The Role of Palliative Care in Patients with Lung Cancer

Educational Objectives

The goals of this program are to improve diagnosis and treatment of lung cancer. After hearing and assimilating this program, the clinician will be better able to:

1. List the benefits of early palliative care in patients with lung cancer.
2. Manage simultaneous presentation of multiple symptoms during therapy for lung cancer.

Summary

Early palliative care (PC): introducing PC at time of diagnosis improves quality of life (QOL), mood, end-of-life care, and survival; study randomized patients with lung cancer to early PC vs best supportive care; patients receiving PC had better scores on Functional Assessment of Cancer Therapy-Lung (FACT-L); 16% of patients treated with PC had depression (vs 31% in standard-care group); fewer patients in PC group received aggressive interventions (hospitalizations and visits to emergency department) toward end of life (33% vs 54%); more patients in PC group had resuscitation preferences documented (53% vs 28%); PC group had longer survival (11 vs 8.9 mo)

Benefits of PC: patients receiving PC may participate in monthly visits at which symptoms identified and addressed; studies show that patients want their physicians to ask them about coping; feeling cared for in this way may help patients and caregivers with depression and improve QOL; patients may benefit from talk therapy or medication

Guidelines: American Society of Clinical Oncology (ASCO) guideline recommends that PC be integrated with other care for cancer; for patients with late-stage disease and expected survival of 6 to 24 mo, PC should be started early in course of treatment

Goals of PC: interdisciplinary PC teams useful, but if these resources unavailable, clinician may consider taking 1-day course in PC for cancer patients; PC offers psychological and spiritual support and addresses goals of care, end of life, and hospice care; although some people have negative image of PC and think of it as limited to end of life, PC includes management of symptoms and supportive care from time of diagnosis throughout disease process

Persistent cough: patients with lung cancer may have persistent cough that interferes with sleep; underlying causes should be treated, but etiology may not be obvious; meta-analyses of trials in patients with lung cancer have not generated specific recommendations; antitussives — options include benzonatate (Tessalon) and dextromethorphan; expectorant — for patients with mucus secretion, expectorant such as guaifenesin makes cough more productive; antitussive may be combined with expectorant; opiates — may be added if necessary, but if patient already on opiates for pain, adding more in cough medicine not likely to help; in randomized trials, opiates decreased frequency and severity of cough; steroids — for patients with reactive airways, corticosteroids may be used as inhalational agent or nasal spray; short course of oral dexamethasone sometimes helps; fluticasone may be given as inhaled aerosol or combined with β–agonist (Advair, Airduo); adrenergic bronchodilators — such as albuterol may be used in acute setting or to supplement daily therapy

Dyspnea: may be addressed with oxygen, opioids, anxiolytics, and nonpharmacologic treatments; opioids — may relieve dyspnea without changing blood gases; doses of opioids similar to those needed for pain; clinician should begin with low dose and titrate upward while watching for sedation; anxiolytics — include benzodiazepines (eg, lorazepam or clonazepam); however, when combined with opioids, benzodiazepines may lead to sedation and overdose; extended-release opioids do not have anxiolytic effect but may relieve sensation of dyspnea; nonpharmacologic interventions — include fans, avoiding crowded rooms, having someone else in room, cool temperature, open window or window in line of sight, and elevation of head of bed

Pain: bony metastases seen in two-thirds of patients; patients often need bisphosphonate or inhibitor of receptor activator of nuclear factor-κB ligand; for pain, clinician may begin with nonsteroidal anti-inflammatory drugs and add opioids if needed; multimodal therapy preferred; physical and occupational therapy may be used to address pain with movement or loading; assistive devices may help patient dress and perform other activities of daily living; single-fraction radiation therapy may be as useful for bone pain as fractionated therapy; however, higher proportion of patients treated with single fraction may need additional treatment later; extended fractionation schemes (>10 fractions) usually avoided as palliative treatment for bone metastases

