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Treatment of Dyspnea in Cancer Patients

Treatment of Dyspnea in Cancer Patients

A 54-year-old female seeks medical attention with a complaint of worsening
exertional dyspnea of 3 to 4 weeks’ duration. She has a history of small-cell
lung carcinoma, first diagnosed 3 months previously, and has had an excellent
response to treatment, which included both chemotherapy and external-beam
radiation. Consistent with her cancer diagnosis, she has a 30 pack-year
history of cigarette smoking, and her pulmonary function tests indicate mild
airflow obstruction, slight hyperinflation on lung volumes, and a mildly
decreased diffusion capacity. In addition to her dyspnea with exertion, the
patient describes symptoms of an intermittently productive cough, fatigue, and,
recently, a poor appetite.

This could be a typical case encountered by an oncologist,
pulmonary/critical-care physician, or primary-care physician. Variations on the
theme of dyspnea and cough are two of the most common problems that the
pulmonary specialist deals with on an outpatient basis, and it would not be
unusual for the above patient to be referred to us or one of our colleagues at
some point for further evaluation. In this issue of ONCOLOGY, Jay R. Thomas and
Charles F. von Gunten provide a succinct template for the treatment of such
patients.

A Complex, Integrated Process

As the authors state in their first paragraph, dyspnea is defined as a
sensation of difficult or uncomfortable breathing and has been reported to occur
in 21% to 90% of cancer patients. For some individuals, dyspnea is described as
breathlessness, while others feel a sense of restriction in their breathing or
even a vague feeling of chest discomfort. Drs. Thomas and von Gunten
appropriately emphasize that this subjective sense of discomfort while breathing
is the physiologic manifestation of a complex and integrated process involving
input from several sources—ie, from the airway and lung parenchyma as well as
the brain’s respiratory center, the cerebral cortex, peripheral musculature,
and the central and peripheral chemoreceptors.

Although the subjective feeling of dyspnea is a common symptom among
individuals with advanced primary lung cancer or those with metastatic spread to
the lung, it is also found in individuals with no demonstrable pulmonary or
pleural involvement. It is not surprising that the National Hospice Study[1]
found that 24% of oncology patients experienced dyspnea with no known
cardiopulmonary process.

Etiology of Dyspnea

The authors state that it is important to initiate a reasonable evaluation of
the cause of the patient’s dyspnea. As they point out, dyspnea in cancer
patients is usually multifactorial, with more than one potential cause per
patient. Their review suggests that, as potential causes of dyspnea, pulmonary
or pleural involvement should be at the forefront of such an evaluation.

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