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元培科技大學護理系 廖幼媫 助理教授
2/9/2012
2013/1/2 1
Concept of symptom: Unpleasant Symptom Theory Dyspnea
- Definition - Significance and Prevalence - Causes of cancer dyspnea - Management of dyspnea
Cancer-related fatigue (CRF) - Definition - Significance and Prevalence - Causes of cancer CRF - Management of CRF
Pain - Definition - Significance and Prevalence - Causes of cancer pain - Management of pain
2013/1/2 2
Source: Lenz, E. R., Pugh, L. C., Miligan, R. A., Gift, A., & Suppe, F. (1997). The middle-
range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14-27.
2013/1/2 3
Dyspnea
2013/1/2 4
A subjective experience of breathing discomfort that
consists of qualitatively distinct sensations that vary in
intensity. The experience derives from interactions
among multiple physiological, social, and environmental
factors, and may induce secondary physiological and
behavioral responses
A very common and most distressing symptom
described by patients with life-limiting illnesses
(Buckholz et al., 2009; DiSalvo etal., 2008)
2013/1/2 5
Dyspnea occurs in up to 60% of patients with cancer
Estimated to occur in 15%–55% at diagnosis to 18%–
79% during the last week of life
Up to 50% of solid tumors or hematologic malignancies
who present to the emergency room with dyspnea die
within 6 months of presentation
Associated with poor prognosis
Caused by the tumor burden and effects or anticancer
therapy and/or lifestyle perturbations
A difficult one for caregivers to manage
(Beckles, Spiro, Colice, & Rudd, 2003; DiSalvo et al., 2008; Koelwyn et al., 2012; Ripamonti & Fusco, 2002).
2013/1/2 6
Dyspnea Caused Directly by Cancer
Pulmonary parenchymal
involvement
Hepatomegaly
Airway obstruction by tumor Phrenic nerve paralysis
Pleural tumor / effusion Pulmonary leukostasis
Ascites Superior vena cava syndrome
Dudgeon et al. (2001) 2013/1/2 7
Dyspnea Caused Indirectly by Cancer
Cachexia Pulmonary emboli
Electrolyte abnormalities Surgery
Anemia Radiation pneumonitis or
fibrosis
Pneumonia Chemotherapy-induced
pulmonary toxicity
Pulmonary aspiration
Chemotherapy-induced
cardiomyopathy
Dudgeon et al. (2001) 2013/1/2 8
For those advanced cancer patients who have poor
performance status and very short estimated life
expectancy and who cannot tolerate further treatment,
relief of dyspnea symptoms becomes the most important
medical service.
Dyspnea treatment can follow either a pharmacological
or nonpharmacological approach or can draw from
both types of intervention.
2013/1/2 9
The optimal treatment of dyspnea includes the use of specific therapies or palliative therapies as appropriate to reverse the causes of dyspnea
Pharmacologic interventions Oral and parenteral opioids - morphinel can reduce ventilatory demand by decreasing central respiratory drive for management of dyspnea in patients with terminal or advanced cancer Chest tube drainage or chemical pleurodesis for pleural effusion
Oxygen therapy is beneficial for hypoxic patients with dyspnea at rest
(DiSalvo et al., 2008; Qaseem et al., 2008)
2013/1/2 10
Cont’d
Nonpharmacologic Interventions
Relatively few data suggesting the effect of other
approach:
Cognitive-behavioral Approach
Breathing retraining combined with
Psycho-educational strategies
Relaxation technique
Pulmonary rehabilitation
Exercise therapy (for postoperation)
(Koelwyn et al., 2012; Xu & Abernethy , 2010)
2013/1/2 11
Cont’d
Physiologic
Approaches
Emotional /Cognitive
Approaches
Muscle strengthening (i.e. exercise,
neuromuscular electrical stimulation,
respiratory muscle training
Counseling and support
Sit up or lean forward position Relaxation (i.e. guided imagery,
progressive muscle relaxation)
Energy conservation Distraction (i.e. music)
Breathing training (i.e. pursed lips,
diaphragmatic breathing)
Psycho-education
Cool air/Moving air
Acupuncture/acupressure
Nutritional supplementation
(Buckholz & von Gunten, 2009; Koelwyn et al., 2012; Xu & Abernethy , 2010) 2013/1/2 12
Cancer-Related Fatigue
(CRF)
2013/1/2 13
A persistent, subjective sense of tiredness related to
cancer and cancer treatment that interferes with usual
functioning
tiredness
weakness
lack of energy
not relieved by rest or sleep
feelings of exhaustion
loss of drive and personal interests
impaired memory and concentration.
