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ONCOLOGY

THE VALUABLE INFORMATION SECTION CONTAINS USEFUL BRIEFING AND GUIDELINES CONCERNING ONCOLOGY, SUCH AS CANCER TESTS FOR WOMEN AGE 65 AND OLDER, WHAT IS MAMMOGRAM, LEADING SITES OF NEW CANCER CASES AND DEATHS-2002: ESTIMATES FOR FEMALES/ ESTIMATES FOR MALES, SYSTEMIC GENERAL ANESTHETICS, AND USEFUL WEBSITE ADDRESSES.

 

                                          CANCER TESTS FOR WOMEN AGE 65 AND OLDER*                                          

 

  • This information is from the National Cancer Institute (NCI), USA.

 

BREASTS

 

A woman’s risk of breast cancer increases with age. Fortunately, women can take three steps to find cancer early:

Mammogram- This x-ray of the breast can reveal problems up to 2-years before a lump can be felt. Your doctor will tell you where and when to do your mammogram. This test is recommended every one to two years.

Breast Exam- Your doctor should check your breasts for problems or changes that could be a sign of breast cancer. This test is recommended every one to two years, or as part of your regular health checkup.

Breast Self-Exam- Ask your doctor for instructions of how and when to do this exam. Breast self-examination should be done monthly.

 

UTERUS & CERVIX

 

As women get older they have a higher risk of cancers of the female sex organs-- especially cancers of the uterus and cervix. After menopause , it is important to ask the doctor about the following tests:

Pelvic Exam- The doctor feels the internal sex organs, bladder, and rectum for any changes in size or shape. This test is recom- mended every year.

Pap Smear- A Pap smear, also called a Pap test, is usually done at the same time as the pelvic exam. During this test, the doctors removes a few cells from the cervix with a swab. The cells are then checked under a microscope. After three normal annual Pap smears, your doctor may decide not to do the test for the next 1 to 3 years. This test is recommended every year.

 

COLON & RECTUM

 

Cancers of the colon and rectum are more likely to occur as people get older.Three tests can help find these cancers early: Rectal Exam- In this test, the doctor gently feels for any bumps or irregular areas on the rectum. This test is recommended every year, or as part of your regular health checkup.

Guaiac Stool Test- The guaiac stool test is sometimes called a “fecal” or “stool” occult test or “hemoccult” test. This test can find unseen blood in stool samples. The doctor can give his patient

a simple kit to collect stool samples at home. Or, he can do the test as part of a rectal exam. A guaiac stool test is recommended every year.

Sigmoidoscopy or “Procto”- The doctor looks for cancer in the colon and rectum with a thin, lighted instrument called a sigmoido- scope. This test is recommended every 3 to 5 years.

 

                                                                  WHAT IS A MAMMOGRAM*                                                                   

 

(*) This information is from the Agency for Health Care Policy and Research

 

A mammogram is a safe, low-dose x-ray picture of the breast.

Mammograms are taken during a mammography exam. There are two kinds of mammography exams-screening and diagnostic. A screening mammogram is a quick, easy way to detect breast cancer early, when treatment is more effective and survival is high. Usually, two x-ray pictures are taken of each breast. A physician trained to read x-ray pictures -a radiologist- examines them later. It is generally agreed that screening mammography decreases deaths from breast cancer in women aged 50 and over. There is a range of opinion about the value of screening mammography for women under 50.

Have a screening mammogram as often as your doctor or other health care provider suggests. A screening mammogram often can show breast changes like lumps long before they can be felt.

A diagnostic mammogram is used if there may be a problem. It is also used if it is hard to get a good picture because of special circumstances (for instance, in women with breast implants). Diagnostic mammography takes a little longer than screening mam- mography because more x-ray pictures usually are taken. A radiologist may check the x-ray pictures while you wait.

After your mammogram, your doctor receives your mammography results. Make sure you get your results from either your doctor or the mammography facility.

Make sure you understand the results and any recommendations for follow-up. and never be afraid to ask questions.

 

SCHEDULING A MAMMOGRAM

 

During mammography, the breast is pressed between two clear plastic plates for a few seconds. This gives a clear picture of the breast with the least amount of x-rays. But it may be uncomfortable, and a few women complain of some pain.

If the woman has sensitive breasts, she should try to have the mammogram at a time of month when your breasts will be least tender, avoiding the week right before the period. This will help to lessen discomfort.

 

KNOW WHAT TO EXPECT DURING A MAMMOGRAM

 

Understanding what happens during a mammogram will help reduce any anxious feelings you might have. It is important to that only a small amount of radiation is used in mammography.

To have a mammogram, the patient will stand in front of a special x-ray machine. The radiologictechnologist lifts each breast and places it on a platform that holds the x-ray film. The platform can be raised or lowered to match her height.

The breast is then gradually presseed against the platform by a specially designed clear plastic plate. Some pressure is needed for a few seconds to make sure the x-ray show as much of the breast as possible. This pressure is not harmful to the breast. In fact, flattening the breast lowers the x-ray dose needed.

 

Studies show that most women do not find mammogram painful for the short time needed to take the picture. If the pressure becomes painful, the patient can tell the radiologic technicnologist to stop.

If there is an ares of the breast that appears to have a problem, the radilogist or radiologic technologist will examine the breast.

