元培科技大學護理系 廖幼媫 助理教授

2/9/2012

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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

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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.

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Dyspnea

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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)

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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).

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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.

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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)

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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)

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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)

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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)

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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)

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The etiology of CRF is multifactorial and most likely

involves the dysregulation of several interrelated

physiological, biochemical, and psychological systems

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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

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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)

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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)

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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)

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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

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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)

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Pain

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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)

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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

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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

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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

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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

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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

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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)

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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

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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

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Pharmacologic approaches

Non-opioids

Opioids

Adjuvant analgesics

Psychological approaches

Physical modalities

Cognitive modalities

Spiritual care

(NCCN, 2012b; Ripamonti et al., 2011)

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Cont’d

WHO analgesic ladder

By Mouth

By the Clock

By the Ladder

For the individual

Attention to detail

(WHO, 1986)

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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)

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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

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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

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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

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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

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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)

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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

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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

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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.

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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.

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Ripamonti, C., & Fusco, F. (2002). Respiratory problems in advanced cancer. Supportive Care in Cancer, 10(3), 204–216.

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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.

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