Symptom Control in Cancer Rehabilitation - TIRR...
Transcript of Symptom Control in Cancer Rehabilitation - TIRR...
Symptom Control in
Cancer Rehabilitation Ying Guo, MD
Department of Palliative, Rehabilitation and Integrative Medicine
UT MD Anderson Cancer Center
Cancer Patients’ Symptoms
Pain- 90% of patients with advanced cancer
Fatigue–60-90% of cancer patients
Cachexia/Anorexia Syndrome-80% patients with advanced cancer
How to Assess Symptoms
Symptom During Inpatient
Rehabilitation
Patients who were admitted to an acute inpatient rehabilitation unit
(N=96). Patients’ median age was 64 years (range, 26–87y), and 49% were
women.
Cancer patient’s symptom intensity is high at admission
Symptoms with high intensity:
Pain
Fatigue
Anorexia
Insomnia
Symptom During Inpatient
Rehabilitation
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Admission
Discharge
Symptom During Inpatient
Rehabilitation
Significant improvements
Anxiety (P=.001)
Constipation (P=.001)
Fatigue (P=.002)
Pain (P=.003)
Appetite (P=.004)
Insomnia (P=.04)
Sense of well-being (P=.01)
Symptom During Inpatient
Rehabilitation
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Ana
lgesi
cs
App
etite
stim
ulant
Mirt
azapi
ne
Met
oclo
pram
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Ant
idep
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ants
Met
hylp
henida
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Laxa
tives
Hyp
notic
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Perc
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tag
e o
f P
ati
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Symptom During Inpatient
Rehabilitation
The poor appetite at admission scores correlated positively with hospital
LOS (P<.001)
Depression at admission scores also correlated positively with hospital LOS
P=.05)
Average acute rehabilitation LOS was 9 days.
Symptom at Outpatient Rehabilitation
Clinic
Survivorship definition by NCI: In cancer, a person is considered to be a survivor from the time of diagnosis until the end of life.
Short-term survivor: ≤5 years since cancer diagnosis
Long-term survivor: ≥5 years since cancer diagnosis
Comparison of symptoms in short-term and long-term cancer survivor
Similar symptom pattern
Highest intensity symptoms are:
Pain
Fatigue
Anorexia
Insomnia
Characteristics of Patients in the Two Study
Groups <5 YSD (N=133) ≥5 YSD (N=67)
Age, Mean (SD) 53.4 (16.9) 57.8 (15.6)
Female 63 (47.4) 40 (59.7)
Weight (Kg), Mean (SD) 81.0 (22.2) 78.6 (21.9)
Height (cm), Mean (SD) 168.9 (10.5) 166.8 (11.1)
BMI, Mean (SD) 28.5 (8.3) 28.3 (8.1)
N (%)
N (%)
Race
Asian 7 (5.3) 7 (10.4)
Black 14 (10.5) 12 (17.9)
Hispanic 16 (12.0) 6 (9.0)
White 94 (70.7) 42 (62.7)
Unknown 2 (1.5) 0
Cancer Treatment History
Prior Chemotherapy 75 (56.4) 44 (65.7)
Prior Radiation therapy 74 (55.6) 44 (65.7)
Prior Surgery 115 (86.5) 59 (88.1)
Types of cancer
Brain/spinal 42( 31.6) 15 (22.4)
Breast 14 (10.5) 18 (26.9)
Gastroenterological 12 (9.0) 5 (7.5)
Head & Neck 10 (7.5) 4 (6.0)
Leukemia 9 (6.8) 3 (4.5)
Lung 7 (5.3) 3 (4.5)
Lymphoma 4 (3.0) 5 (7.5)
Melanoma 6 (4.5) 2 (3.0)
Prostate 3 (2.3) 2 (3.0)
Sarcoma 15 (11.3) 5 (7.5)
Other* 11 (8.3) 5 (7.5)
Comparison of Symptom based on ESAS in the Short-term and Long-term Survivor Groups
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Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Feeling of
WellBeing
Shortness of
Breath
Sleep
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ESAS Symptoms
<5 Year Since Diagnosis
≥ 5 Year Since Diagnosis
Comparison of Medications Used for Symptom
Management in the Short-term and Long-term Survivor Groups
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<5 Years Since Diagnosis
≥ 5 Years Since Diagnosis
Comparison of Symptom Treatment in the Short-term and Long-term Survivor Groups
132/200 (66%) total patients had fatigue ratings of ≥3
Methylphenidate is the most studied pharmacological agent for the treatment of cancer-related fatigue.