 

Leading sites of new cancer cases and deaths-- 2002 estimates for females* Cancer cases by site   Cancer deaths by site

Breast

203,500 (31%)

Lung & Bronchus

65,700 (25%)

Lung & Bronchus

79,200 (12%)

Breast

39,600 (15%)

Colon & rectum

75,700 (12%)

Colon & rectum

28,600 (11%)

Uterine corpus

39,300 (6%)

Pancreas

15,200 (6%)

Non-Hodgkin’s

25,700 (4%)

Ovary

13,900 (5%) Lymphoma

Melanoma of the Skin

23,500 (4%)

Non-Hodgkin’s

11,700 (4%) Lymphoma

Ovary

23,300 (4%)

Leukemia

9,600 (4%)

Thyroid

15,800 (2%)

Uterine Corpos

6,600 (2%)

Pancreas

15,600 (2%)

Brain

5,900 (2%)

Urinary Bladder

15,000 (2%)

Multiple Myeloma

5,300 (2%)

All sites

647,000 (100%)

All sites

267,300 (100%)

 

  • Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder. Percentages may not total to 100% due to rounding

Source: Cancer Facts & Figures 2002. American Cancer Society.

 

Leading sites of new cancer cases and deaths- 2002 estimates for males*

Cancer

Cases by site

Cancer deaths

by site

Prostate

189,000 (30%)

Lung & bronchus

89,000 (31%)

Lung & bronchus

90,000 (14%)

Prostate

30,200 (11%)

Colon & rectum

72,600 (11%)

Colon & rectum

27,800 (10%)

Urinary bladder

41,500 (7%)

Pancreas

14,500 (5%)

Melanoma of the skin

30,100 (5%)

Non-Hodgkin’s lymphoma

12,700 (5%)

Non-Hodgkin’s lymphoma

28,200 (4%)

Leukemia

12,100 (4%)

Kidney

19,100 (3%)

Esophagus

9,600 (3%)

Oral cavity

18,900 (3%)

Liver

8,900 (3%)

Leukemia

17,600 (3%)

Urinary bladder

8,600 (3%)

Pancreas

14,700 (2%)

Kidney

7,200 (3%)

All sites

637,500 (100%)

All sites

288,200 (100%)

* Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder. Percentages may not total to 100% due to rounding.

Source: Cancer Facts & Figures 2002. American Cancer Society.

 

                     SYSTEMIC GENERAL ANESTHETICS  

 

General anesthetics normally are used to produce loss of consciousness before and during surgery. However, for obstetrics or cer- tain minor procedures, an anesthetic may be given in small amounts to relieve anxiety or pain without causing unconsciousness. Some of the anesthetics may be used for certain procedures in a medical doctor’s or dentist’s office.

 

Propofol is used sometimes in patients in intensive care units in hospitals to cause unconsciousness. This may allow the patients to withstand the stress of being in the intensive care unit and help the patients cooperate when a machine must be used to assist with breathing. However, propofol should not be used in children in intensive care units.

 

Thiopental also is sometimes used to control convulsions caused by certain medicines or seizure disorders. Thiopental may be used to reduce pressure on the brain in certain conditions. Thiopental also is used to help treat some mental disorders. Thiopental may also be used for other conditions as determined by the doctor.

 

General anesthetics are usually given by inhalation or by I.V. injection. However, certain anesthetics may be given rectally to help produce sleep before surgery or certain other procedures. Although most general anesthetics can be used by themselves in pro- ducing loss of consciousness, some are often used together. This allows for more effective anesthesia in certain patients. General anesthetics are given only by or under the immediate supervision of a medical doctor or dentist trained to use them. General anesthetics are available in the following dosage forms:

 

Inhalation

Enflurane, Halothane, Isoflurane, Methoxyflurane, Nitrous oxide

 

Parenteral

Etomidate, Ketamine, Methohexital, Propofol,Thiopental

 

Rectal

Methohexital, Thiopental

 

Precautions

For general anesthetics, allergies to barbiturates or general anesthetics should be considered. Also allergy to any other substanc- es, such as foods, preservatives, or dyes.

 

Pregnancy

  • Barbiturate anesthetics (methohexital and thiopental) -- Methohexital has not been studied in pregnant women. However, it has not been shown to cause birth defects or other problems in animal studies. Studies on effects in pregnancy with thiopental have not been done in either humans or animals. However, use of barbiturate anesthetics during pregnancy may affect the nervous sys- tem in the fetus.
  • Etomidate -- Etomidate has not been studied in pregnant women. Although studies in animals have not shown etomidate to cause birth defects, it has been shown to cause other unwanted effects in the animal fetus when given in doses usually many times the human dose.
  • For inhalation anesthetics (enflurane, halothane, isoflurane, methoxyflurane, and nitrous oxide) -- Enflurane, halothane, isoflurane, methoxyflurane, and nitrous oxide have not been studied in pregnant women. However, studies in animals have shown that inhala- tion anesthetics may cause birth defects or other harm to the fetus.
  • When used as an anesthetic for an abortion, enflurane, halothane, or isoflurane may cause increased bleeding.
  • When used in small doses to relieve pain during labor and delivery, halothane may slow delivery and increase bleeding in the mother after the baby is born. These effects do not occur with small doses of enflurane, isoflurane, or methoxyflurane. However, they may occur with large doses of these anesthetics.
  • Ketamine -- Ketamine has not been studied in pregnant women. Studies in animals have not shown that ketamine causes birth defects, but it has caused damage to certain tissues when given in large amounts for a long period of time.
  • Propofol -- Propofol has not been studied in pregnant women. Although studies in animals have not shown propofol to cause birth defects, it has been shown to cause deaths in nursing mothers and their offspring when given in doses usually many times the human dose.

