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Chapter28:Vascular access:Venous and arterialports
single-lumen, but there are others with two lumens for separate
administration of incompatible drugs. e connection between
the catheter and the port can either be sealed during manufacture or made at the time of placement. Most ports are now
validated for high-pressure injection of contrast agent with a
maximum pressure of 300psi, which corresponds to ow rates
of up to 5mL/s.
30
Indications
e main indications for port insertion is cytotoxic chemotherapy for solid tumors and long-term antibiotic chemotherapy
(e.g., cystic brosis), whereas externalized catheters are used
in hematologic diseases and long-term parenteral nutrition.
Blood sampling is possible with ports provided copious ushing is completed aer sampling.
Preoperative assessment
Platelet count should be more than 50,000/mm3, white cells
more than 1,000/mm3 and international normalized ratio less
than 1.5. A preoperative chest radiograph is not mandatory
but is useful in cases of lung cancer, lymphoma, and ear, nose,
and throat (ENT) tumors. In such cases and when a mediastinal invasion, compression, or thrombosis is suspected, a chest
computed tomography (CT) scan is necessary to verify the
absence of superior vena cava occlusion or partial thrombosis.
Vitamin K antagonists should be replaced by
Figure 28.4 Fracture of catheter and extravasation of contrast in the
costoclavicular space of an 18-month-old infant (pinch-off syndrome).
low-molecular-weight heparin (LMWH). Areduced dose of
LMWH should be administered the day before implantation
and none the morning of the implantation. Subcutaneous fondaparinux and new oral anticoagulants (rivaroxaban, dabigatran, apixaban) should be stopped 2days before implantation
or even earlier in patients with renal failure. When possible,
antiplatelet therapies should be discontinued and replaced by
low-dose aspirin 5days before implantation, except in patients
with recent coronary or arterial stenting. ere is no need to
stop aspirin or non-steroid anti-inammatorydrugs.
Accessroute
Ultrasound imaging and real-time guidance are the standard for port placement.31 In our institution 2,000 indwelling
catheters and ports are implanted each year under ultrasound
guidance. e distribution of central venous access is as follows: 30% access of the internal jugular vein, 50% access of
the brachiocephalic vein via a supraclavicular approach, 15%
access of the axillary or subclavian vein via an infraclavicular
approach, and 5% access of the femoralvein.
Figure 28.5 Ultrasound-guided infraclavicular access of the subclavian vein
with the needle “in plane.”
Percutaneous subclavian access was the rst described.
Access to the subclavian vein is usually easy and rapid because
there are reliable anatomical marks, especially the bones.
It can be approached by an infra- or supraclavicular route.
When anatomical landmarks are used, there is a non-reducible
incidence of pneumothoraces (1–5%) and a risk of compression between the clavicle and rst rib (pinch-o syndrome)
concerning long-term catheters inserted via the infraclavicular route. Pinch-o syndrome occurs in 1% of cases and
may lead to fracture of the catheter (Figure 28.4) and the
embolization of a fragment in the cardiac chambers or the pulmonary arteries.
32,33
For these reasons subclavian infraclavicular access using anatomical landmarks is not the best route for
long-term central venous catheters and should be replaced by
ultrasound-guided infraclavicular access of the axillary/subclavian vein (Figure28.5) or by ultrasound-guided supraclavicular access of the brachiocephalic vein (Figure28.6).
e percutanous access of the internal jugular vein has
gained popularity because of the absence of pneumothoraces
289
Section X:Specialized interventional techniques in cancercare
Figure 28.6 Ultrasound-guided supraclavicular access of the brachiocephalic
vein in a 3-year-old infant.
Figure 28.8 Mediastinal compression of the superior vena cava.
Figure 28.7 Ultrasound-guided posterior access of the internal jugular vein.
Figure 28.9 Anterior mediastinal invasion and superior vena cava
thrombosis.
e brachial and forearm veins may be used for central ven-
and pinch-o syndrome. e relatively high rate of inadvertent
carotid puncture becomes irrelevant (incidence close to zero)
when using ultrasound guidance.