11/133(8%) of short-term survivors uses Methylphenidate
9/67 (13%) of long-term survivors uses Methylphenidate
99/200 (49.5%) total patients had anorexia ratings of ≥3
Appetite stimulants were prescribed for 61 (46%) of short-term survivors
Appetite stimulants were prescribed for 27 (40%) of long-term survivors
Among those patients with poor appetite ratings of ≥3, only 51/100 (51%) had appetite stimulants in their medication lists.
110 (56%) total patients had poor sleep ratings of ≥3
Hypnotics were prescribed for 20 (15%) of short-term survivors
14 (21%) of long-term survivors.
Symptoms are Under-treated
Lack of effective and standardized treatment for these symptoms.
Lack of emphasis in symptom control in rehabilitation community.
Patient’s hesitation in taking additional medications.
Physician’s worry of polypharmacy, and side effect of the medication.
Finding Reversible Causes-Pain
Etiology of pain
Neuropathic pain:
Nociceptive pain:
Somatic:
Bony pain: bracing
Joint pain: bracing, joint injection
Myofascial pain: myofascial release, heat, cold, acupuncture, massage, stretching
Visceral: distention due to gas/constipation: proper bowel and bladder management
Secondary pain:
Central sensitization and a windup phenomenon: causing prolongation and amplification nociceptive activity even after the cessation peripheral input: medication, acupuncture
Spiritual pain: support from family, social worker, psychologist, chaplain, Priest
Case Report
Plantar fasciitis in a 60 year old female patient with metastatic renal cancer
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Oxycontin ER (mg/day)
Pain
Finding Reversible Causes-Fatigue
Central fatigue:
Depression: involve supportive care on psychiatry
Brain dysfunction due to brain metastasis/tumor
Paraneoplastic neurological syndrome
Peripheral fatigue:
Effect of inflammatory cytokines (TNF alpha, IL-6,IL 1,
IL-2): causing anorexia, progressive loss of muscle
mass.
Correct anemia: iron deficiency, Vitamin B12
deficiency, folate deficiency, GI bleed
Bed rest, immobility lead to low exercise tolerance:
endurance training and aerobic exercises
Hb
BUN
↑ Low Fe,
high retic
Finding Reversible Causes-Fatigue
Peripheral fatigue:
Respiratory related to reason: Pulmonary toilet, each patient abdominal /diaphragmatic breathing
Infections
Endocrine disorders: adrenal insufficiency; hypothyroidism; hypogonadism
Anticancer treatment related side effect, such as nausea and vomiting
Poor sleep: cluster care
Hypocalcemia
Calcium
Vit D
Finding Reversible Causes-Insomnia
Anxiety: Cognitive behavior therapy
Sun-downing/delirium
Circadian rhythm dysfunction: Melatonin; increase exposure to sun, sleep
hygiene
Symptom control: frequent urination, pain, shortness of breath, depression
and anxiety
High-dose steroid-induced insomnia: taper down steroid, may use short-
term hypnotics.
Finding Reversible Causes-Anorexia/
Poor Appetite
Medication caused:
Pain medication: opioids
Antibiotics
Constipation: laxative and bowel program
Disturbed GI function due to antibiotics treatment, chemotherapy,
radiation treatment: probiotics