symptoms may manifest as frequency, urgency, and incontinence. These problems can be caused by pain, polyuria, and cystitis due to radiation therapy, infection, or cyclophosphamide (Cytoxan, Neosar). Urinary hesitancy and retention can arise from prostate enlargement, infiltration of the bladder neck, spinal cord compression, plexopathy of the sacral plexus, constipation, and impaction. Bladder spasms can be caused by urinary bladder irritation and infiltration, fibrosis, anxiety, and indwelling catheters.
Mental changes such as mental clouding, amnesia, anxiety, and even hallucinations may be acute, sometimes caused by medications. These symptoms may be remitting and reversible, but dementia is a chronic, progressive, and irreversible condition.
Care for the Caregiver
The need for care for the caregivers must not be forgotten. Cancer is a disease of the elderly, and as their caregivers are frequently elderly as well, they may have chronic conditions. Findings from a study of caregivers of patients with Alzheimer's disease can most likely be applied to this population as well. Compared to matched control noncaregiving subjects, caregivers had decreased cellular immunity that translated into more days of sickness due to infection- especially upper respiratory infection. The caregivers also did not respond as robustly to vaccinations and had delayed wound healing and more depressive disorders. These alterations persisted even 2 years after the patient had died.
One of the most important roles of health-care professionals is to support the patient and the family. Albert Schweitzer said, "Pain is a more terrible Lord of mankind than even death itself," and a translated quote by the Italian writer Primo Levi affirms, "If we know that severe pain and suffering can be alleviated and we do nothing about it, we, ourselves, are tormentors." Poorly treated, intense pain and symptoms are tragic cases of human rights violations. Patients have a basic right to proper treatment of pain and other symptoms of cancer.
1. Woodforde JM, Fielding JR: Pain and cancer. J Psychosom Res
2. Kiecolt-Glaser J, Glaser R: Depression and immune function:
Central pathways to morbidity and mortality. J Psychosom Res 53(4):873-
3. Schweitzer A: On the Edge of the Primeval Forest, p 62. New York,
4. Benedetti C: Pain: The magnitude of the problem and unmet
therapeutic needs. Biomed Microdevices 3:125-132, 2001.