34,35
e right internal jugular
vein is in direct line with the superior vena cava and the right
auricle and is ideally suited for long-term access. On the other
hand, the aesthetic aspect is not always perfect because the
catheter is sometimes clearly visible around the neck area. For
aesthetic reasons, the best approach for jugular vein catheterization is probably a low and posterior approach behind the clavicular head of the sternocleidomastoid muscle (Figure28.7).
e external jugular vein is not used very oen because its
junction with the brachiocephalic trunk is sometimes acute
and will not always allow passage of the catheter.
e cutdown approach of the cephalic vein is oen used by
surgeons. Here, an aesthetic advantage is evident, particularly
in women, but it also has some disadvantages, such as 5–10%
failure, because the vein is either too small or sinuous to be
catheterized,36 thereby causing more venous thromboses than
when using the other methods.
ous access, either via a cutdown or through a percutaneous
vein puncture guided by venography or ultrasound.
37
e percutaneous access of the femoral vein has specic
indications, such as mediastinal compression or invasion of the
superior vena cava in lung cancer or lymphoma (Figure28.8),
superior vena cava thrombosis (Figure 28.9), impossibility
to puncture neck or chest veins due to local tumor invasion,
infection, and postradiation therapy stenosis. Provided that
the technique is well applied and the tip is close to the right
atrium, infectious and thrombotic complications are comparable to those seen aer subclavian or jugular access.
38,39
Because
of the frequency of lung cancer and mediastinal localizations of
lymphoma, femoral access should represent around 5% of all
implanted ports. e port can be implanted at the outer side of
the thigh or on the abdominal wall (Figure28.10).
Catheter tip location
All recent studies have shown that the position of the tip of
central venous devices is a signicant factor for predicting
290
Chapter28:Vascular access:Venous and arterialports
of Chest Physicians and French multidisciplinary cancer network are that the optimal tip position for central venous catheters and ports is the distal third of the superior vena cava or
the proximal right atrium (Figure28.11).
42,43
is last position
does not conform to manufacturer and old Food and Drug
Administration guidelines, although no complications have
been observed in long-term Silastic central venous lines, the
tip of which lay in the right atrium.
Update on vein thrombosis prophylaxis and treatment
Symptomatic deep-vein thrombosis of the upper limbs devel-
Figure 28.10 Femoral long-term access; the port is implanted on the
abdominal wall in front of the iliac bone.
ops in 2.4% of patients when ultrasound guidance is used for
central venous access.44 e presence of mediastinal lymph
nodes has been shown to be a risk factor for catheter-related
venous thrombosis,45 and one should carefully examine the
chest CT scan before implanting a central venous device in
patients suering from lung cancer, lymphoma, and other diseases, including advanced ENT or thyroid cancer, for example. Patients with catheters that are too short, gastrointestinal
cancers, or extensive metastatic disease have a higher risk of
deep-vein thrombosis aswell.
For patients with catheter-related deep-vein thrombosis
and cancer, treatment with LMWH for at least 3–6 months
is recommended.
42,43
If the tip of the catheter is in the correct
location and the port is functioning well, it is possible to keep it
in place and to avoid retrievingit.
Recent studies have failed to show any benet from prophylaxis with warfarin or LMWH compared to placebo for the
prevention of catheter-related thrombosis.
46,47
Based on these
ndings, the American College of Chest Physicians Conference
on Antithrombotic and rombolytic erapy and the French
working group both suggested that the risk of clinically important catheter-related venous thrombosis may be too low to warrant routine prophylaxis and has recommended that clinicians
do not routinely use prophylaxis in cancer patients.
42,43
Catheter-related infection
Minor temporary local infections should be treated with local
antiseptics and possibly oral antibiotics. Nevertheless, the port
should be explanted where there is local swelling or purulent
drainage.
Systemic infection is dened as fever, chills, and a positive
blood culture. Methods of diagnosing catheter-related infection without removing the catheter consist of comparison of
Figure 28.11 Ideal position of the catheter tip: 2–4 cm below the carina.
catheter dysfunction and catheter-related venous thrombosis. When the tip is located in the last third of the superior
vena cava or the right atrium, the rate of venous thrombosis
is between 3% and 5%, compared with 42–46% when the tip
lies in the proximal third of the vena cava or in the brachiocephalic veins.
40,41
Recommendations of the American College
paired blood cultures drawn simultaneously via the port and
from a peripheral venous site. Quantitative blood cultures or
measurement of dierential time to germ growth are used for
this purpose.
