Advanced Cancer

Question 1

What are the approaches to pain control in palliative care?

Answer 1

1. Thorough assessment
   (hx, detailed description,
   physical exam – be careful
   of risks of path #)
2. Pause ® discuss with
   patient/family the goals of
   care, hopes, expectations,
   and anticipated course of
   illness.
3. Investigations – xray, CT,
   MRI, etc. (if they will affect
   care)
4. Treatments – pharm/nonpharm. Don’t forget about
   RadTx and interventional
   analgesia (i.e., spinal)
5. Ongoing reassessment
   and review

Question 2

What are the types of nociceptive pain?

Answer 2

visceral and somatic

Question 3

What is visceral pain?

Answer 3

pain from an organ or tissue; dull ache, cramping, diffuse, poorly localized
ex. pancreas cancer, liver capsule distention, angina, esophageal cancer

Question 4

What is somatic pain?

Answer 4

bone, muscle, ligament, fascia pain; dull ache that increases with movement, site-specific, incident pain
-most common in cancer
-ex. bone and soft tissue

Question 5

What is deafferentation?

Answer 5

neuropathic, due to damaged nerves
-burning, tingling, sharp, numbness, clearly localized

Question 6

Define incident pain

Answer 6

predictable elicited by specific activities

Question 7

Define end of dose failure

Answer 7

pain that occurs at the end of the usual dosing interval of regularly scheduled analgesic

Question 8

What are the pain assessment scales?

Answer 8

NRS
VAS (visual analogue scale)
NRS
Victoria symptometer
Faces pain rating scale
ESAS
Dermatome chart (for neuropathic pain)

Question 9

What are the pharm interventions for chronic pain?

Answer 9

Opioids:
-hydromorphone
-fentanyl

sustained/continuous release formulations, BID/TID

Question 10

What is the pharm intervention for breakthrough pain?

Answer 10

Opioids, given q30 min or q1h depending on the site

Question 11

What is the pharm intervention for incident pain?

Answer 11

PRN fentanyl or sufentanil (IN/SL)

Question 12

What are some adjunct for pain management in cancer?

Answer 12

NSAIDS (naproxen, ibuprofen, celecoxib)

Corticosteroids (dexamethasone)

Bisphosphonates (pamidronate or zoledronic acid)

Question 13

What are the non-pharm interventions for pain in advanced cancer?

Answer 13

psychological approaches: relaxation, guided imagery, distraction, behaviour therapy

complementary therapies: massage, music neurostimulation, anesthetic, surgical

physical therapy: exercise, muscle relaxation, cold therapy

cancer treatments: radiation, chemotherapy

Question 14

Describe anorexia-cachexia syndrome

Answer 14

• Metabolic and neuroendocrine changes directly associated
  with underlying disease and an ongoing inflammatory state
• Wasting away syndrome: body’s inability to utilize nutrients
  from ingested food.
• Nutritional supplementation does not restore lean body mass
• Grave prognostic sign

Question 15

What is the difference between cachexia and starvation?

Answer 15

starvation = temporary; decreased caloric intake causes weight loss of fat; reversible with refeeding

cachexia = hyper-catabolism of muscle; not reversible

Question 16

What is the primary cause of anorexia-cachexia syndrome?

Answer 16

Cancer metastasis leads to release of inflammatory mediators (cytokines, interleukin tumour factors) –> chronic inflammation –> catabolism
-irreversible

Question 17

What is the secondary cause of anorexia-cachexia syndrome?

Answer 17

aggravating factors (pain, nausea, dysphagia, dyspnea, infection)
-can be related to food intake
-potentially reversible by treating the above issues

Question 18

What are the pharm interventions for anorexia-cachexia syndrome?

Answer 18

Megestrol Acetate (synthetic progesterone)

Dexamethasone, Methylprednisolone (corticosteroids)

Metoclopramide, Domperidone (antiemetic + prokinetic)

Question 19

What are the 3 types of delirium?

Answer 19

Hypoactive Delirium: confusion, somnolence, ¯ alertness

Hyperactive Delirium: agitation, hallucinations, aggression

Mixed: features of both

Question 20

What are the risk factors for delirium?

