28 Cancer and palliative care

If cancer is suspected, comprehensive assessment of patient and disease is needed before treatment decisions are made. Treatment can be:

Staging allows the plan of treatment to be made.

Widely used classification of tumours. Exact criteria for staging depend on the primary organ site:

Surgery has 3 main roles in cancer management:

Advances in imaging and laparoscopic techniques have ↓ the number of patients requiring open surgery to confirm a cancer diagnosis. Surgical staging remains important in:

Surgery with curative intent is dependent on complete resection of the tumour with a margin of normal tissue. Local control of tumours with a propensity to spread to lymph nodes may be improved with resection of the draining group of nodes, e.g. vulval tumours. However, even if the tumour was completely resected, surgery can still fail to cure either as a result of:

Surgery may be curative in a limited number of tumours with metastases. However, this is much less common, requires careful patient selection, and is best performed by a specialist team. Circumstances in which curative surgery may be offered include:

Surgery can be effective in achieving good symptom control in the palliative setting, but decision to proceed must be carefully considered particularly as patients may have limited life expectancy, poor performance status, and rapid tumour progression. Ideally such decisions should be multidisciplinary and involve surgeons specialized in oncology and experienced in palliative management (see Table 28.3).

Chemotherapy is the use of chemical agents in the cure or palliation of malignant disease.

Include:

These agents work in a variety of ways to inhibit tumour growth and/or cause tumour cell damage. Normal cells may be damaged at the same time as tumour cells, resulting in the high levels of toxicity experienced by patients.

Depends on known activity of the agent, cost, and patient factors. It is a specialist decision.

Response to chemotherapy depends on type and grade of tumour being treated. Broadly tumours can be divided into:

Often different chemotherapeutic agents are combined to ↑ their chances of effect. Agents acting in different ways may potentiate each others’ actions, and using combinations reduces the risk of resistance (if one agent does not have any effect, another may). Choosing agents with different side effect profiles reduces cumulative toxic effects.

Particularly useful for cytotoxic drugs. Intermittent treatment exploits the difference in recovery rates between normal and malignant tissues. Gaps between cycles of treatment allow normal tissue (particularly the immune system) to recover, but the malignant tissue does not recover to such a large extent (see Figure 28.1). The population of malignant cells diminishes relative to the normal cells with each cycle.

Given to prevent relapse after primary treatment of a non-metastatic tumour for which relapse rate is known to be high. An example is adjuvant chemotherapy for breast cancer.

Neutropenic sepsis is defined as fever of ≥38.0°C for ≥2h when the neutrophil count is <1.0 × 10⁹/L. Causes:

Bacterial and fungal infection. Risk of infection ↑ sharply as neutrophil counts fall to <1.0 × 10⁹/L, with greatest risk at counts <0.1 × 10⁹/L. Neutropenia for >5d is a further risk factor. Usually patients are most at risk in the nadir period from 1wk after therapy.

Symptoms/signs may be minimal—have a high index of suspicion. Neutropenic, septic patients can deteriorate rapidly and become hypotensive or moribund within hours. Early referral for investigation and specialist management is critical.

Ionizing radiation damages cells. Radiotherapy aims to deliver a dose of irradiation to an area which allows normal tissues, but not the cancer, to recover from the damage.

May be used alone or with chemotherapy. Once maximum dose of radiotherapy has been received by any area, that area cannot usually be irradiated again

Skin reactions—see Table 28.4; non-skin reactions—see Table 28.5.

‘Any man’s death diminishes me because I am involved in mankind’

Devotions Meditation 17, John Donne (1572–1631)

Palliative care starts when the emphasis changes from curing disease and prolonging life to relieving symptoms and maintaining well-being or ‘quality of life’. On average, GPs have 1–2 patients with terminal disease at any time and can get more personally involved with them than other patients.

75% of deaths are ‘predictable’ and follow a period of chronic illness where end-of-life care (for those likely to die in <12mo) would be appropriate.

Problems arising are a complex mix of physical, psychological, social, cultural, and spiritual factors involving both patients and carers. To respond adequately good lines of communication and close multidisciplinary teamwork is needed. Local palliative care teams are invaluable sources of advice and support and frequently produce booklets with advice on aspects of palliative care for GPs.

It may be difficult to identify when patients are nearing end of life, particularly for non-cancer illness (see Figure 28.2). This can lead to access to EOLC not being offered at all or being offered late.

The 2008 National End-of-life Care Strategy recommends assessment of people identified as approaching the end of life and agreement with them about how to meet their preferences using advanced care planning with regular review. This may include:

People are more likely to talk about end of life with their GP than any other professional, but only 33% of GPs are confident to initiate a discussion with a patient about end-of-life issues. Specific training ↑ confidence.

The PPC document is a tool for discussion and recording of EOLC wishes. It is available to download from the NHS EOLC website.

Aims to improve quality of palliative care provided by the primary care team by improving the practice-based organization of care of dying patients. The Framework focusses on: optimizing continuity of care, teamwork, advanced planning (including out-of-hours), symptom control, and patient, carer, and staff support. Evaluation data show the framework ↑ the proportion of patients dying in their preferred place and improves quality of care as perceived by the practitioners involved.