 

General anesthetics may cause side effects, such as drowsiness, in the newborn baby if large amounts are given to the mother during labor and delivery.

 

Breast Feeding

Barbiturate anesthetics (methohexital and thiopental), halothane, and propofol pass into the breast milk. However, general anes- thetics have not been reported to cause problems in nursing babies.

 

Children and Adolescents

Anesthetics given by inhalation and ketamine have been tested in children and have not been shown to cause different side effects or problems in children than they do in adults.

Although there is no specific information comparing use of etomidate in children with use in other age groups, it is not expected to cause different side effects or problems in children than it does in adults.

Although there is no specific information comparing use of thiopental administered intravenously in children with use in other age groups, using thiopental intravenously in children is not expected to cause different side effects or problems in children than it does in adults.

 

Propofol has been tested in children to produce loss of consciousness before and during surgery. It has not been shown to cause different side effects or problems in children than it does in adults. Propofol should not be used in critically ill children to help the children withstand the stress of being in the intensive care unit. Some critically ill children have developed problems with their body chemistries after receiving propofol, and a few children have died as a result of this. It is not known if propofol or the severe illnesses of the children caused this problem.

 

Older Adults

Elderly people are especially sensitive to the effects of the barbiturate anesthetics (methohexital and thiopental), etomidate, propo- fol, and anesthetics given by inhalation. This may increase the chance of side effects.

Ketamine has not been shown to cause different side effects or problems in older people than it does in younger adults.

 

Precautions After Receiving This Medicine

For patients going home within 24 hours after receiving a general anesthetic:

  • As General anesthetics may cause drowsiness, tirednes, or weaknes for up to a few days after they have been given, They may also cause problems with coordination. Therefore, for at least 24 hours the patient should not drive, use machines, or do anything

 

else that could be dangerous.

  • Unless otherwise directed by the doctor, alcoholic beverages or other CNS depressants such as antihistamines, sedatives, tran- quilizers, narcotics, other barbiturates; antiepileptics, and muscle relaxants, are not allowed for about 24 hours after the general anesthetic .

 

Drug Interactions

Serious, possibly fatal, side effects may occur if the patient is taking on of the following drugs simultaneously with the general anaesthetics:

Amphetamines, barbiturates, cocaine, marijuana, phencyclidine, and heroin or other narcotics .

 

Warnings

The presence of other medical problems may affect the use of general anesthetics, such as:

Malignant hyperthermia, during or shortly after receiving an anesthetic (history of, or family history of). Signs of malignant hyper- thermia include very high fever, fast and irregular heartbeat, muscle spasms or tightness, and breathing problems -- This side effect may occur again

 

Dosage and Administration

The dose of a general anesthetic will be different for different patients. factors that play role in this are: age; general physical con- dition; the kind of surgery or other procedure; other medicines taken before or will be taken after surgery

 

Side Effects

Rare

  • Abdominal or stomach pain; back or leg pain; black or bloody vomit; fever; headache (severe); increase or decrease in amount of urine; loss of appetite; nausea (severe); pale skin; unusual tiredness or weakness; weakness of wrist and fingers; weight loss (unusual); yellow eyes or skin

 

Other side effects may occur that usually do not need medical attention. The following side effects should go away as the effects of the anesthetic wear off:

More common

  • Shivering or trembling

Less common

  • Blurred or double vision or other vision problems; dizziness, lightheadedness, or feeling faint; drowsiness; headache; mood or mental changes; nausea (mild) or vomiting; nightmares or unusual dreams

 

Additional Information

Ketamine and thiopental are used in certain patients with the following medical conditions:

  • Anesthesia in children (ketamine)
  • Hypoxia, cerebral (thiopental)
  • Ischemia, cerebral (thiopental)
  • Sedation in children (ketamine).
  •  

                       USEFUL WEBSITE ADDRESSES  

 

Sites for various cancer research centers and subjects

 

Cancer Information my.webmd.com/condition

 

American Cancer Society Homepage http://www.cancer.org

 

OncoLin www.oncolink.com

 

Cancer Care www.cancercare.org

 

Breast cancer site www.thebreastcancersite.com

 

Cancer information clinical trials statistics research www.cancer.gov

 

CancerNews - MedNews.Net® service * www.cancernews.com

 

Canadian Cancer Society www.cancer.ca

 

National Alliance of Breast Cancer Organizations (NABCO) www.nabco.org

 

CancerGuide: Steve Dunn’s Cancer Information Page www.cancerguide.org

 

IARC - International Agency for Research on Cancer, a part of The WHO. www.iarc.fr

 

Cancer Research cancerres.aacrjournals.org

 

ACOR Home Page www.acor.org

 

NBCC - NBCC - National Breast Cancer Coalition www.natlbcc.org

 

American Institute for Cancer Research

Cancer prevention information from the American Institute for Cancer Research - AICR - www.aicr.org

 

CancerBACUP - The UK’s leading cancer information www.cancerbacup.org.uk

 

Home Main - American Association for Cancer Research www.aacr.org

 