Answer 20

• Frail, elderly who have decreased renal function
• Benzodiazepines, anticholinergics, opioids, psychotropic
  agents
• Substance abuse, alcohol withdrawal
• Infection (UTI, pneumonia)
• Comorbidities (dementia)
• Recovery from surgery
• Unrelieved pain

Question 21

What are the characteristics of delirium?

Answer 21

1. Abrupt onset
2. Disorientation, fluctuation of symptoms
3. Changes in sleeping patterns
4. Incoherent, rambling speech
5. Fluctuating emotions
6. Activity that is disorganized and without purpose

Question 22

What assessments should be done for delirium?

Answer 22

• Confusion Assessment Method (CAM)
• SQID: Single question in delirium – “Do you feel that
  [patient] has been more confused lately?”
• WRHA Delirium Decision Tree

Question 23

What is the first-line pharm intervention for hyperactive delirium?

Answer 23

Typical antipsychotics:
1) haloperidol
2) methotrimeprazine

Question 24

What is the second-line pharm intervention for hyperactive delirium?

Answer 24

Atypical antipsychotics: Olanzapine, Risperidone, Quetiapine

Benzodiazepines/anxiolytics: Lorazepam, Clonazepam, Midazolam

Question 25

What is the pharm intervention for hypoactive delirium?

Answer 25

DOES NOT require pharm interventions

Question 26

Describe dyspnea

Answer 26

the uncomfortable awareness or sensation of not breathing or not getting enough air into the lungs "air hunger"

Question 27

What is the assessment for dyspnea?

Answer 27

Subjective to patient, Unable to assess dyspnea, may not correlate with ABG, O2 sat, PFT. We do not have a test that can validate dyspnea. There is no gold standard tool. NOT observable from outside the body.

Question 28

What is the first line therapy for dyspnea?

Answer 28

systemic opioids Long acting: Morphine or Hydromorphone Incident dyspnea: Fentanyl, Sufentanil Helps reduce the sensation of “air hunger”

Question 29

What is the second line therapy for dyspnea?

Answer 29

Benzos Used if the dyspnea is accompanied by anxiety. These treat the anxiety while the opioids manage the air hunger

Question 30

What are the non-pharm interventions for dyspnea?

Answer 30

- Treat underlying reversible causes - Position: semi/high fowler, leaning forward with arms supported - Breathing techniques (pursed lip, diaphragmatic) - Increase air flow – open window, turn on fan - Environment: keep smoke free, cool - Energy conservation: use walking aids, have lots of breaks - Relaxation therapy: dyspnea that is NOT severe, anxiety present - Calm presence: moving purposely without agitation - Pacing exercises to maintain muscle mass

Question 31

When should O2 be used for dyspnea?

Answer 31

if the pt is hypoxic-- should NOT be the only therapy used in moderate to severe dyspnea

Question 32

Describe Xerostomia

Answer 32

sensation of dry mouth; patient produces sticky saliva

Question 33

What are the causes of xerostomia?

Answer 33

- mouth breathing, dehydration, NV - dry mucosa, swallowing difficulties - cytotoxic agents, side effects of cancer therapy - low PPS - infection (fungal, viral, bacterial) - ↓ saliva production d/t opioids, diuretics, anticholinergics, antidepressants, radiation

Question 34

What are the assessments for xerostomia?

Answer 34

1. Cracker biscuit test 2. Tongue Blade 3. Oral assessment, mouth care flow sheet

Question 35

What are the pharm interventions for xerostomia?

Answer 35

-mouth lubricant -artificial saliva: saliment, orex

Question 36

What are the non-pharm interventions for xerostomia?

Answer 36

- Treat underlying infection or disease - Toothpaste with fluoride (can use biotene if sensitive) - Rehydration - Sugarless chewing gum - Room humidifier at night (ensure caregivers change water daily, breeding ground for germs) - Acupuncture (also used for nausea and pain) - Dietary modifications: add sauces, gravies, dressings and encourage to take 2-3 sips of water with each bite. - Avoid alcohol as it is drying. - Avoid spicy foods which can irritate mouth

Question 37

What are the pharm interventions for mucositis/stomatitis?

Answer 37

magic mouth wash tantum nystatin flucanazole acyclovir oral zinc sulfate