Symptom Control in Patients with Cancer¶
Chapter 74 | Symptom Control in Patients with Cancer
KEY CLINICAL POINTS¶
- Patient-reported outcomes (PROs) are critical for early symptom detection and improve survival in metastatic cancer patients.
- Fatigue (70–80% prevalence) and pain (40–70% overall) are the most common cancer-related symptoms.
- Multidisciplinary management, including pharmacologic agents (e.g., olanzapine, duloxetine) and non-pharmacologic strategies (e.g., exercise, palliative care), is essential for symptom control.
1. DEFINITION & OVERVIEW¶
Symptom control in cancer patients involves proactive assessment and management of distressing symptoms to improve quality of life and survival. Key tools include PROs (e.g., Edmonton Symptom Assessment System–Revised) and structured symptom monitoring.
Table 74-1: Common Cancer Symptoms and Their Association¶
| SYMPTOM | PREVALENCE | COMMONLY FOUND CAUSES/EXAMPLES |
|---|---|---|
| Fatigue | 70–80% | Chemotherapy, immunotherapy, anemia, hypothyroidism |
| Pain, all | 40–70% overall | Nociceptive (pancreatic cancer), visceral (intestinal obstruction), neuropathic (chemotherapy-induced) |
| Nausea due to chemotherapy | 10–90% | Cisplatin, doxorubicin |
| Anorexia/cachexia | 20–80% due to cancer | Lung/pancreatic cancers, chemotherapy, cachexia |
| Dyspnea | 10–80% during a lifetime | Lung cancer, effusions, pulmonary metastases |
| Hot flashes | Two-thirds of breast cancer patients | Androgen deprivation therapy |
| Nasal vestibulitis | Up to 75% | Taxanes, bevacizumab |
1.1 Symptom Assessment Tools¶
The Edmonton Symptom Assessment System–Revised (ESAS–FS) evaluates pain, fatigue, nausea, depression, anxiety, dyspnea, and spiritual distress on a 0–10 scale. It is available in multiple languages and takes ~117 seconds to complete.
1.2 Proactive Management¶
Early intervention with PRO-based monitoring improves outcomes. Concurrent palliative care is associated with longer survival in advanced cancer patients.
2. EPIDEMIOLOGY¶
Symptoms are prevalent in 80% of cancer patients during their lifetime. Fatigue (80% prevalence) and pain (40–70% overall) are most common. Hypothyroidism (5–22%) and hypophysitis (1–2%) are common immune-checkpoint inhibitor-related complications.
2.1 Demographics¶
Fatigue and pain are most common in older adults and patients with advanced-stage disease. Hot flashes affect 2/3 of postmenopausal breast cancer patients and 3/4 of prostate cancer patients receiving androgen deprivation.
3. ETIOLOGY & PATHOPHYSIOLOGY¶
Symptoms arise from cancer biology, treatment toxicity, or comorbidities. Fatigue is linked to anemia, hypercalcemia, and chemotherapy. Pain is classified as nociceptive, visceral, neuropathic, or incident (bone metastases).
Table 74-2: Types of Commonly Encountered Cancer Pain¶
| TYPE OF PAIN | CAUSE | CHARACTERISTICS | EXAMPLES |
|---|---|---|---|
| Nociceptive | Pressure on nerves | Deep, dull, aching, constant and worsening | Pancreatic cancer pain, epigastric pain |
| Visceral | Distention of hollow viscus | Cramping, bloating, intermittent | Intestinal obstruction, renal colic |
| Neuropathic | Direct nerve damage | Local pain, sharp, burning, allodynia | Chemotherapy-induced neuropathy |
| Incident/movement | Bone metastases | Minimal rest pain, excruciating with movement | Pathologic fractures, "bone on bone" pain |
3.1 Pain Mechanisms¶
Nociceptive pain results from tissue damage; visceral pain from hollow viscus distention; neuropathic pain from nerve damage (e.g., chemotherapy-induced); and incident pain from bone metastases.