Is a model of ‘best practice’ to improve care of the dying in the last hours/days of life. It covers physical, psychological, social, and spiritual aspects of care and widely used in the community, both in care homes and in private residences. Over recent years the Liverpool Care Pathway has gained a controversial reputation as a ‘pathway to death’ but, if used correctly, with full consultation with all medical staff and family members/carers involved, it still has a very important place in managing the final days/hours of a patient’s life.

Pain control is the cornerstone of palliative care. Cancer pain is multifactorial—be aware of physical and psychological factors.

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Table 28.6

Almost a universal symptom.

Treat reversible causes. Provide advice on modification of lifestyle. If drowsiness/fatigue persist consider a trial of dexamethasone 4mg/d or antidepressant. Although steroids make muscle wasting worse, in the short term they may improve general fatigue and well-being. Provide psychological support to patients and carers. Consider referral to physiotherapy; review aids and appliances; review home layout (possibly with referral to OT); and/or review home care arrangements.

Occurs with 10% malignant tumours—particularly myeloma (>30%) and breast cancer (40%).

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Depending on the general state of the patient, make a decision whether to treat the hypercalcaemia or not. If a decision is made not to treat, provide symptom control and do not check the serum calcium again. If you decide to treat:

Treat nausea, mouth problems, pain, and other symptoms. ↓ psychological distress and treat depression. Advise small, appetizing meals frequently in comfortable surroundings.

If there is >1 cause for nausea/vomiting, you may need >1 drug.

Do not forget non-drug measures to ↓ nausea:

Drugs with antimuscarinic effects (e.g. cyclizine) antagonize prokinetic drugs (e.g. metoclopramide)—if possible, do not use concurrently.

Review medication making the mouth sore or dry. Refer to the DN for advice on mouth care (e.g. use a toothbrush to keep the tongue clean). Consider mouthwashes, e.g. saline, Oraldene®, chlorhexidine, benzydamine (for pain). Try ¼–½ ascorbic acid 1g effervescent tablet/d— place on tongue and allow to dissolve.

May be due to physical obstruction (by tumour bulk) or functional obstruction (neurological deficit).

A distressing symptom. Treatment is often unsatisfactory.

Free fluid in the peritoneal cavity. Common with ovarian cancer (50% patients). Presents with abdominal distension. Signs: shifting dullness to percussion ± fluid thrill. Depending on clinical state consider referring for radio- or chemotherapy if appropriate.

Passage of hard stools less frequently than the patient’s own normal pattern. It is a very common symptom. Occult presentations are common in the very elderly and frail and include:

Pre-empt constipation by putting everyone at risk (e.g. patients on opioids) on regular aperients. Treat reversible causes, e.g. give analgesia if pain on defecation, alter diet (e.g. add prunes), ↑ fluid intake.

Connections from the gut to other organs—commonly skin, bladder, or vagina. Bowel fistulae are characterized by air passing through the fistula channel. If well enough for surgery, refer to a surgeon. If not fit for surgery consider referring to palliative care for octreotide.

Clarify what the patient/carer means by diarrhoea. Less common than constipation but can be distressing for the patient and difficult for the carer—especially if incontinence results.

Due to pressure necrosis of the skin. Immobile patients are at high risk—especially if frail ± incontinent. Likely sites of pressure damage—shoulder blades, elbows, spine, buttocks, knees, ankles, and heels. Bed sores heal slowly in terminally ill patients and are a source of discomfort and stress for both patients and carers (who often feel guilty that a pressure sore is a mark of poor care).

Large wounds can have major impact on quality of life. Patients with advanced disease have major risk factors for development and poor healing of wounds—immobility, poor nutrition, skin infiltration ± breakdown due to malignancy. Skin infiltration causing ulceration or fungating wounds can be particularly distressing.

The primary aim is comfort. Healing is a secondary aim and may be impossible. Always involve the DN and/or specialist palliative care nursing team early. Many hospitals also have wound care specialist nurses who are valuable sources of advice.

See Table 28.8.

Occurs with 1° or 2° brain tumours. Characterized by

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Common in advanced cancer due to osteoporosis, trauma as a result of falls, or metastases. Have a low index of suspicion if a new bony pain develops. Treat with analgesia. Unless in a very terminal state, confirm the fracture on X-ray and refer to orthopaedics or radiotherapy urgently for consideration of fixation (long bones, wrist, neck of femur) and/or radiotherapy (rib fractures, vertebral fractures).

Troublesome symptom. Prolonged bouts of coughing are exhausting and frightening—especially if associated with breathlessness and/or haemoptysis.

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Affects 70% of terminally ill patients. It is usually multifactorial. Breathlessness always has a psychological element—being short of breath is frightening. Causes—see Figure 28.4.

Coarse wheezing sound that results from the obstruction of a major airway, e.g. larynx.

In all patients likely to bleed (e.g. in end-stage leukaemia) pre-warn carers and give them a strategy.

Make a decision whether the cause of the bleed is treatable or a terminal event. This is best done in advance but bleeding cannot always be predicted.