Neuropathic pain: Pancoast tumors that invade brachial plexus may cause neuropathic pain in shoulder or arm; such pain often described as burning, like nails or pins, or like electrical shock; neuropathic agents — should be considered; gabapentin should be started at low dose, then titrated upward by 50% to 100% every 3 days; lower doses used for elderly patients and those with renal insufficiency; although many patients have no side effects from gabapentin (Neurontin), drowsiness most common reason for stopping drug; pregabalin (Lyrica) superior to placebo in randomized trial, and improves sleep scores and score on Global Impression of Change; antidepressants — may be given with or without agents for neuropathic pain; dose of antidepressants may be lower when targeting analgesia than when used for depression; dose of tricyclic may be increased every 3 to 5 days; nortriptyline good choice (amitriptyline and other tricyclics have more side effects); serotonin-norepinephrine reuptake inhibitors include duloxetine and venlafaxine; these drugs may be combined with nortriptyline or antiepileptic agent; opiates — patients on these combinations who have persistent, severe neuropathic pain may need opiate; methadone most effective opiate for neuropathic pain because it acts on N-methyl-d-aspartate receptors; methadone has longer half-life than some opiates, so full effect may not be observed for several days

Opioids and safety: ASCO — published policy on opioid therapy, with objective of protecting access for cancer-related pain; policy emphasizes that patients with cancer special population who should be exempt from regulations; however, some safety precautions necessary; opiates may be first-line treatment for moderate to severe pain in patients with cancer; controlled substance agreements — desirable for safety of patients; patients often appreciate this approach when clinician emphasizes safety; standard agreement may list side effects and mention increased toxicity when opioids combined with alcohol or illegal drugs, possibility of symptoms of withdrawal, and need for single prescriber; patients should know that stolen or lost prescriptions cannot be replaced and that prescriptions should not be shared; annual urine toxicology screen reasonable; other safety measures — statewide automated prescription systems and electronic medical records should be checked; checklists for prescribers of opiates may be used to increase safety for patients; naloxone (Narcan) available as nasal spray and may be provided when clinician concerned about patient

Fatigue: clinician should first address treatable causes such as anemia, pain, nausea, depression, and sleep disturbance; exercise — most meta-analyses confirm efficacy of exercise and physical activity; patients should be given ideas on how to begin and how to increase activity over time; yoga increases energy levels; other interventions — quality of sleep should be addressed, but cognitive behavioral interventions such as going to bed at same time each night may be effective; restless legs syndrome should be treated; in randomized trials, exercise improves quality of sleep; ginseng (2000 mg/day) significantly better for relieving fatigue than placebo in randomized trial of 364 patients; although insufficient evidence available to support efficacy of methylphenidate (Aptensio, Concerta, Ritalin), drug sometimes effective; however, exercise should be main recommendation

Readings

American Society of Clinical Oncology: Policy issue brief: Prescription opioids. Curbing misuse and abuse while protecting access for cancer patients. October 10, 2017. Available at: https://www.asco.org/advocacy-policy/asco-in-action/policy-issue-brief-prescription-opioids. Accessed March 18, 2018; Ferrell BR et al: Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2017 Jan;35(1):96-112; Freynhagen R et al: Efficacy of pregabalin in neuropathic pain evaluated in a 12-week, randomised, double-blind, multicentre, placebo-controlled trial of flexible- and fixed-dose regimens. Pain 2005 Jun;115(3):254-63; Greer JA et al: Role of patient coping strategies in understanding the effects of early palliative care on quality of life and mood. J Clin Oncol 2018 Jan 1;36(1):53-60; Nguyen HQ et al: Integration of a palliative care intervention into community practice for lung cancer: a study protocol and lessons learned with implementation. J Palliat Med 2017 Dec;20(12):1327-1337; Paice JA et al: Management of chronic pain in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2016 Sep 20;34(27):3325-45; Temel JS et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010 Aug 19;363(8):733-42; Temel JS et al: Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. J Clin Oncol 2017 Mar 10;35(8):834-841.

Disclosures

For this program, Dr. Urba and the planning committee reported nothing to disclose. In her lecture, Dr. Urba presents information related to off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Urba was recorded at State of the Art Management of Lung Cancer Symposium, presented by the University of Michigan Comprehensive Cancer Center and held November 11, 2017, in Dearborn, MI. To learn about upcoming meetings presented by the University of Michigan, please visit: ocpd.med.umich.edu/cme. The Audio Digest Foundation thanks the speakers and the University of Michigan for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

ON091002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.