3.2 Fatigue Pathogenesis¶
Fatigue is multifactorial, involving cancer cachexia, anemia, hypothyroidism, chemotherapy, and cytokine release. Cachexia is characterized by skeletal muscle and adipose tissue loss.
4. CLINICAL FEATURES¶
Symptoms vary by type: pain (80% prevalence), fatigue (80%), nausea (10–90% with chemotherapy), and dyspnea (10–70% near end of life). Hot flashes affect 2/3 of postmenopausal breast cancer patients.
4.1 Pain Presentation¶
Nociceptive pain is localized and constant; visceral pain is cramping and intermittent; neuropathic pain is burning/sharp with allodynia; incident pain is excruciating with movement.
4.2 Fatigue Impact¶
Fatigue is the most reported symptom, often mistaken for depression. It correlates with reduced quality of life and increased mortality in advanced cancer.
5. DIFFERENTIAL DIAGNOSIS¶
For fatigue: anemia, hypothyroidism, depression, cachexia. For pain: metastases, infection, neuropathy, visceral distension. For nausea: chemotherapy, opioids, bowel obstruction, infections.
5.1 Pain Differentiation¶
Differentiate between nociceptive (localized), visceral (cramping), neuropathic (burning), and incident (movement-related) pain using clinical history and physical exam.
6. INVESTIGATIONS & DIAGNOSIS¶
Laboratory tests include CBC, electrolytes, TSH, and renal function. Imaging (e.g., CT, MRI) identifies metastases. PRO tools (ESAS–FS) quantify symptoms. Algorithms guide antiemetic and analgesic selection.
6.1 Diagnostic Criteria¶
Diagnose hypothyroidism with TSH elevation and low free T4. Confirm pain type via history, physical exam, and imaging. Assess for cachexia with weight loss >10% of pre-cancer weight.
7. MANAGEMENT & TREATMENT¶
Pharmacologic: acetaminophen/NSAIDs for nociceptive pain; opioids + adjuvants for neuropathic pain; olanzapine for nausea; duloxetine for CIPN. Non-pharmacologic: exercise, palliative care, and symptom monitoring.
7.1 Pain Management¶
Nociceptive: acetaminophen → NSAIDs → opioids. Visceral: opioids + octreotide. Neuropathic: gabapentin, pregabalin, duloxetine. Incident pain: low-dose gabapentin + opioids.
7.2 Nausea/Vomiting¶
Highly emetogenic: dexamethasone + 5-HT3 antagonists + NK1 inhibitors. Moderate: 5-HT3 antagonists. Low: ondansetron. Olanzapine (2.5–5 mg/d) is effective for advanced cancer.
7,3 Constipation¶
Prevent with opioid use. Treat with senna (1–8 tablets/d), polyethylene glycol, or lactulose. Opioid antagonists (e.g., naloxone) for refractory cases.
8. PROGNOSIS & COMPLICATIONS¶
Untreated symptoms reduce quality of life and survival. Cachexia is associated with 20% of cancer deaths. Hypothyroidism and hypophysitis are common immune-checkpoint inhibitor side effects.
8.1 Complications¶
Cachexia leads to muscle wasting and poor prognosis. Severe pain and dyspnea are associated with end-of-life care needs. Opioid toxicity (constipation, respiratory depression) is a risk.
9. SPECIAL CONSIDERATIONS¶
Pregnancy: avoid chemotherapy and radiation. Pediatrics: manage symptoms with lower opioid doses. Elderly: monitor for drug interactions and renal function. Immunotherapy-related hypothyroidism requires thyroid hormone replacement.
9.1 Palliative Care¶
Integrate palliative care early for symptom management. Use hospice for end-of-life care. Address spiritual distress and financial burden with multidisciplinary teams.
10. KEY POINTS & CLINICAL PEARLS¶
- Use PRO tools (e.g., ESAS–FS) for early symptom detection. 2. Olanzapine (2.5–5 mg/d) is effective for advanced cancer-related nausea. 3. Duloxetine is the only proven treatment for CIPN. 4. Palliative care improves survival in advanced cancer patients.