Supportive and Palliative Care for Lung Cancer Patients _2013_CENICU

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R E V I E W A R T I C L E

Introduction

Lung cancer paiens experience muliple sympoms ha ofen

co-occur, he mos common being dyspnoea, cough, aigue,

pain, anorexia, anxiey and depression. As survival raes or lung

cancer are poor (ive-year relaive survival raes in Ausralia o

14.1%) (1), hese eecs oen persis over ime and inensiy

as he disease progresses. Sudies repor ha more han 80% o

lung cancer paiens have muliple sympoms, ofen experiencing

more sympoms and psychological disress han paiens wih

oher cancer ypes (2). I has been esimaed ha 43% o paiens

wih lung cancer repor psychological disress, compared o an

overall prevalence rae o 35% across 14 cancer sies (3). Such

sympoms can resul in significan burden, impaired physical and

social uncion and poor qualiy o lie. Newly diagnosed lung

cancer paiens also repor eeling shocked and righened and

display a high need or inormaion (4). Given he burdensome

naure o his disease, i is no surprising ha sudies have

confirmed ha paiens wih lung cancer repor a higher burden

o psychological and daily living unme needs compared wihpaiens who have oher ypes o cancer (5-8). his paper

provides a review o evidence based inervenions ha suppor

bes pracice supporive and palliaive care or paiens wih lung

cancer. Speciically, pharmacological and non-pharmacological

inervenions o manage dyspnoea, one o he mos common

sympoms experienced by his group, will be discussed o

illusrae he emerging evidence base in he field. Te evidence

o suppor inervenions ha ocus speciically on addressing

psychological disress and unme needs is also discussed. In

addiion, given he complex naure o he healh and suppor

needs experienced by paiens wih lung cancer, we consider

recen evidence regarding healh service level inervenions

Supportive and palliative care for lung cancer patients

Patsy Yates1, Penelope Schofield

2,3,4,5, Isabella Zhao

1, David Currow

6

1Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; 2Department of Cancer

Experiences Research, Peter MacCallum Cancer Centre, Melbourne, Australia; 3Sir Peter MacCallum Department of Oncology, (Faculty

of Medicine, Dentistry and Health Sciences), 4School of Behavioural Science, 5School of Nursing, The University of Melbourne, Parkville,

Australia; 6Discipline of Palliative and Supportive Services, Adelaide, Flinders University, Australia

ABSTRACT Lung cancer paiens ace poor survival and experience co-occurring chronic physical and psychological sympoms. Tese

sympoms can resul in significan burden, impaired physical and social uncion and poor qualiy o lie. Tis paper provides

a review o evidence based inervenions ha suppor bes pracice supporive and palliaive care or paiens wih lung

cancer. Specifically, inervenions o manage dyspnoea, one o he mos common sympoms experienced by his group, are

discussed o illusrae he emerging evidence base in he field. Te evidence base or he pharmacological managemen o

dyspnoea repor sysemic opioids have he bes available evidence o suppor heir use. In paricular, he evidence srongly

suppors sysemic morphine preerably iniiaed and coninued as a once daily susained release preparaion. Evidence

supporing he use o a range o oher adjuncive non-pharmacological inervenions in managing he sympom is also

emerging. Inervenions o improve breahing efficiency ha have been repored o be effecive include pursed lip breahing,

diaphragmaic breahing, posiioning and pacing echniques. Psychosocial inervenions seeking o reduce anxiey and

disress can also improve he managemen o breahlessness alhough urher sudies are needed. In addiion, evidence

reviews have concluded ha case managemen approaches and nurse led ollow-up programs are eecive in reducing

breahlessness and psychological disress , providing a useul model or supporing implemenaion o evidence based

sympom managemen sraegies. Opimal oucomes rom supporive and palliaive care inervenions hus require a muli-

level approach, involving inervenions a he paien, healh proessional and healh service level.

KEY WORDS Lung cancer; palliaive care; dyspnoea

J Thorac Dis 2013;5(S5):S623-S628. doi: 10.3978/j.issn.2072-1439.2013.10.05

Corresponding to: Patsy Yates. Institute of Health and Biomedical Innovation,

60 Musk Ave, Kelvin Grove, QLD 4059, Australia. Email: [email protected].

Submitted Oct 07, 2013. Accepted for publication Oct 12, 2013.