(Horneber et al., 2012; NCCN, 2012a; Ryan et al., 2007)
2013/1/2 14
CRF is extremely common with 60% -90% of prevalence
rate
Persists for months in treatment or even years after the
completion of cancer treatment, end-of-life and
survivorship
98% of patients considered fatigue to be the most
distressing symptom, impacts patients’ physical,
psychological, social and spiritual well-being and quality
of life considerably
Under-reported, under-diagnosed and under-treated
(NCCN, 2012a; Ryan et al., 2007) 2013/1/2 15
NCCN guideline suggests screen every patient for
fatigue as vital sign at regular intervals on a scale of 0 -
10
None (0)
Mild (1-3)
Moderate (4-6)
Severe (7-10)
Fatigue severity Inventory (severity and interference)
(NCCN, 2012a)
2013/1/2 16
The etiology of CRF is multifactorial and most likely
involves the dysregulation of several interrelated
physiological, biochemical, and psychological systems
2013/1/2 17
Medication effect
Malnutrition -anorexia/cachexia
-dehydration -electrolyte
disturbance
Sleep disturbance - insomnia
- hypersomnia - OBSA
- narcolepsy
Diminished physical
performance - reduced fitness - lack of exercise
-myopathy/sarcopenia
Emotional distress - depression
- anxiety - adaptive disorder
- stress reaction
Cancer-related Fatigue
Pain Anemia
Comorbidities - infection
- cardiac and respiratory disease
- renal, hepatic, endocrine…disorder
- paraneoplasty syndrome
2013/1/2 18
Cont’d
Serotonin (5-HT) dysregulation
Increased proinflammatory cytokines (TNF-α interleukin (IL)-1β, IL-6, interferon (IFN)-α, IFN-γ)
Neuroendocrine dysfunctions of the hypothalamic
pituitary adrenal axis
Circadian rhythm desynchronization
Skeletal muscle wasting
Genetic dysregulation
Anemia
(Ryan et al., 2007)
2013/1/2 19
All patients/families need to receive education,
counseling, and general strategies for managing CRF
General strategies
Nonpharmacologic
Pharmacologic
(NCCN guideline, 2012) (NCCN, 2012a) 2013/1/2 20
Self-monitoring of fatigue levels
Energy conservation
Set priorities
Pace
Delegate
Schedule activity at times of peak energy
Postpone nonessential activities
Limit naps to < 1 hr
Structure daily routine
Attend to one activity at a time
Use distraction (eg, games, music, reading, socializing)
(NCCN, 2012a) 2013/1/2 21
Activity enhancement
Maintain optimal level of activity
Energy management
Rational apportionment of physical effort, task
planning, taking of breaks and rest periods
Exercise
Endurance and strength training at moderate
intensity several times a week for 30 to 45 minutes,
Gradually increasing intensity supervision by
physician or physical therapist desirable (necessary
for strength training)
Physical-based therapy (eg, massage therapy) (Horneber et al., 2012; NCCN, 2012a)
2013/1/2 22
Cautions for activity enhancement
Patients with following conditions should be constrained
Bone metastases
Thrombocytopenia
Anemia
Fever or active infection Assessment of safety issue (risk of falls, stability)
(NCCN, 2012a)
2013/1/2 23
Cont’d
Psychoeducation therapy & CBT
Targeted information and counseling about CRF
stress reduction
identification of adaptive and maladaptive
attitudes
relief of anxiety
assistance in coping with stress
promotion of active problem-centered coping
strategies
learning of control techniques
sleep management (stimulus control, sleep restriction,
sleep hygiene)
(Horneber et al., 2012; NCCN, 2012a) 2013/1/2 24
Cont’d
Psychotherapy for depression
Relaxation techniques and mindfulness
2013/1/2 25
Cont’d
Psychostimulated (eg, methylphenidate, modafanil)
Treatment for anemia during chemotherapy with
erythropoietin
Treatment for pain, emotional distress as indicated
Treatment for sleep dysfunction, nutritional
deficit/imbalance, and comorbidity
(NCCN, 2012a)
2013/1/2 26
Pain
2013/1/2 27
One of the most common symptoms associated with
cancer
An unpleasant multidimensional, sensory and emotional
experience associated with actual or potential tissue
damage, or described in relation to such damage.