Follow-up is directed at cause if appropriate:

Do not check for anaemia if no intention to transfuse.

Due to infiltration of the vessel wall, clot within the superior vena cava or extrinsic pressure. 75% are due to 1° lung cancer (3% of patients with lung cancer have SVC obstruction). Lymphoma and clotting associated with long central lines are the other major causes.

Due to obstruction of lymphatic drainage, resulting in oedema with high protein content. Affects ≥1 limbs ± adjacent trunk. If left untreated, lymphoedema becomes increasingly resistant to treatment due to chronic inflammation and subcutaneous fibrosis. Cellulitis causes rapid ↑ in swelling. Causes:

See Table 28.9

All patients with terminal disease are anxious at times for a variety of reasons, including fear of uncontrolled symptoms and of being left alone to die. When anxiety starts interfering with quality of life, intervention is justified.

Often all that is needed:

If anxiety is not responding to simple measures, seek specialist help from either the psychiatric or palliative care team.

A terminal diagnosis commonly makes patients sad. 10–20% of terminally ill patients develop clinical depression but in practice it is often difficult to decide whether a patient is depressed or just appropriately sad about his/her diagnosis and its implications. Many symptoms of terminal disease (e.g. poor appetite) are also symptoms of depression so screening questionnaires for depression are often unhelpful. If in doubt, a trial of antidepressants can help.

Ask about suicidal ideas and plans in a sensitive but probing way. It is a common misconception that asking about suicide can plant the idea into a patient’s head and make suicide more likely. Evidence is to the contrary.

If not responding or suicidal refer for psychiatric opinion.

Characterized by overwhelming distress. Often related to unresolved conflict, guilt, fears, or loss of control.

Listening can itself be therapeutic. Talk to the patient, if possible, about dying and try to break down fears into component parts. Address fears that can be dealt with. As a last resort, and after discussion with the patient (where possible) and/or relatives, consider sedation.

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It is notoriously difficult to predict when death will occur. Symptoms and signs of death approaching include:

Dying is a unique and special event for each individual. Helping to explore a patient’s wishes about death and dying should not be a discussion left to the last 24h.

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Alert out-of-hours providers if a patient is dying at home. This will ensure appropriate response to calls and avoid unnecessary and unwanted admissions. Consider a ‘just-in-case’ box to leave at the patient’s home containing drugs that might be needed should the patient deteriorate outside normal working hours.

Different religious and cultural groups have different approaches to the dying process. Be sensitive to cultural and religious beliefs. Never assume; if in doubt ask a family member.

Ask which problems are causing the patient/carers most concern and address those concerns where possible. Patients often under-report symptoms.

Keep examination to a minimum to avoid unnecessary interference. Check sites of discomfort/pain suggested by history or non-verbal cues; mouth; bladder and bowel.

Find out what the patient wants to know. Gently assessing how patients feel about their disease and situation can shed light on their needs and distress.

Any investigation at the end of life should have a clear and justifiable purpose (e.g. excluding a reversible condition where treatment would make the patient more comfortable). The need for investigations in the terminal stage of illness is minimal.

Comfort is the priority. Stop all unnecessary medication.

Dying patients tolerate symptoms very poorly because of their weakness. Nursing care is the mainstay of treatment, GPs do have a role:

Noisy, moist breathing. Can be distressing for relatives. Reassure that the patient is not suffering or choking. Try repositioning and/or tipping the bed head down (if possible) to ↓ noise. Treat prophylactically—it is easier to prevent than remove accumulated secretions. Suitable drugs:

Distressing symptom for patients/carers. Support carers in attendance and explain management:

Causes:

Treat reversible causes, e.g. catheterization for retention, hyoscine to dry up secretions. If still restless, treat with a sedative. This does not shorten life but makes the patient/relatives more comfortable. Suitable drugs: haloperidol 1–3mg tds po; chlorpromazine 25–50mg tds po; diazepam 2–10mg tds po, midazolam (10–100mg/24h via syringe driver or 5mg stat), or levomepromazine (50–150mg/24h via syringe driver or 6.25mg stat).

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Syringe drivers are used to aid drug delivery when the oral route is no longer feasible. Indications include:

In recent years, many PCOs, hospitals, and hospices have been changing their syringe drivers from the traditionally used blue or green Graseby drivers, which are being phased out. Newer devices with additional safety and monitoring features (e.g. McKinley T34 or Alaris) are now in common use. It is important to find out which devices are used in your locality and how they work.

See Table 28.10.

Draw up the prescribed 24h medication. The diluent of choice in most cases is water for injection but 0.9% sodium chloride should be used if using levomepromazine, diclofenac, octreotide or ondansetron; cyclizine should not be diluted with saline. Then set the rate on the syringe driver.

Local policies may differ. Hands-on training is essential.

Provided there is evidence of compatibility, drugs can be mixed in syringe drivers. Diamorphine or morphine can be mixed with:

If combining 2 or 3 drugs in a syringe driver, a larger volume of diluent may be needed (e.g. 20 or 30mL syringe). If >3 drugs are needed in 1 syringe driver, reassess treatment aims.