Available at www.jthoracdis.com

ISSN: 2072-1439

Pioneer Bioscience Publishing Company. All rights reserved.


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Yates et al. Supportive & palliative care in lung cancerS624

designed o achieve opimal oucomes his populaion.

Interventions to manage dyspnoea in patients

with lung cancer

Pharmacological management of dyspnoea in lung cancer

he evidence base or he pharmacological managemen o

chronic reracory breahlessness is coninuing o improve. In

his conex, chronic is deined as daily or more han hree

o he las six monhs, and reracory reers o cases where all

underlying causes conribuing o breahlessness have been

assessed as o wheher hey can be reversed and, i so, wheher

hey should be reversed. Breahlessness in his case is deined

as modiied Medical Research Council (mMRC) scale 3 or

4--breahless a res or on minimal exerion such as he basic

aciviies o daily living (dressing, bahing or preparing ood).I is likely, however, ha people wih mMRC scale 2 will also

bene i ro m breah les sne ss iner venions (9,10). he aim

o a herapeuic inervenion or his populaion is o reduce

sympomaic breahlessness, as breahlessness will rarely be

conrolled a all imes once chronic irreversible underlying

causes o he sympom are esablished. Alhough his may

ranslae or some people ino improved or beer mainained

levels o uncion, ulimaely he ocus is on reducing he

subjecive experience ha we call breahlessness. I is imporan,

hereore, ha boh he severiy (inensiy) o breahlessness and

an aecive componen (he unpleasanness o breahlessness)should be assessed in his conex.

Sysemic opioids have he bes available evidence o suppor

heir use in he clinical seting o people wih chronic reracory

breahlessness. A mea-analys is and an adequaely powered,

double blind, randomised conrolled crossover rial boh repor

he same order o magniude o benei (9,11). he major

adverse eec in boh o hese sudies was consipaion, which

should be reaed expecanly, wih no recorded episodes o

respiraory depression. In prospecively done clinical rials, wih

careully iraed opioids, paiens have no been admied o

hospial wih obundaion, respiraory depression nor conusion.

Sysemic opioids, where morphine has been he mos requenlysudied medicaion, are likely o offer he mos benefi.

More recen work has ollowed paiens who gained

sympomaic benei rom opioids or chronic reracory

breah les sne ss or up o 660 days o ex plo re he long er m

eicacy o once daily susained release morphine (12). In his

case, beween 10-30 mg o oral morphine per 24 hours was used

and delivered a susained benefi or wo hirds o paiens who

were sar ed on he medicaion. he majoriy o his sample

derived benefi rom jus 10 mg per 24 hours.

Oher opioids are saring o be sudied, bu he evidence

base srongly suppors sysemic morphine preerably iniiaed

and coninued as a once daily susained release preparaion. In a

sub sudy exploring response o he iraion o susained release

morphine or chronic reracory breahlessness, when benei

was derived, here was no only a reducion in breahlessness in

he firs 24 hours, bu coninued improvemen over he ensuing

week (13). Tis suggess ha susained release morphine should

be iraed o effec and, when benefi is gained, urher iraion

delayed or a leas one week.

However, he same sysemaic review did no demonsrae

benefi rom nebulised opioids, despie he wide-spread presence

o opioids recepors in he bronchial ree. his poenially was

a ype II error and may relae o he way in which opioids were

nebulised (14). However, more recen work suggess ha opioids

delivered a he alveolar level are likely o help reduce chronic

reracory breahlessness. A recenly repored randomised

conrol rial demonsraed susained reducion in breahlessness,

improved sleep and decreased cough in a relaively small cohoro people who have long erm respiraory damage rom previous

musard gas exposure (15).

A number o oher medicaions are being sudied. A recen

sysemaic review suggesed ha here may be beneis rom

nebulised rusemide unrelaed o a diureic effec (16). Te firs

large sudy o his has recenly been repored and suggess ha

here may be susained sympomaic benefi by using nebulised

rusemide a a dose o 40 mg/4 mls compared o 4 mls o normal

saline. his herapy appeared o be well oleraed (17). O

noe, he widespread use o benzodiazepines is no suppored

wih cur ren eviden ce (18). Al hough one rand omi sed rialsuggesed sympomaic benefi was generaed more quickly wih

benzodiazepines in he seing o acue breahlessness where

a diagnosic workup was required, he rade-o was increased

somnolence.