Sloan-Kettering - Memorial Sloan-Kettering Cancer www.mskcc.org/

 

The Susan G. Komen Breast Cancer Foundation www.komen.org

 

UICC Home Page

International Union Against Cancer, International Union Against Cancer www.uicc.org

 

Cancer.gov

This site is managed by the Office of Communications at the NCI and is designed to help science writers and reporters find infor- mation about cancer research.

newscenter.cancer.gov

 

Fred Hutchinson Cancer Research Center www.fhcrc.org

 

National Childhood Cancer Foundation www.nccf.org

 

Y-ME National Breast Cancer Organization www.y-me.org

 

Your Cancer Risk: The Source on Prevention www.yourcancerrisk.harvard.edu

 

MD Anderson Cancer Center www.mdanderson.org

 

Sites for Biotechnology research centers

 

The National Center for Biotechnology Information (NCBI) www.ncbi.nlm.nih.gov

 

BIO 2003 Newsroom www.bio.org

 

Bio.com

Advanced Search. Site Search. Research News www.bio.com

 

Council for Biotechnology Information www.whybiotech.com

 

The Biotechnology and Biological Sciences Research Council ( BBSRC ) www.bbsrc.ac.uk

 

The ICGEB WWW Home Page

An international organisation organization dedicated to advanced research and training in Molecular Biology and Biotechnology www.icgeb.trieste.it

 

North Carolina Biotechnology Center www.ncbiotech.org

 

 PRINCIPLES OF PALLIATIVE CARE AND PAIN CONTROL

 

 

PRINCIPLES OF PALLIATIVE CARE

 

The World Health Organisation defines palliative care as “ the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families.”

Palliative care is necessarily multidisciplinary. It is unrealistic to expect one profession or individual to have the skills to make the necessary assessment, institute the necessary interventions and provide ongoing monitoring.

 

COMPONENTS OF PALLIATIVE CARE

 

The essential components of palliative care are effective control of symptoms and effective communication with patients, their families and others involved in their care. Rehabilitation, with the aim of maximising independence, is also essential to good care. As a disease progresses, continuity of care becomes increasingly important–coordination between services is required, and infor- mation must be transferred promptly and efficiently between professionals in the community, in hospitals, and in hospices.

 

PRINCIPLES OF MANAGING CANCER PAIN

 

In most patients, physical pain is only one of several symptoms. Relief of pain should therefore be seen as part of a comprehen- sive pattern of care encompassing the physical, psychological, social, and spiritual aspects of suffering. Physical aspects of pain cannot be treated in isolation from other aspects, nor can patients’ anxieties be effectively addressed when patients are suffering physically. The various components must be addressed simultaneously. The first principle of managing cancer pain is an adequate and full assessment of the cause of the pain, bearing in mind that most patients have more than one pain and different pains have different causes. A comprehensive knowledge of the underlying pathophysiology of pain is essential for effective management. With effective assessment and a systematic approach to the choice of analgesics, over 80% of cancer pain can be controlled with the use of inexpensive drugs that can be self administered by mouth at regular intervals. Consideration must always be given to treating the underlying cause of the pain by means of surgery, radiotherapy, chemotherapy, or other appropriate measures.

 

NAUSEA AND VOMITING

 

Nausea, vomiting, and retching are common and distressing complaints: surveys have found that 50-60% of patients with advanced cancer suffer from one or more of these. These symptoms are more common in patients under 65 years old, in women and those with cancer of the stomach or breast.

Assessment

As well as the specific causes of vomiting resulting directly or indirectly from advanced malignancy, patients may develop unrelat- ed conditions such as gastroenteritis or gall bladder disease. In most cases the cause of vomiting is multifactorial, but it is helpful in planning treatment to list all contributing factors.

The causes of vomiting can usually be determined from a careful patient’s history and clinical examination. Note should be taken of the volume, content, and timing of vomits. A biochemical profile may be needed, but other investigations are often inappropri- ate.

Management

Nausea can be treated with oral drugs, but alternative routes are needed for patients with severe vomiting. It must be remem- bered, however, that persistent nausea may decrease gastric emptying, with a resultant decrease in drug absorption. An anti- emetic injection is suitable to control a single episode, but with a persistent problem it is preferable to give drugs by subcutaneous infusion using an infusion device such as a pocket sized syringe driver. Antiemetics, in suppository or tablet form, can also be given rectally, but buccal administration of antiemetics is poorly tolerated.

Non-drug methods are important; these include avoidance of food smells or unpleasant odours, diversion, and relaxation. Some patients report benefit from acupuncture or acupressure bands.

 

Common causes of vomiting in patients with advanced cancer

  • Drugs            Especially opioids and chemotherapy

–Gastric causes

Gastritis or ulceration, Functional gastric stasis, External pressure, Carcinoma of stomach, Gastroduodenal obstruction

–Constipation

  • Intestinal obstruction
  • Biochemical causes

Renal failure, Hypercalcemia, Infection, Tumour toxins

–Raised intracranial pressure

  • Vestibular disturbance
  • Abdominal or pelvic radiotherapy
  • Anxiety

 

  • Cough induced

 

 

 

bmj.com Bruera 315 (7117): 1219

 

 

ANOREXIA, CACHEXIA AND NUTRITION

 

Cachexia is a complex syndrome that combines weight loss, lipolysis, loss of muscles and visceral protein, anorexia, chronic nau- sea, and weakness. Severe cachexia occurs in most patients with advanced cancer.