48,49
Aer a port infection has been proved, the
port should be removed in the presence of severe neutropenia
or septic shock, or when Staphylococcus aureus, Pseudomonas,
Stenotrophomonas, or Candida species are isolated from blood
culture. Parenteral then oral antibiotic therapy should be prescribed for at least 10days in case of bacteremia. Antibiotic-lock
technique without removing the port is a possible alternative
291
Section X:Specialized interventional techniques in cancercare
when Staphylococcus epidermidis, Escherichia coli, or other
digestive microorganisms are isolated.
50,51
Local antibiotic
locks consist of 2 mL of highly concentrated amikacin or
vancomycin (5mg/mL) that are changed every day for at least
10days, aer which blood cultures should be performed a few
days aer the end of the treatment to conrm the success or the
failure of this treatment.
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19. Aldrighetti L, Arru M, Angeli E, etal. Percutaneous vs. surgical
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21. Ensminger WD, Rosowsky A, Raso V, etal. A
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VX2 tumor model. Anticancer Drugs 2004; 15:647–650.
23. Allen-Mersh TG, Earlam S, Fordy C, Abrams K, Houghton
J. Quality of life and survival with continuous hepatic-artery
oxuridine infusion for colorectal liver metastases. Lancet 1994;
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24. Rougier P, Laplanche A, Huguier M, etal. Hepatic arterial
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25. Lorenz M, Muller HH. Randomized, multicenter trial of
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31. Lamperti M, Bodenham AR, Pittiruti M, etal. International
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32. Aitken DR, Minton JP. e “pinch-o sign”:a warning of
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T, Roche A. [e pinch-o syndrome:main cause of catheter
embolism.] Ann Fr Anesth Reanim 1999; 18:949–955.
34. Karakitsos D, Labropoulos N, De Groot E, etal. Real-time
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35. Wu SY, Ling Q Cao LH, etal. Real-time two-dimensional
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37. Marcy PY, Magne N, Castadot P, etal. Is radiologic
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38. Bertoglio S, DiSomma C, Meszaros P, etal. Long-term femoral
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39. Wolosker N, Yazbek G, Munia MA, etal. Totally implantable
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41. Cadman A, Lawrance JA, Fitzsimmons L, Spencer-Shaw A,
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43. Debourdeau P, Kassab Chahmi D, Le Gal G, etal. 2008 SOR
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44. Cavanna L, Civardi G, Vallisa D, etal. Ultrasound-guided
central venous catheterization in cancer patients improves
the success rate of cannulation and reduces mechanical
complications:a prospective observational study of 1,978
consecutive catheterizations. World J Surg Oncol 2010;8:91
45. Labourey JL, Lacroix P, Genet D, etal. rombotic
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46. Couban S, Goodyear M, Burnell M, etal. Randomized
placebo-controlled study of low-dose warfarin for the
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47. Karthaus M, Kretzschmar A, Kroning H, etal. Dalteparin for
prevention of catheter-related complications in cancer patients
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49. Mermel LA, Farr BM, Sherertz RJ, etal. Guidelines for the
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50. Messing B, Peitra-Cohen S, Debure A, Beliah M, Bernier JJ.
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293
Chapter
Palliative care and symptom management
29
Drew A. Rosielle, Melissa Atwood, Sean Marks, and William S. Rilling
Palliative care and communication with cancer patients
palliative care services, acute inpatient palliative care wards,
outpatient palliative care clinics, cancer pain and symptom
management clinics, emergency departments, nursing home
palliative care services, and hospice settings. Palliative care is
Overview of palliativecare
e World Health Organization denes palliative care as an
approach that improves the quality of life of patients and their
families facing the problems associated with life-threatening
illness, through the prevention and relief of suering by means
of early identication and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and
spiritual.1 Palliative care is focused on symptom relief and
maximizing function, without necessarily impacting the natural history of the underlying illness. Bereavement support
is integral to its mission as it views the patient and his or her
loved ones as a unit of care. Palliative care is interdisciplinary,
involving not only nurses and physicians, but chaplains, psychologists, social workers, and speech, physical, occupational,
and other therapists. While palliative care has historic roots in
the terminal care of cancer patients, its scope encompasses a
wide variety of patients with non-malignant diseases. ese
include neurodegenerative disorders; advanced organ disease;
and patients in critical care units.
