Palliative chemotherapy and radiotherapy

Chemotherapy and radiotherapy are primarily employed as disease-modifying treatments but they may also be used in a palliative context to relieve symptoms and improve quality of life. Any side-effects of such treatment must be carefully weighed against the likely symptom control. Chemotherapy may thus be used to limit the degree of troublesome lymphadenopathy in advanced lymphoma or to reduce the systemic upset from a high malignant cell burden in end-stage leukaemia. Similarly, attenuated radiotherapy can give local relief from tumour infiltration in lymphoma and can reduce pain from myeloma bone lesions (Fig 47.3). Surgical interventions are used more sparingly but lymphomatous pleural effusions can be drained and the severe pain of myelomatous spinal disease can be ameliorated by the operation of vertebroplasty where the vertebrae are reinforced with a cement-like substance.

Management of cancer pain

Pain is a common symptom of cancer, particularly in patients with advanced or refractory disease. The means are available to give the great majority of patients good quality pain relief but, in practice, this goal may be compromised by the time, skill and commitment required of the medical team. Before initiating therapy, it is important to fully assess the severity (pain scales are available) and nature of the pain – visceral pain is often described as a dull ache, somatic pain may be sharp and postural, while neuropathic pain can be ‘burning’ or ‘numbing’.

Pharmacological therapy is the mainstay of pain management in patients with haematological malignancy. Patients experiencing mild pain on no analgesia may be commenced on an oral non-opiate agent (e.g. paracetamol, nonsteroidal anti-inflammatory drug (NSAID)) but more severe pain is likely to require an opiate analgesic given at an appropriate dose and interval, possibly in combination with a specific co-analgesic dependent on the nature of the pain. There is no one optimal opiate dose and the correct dose must be achieved by proactive titration so that the patient is pain free without unacceptable toxicity. For most patients with chronic cancer pain, the oral route is preferable but parenteral, transdermal and rectal preparations are also widely employed. Pain prevention must be complemented by management of drug side-effects – patients on opiates will generally need laxatives and antiemetics. Particular care is necessary when analgesics are changed. This requires an understanding of their relative strengths and durations of action.

Opiates may be combined with co-analgesics to maximise their effect. Examples in haematological practice include the use of corticosteroids (usually dexamethasone) to tackle symptoms of raised intracranial pressure or nerve infiltration secondary to lymphoma and the prescription of NSAIDs and bisphosphonates to optimise control of bone pain in myeloma. Tricyclic antidepressants can be a useful adjunct in neuropathic pain.

Control of non-pain symptoms

Fatigue. In the haematology clinic, many patients with leukaemia, lymphoma and myeloma complain of demoralising fatigue. This is usually of multifactorial aetiology with a mixture of physiological and psychosocial factors, the latter including anxiety and sleep disruption. Anaemia is the most common reversible physical cause and regular administration of subcutaneous erythropoietin improves haemoglobin levels and quality of life in selected patients with myeloma, lymphoma and other cancers.

Nausea and vomiting. These symptoms are common, both due to tumour infiltration and as a side-effect of chemotherapy and analgesics. It is crucial to identify the cause. A centrally acting antiemetic drug (e.g. ondansetron) is indicated for drug-induced nausea whereas a pro-kinetic agent (e.g. metoclopramide) is more appropriate for gastric stasis or functional bowel obstruction. In more difficult cases, it is important to combine antiemetics logically and to consider alternative routes of administration.

Anorexia and cachexia. Patients with loss of appetite and weight loss need expert dietary assessment and advice. Oral corticosteroids can improve appetite and lead to weight gain. Poor nutrition may be exacerbated by drug-induced mucositis, painful neutropenic mouth ulcers and oral infections such as candida and herpes simplex. This can be minimised by good mouth care and early recognition of infections.

Dyspnoea. Lymphoma can cause dyspnoea because of bulky mediastinal lymphadenopathy or lung infiltration. Patients with advanced leukaemia more commonly develop the symptom during fulminant respiratory infections or after bleeds into the lung parenchyma. Once correctable causes of dyspnoea have been excluded, other options include the selective administration of oxygen, opiates and sedation to minimise the subjective sensation of breathlessness.

Care at of the end of life. In patients with advanced disease and refractory symptoms in the final days of life, sedation may be used in the form of continuous drug infusions via portable syringe drivers (Fig 47.4). Strict criteria must be used for patient selection and fully informed consent must be obtained from the patient (where possible) and their family. Such measures should only be resorted to after consultation with the palliative care team.

Psychosocial oncology

It is important (but not always easy) to distinguish the inevitable emotional upset following a diagnosis of a life-threatening disease such as leukaemia from a more severe disturbance that meets the criteria for a mental disorder. In practice, there is a need for a multidisciplinary strategy with the involvement of specialist haematology/oncology nurses, psychologists, psychiatrists and social workers. High quality communication between the patient and their physician and other members of the caring team is crucial to blunt the distress caused by setbacks and the toxicity of treatment. Psychotherapeutic approaches may be on an individual or group basis and have been shown to diminish any sense of isolation and to boost optimism. The provision of good quality information, exploiting the internet and other new technologies, is complementary to this process. Where there is significant anxiety and depression – and correctable causes have been excluded – anxiolytics and antidepressants can be beneficial. Support must also be given to the patient’s family, particularly at the time of bereavement.

Complementary therapy

Patients may turn to complementary and alternative medicine. Staff specialising in traditional cancer medicine may be ignorant of and even threatened by such modalities. However, they should not hesitate to advise against any unorthodox intervention which is likely to lead to harm. There is some evidence for the use of hypnosis in pain relief, for acupuncture in the management of drug-induced nausea and vomiting, and for massage and meditation techniques in decreasing distress and improving sense of well-being. Centres specialising in the treatment of haematological malignancy are increasingly offering these therapies to their patients.