One of the symptoms patients fear most
To maximize patient outcomes, pain is an essential part
of oncologic management
Encouraging patients to communicate with the physician
and/or the nurse about their suffering
(NCCN, 2012b; Ripamonti et al., 2011)
2013/1/2 28
About 25% of newly diagnosed and 75% of advanced
cancer patients suffered from pain
Pain was present in all phases of cancer disease (early
and metastatic) and was not adequately treated in a
significant percentage of patients, ranging from 56 to
82.3%.
The pathophysiology of cancer pain may involve
nociceptive (somatic and visceral) or neuropathic
mechanisms, or both
2013/1/2 29
Nociceptive
pain
Bone meta Surgical process
Visceral pain Somatic pain
treatment-related Surgical process
Tumor involvement
Sharp, well-localized, throbbing,
pressure-like
Central nervous Peripheral nervous
Neuropathic pain
Diffused, aching, cramping
Compression, infiltration,
distension of viscera
Burning, sharp, shooting, dysesthesia ,allodynia, hyperesthesia,
hypalgesis
2013/1/2 30
Caner treatment
Diagnostic procedure
- venepuncture, lumbar puncture, angiography,
endoscopy, biopsy
Chemotherapy
- arthralgia, cardiomyopathy, gastrointestinal distress,
mucositis, myalgia
Radiation therapy
- esophagitis, mucositis, pharyngitis, skin burns
Surgical therapy
- postoperative pain, ileus, urinary retention
2013/1/2 31
Tumor invasion of bone
vertebral body metastases, base of the skull
metastases, pelvis, long bone
Tumor involvement of nerves, plexus, or spinal cord
peripheral, cranial, or spinal neuropathy; brachial
plexus; epidural spinal cord compression
Tumor Involvement of Viscera
obstruction of hollow viscus or of ductal system of
solid viscus; rapid tumor growth in solid viscus
2013/1/2 32
Cont’d
Tumor involvement of blood vessels
Infiltration; obstruction of large vein/artery
Postsurgical syndromes
Post-thoracotomy; postmastectomy
Postchemotherapy pain
Peripheral neuropathy; aromatase inhibitors; steroid
Postradiation therapy pain
Radiation fibrosis of brachial or lumbosacral plexus;
radiation myelopathy; painful peripheral nerve tumors
2013/1/2 33
Cont’d
All patients must be screened for pain at each contact Comprehensive assessment and managemenmust be
performed as most patients have multiple pathophysiologies
Analgesic therapy is done with management of multiple symptoms
Pain intensity must be quantified by patients Determine patient goals for comfort and function Reassessment of pain intensity to ensure benefits from
analgesic therapy with as few adverse effects as possible
A multidisciplinary team may be needed Psychosocial support must be available Specific education material must be provided
(NCCN, 2012b)
2013/1/2 34
2013/1/2 35
2013/1/2 36
Cont’d
For cognitive impairment, older or limited communication
skills patients:
Observation of pain-related behaviors and
discomfort
- facial expression
- body movements
- verbalization or vocalizations
- changes in interpersonal interactions
- changes in routine activity
2013/1/2 37
Cont’d
Pain related to a oncologic emergency should be directly
treated the underline conditions
Bone fracture
Brain/epidural/ leptomeningeal metastases
Infection,
Obstructive or perforated viscus
2013/1/2 38
Pharmacologic approaches
Non-opioids
Opioids
Adjuvant analgesics
Psychological approaches
Physical modalities
Cognitive modalities
Spiritual care
(NCCN, 2012b; Ripamonti et al., 2011)
2013/1/2 39
Cont’d
WHO analgesic ladder
By Mouth
By the Clock
By the Ladder
For the individual
Attention to detail
(WHO, 1986)
2013/1/2 40
Cont’d
Mild pain (1-3)
paracetamol and/or a non-steroidal anti-inflammatory
Moderate pain (4-6)
codeine, tramadol and dihydrocodeine
low doses of strong opiods in combination with
non-opioid analgesics
Severe pain (7-10)
oral morphine
The average relative potency ratio of oral to
subcutaneous/intravenous morphine is between 1:2 and
1:3
(NCCN, 2012b; Ripamonti et al., 2011)
2013/1/2 41
Patients with pain from bone metastases
external beam radiotherapy or radioisotope
treatment
bisphosphonates
Patients with resistant and neuropathic pain
non-opioid and opioid analgesics may be combined
with tricyclic antidepressant or a anticonvulsant