2,3
Ideally, palliative care is
provided to patients with severe illnesses early in the course of
their disease, alongside disease-modifying or curative therapy.
As an illness progresses, and as disease-modifying or even
life-prolonging interventions become less available, a patient’s
entire care may become palliative-focused. While much of the
care of patients with life-threatening illness can be described
as palliative, many patients will not require specialist palliative
care, and basic competency in palliative care is important for
clinicians across a variety of specialties and practice types.
4
Palliative medicine describes the physician’s role in the
aforementioned care model. Besides expert symptom assessment and treatment, palliative medicine physicians oer
subspecialty expertise in determining prognosis and communication encounters with patients and families involving breaking bad news, establishing goals of medical care, and planning
for the future in light of a life-threatening illness. e scope of
practice of palliative medicine physicians varies by location and
institution. Common settings include inpatient consultative
increasing by number of programs and prevalence among adult
and pediatric hospitals such that many cancer care providers
will have access to palliative care specialists if needed.
5,6
ere are many benets when specialist palliative
care is added to a patient’s treatment plan. Patients with
life-threatening illnesses oen experience pain, fatigue, nausea, constipation, and dyspnea. Palliative care providers are
trained to evaluate and treat these distressing symptoms and
to escalate and/or transition medications as needed. In addition to physical complaints, palliative care also improves other
domains of life for patients and families. One study showed
improved quality of life, less aggressive care at the end of life,
earlier referral to hospice, and longer length of stay in hospice for those enrolled in early palliative care. is same study
showed prolonged survival in patients receiving palliative
care.7 Further, families report enhanced care for their loved
ones and better access to bereavement care when palliative
specialists were consulted.8 Palliative care involvement has
been associated with improvement in several symptom-based
quality measures as well, including decreased Intensive Care
Unit length of stay9; reduction in hospital costs
10,11
; reduction
in readmission rates12; and reduced utilization of Emergency
Department services.
13
Overview of hospicecare
Hospice care is related but distinct from palliative care. eir
underlying philosophies and interdisciplinary approach to care
are identical. Hospice, however, has a distinct model of care and
reimbursement system that is largely dened by the Medicare
Hospice Benet (MHB) in the USA. Medicaid and private
insurers generally provide similar benets. e MHB requires
physician certication that a patient has an expected prognosis of 6months or less if the disease runs its expected course.
Patients can continue to receive hospice care beyond 6months
as long as their anticipated life expectancy remains less than
6 months. e vast majority of hospice care is provided in
patients’ homes or is provided to patients within long-term care
Interventional Oncology, Second Edition, ed. Jean-François H. Geschwind and Michael C. Soulen. Published by Cambridge University Press.
©Cambridge University Press2016
294
Chapter29:Palliative care and symptom management
Table 29.1 Palliative care and hospice care: A comparison
Palliative care Hospice care
Goals of care To prevent and alleviate physical, emotional, spiritual, and
psychosocial suffering and to optimize quality of life
Patients Patients with serious illnesses at any point along the
continuum of disease. Patients can receive life-prolonging
therapy in conjunction with palliative care
Where care occurs Typically inpatient and outpatient settings; occasionally
in the home
Who provides the care Medical specialty of physicians and nurses; many
programs will also have support of psychology, social
work, chaplain
facilities where the facility is considered the patient’s “home.”
e MHB provides payment for skilled nursing, home health
aides, and volunteer visits; durable medical equipment and
medications related to the terminal diagnosis; respite care;
physical and occupational therapy; social work and chaplaincy
services; and bereavement follow-up.
6,14
Medicare-certied
hospice agencies must be able to provide acute, inpatient-level
care for severe symptom control or imminent death; the MHB
does not cover room and board fees for long-term care facilities, including residential hospices (Table29.1).
Communication with cancer patients
Cancer is oen a terrifying diagnosis and cancer treatments are
oen dicult to understand. In fact, it has been shown that
many advanced cancer patients do not understand that their
cancer is incurable, or that their treatment is not intended to
cure them.