When faced with a cachectic patient, the clinician may approach the problem with four questions:

  • Does the patient have cachexia?
  • Why is the patient cachectic?
  • Which treatment is effective?
  • How should treatment be individualised?

 

Does the patient have cachexia?

Frequency of cachexia

More than 80% of patients with cancer or AIDS develop cachexia before death. At the moment of diagnosis, about 80% of patients with upper gastrointestinal cancers and 60% of patients with lung cancer have substantial weight loss. In general, patients with solid tumours (with the exception of breast cancer) have a higher frequency of cachexia. Cachexia is also more common in children and elderly patients and becomes more pronounced as disease progresses.

Assessing nutritional status

Because of the chronic nature of cancer cachexia, the diagnosis is simple. A patient’s clinical history, the presence of substantial weight loss, and physical examination are adequate for an accurate diagnosis.

Plasma albumin concentration is usually decreased. Simple bedside measurements–such as triceps or subscapular skin folds (for body fat) and arm muscular circumference (for body mean mass)–may be useful to monitor nutritional changes or the effect of treatments in patients in whom body weight might be unreliable (such as those with ascites or oedema).

 

Why is the patient cachectic?

While metabolic abnormalities are the main cause of malnutrition, decreased caloric intake and malabsorption also contribute to the cachexia syndrome.

Decrease caloric intake

Anorexia is an almost universal component of cachexia. Reduced caloric intake may be more severe in patients with dysphagia due to head and neck pain or oesophageal carcinoma, psychological depression, abnormalities of taste, or chronic nausea. The last is a common symptom in malignant diseases and can be due to autonomic failure, opioids and other drugs, constipation, or bowel obstruction.

Choice of treatment

Nutritional counselling should be based on eating high calorie meals of small portions that are pleasant for the patient. It is impor- tant to include the patient’s family in such discussions. It is useful to clarify that an excess of calories is unlikely to benefit the patient by explaining that his or her metabolic system does not have the ability to use these calories in the same way as that of a healthy person. Although cachectic, the patient is not “starving”.

Patients who are unable to swallow because of severe dysphagia (for example, because of head and neck or oesophageal can- cers and neurological disorders) and who complain of hunger or express concerns related to malnutrition may benefit from nutri- tion via a gastronomy tube. Such tubes can be inserted with ultrasonographic or endoscopic guidance.

Patients with chronic nausea, early satiety, or other findings suggesting gastroparesis should receive a trial of a prokinetic drug.

 

Which treatments are effective?

Weight loss is an independent risk factor for poor survival. Cachectic patients have a higher incidence of complications after surgery, radiotherapy, and chemotherapy. In addition, cachexia aggravates weakness, is associated with anorexia and chronic nausea, and is a source of psychological distress for patients and families because of the associated symptoms and the changes in body image. This prompts some to attempt aggressive nutritional supplementation.

 

Advantages of intensive nutrition

Intensive nutrition is appropriate in certain clinical situations, such as in patints recovering from surgery and awaiting chemother- apy. When selecting patients for nutrition, doctors must take into account the morbidity (15% in some studies) and the financial cost.

 

Therapeutic options

  • Dietary advice
  • Nutritional supplementation
  • Prokinetic drugs
  • Corticosteroids
  • Progestational drugs
  • Tumoricidal treatment (if appropriate)

 

Effects of intensive nutrition

  • No increase in survival
  • No improved tumour shrinkage
  • Minimal decrease in toxicity of chemo- therapy or radiotherapy
  • Minimal decrease in surgical morbidity
  • Unknown symptomatic effects

 

Effects of pharmacological management

Several drugs have beneficial effects on the symptoms of cachexia, and some have effects on patients’ nutritional status:

  • Corticosteroids
  • Progestational drugs
  • Prokinetic agents
  • Other drugs

 

Individualising treatment

Determining expectations and outcomes

It is extremely important to establish initially what patients, their family, and their physician expect from any treatment. Neither nutritional nor drug treatments confer any survival advantage in metastatic cancer. Intensive

nutritional replacement has limited, if any, value for patients with advanced and progressive disease; exceptions may include head and neck tumours that advance locally but metastasise slowly and neurological disorders such as motor neurone disease. Although megestrol acetate and, in some cases, artificial nutrition provide nutritional improvement, this alone does not justify treat- ments that are potentially toxic for terminally ill patients unless there is a substantial

benefit to quality of life.

Future developments

Clinical trials are currently being conducted on drugs with a subjective effect on appetite and energy, anabolic agents, and drugs capable of inhibiting the release of cachectin-tumour necrosis factor. Differential nutrition with amino acids and fatty acids capa- ble of influencing the metabolic response of the tumour are also being investigated.

Choosing treatments for cachexia

  • Intensive nutrition is expensive, associated with morbidity, and there is limited evidence that it can reverse these problems
  • Corticosteroids and megestrol acetate are effective appetite stimulants. The weight gain associated with megestrol acetate takes some weeks to manifest
  • Prokinetic drugs may improve nausea and early satiety
  • The psychological aspects of cachexia can be the most important for patients and their carers. Feeding a dependant is the essence of nature and this fundamental breakdown must be addressed. Explanations and practical solutions are often more important than any drugs administered

 

CONSTIPATION AND DIARRHOEA

 

 

PREVALENCE OF CONSTIPATION

 

Constipation can be defined as the passage of small hard faeces infrequently and with difficulty. Constipation is more common in patients with advanced cancer than in those with other terminal diseases, and many of the associated symptoms may mimic features of the underlying disease. About half of patients admitted to specialist palliative care units report constipation, but about 80% of patients will require laxatives.