Non-pharmacological management of dyspnoea in lung cancer

In addiion o he growing evidence base supporing he role

o various pharmacological agens in he managemen o

breahlessness, evidence o suppor he use o a range o oher

adjuncive non-pharmacological inervenions in managing

he sympom is also emerging. Recenly a landmark sudy hasrepored on he use o non-invasive venilaion in people wih

chronic reracory breahlessness and advanced disease wihou

over respiraory ailure. Paricipans were randomised o oxygen

or non-invasive venilaion se o suppor mode. Non-invasive

venilaion was well oleraed in people wih advanced disease

many o whom derived sympomaic benefi a raes greaer han

hose people reaed only wih oxygen (19). I is a herapy which

wil l require careul ongoing evaluaion in order o undersand

he ne effec ha such inervenions will deliver o paiens wih

chronic reracory breahlessness in he las days or weeks o lie.

A number o recen sysemaic reviews have also repor ed


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Journal of Thoracic Disease, Vol 5, Suppl 5 October 2013 S625

beneis rom use o behavioural, psychosocial and environmenal

modificaion inervenions in he managemen o dyspnoea (20-22).

Mos sudies in his ield involve esing o mulicomponen

inervenions, where a range o sraegies are combined ino a

bundled iner venion, making i di icul o ascerain speci ic

componens ha have mos benefi. I is also difficul o conclude

which groups o paiens are mos likely o benei rom hese

complex inervenions, as here is significan variaion in sudy

samples (21). A leas one review has concluded ha paiens

who enroll and complee hese ypes o inervenions appear o

be in he earlier sages o heir disease or have beter uncional

abiliies han hose who do no complee he sudy (21). he

applicaion o hese approaches, and wha modiicaions are

required or paiens as he disease progresses, has no been well

esablished.

Nowihsanding hese limiaions, behavioural and

psychosocial inervenions or paiens wih lung cancer hahave some supporing evidence can be caegorised according o

wo main mechanisms o acion (20). Tese caegories include

inervenions o improve breahing efficiency and inervenions

argeing he affecive componen o breahlessness by seeking o

reduce anxiey and disress. Inervenions o improve breahing

eiciency include a range o breahing reraining echniques,

wih sysemaic reviews concluding here is good evidence o

suppor he effeciveness o hese echniques, including pursed

lip breahing, diaphragmaic breahing, blow-as-you-go,

posiioning and pacing echniques (20).

Anoher review has concluded ha ev idence sup por inghe beneis o exercise programs in conrolling breahlessness

is no conclusive (23). his review o 16 sudies on 13 unique

paien groups oaling 675 paiens wih NSCLC concluded

ha exercise inervenions or paiens wih NSCLC is sae

beore and aer cancer reamen. While no all sudies in his

review included breahlessness as an oucome, he auhors did

conclude here were some posiive benefis on exercise capaciy,

sympoms and some domains o healh-relaed qualiy o lie.

Te majoriy o he sudies reviewed were, however, small case

series and ocused mosly on paiens immediaely pre- and pos-

surgery. Te auhors concluded, hereore, ha urher research

is required o esablish he eec o exercise, especially in headvanced sage o disease, as well as o deermine he opimum

ype and dose o exercise raining.

Wih reg ard o inerven ions aiming o red uc e dis res s

associaed wih breahlessness, inervenions including

relaxaion echniques, coping skills raining, and general suppor

or paiens and heir carers have been repored o achieve

posiive oucomes (20-22). Relaxaion echniques in paricular

are repored o be beneicial, alhough he accepabiliy and

susainabiliy o his approach or all paiens has no been

deermined. As wih oher non-pharmacological inervenions,

he available Cochrane Reviews recommend urher esing o

deermine he naure and scope o psychosocial inervenions

seeking o improve he managemen o breahlessness (20,22).

Applicaion o such echniques also requires careul assessmen

o a paiens preerences and capaciy o implemen hem.