Patients with refractory pain at the end of life
sedative drugs
2013/1/2 42
Cont’d
Side effects Frequency with oral opioids
Constipation Very common
Sedation Common
Nausea Common
Cognitive impairment Occasional
Pruritus Occasional
Dysphoria Occasional
Hypnogogic imagery Rare
Myoclonus Rare with oral route
Respiratory depression Very rare
2013/1/2 43
Psychosocial support
Ensure patients encountering common barriers to
appropriate pain control
Provide patient and family education and support
Work together to address the pain problem
Inform patient and family there is always something
that can be done to relief pain
2013/1/2 44
Physical modalities
Bed, bath, and walking supports
Position instruction
physical therapy
Energy conservation, pacing of activites
Massage
Heat and /or ice
TENS
Acupunture or acuperssure
Ultrasonic stimulation
2013/1/2 45
Cont’d
Cognitive modalities Imagery/hypnosis Distraction training Relaxation training Active coping training Graded task assignments, setting goals, pacing and prioritizing Cognitive behavioral training
Spiritual care Determine importance to patient/family and current availability of support Management of spiritual, existential concerns
(NCCN, 2012b)
2013/1/2 46
Cont’d
Dyspnea, fatigue and pain are distressing and
debilitating symptoms for patients with cancer
Multidisciplinary cancer care team pay more efforts to
identify evidence-based interventions to reduce the
symptoms and improve quality of life are essential
Both pharmacologic agents and nonpharmacologic
approaches are necessary to impede effective symptom management for patients with cancer
2013/1/2 47
臺灣癌症臨床研究合作組織 (2007)‧癌症疼痛處理指引‧國家衛生研究院
Beckles, M.A., Spiro, S.G., Colice, G.L., & Rudd, R.M. (2003). Initial evaluation of the patient with lung cancer: Symptoms, signs, laboratory tests, and paraneoplastic syndromes. Chest, 123(1, Suppl.), 97S-104S.
Buckholz, G. T., & von Gunten, C. F. (2009). Nonpharmacological management of dyspnea. Current Opinion in Supportive and Palliative Care, 3(1), 98-102.
DiSalvo, W. M., Joyce, M. M., Tyson, L. B., Culkin, A. E., & Mackay, K. (2008). Putting evidence into practice: Evidence-based interventions for cancer-related dyspnea. Clinical Journal of Oncology Nursing, 12 (2), 341- 352.
Dudgeon, D.J., Kristjanson, L., Sloan, J.A., Lertzman, M, & Clement, K (2001). Dyspnea in cancer patients: Prevalence and associated factors. Journal of Pain and Symptom Management, 21(2), 95-102.
Horneber, M., Fischer, I., Dimeo, F., Rüffer, J. U., & Weis, J. (2012). Deutsches Ä rzteblatt International, 109(9), 161-172.
Koelwyn, G. J., Jones, L. W., Hornsby, W., & Eves, N. D. (2012). Exercise therapy in the management of dyspnea in patients with cancer. Current Opinion in Supportive and Palliative Care, 6(2), 129-137.
Lenz, E. R., Pugh, L. C., Miligan, R. A., Gift, A., & Suppe, F. (1997). The middle-range theory of unpleasant symptoms: An update. Advances in Nursing Science, 19(3), 14-27.
National Comprehensive Cancer Network. (2012). NCCN clinical practice guideline in Oncology: Cancer-related fatigue (versin I. 2012).
Qaseem, A., Snow, V., Shekelle, P., Casey Jr, D. E., Cross Jr, J. T. et al. (2008). Evidence-based intervention to improve the palliative care of pain, dyspnea, and depression, at the end of life : A clinical practice guideline from the America College of Physicians. Annals of Internal Medicine, 148 (2), 141-146.
Ripamonti, C. I., Bandieri, E., & Roila, F. (2011). Management of cancer pain: ESMO clinical practice guideline. Annals of Oncology, 22 (Suppl 6), vi69-vi77.
Ryan, J. L., Carroll, J. K., Ryan, E., Mustain K. M., Fiscella, K., & Morrow, G. R. (2007). Mechanisms of cancer-related fatigue. The Oncologist, 12 (Suppl 1), 22-34.
Ripamonti, C., & Fusco, F. (2002). Respiratory problems in advanced cancer. Supportive Care in Cancer, 10(3), 204–216.
World Health Organization (2012). WHO’s pain ladder. http://www.who.int/cancer/palliative/painladder/en/
Xu, D., & Abernethy, A. P. (2010). Management of dyspnea in advanced lung cancer: recent data and emerging concepts. Current Opinion in Supportive and Palliative Care, 4(1), 85-91.
2013/1/2 48
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