 

 

History

 

ASSESSMENT OF CONSTIPATION

 

An accurate history is essential for effective management. Inquiry should be made about the frequency and consistency of stools, nausea, vomiting, abdominal pain, distention and discomfort, mobility, diet, and any other symptoms. In patients with a history of diarrhoea, care should be taken to distinguish true diarrhoea from overflow due to faecal impaction.

Careful questioning about access to a toilet or commode is important. Limited mobility may mean that using the toilet or com- mode is avoided. Other issues, such as lack of privacy or the need for nurses or carers to help with toileting, can exacerbate constipation.

Examination

A constipated patient may have malodorous breath, or the smell of faecal leakage may be obvious. Bacterial degradation of hard stools can result in leakage, of which the patient has no warning. General observation may reveal that a patient is in pain, confused or disorientated, or unable to reach the toilet. Abdominal distension, visible peristalsis, and borborygmi can suggest obstruction. Palpation may reveal an easily palpable colon with indentable and mobile (and rarely tender) faecal masses. In con-

trast, tumour masses are usually hard, not indentable, fixed, and often tender. In constipation complicated by obstruction, auscul- tation of the abdomen may reveal high pitched tinkling bowel sound, although the abdomen can also be silent.

 

CAUSES OF CONSTIPATION

 

Knowledge of the underlying cause helps in both prophylaxis and treatment. The most important of these are immobility, poor fluid and dietary intake, and drugs, particularly opioids.

Opioid induced constipation

In patients with cancer and pain, the use of opioids is the commonest cause of constipation, particularly in

immobile patients. Opioids cause constipation by maintaining or increasing intestinal smooth muscle tone, by suppressing forward peristalsis, by raising sphincter tone at the ileocaecal valve and anal sphincter, and by reducing sensitivity to rectal distension. This results in delayed passage of faeces through the gut, with resultant increase in absorption of electrolytes and water in the small intestine and colon.

Gastrointestinal obstruction

Sometimes, a combination of hard stools in the bowel and intrinsic or extrinsic bowel tumour or pelvic tumour coexist, causing gastrointestinal obstruction. With appropriate management of the constipation, the obstructive symptoms may resolve.

Neurological problems

Bowel management is particularly troublesome and is a common problem in patients with spinal cord compression or cauda equina syndrome. A combination of immobility, loss of rectal sensation, poor anal and colonic tone, and pain may result in consti- pation with overflow and variable degrees of abdominal distension, nausea, and vomiting.

A cauda equina lesion will abolish the anocolonic reflex, but a higher spinal cord lesion leaves this reflex intact. In the latter case, digital rectal stimulation or suppositories will stimulate colonic contraction and aid evacuation of the colon, whereas in the cauda equina syndrome the colon remains lax.

The aim in managing spinal cord compression or cauda equina syndrome is to attain a “controlled continence”. This means giving an individual combination of oral laxatives daily with suppositories or enemas every two to three days to enable rectal evacuation. The intention is to avoid incontinence in those patients with loss of rectal sensation.

 

MANAGING CONSTIPATION

 

The management of constipation extends well beyond the use of laxatives. Attention to other symptoms–especially pain and advice on diet, fluid intake, mobility, and toileting–contributes to an effective outcome.

The aim of laxative therapy is to achieve comfortable defecation, rather than any particular frequency of evacuation. Although most laxatives are not very palatable, oral laxatives should be used whenever possible. The choice of laxative depends on the nature of the stools, the cause of the constipation, and acceptability to the patient.

 

DIARRHOEA

 

Diarrhoea is much less common than constipation in patients with advanced disease. Less than 10% of those with cancer admit- ted to hospital or palliative care units have diarrhoea. Diarrhoea can be highly debilitating in a patient with advanced disease because of loss of fluid and electrolytes, anxiety about soiling, and the effort of repeatedly going to the lavatory.

Causes

The commonest cause of diarrhoea in patients with advanced disease is use of laxatives. Patients may use laxatives erratically; some wait until they become constipated and then use high doses of laxatives, with resultant rebound diarrhoea. Some patients complain that their laxatives are too strong; adequate explanation on the use of laxatives may solve the problem.

Among elderly patients admitted to hospital with nonmalignant disease, constipation with faecal impaction and overflow accounts for over half the cases of diarrhoea. Such patients require rectal laxatives together with a stool softener; care is required with stimulant laxatives as they may cause colic.

 

                   DEPRESSION, ANXIETY AND CONFUSION                   

 

A common mistake is to assume that depression and anxiety represent nothing more than natural and understandable reactions to incurable illness. When cure is not possible, the analytical approach we adopt to physical and psychological signs and symptoms is often forgotten.

 

The emotional and cognitive changes in patients with advanced disease reflect both psychological and biological effects of the medical condition and its treatment.