7,15
Strong emotions and intrafamily conicts are
common, making communication about important issues
challenging. is section will highlight important elements of
communication with cancer patients.
Prognostication
For patients with advanced cancer, goals of care discussions
can be particularly challenging. e rst step is for the clinician to establish a prognosis based on current best evidence.
Prognostication in advanced cancer, as with any illness, is inexact; however, a substantial amount of research is available for
guidance. For cancers that are not advanced, disease-specic
factors such as the type of cancer, its stage and histologic grade,
and early responses to chemotherapy are important for determining a broad prognostic range. As cancer progresses, however, patient factors, particularly functional status, become
more important for prognostication.
Functional status, also known as performance status, is a
global measure of a patient’s mobility and ability to care for
him- or herself. As a patient becomes more debilitated from
her or his advancing cancer, performance status and length of
survival diminish. e Karnofsky Performance Status (KPS)
is a reliable and widely used scale to measure functional
16,17,18
status.
It rates a patient’s functional status from 0 (dead)
to 100 (no disease-related symptoms) (Table29.2). Prognosis
with the KPS has been studied across multiple cohorts of terminally ill cancer patients, with overall consistent results.
Patients with metastatic cancer and a KPS of 40 have a median
life expectancy of approximately 2–3 months; expected survival decreases rapidly with poorer performance status.
Agood way to assess performance status is to ask the patient
how much of the day she or he spends in bed or in a chair;
greater than 50% of the day indicates substantial disability and
a prognosis of less than 3months for most patients. Functional
status is also strongly correlated with survival in patients in
phase Ichemotherapy trials.
Other factors that inuence prognosis include age and
symptom burden. Younger individuals tend to decline less
quickly than the elderly, although this protective eect is
lost as disability progresses.21 e onset of certain symptoms
in advanced cancer portends a worse prognosis. Cognitive
impairment, xerostomia, dysphagia, anorexia and weight loss,
and dyspnea, have all been individually and independently
associated with a decreased survival.
vival is only 1–2months aer the onset of hypercalcemia of
malignancy, except for tumors which readily respond to treatment such as breast cancer or myeloma.
with untreated brain metastases is 1 month; it improves to
3–6months with treatment.
Considering that clinicians do not always perform an accurate assessment of functional status on each clinical encounter,
the Glasgow Prognostic Score (GPS) is an additional validated
prognostic tool which takes into account serum C-reactive
protein (CRP) and albumin as a marker of systemic inammation. Ahigher GPS score (elevated CRP and low albumin) has
been reliably shown to predict poor survival in patients with
many dierent types of cancer.
Despite readily available prognostic indices and criteria,
physicians are generally poor prognosticators.
ies have shown that physicians oen overestimate prognosis of
terminally ill cancer patients by a factor of three to ve.
addition, physicians oen deliberately disclose an overly optimistic prognosis to terminally ill cancer patients,,33 usually in
an attempt to avoid emotional harm to a patient.
Although there is a large amount of heterogeneity in patients’
reports of what they want to know from prognostic disclosures,
in general, patients want honest, straightforward information
presented compassionately.
recommended to give accurate but general ranges, such as “days
to weeks,” “weeks to short months,” or “months to years”.36 It is
Same goals
Patients with serious illnesses who have a life expectancy
of less than 6 months if the disease runs its typical course.
The focus of care is on comfort
Most often in the home, but also nursing home, inpatient
hospice facility, and, rarely, the hospital
Team approach led by physicians and nurses with support
of chaplain, social work, bereavement specialists, and
volunteers
18,19,20,21
22
17,20,21,22,23
24,25,26
27
28
34,35
When discussing prognosis it is
Median sur-
Median survival
29,30
Most stud-
19,31,32
In
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Table 29.2 Karnofsky Performance Status scale
Condition Performance status (%) Comments
Able to carry on normal activity and to work. No
special care is needed
Unable to work. Able to live at home and care
for most personal needs. A varying degree of
assistance is needed
Unable to care for self. Requires equivalent of
institutional or hospital care. Disease may be
progressing rapidly
Original reference: Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In Macleod CM, ed. Evaluation of
Chemotherapeutic Agents. New York, NY: Columbia University Press, 1949; pp. 199–205.
