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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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Yates et al. Supportive & palliative care in lung cancerS626
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