Should Dyspnea in Lung Cancer Be Medicated?

September 24, 2018
Naveed Saleh, MD, MS
Naveed Saleh, MD, MS

Two presentations at the IASLC WCLC 2018 discussed the evidence on treating breathlessness with pharmacologic vs nonpharmacologic therapy.

Lung cancer manifests with several complex symptoms, including dyspnea-and much controversy has surrounded whether to manage dyspnea in particular with pharmacologic treatment, such as opioids, or nonpharmacologic treatment. A discussion on this topic took place during two complementary presentations at the International Association for the Study of Lung Cancer (IASLC) 19th World Conference on Lung Cancer, held September 23–26 in Toronto.

Lung cancer carries a high disease burden and exacts physical hardship. Up to 60% of patients with lung cancer suffer from dyspnea. Severity varies, and, according to the results of a recent systematic review, is unrelated to disease stage.

In addition to dyspnea, other complex symptoms that occur with lung cancer include fatigue, cough, and pain. Comorbid health conditions-including heart disease-are also linked to complaints of dyspnea. Smoking in particular often plays a major role. 

Initial treatment of dyspnea should focus on optimizing the medical and pharmacologic treatment of the cancer itself. Once the cancer treatment is optimized, one first-line treatment of dyspnea is opioids, such as morphine. Another approach involves nonpharmacologic interventions, such as rehabilitation and exercise.

Pulmonary rehabilitation has been proven to decrease dyspnea in chronic respiratory conditions, including chronic obstructive pulmonary disease and interstitial lung disease. Furthermore, cardiac rehabilitation is effective at reducing dyspnea in chronic heart failure. Nevertheless, only a limited number of studies demonstrating the efficacy of pulmonary rehabilitation in reducing dyspnea have been conducted.

Rehabilitation programs usually involve 6 to 12 weeks of outpatient exercise, which consists of aerobic and resistance exercise training, as well as behavior changes and education. These rehabilitation programs are correlated with decreased self-reported dyspnea, decreased exercise-induced exertional dyspnea, and a boost in exercise tolerance. Experts suggest that exercise helps reduce dyspnea by boosting system efficiency, reducing dynamic hyperinflation, and decreasing sensitivity to breathlessness.

For acute relief, the utilization of chest wall vibration and walking aides has been proven to help reduce dyspnea. Other nonpharmacologic interventions that have been tried to treat breathlessness include breathing control, activity pacing, relaxation techniques, hand-held fans, psychosocial support, multidisciplinary input, acupuncture, and music.

Despite emerging evidence supporting the nonpharmacologic treatment of dyspnea, however, this approach has yet to take hold in clinical practice. 

When asked to weigh in on the debate between pharmacologic vs nonpharmacologic treatment of dyspnea, Paul A. Bunn, Jr, MD, distinguished professor of medical oncology at the University of Colorado in Aurora, Colorado, sees a middle ground.

“There is some truth to both points of view, and much depends on an individual’s status and desires,” he said. “Before such patients reach a terminal condition, it is true that an exercise and diet program can improve functioning, activity, weight, and overall wellbeing. Unfortunately, all stage IV lung cancer patients eventually experience disease progression and death despite our best therapies.”

However, Bunn stressed that opioids do have the ability to relieve suffering-especially in terminal cases.

“Because of their underlying lung and heart disease and their lung cancer,” he said, “shortness of breath is a frequent cause of severe distress at life’s end. It is quite clear that, at this time, opioids and other medications can relieve suffering.”