Reproduced from Schagg CC, Heinrich RL, Ganz PA. Karnofsky performance status revisited: reliability, validity, and guidelines. J Clin Oncol 1984; 2: 187–193.
also important to share prognostic uncertainty with patients,
preparing them for the worst while hoping for the best. An
example would be saying:“Because of all the things we have
spoken about, Iam worried that you may have only weeks to a
few months to live. It is important for you to know that doctors
are oen wrong when we predict time. Some people live longer
that we think they will and some people live a lot shorter than
we predict. Ido not know what will happen in yourcase.”
In a sense, prognostic disclosures can be viewed as any
other medical intervention, presenting a balance of risks and
benets. Risks include emotional harm to a patient and its consequences. Potential benets include allowing patients to make
appropriate future plans, to identify life priorities, and to more
fully weigh burdens and benets of future medical care in light
of their prognosis.
Breaking badnews
Breaking bad news is emotionally dicult for patients and
clinicians. No approach to breaking bad news can ameliorate the psychic impact on a patient or a family of life-altering
news about one’s health. However, certain approaches can be
utilized to reduce harm. In general patients want information oered in an honest and simple manner, for a loved one
to be present, and for there to be ample time for questions.35
It can be helpful to consider four elements or steps to breaking bad news: preparation, content, patient’s response, and
summary (Table 29.3).
19,37,38
In preparation, it is helpful to
arrange a quiet environment with minimal chance of interruption. Additionally, it is important to be prepared for questions regarding the patient’s past care, prognosis, and treatment
options. Prior to delivering bad news it is recommended to ask
the patient what she or he understands about her or his disease,
treatment, what she or he foresees in the future, and what the
patient wants to know. is way the clinician can establish how
much and what sort of information she or he needs toshare.
100 Normal. No complaints. No evidence of disease
90 Able to carry on normal activity. Minor signs or symptoms of disease
80 Normal activity with effort. Some signs or symptoms of disease
70 Able to take care of self. Unable to carry on normal activity or to do
active work
60 Requires occasional assistance, but is able to care for most needs
50 Requires considerable assistance and frequent medical care
40 Disabled. Requires special care and assistance
30 Severely disabled. Hospitalization is indicated although death is not
imminent
20 Hospitalization necessary, very sick; active supportive treatment
necessary
10 Moribund. Fatal processes progressing rapidly
0 Dead
Prior to delivering the content of the bad news, many experts
suggest that clinicians issue a warning that bad news is forthcoming. Next, the news should be delivered in straightforward
language which avoids medical terminology and complicated
statistics. If a patient wants detailed medical explanations he or
she will generally tell you. If it is believed the patient is dying,
and especially if the patient’s knowledge of this is important for
planning appropriate future care, the word “dying” should be
stated explicitly. For example, one might say “You have received
several chemoembolization treatments for your liver cancer.
e rst one seemed to help you– the cancer shrunk and you
felt better for a while. However, aer the last two treatments
the cancer didn’t shrink and you have been getting sicker, and
are now so weak that you are spending most of the day on the
couch. Because of this, unfortunately, more treatments aren’t
going to help you live longer or feel better. Iwish it wasn’t this
way, but you are dying from the cancer.”
Aer delivering the bad news it is important to stop and
allow the patient and family to respond, even if there is a
period of silence. Patients may express grief, despair, anger,
guilt, or other strong emotions. Some patients may express
relief at knowing what is going on. Regardless, it is important to empathetically acknowledge the patient’s emotions
and to allow the patient time to present them before moving
forward. e summary of the interaction will depend on the
nature of the news. Patients and families will generally want
to know what the news means for the future, such as the availability and types of future treatments. If the bad news marks
a distinct turn in the focus of a patient’s care from curative to
non-curative, the patient’s own goals for the future should be
assessed.39 One can ask, “In light of this information, I’d like
to discuss what is important for you in the future, in regard
to both your personal life and your future medical care.” is
allows the patient opportunity to bring up personal, spiritual,
and familial goals and concerns, as well as opening a discussion
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Table 29.3 Four elements of an approach to delivering a prognosis
Tasks Possible ways to express it
Preparation
Research the patient’s condition to determine prognostic parameters with
and without therapy, both “life-prolonging” and “palliative”
Arrange meeting in private place with ample time, seating, tissues, and no
interruptions (e.g., telephones, pagers, staff)
Alert the patient ahead of time that you need to discuss important aspects
of his or her health. Suggest that the patient bring a person important in his
or her life to the meeting
At the meeting, first establish how the patient is feeling, identifying
symptoms that can be the later focus of discussion of palliative therapies.