Te use o a hand held an has been considered in a limied

number o sudies. his inervenion is hough o produce a

low o air which may aler venilaion when direced o he

ace, alhough he exac mechanism o his eec is unclear

(24). One small randomised conrolled rial (RC) concluded

ha he eeciveness o he an could no be proved, alhough

a small group seemed o benei, no necessarily relaed o a

relie in breahlessness (24). Work is ongoing o evaluae he

effeciveness o his approach.

Interventions to manage psychological distress

and unmet needs in lung cancer patients

Despie high levels o disress and perceived unme need

experienced by his group, evidence o inorm effecive psycho-

educaional and supporive care inervenions or lung cancer

paiens is scarce (25). Te probable reason is he considerable

challenges aced in conducing rials o complex inervenions

wih his popula ion. No abl y, high re usal raes and poor

reenion have been acknowledged as a signiican diiculy in

recruiing paiens wih lung cancer o hese rials (26).

Given he high morbidiy o people wih lung cancer, a ocus

o work in his area has been on rialing muliaceed inervenion

argeing he psycho-social well-being o people wih lung cancer.In one sudy, wo sessions o nurse-led coaching in progressive

muscle relaxaion combined wih educaion on sel-managemen

o sympoms a he beginning and middle o radioherapy were

compared agains usual care in a RC (n=140). Te inervenion

was demonsraed o be more eecive in erms o reduc ing

breahlessness, aigue and anxiey compared wih usual care (27).

Anoher large rial (N=233) o educaion versus coping skil ls

raining or caregivers showed improvemens in paien- and

caregiver-repored oucomes, including depression and sel-

eicacy over ime or boh groups (28). Boh inervenions

were eleph one based and he educaion consised o basic

inormaion on he illness and paien care and coping skillsraining incorporaing relaxaion pracices, problem-solving and

communicaion. Inerpreaion o benefis is complicaed by he

absence o a suiable no reamen conrol. Te mos recen rial

(n=108) esed wheher a ailored, mulidisciplinary supporive

care program based on sysemaic needs assessmen wih wo

sessions a he commencemen and end o reamen was

effecive in reducing unme needs and psychological disress and

improving qualiy o lie (29). However, due o mehodological

limiaions here were no differences beween he wo arms.

In summary, available sudies o psychosocial and

psychoeducaional inervenions have noable limiaions in heir


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design including selecion, ariion and reporing bias, small

samples, insufficien inervenion dose and/or a lack o a suiable

conrol group. Nowihsanding hese limiaions, i is highly

plausible ha psychosocial inervenions can reduce disress

associaed wih lung cancer. Such approaches are hereore an

imporan par o a comprehensive managemen plan or his

populaion, alhough urher research is needed o deine he

precise naure and scope o hese inervenions and applicaion

in differing paien conexs.

Service delivery models to optimise outcomes

for patients with lung cancer

Te complex, mulidimensional and chronic naure o lung cancer-

relaed sympoms and associaed psychological disress requires

an approach o care ha enables collaboraion beween a range o

healh care providers across inpaien and communiy setings osuppor consisen implemenaion o evidence based supporive

care inervenions. In recen years, a body o evidence has emerged

regarding various healh service level inervenions ha have

been designed o achieve opimal oucomes or his group. For

example, wo sudies have invesigaed pos-reamen nurse

ollow-up versus sandard physician ollow-up. One hree-arm

sudy involved a sample size o 166 people wih progressive lung

cancer who were randomised o receive a specialised oncology

home care program delivered by nurses, a sandard home care

program delivered by a mulidisciplinary eam or an oice

care program delivered by physicians (conrol group) (30).Paricipans who received one o he wo home-based nurse

groups had lower sympom disress, bu sel-perceived healh

was also poorer in comparison o he physician ollow-up (30).