Psychological adjustment reactions after diagnosis or relapse often include fear, sadness, perplexity and anger. These usually resolve within a few weeks with the help of the patients’ own personal resources, family support, and professional care. A minor- ity of patients, about 10-20%, develop formal psychiatric disorders that require evaluation and management in addition to general support. It is important to recognise psychiatric disorders because, if untreated, they add to patients suffering and hamper their ability to come to terms with their illness, put their affairs in order, and communicate with others.

Emotional distress and psychiatric disorder also affect some relatives and staff.

 

LOSSES AND THREATS OF MAJOR ILLNESS

 

  • Knowledge of a life threatening diagnosis, prognostic uncertainty, fears about dying and death
  • Physical symptoms such as pain and nausea
  • Unwanted effects of medical and surgical treatments
  • Loss of functional capacity, loss of independence, enforced changes in role
  • Practical issues such as finance, work, housing
  • Changes in relationships, concern for dependants
  • Changes in body image, sexual dysfunction, infertility
  • Organic mental disorders
  • Poorly controlled physical symptoms

 

 

RISK FACTORS FOR ANXIETY AND DEPRESSION

 

  • Poor relationships and communication between staff and patient
  • Past history of mood disorder or misuse of alcohol or drugs
  • Personality traits hindering adjustment–Such as rigidity, pessimism, extreme need for independence and control
  • Concurrent life events or social difficulties
  • Lack of support from family and friends

 

COMMON CAUSES OF ORGANIC MENTAL DISORDERS

 

  • Prescribed drugs - Opioids, psychotropic drugs, corticosteroids, some cytotoxic drugs
  • Infection - Respiratory or urinary infection, septicaemia
  • Macroscopic brain pathology - Primary or secondary tumour, Alzheimer’s disease, cerebrovascular disease, HIV dementia
  • Metabolic - Dehydration, electrolyte disturbance, hypercalcemia, organ failure
  • Drug withdrawal - Benzodiazepines, opioids, alcohol

 

SYMPTOMS AND SIGNS OF DELIRIUM

 

  • Clouding of consciousness (reduced awareness of environment)
  • Impaired attention
  • Impaired memory, especially recent memory
  • Impaired abstract thinking and comprehension
  • Disorientation in time, place, or person
  • Perceptual distortions - Illusions and hallucinations, usually visual or tactile
  • Transient delusions, usually paranoia
  • Psychomotor disturbance - Agitation or underactivity
  • Disturbed cycle of sleeping and waking, nightmares
  • Emotional disturbances - Depression, anxiety, fear, irritability, euphoria, apathy, perplexity

 

UNDER RECOGNITION OF PSYCHIATRIC DISORDERS

 

  • Patients reluctant to voice emotional complaints - Fear of seeming weak or ungreatful; stigma
  • Professionals reluctant to inquire - Lack of time, lack of skill, emotional self protection
  • Attributing somatic symptoms to medical illness
  • Assuming emotional distress is inevitable and untreatable

 

REFERENCES FOR SCREENING INSTRUMENTS

 

Hospital anxiety and depression scale–Zigmond AS, Snaith RP. The hospital anxiety and depression (HAD) scale. Acta Psychiatr Scand 1983; 67; 361-70

Mini mental state – Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”– a practical method of grading the cognitive state of patients for the clinician. Psychiatr Res 1975;12: 189-98

Mental status schedule – Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1972;1:233-8

 

PREVENTION AND MANAGEMENT

 

General guidelines for both prevention and management include providing an explanation about the illness, in the context of ongo- ing supportive relationships with known and trusted professionals. Patients should have the opportunity to express their feelings without fear of censure or abandonment. This facilitates the process of adjustment, helping patients to move on towards accept- ing their situation and making the most of their

remaining life.

Religious or spiritual counselling may be relevant. Psychiatric referral is indicated when emotional disturbances are severe, atypi- cal, or resistant to treatment and when there is concern about suicide.

Non-drug therapies, both “mainstream” and “complementary”, share the common features of increasing patient’s sense of partici- pation and control, providing interest and occupation when jobs or hobbies have had to be discontinued, and offering a support- ive personal relationship.

PSYCHOTROPIC DRUGS

 

For more severe cases, drug treatment is indicated in addition to, not instead of, the general measures described below.

Sensitive breaking of bad news

 

 

PRINCIPLES OF PSYCHOLOGICAL MANAGEMENT

 

  • Providing information in accord with individual wishes
  • Permitting expression of emotion
  • Clarification of concerns and problems
  • Patient involved in making decisions about treatment
  • Setting realistic goals
  • Appropriate package of medical, psychological, and social care
  • Continuity of care from named staff

 

SOME PSYCHOLOGICAL AND PRACTICAL THERAPIES

 

  • Brief psychotherapy– Cognitive -behavioural, cognitive -analytic, problem solving
  • Group discussions for information and support
  • Music therapy
  • Art therapy
  • Creative writing
  • Relaxation techniques
  • Meditation
  • Hypnotherapy
  • Aromatherapy
  • Practical activity – Such as craft work, swimming.

 

OUTCOME

 

Emotional disorders in patients with incurable disease should never be dismissed as inevitable or untreatable. Worthwhile improvements in psychological state can often be achieved even though the physical illness continues to advance. We must be wary of projecting any sense of hopelessness onto our patients and avoid dismissing anxiety and depression as understandable, thereby denying appropriate treatment in many cases.

 

THE LAST FOURTY EIGHT HOURS

 

During the final 48 hours of life, patients experience increasing weakness and immobility, loss of interest in food and drink, dif- ficulty swallowing and drowsiness.