Establish current level of debilitation (i.e., performance status)
Establish the patient’s understanding of his or her illness. Ask what the
patient hopes you will be able to do
Finally, establish what the patient wishes to know from you about the illness “Some people want to know everything possible about their illness and
Content
Tell the patient that you have bad news to share (“Give a warning shot”)
33
State the news clearly, simply, and sensitively “It appears that the cancer has spread to your bones, which means that it is
Provide information in small amounts at a time
Make optimistic statements that are truthful “I am very hopeful that with medicine we can control your bone pain.”
Anchor the survival estimate you communicate in previously published data
and modify it by the patient’s current clinical status
Patient’s response
Acknowledge the patient’s affect and express empathy “I can tell how very difficult it is for you to hear this bad news.”
Assure the patient of your continued involvement in his or her medical
care. Squarely address the issue that forgoing chemotherapy does not
create a therapeutic void; patients often conflate “doing something” with
chemotherapy
Close
Summarize the new news sensitively and outline a short-term plan of care “What we have discussed is that your cancer has progressed to involve your
Arrange a follow-up visit (even if the patient is being referred for hospice
care) since it is a tangible example of your continued commitment to the
patient
Offer to discuss the news with people important to the patient who are not
present
Provide the patient with a means of contacting you or your team in an
emergency
Reproduced with permission from Lamont EB, Christakis NA. Complexities in prognostication in advanced cancer. JAMA 2003; 290: 98–104.
Copyright © 2003 American Medical Association. All rights reserved.
“The next time we meet, we will be reviewing important test results
regarding your illness. I think it is important that you bring with you
someone who is important to you.”
“First, I’d like to find out how you are feeling right now.” “Do you have any
pain or other symptoms from the illness?” “How are you spending your
days?” “Are you able to wash up?” “ Who’s doing the cooking and cleaning
now?” “How much of the day do you think you are in bed or on the couch?”
“I wonder what your current understanding of your illness is and what you
hope we can do for you.”
others prefer to know very little. How much about your illness do you want
to know from me today?”
“I am sorry to say that I have bad news to share today.”
no longer curable.”
“On average, patients with state IV gastric cancer live 4 months. One-quarter
of patients will live 1.5 months or less and one-quarter live 8 months or
more. While I do not know for sure where you are in that group, the fact that
you are feeling so poorly right now and in bed most of the time makes me
concerned that you may not live longer than the average 4 months.”
“Although we cannot cure or shrink your cancer with chemotherapy, we
certainly can continue to take care of you and treat you with medicines for
any symptoms that the cancer may cause. There is always something that
we can do to help you.”
bones, which has caused the calcium in your blood to become dangerously
high. What I recommend we do next is to focus on returning the calcium
level to normal and strengthening the bone around the tumor by adding a
new medicine that is given by vein every month. I recommend that you get
the first dose today in our office.”
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Section X:Specialized interventional techniques in cancercare
between patient and clinician about the best way to meet those
goals given what is medically available and feasible. For some
constipation, anorexia, fatigue, ascites, depression, anxiety, and
insomnia.
patients a change in treatment focus can be quite traumatic.
In this case it is important to stress that, despite this apparent
change, the focus will continue to be providing the patient the
best possible care, even if now aspects of that care are dierent.
Interventional oncologists are oen referred patients who
have failed multiple prior medical and/or surgical treatments
and have very advanced disease. Careful evaluations of patient
performance status, patient and family goals and understanding of the disease, available treatment options, and risks and
benets of treatment are required prior to recommending a
treatment plan. For many of these patients, even minimally
invasive interventional oncology treatments are not indicated
and will only decrease their quality of life. Prospectively identifying these patients can be challenging and patients and
families will oen have unrealistic expectations. However, it is
important to consider and discuss not performing any further
interventional therapy as an option in patients with advanced
disease.