Anoher sudy compared nurse ollow up wih physician ol low

up afer he compleion o iniial reamen. In his sudy, paiens

randomised o nurse-led ollow up had open access o nurse

specialiss Monday o Friday and conac hrough open access

clinic, elephone, and message pager service, and elephone

assessmen or clinic appoinmen wo weeks afer baseline, hen

every our weeks while he paien was sable wih no rouine

invesigaions. Emphasis was on rapid and comprehensive

communicaion wih general praciioners and he primaryhealhcare eam wih regular discussion and reerral o a medical

eam on deecion o any new sympom or rapid worsening

o condiion. Paiens who received he nurse-led ollow up

inervenion had less severe dyspnea a 3 monhs and had beter

scores or emoional uncioning and less peripheral neuropahy

a 12 monhs, alhough no oher signiican dierences in

qualiy o lie domains were ideniied. Paiens who received

he nurse-led ollow up also scored signiicanly higher

compared o convenional ollow up paiens in saisacion

wih he organisaion o care, inormaion and educaion and

personal experience o care a 3, 6 and 12 monhs rom baseline.

Imporanly, he auhors also repored ha he patern o use o

services differed beween he wo groups. Specifically, compared

o convenional ollow up paiens, paiens receiving nurse-led

ollow up had signiicanly ewer medical consulaions wih a

hospial docor a hree monhs, had ewer radiographs aken

(including ches radiographs) a 3 monhs and 6 monhs, and

were more likely o have had radioherapy reamen a 3 monhs.

Addiionally, when place o deah was known, significanly more

paiens who received nurse-led ollow up han convenional

ollow up paiens died a home raher han in a hospial or

hospice. Comparison o he overall coss o care beween groups

showed no significan differences (31).

Given he poor prognosis associaed wih lung cancer,

and he likely increasing burden o sympoms as he disease

progresses, he poenial beneis o reerral o palliaive care

services has also been invesigaed in one recen sudy. his

randomised rial compared he effec o early reerral o palliaivecare or newly diagnosed measaic non-small cell lung cancer

paiens alongside sandard oncology care wih sandard

oncology care alone. As hypohesised, paiens who received

early reerral o palliaive care had beter qualiy o lie and less

depressive sympoms han hose who received sandard care

alone. Addiionally, and perhaps less expecedly, while paiens

in he early reerral group had less aggressive care han hose

in he sandard care alone group, median survival was longer

or paiens receiving palliaive care compared o sandard care

(11.6 versus 8.9 monhs) (32). While he sudy was conduced

in one large cancer cenre in he US wih is unique healhsysem and is ye o be esed in oher healh care conexs, he

findings o he sudy raise imporan quesions or clinicians and

healh service managers abou he adequacy o exising linkages

beween specialis oncology and palliaive care services.

Implications for practice and research

Paiens wih lung cancer experience signiican sympom

burden and wi ll benei rom good suppor ive and pal liaive

care. Over he pas decade, here have been imporan advances

in undersanding o pharmacological and non-pharmacological

approaches o managing some common sympoms experiencedby his group. Tis is paricularly he case or dyspnoea, alhough

some gaps remain in how hese inervenions are implemened in

pracice. Oher common sympoms are similarly gaining increased

aenion, alhough we have ocused on dyspnoea in his review

o illusrae advances in he ield as he evidence base or his

sympom has developed more rapidly han or oher sympoms.

In addiion o he clinical approaches reviewed in his paper,

research in his ield needs o exend o ideniy service delivery

models ha enable implemenaion o bes pracice supporive

and palliaive care. For example, evidence reviews highligh

ha case managemen approaches and nurse-led ollow-up


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Journal of Thoracic Disease, Vol 5, Suppl 5 October 2013 S627

programs are eecive in reducing breahlessness (20,22) and

may be useul in reducing sympom and psychological disress

(27,30,31). Such models also have he poenial o posiively

influence he way healh services are used. Some evidence also

exiss o suppor early reerral o paiens wih measaic lung

cancer o palliaive care, alongside sandard oncology care (32).

While such service delivery models have no been esed across

diering healh care sysems, he indings rom hese sudies

are noeworhy and heir implicaions or healh services are ar

reaching. o achieve opimal oucomes or paiens wih lung

cancer requiring supporive and palliaive inervenions, i is

imporan ha hese healh sysem level reorms be considered.

Acknowledgements

Disclosure: Te auhors declare no conflic o ineres.

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Cite this article as:Yaes P, Schofield P, Zhao I, Currow

D. Supporive and palliaive care or lung cancer

paiens. J horac Dis 2013;5(S5):S623-S628. doi:

10.3978/j.issn.2072-1439.2013.10.15

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Supportive and Palliative Care for Lung Cancer Patients _2013_CENICU