With an incurable progressive illness, this phase can usually be anticipated, but sometimes a deterioration can be sudden and dis- tressing. Control of symptoms and family support take priority, and the nature of the primary illness becomes less important. This is a time when levels of anxiety, stress, and emotion can be high for patients, families and other carers.

 

PRINCIPLES OF MANAGING THE LAST 48 HOURS

 

  • Problem solving approach to symptom control
  • Avoid unnecessary interventions
  • Review all drugs and symptoms regularly
  • Maintain effective communication

PRINCIPLES

 

An analytical approach to symptom control continues but usually relies on clinical findings rather than investigation. This approach spans all causes of terminal illness and applies to care at home, hospital, or hospice.

Drugs are reviewed with regard to need and route of administration. Previously “essential” drugs such as antihypertensives, corti- costeroids, antidepressants, hypoglycaemics are often no longer needed and analgesic, antiemetic, sedative, and anticonvulsant drugs form the new “ essential” list to work from. The route of administration depends on the clinical situation and characteris- tics of the drugs used. Some patients manage to take oral drugs until near to death, but many require an alternative route. Any change in medication relies on information from patient, family, and carers (both lay and professional) and regular medical review to monitor the level of symptom control and side effects. This review should include an assessment of how the family and carers are coping; effective communication with all involved should be maintained and lines of communication made clear and open. The knowledge that help is available is often a reassurance and can influence the place of death.

 

SUPPORT

 

Support means recognising and addressing the physical and emotional issues that may face patients, families, and carers dur- ing this time. Honesty, listening, availability, and assurance that symptom control will continue are valued by patients and carers. Fears or religious concerns should be acknowledged and addressed appropriately, and respect for cultural differences should be assured. Explain what is happening, what is likely to happen, the drugs being used, the support available, and how the family can help with care.

                             BEREAVEMENT             

 

Bereavement is a universal human experience and potentially dangerous to health.

It is associated with a high mortality for some groups, and up to a third of bereaved people develop a depressive illness. When death is anticipated, preparation for bereavement can be made, and this can improve outcome.

 

THE PROCESS OF GRIEF

 

A sense of shock, disbelief, and denial may occur even when death is expected, but these are likely to last longer and be more intense with an unexpected death. During the acute distress that usually follows, bereaved people often experience physical symptoms, which may be due to anxiety or may mimic the symptoms of the deceased. For some, there may be questioning of previously deeply held beliefs, while others find great support from their faith, the rituals associated with it, and the social contact with others of a like mind, which religious affiliation often brings.

A crucial factor is the meaning of the loss for the bereaved person, and the painful search for understanding of why the death occurred is another common feature of bereavement. Throughout the period of bereavement bereaved people may oscillate between concentrating on the pain of the loss and distracting themselves through work or planning for the future.

Patient–young

 

 

RISK FACTORS FOR BEREAVEMENT

 

Illness–Short, protracted, disfiguring, distressing Death–Sudden, traumatic (such as haemorrhage) Relationship–Ambivalent, hostile, dependent Main carer–Young, other dependents, physical or

mental illness, concurrent crisis, little or no support

 

Initial shock

STAGES OF GRIEF

Common emotions and experiences –Numbness, disbelief, relief

Task –Accept the reality of the loss.

Pangs of grief

Common emotions and experiences –Sadness, anger, guilt, feelings of vulnerability and anxiety, regret, insomnia, social with-

 

drawal, transient auditory and visual hallucination of the dead person, restlessness, searching behaviour

Task –Experience the pain of grief.

Despair

Common emotions and experiences –Loss of meaning and direction in life Task –Adjust to an environment in which the deceased is missing.

Adjustment

Common emotions and experiences –Develop new relationships or interests

Task –Emotionally relocate the deceased to an important but not central place in bereaved person’s life and move on.

Predisposing factors

RISK FACTORS FOR POOR OUTCOME OF BEREAVEMENT

 

  • Ambivalent or dependent relationship
  • Multiple prior bereavements
  • Previous mental illness, especially depression
  • Low self esteem of bereaved person

Around the time of death

  • Sudden and unexpected death
  • Untimely death of young person
  • Preparation for the death
  • Stigmatised deaths - such as AIDS, suicide
  • Culpable deaths
  • Sex of bereaved person -elderly male widower
  • Inability to carry out valued religious spirituals

After the death

  • Level of perceived social support
  • Lack of opportunities for new interests
  • Stress from other life crises

Compassionate Friends

ORGANISATIONS FOR BEREAVED PEOPLE

  • 53 North Street, Bristol BS53 1EN (tel 0117 966 5202)
  • National organisation with local branches. Offers befriending to bereaved parents after loss of child of any age.

Cruise Bereavement Care

  • Cruise House, 126 Sheen Road, Richmond TW9 1UR (tel 0181 332 7227)
  • National organisation with local branches. Offers counselling and befriending, home visits, and social meetings. Some specialist services.

National Association of Bereavement Services

  • 20 Norton Folgate, London E1 6DB (tel 0171 247 0617)
  • Referral agency. Published directory of bereavement and loss services. Support organisation for bereavement services.

SANDS (Stillbirth and Neonates Death Society).

  • 28 Portland Place, London W1N 4DE (tel 0171 436 5881)
  • Support for parents after stillbirth or neonatal death.

 

 

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