Medical symptom management
Much of the clinical practice of symptom management for
cancer patients is based on decades of clinical experience
rather than well-controlled clinical trials. Despite this, experience has shown that most cancer-related symptoms can be
eectively treated to the point of an acceptable patient-dened
quality of life. General principles of symptom management are
listedbelow.
1. Consider a wide dierential diagnosis and pursue a
problem-focused evaluation. New or progressive symptoms
in the cancer patient most likely arise as direct eects of the
cancer, but medication side eects, medical comorbidities,
psychological processes, and paraneoplastic syndromes
may be additional etiologies of distress.
2. Reconsider a diagnosis if a symptom is not responding
or progressing as expected. Develop a treatment plan that
involves frequent assessment of the patient’s response to
therapy as well as any adverse eects. If the patient has an
inadequate response to a drug, consider either dose esca-
lation or addition or substitution of a second agent, pref-
erably one that modulates the symptom in a new way. An
example of this would be adding a serotonin antagonist to a
dopamine antagonist for refractory nausea.
3. Arrange close follow-up aer every change in the treatment
plan. Many cancer patients are elderly and should always be
screened for polypharmacy and drug–drug interactions.
4. Employ non-pharmacologic and complementary interven-
tions alongside pharmacological treatment.
5. Prompt referral of patients to specialist providers is recom-
mended when routine treatments fail to provide adequate
symptom relief. Palliative medicine physicians, pain spe-
cialists, and mental health professionals are available at
many institutions.
is section will discuss the medical management of com-
mon symptoms cancer patients face, including pain, nausea,
Pain
At least one-third of cancer patients will experience pain while
undergoing treatment, and at least three-quarters of end-stage
cancer patients will experience signicant pain.40 e vast
majority of patients’ pain can be eectively treated with conscientious management.41 is section will review the evaluation
and treatment of cancer pain, highlighting pain management
approaches for bone metastases.
Pain is categorized as either nociceptive or neuropathic in
origin. Nociceptive pain refers to pain generated by the aerent
neural pathways which respond to tissue damage, whether from
tumor inltration, infection, infarction, distension, or other
unwelcome stimuli. It is divided into two subtypes: somatic
and visceral. Somatic pain arises from the skin, muscles, bones,
and connective tissues. Arthritic pain, fractures, and osseous
metastases are common examples of somatic pain. It is usually
described as dull, achy, and well localized.42 Visceral pain arises
from the abdominal and thoracic organs and is oen described
as deep, poorly localized, but sharp. It can be referred, such as
shoulder pain referred from metastases causing liver capsular
distension. When caused by distension of hollow organs such as
bowel, gallbladder, or ureter, visceral pain is typically described
as crampy or colicky. Neuropathic pain describes pain generated by damaged or dysfunctional neural tissue within the central or peripheral nervous system. It can be localized to a single
nerve or nerve root, as in a radiculopathy, or more diusely
to distal nerve bers as in diabetic or chemotherapy-induced
peripheral neuropathy. Neuropathic pain is described as burning, shooting, or numb, and is oen associated with changes
in pain perception, such as allodynia or hyperesthesia. It is
estimated that approximately 40% of cancer patients with pain
have a neuropathic component.42 Common scenarios include
radicular pain from vertebral metastases impinging on nerves
as they exit the spinal cord, chemotherapy-induced peripheral
neuropathy, or herpes zoster infection (shingles).
Table29.4 outlines key features of a comprehensive pain
assessment. Necessary elements include a thorough physical
examination and evaluation of the location and radiation of the
pain; temporal aspects of the pain; its severity– typically measured by one of several pain scales (e.g., zero to 10); pain quality
(e.g., dull or sharp) to assess for somatic vs. visceral vs. neuropathic origin; aggravating and alleviating factors; and the use
of medications and non-medical treatments and their eects.
Particular attention should be paid to the limitations in function brought about by the pain (e.g., with sleep, eating, movement, and mood). Finally, a thorough pain assessment includes
discussion of social, psychological, and spiritual factors which
may be contributing to or aected by the pain.
Consideration of a broad dierential diagnosis of new or
worsening pain is recommended for the cancer patient, as not
all pain is the direct result of tumor-associated tissue damage. For instance, back pain in a cancer patient may represent
benign chronic or acute musculoskeletal back pain; vertebral
metastases causing bony pain or compressing a nerve root
43
298