Cancer Treatments / Symptoms & Support
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Sleep is a precious commodity. While sleep disturbances in cancer patients include both insomnia as well as other sleep disorders (like sleep apnea), I will focus primarily on insomnia and the lack of sleep in this post, as that is by far the most common problem. Sleep disorders are more prevalent in patients with cancer than the general population—33-40% versus 15-20%. This is due to multiple reasons, related to both the disease and treatments. Cancer patients tend to sleep more total hours on average, but have poorer sleep quality — i.e., the sleep is interrupted or there is not enough restorative sleep (deeper stages). A recent review of the literature on sleep disorders in cancer found lung cancer patients to have the highest incidence of sleep disturbances; this may be due to symptoms related to breathing at night, like coexisting lung conditions (emphysema) or troublesome coughing.
Posted in: Pain and Symptom ManagementAnxiety is common in patients with cancer and can develop as a result of cancer and its treatments. Symptoms of anxiety are seen in up to 48% of all cancer patients, often in the form of a “situational anxiety”—these symptoms include worry as well as physical symptoms like muscle tension, restlessness, palpitations, sweating, and shortness of breath. A smaller percentage of patients actually develop a formal anxiety disorder such as panic disorder, post-traumatic stress disorder, phobias, or generalized anxiety disorder. Typical anxiety symptoms include severe worry, feeling “on edge,” irritability as well as physical symptoms such as nausea/vomiting, diarrhea, shortness of breath, and palpitations. You can see that similar to depression, the physical symptoms of anxiety are similar to those of cancer and treatment side effects. Shortness of breath in particular gives me pause, as it is intimately linked with anxiety—the two can often trigger each other and cause a vicious cycle, making both the anxiety and the shortness of breath much worse.
Posted in: Pain and Symptom ManagementPeople often expect that having cancer would make anyone depressed, that it is “normal,” but clinical depression is anything but normal and is imminently treatable. The challenge is that cancer can often cause the same symptoms that are seen in depression, so that depression is under-recognized and consequently undertreated.
What is depression? It is a clinical condition that is marked by one of two major symptoms, depressed mood and loss of interest in most activities (called anhedonia), as well as at least 4 other symptoms. These could include feelings of hopelessness, helplessness, worthlessness, guilt, and thoughts of suicide as well as physical symptoms such as fatigue, anorexia (loss of appetite), sleep problems (too little or too much), and weight loss. If those physical symptoms sound familiar, it’s because they can also occur due to cancer itself; as a result, the physical symptoms are not as helpful in identifying clinical depression.
To complicate things further, both patients and clinicians often mistake clinical depression as a “normal” emotional reaction to the cancer. There is indeed an expected emotional response to this diagnosis, including sadness, and while patients with cancer may have initially difficulty with their normal functioning and social interactions, patients who aren’t depressed are able to adapt. A patient with clinical depression won’t be able to do normal daily functioning on an ongoing basis. They will also persistently not be able to enjoy activities or experience pleasure. Their thought processes will be affected and consumed by helplessness, guilt and low self-esteem as well as hopelessness. A despondency accompanies the hopelessness, as opposed to a patient who feels hopeless due to discovering their cancer is incurable but can re-direct hope to something else (life prolongation, good quality of life). Actively seeking an early death is more indicative of clinical depression, in the absence of poorly controlled symptoms or inadequate social support.
Posted in: Pain and Symptom ManagementWhat is palliative care? I get this question at least once a day, not only from patients and families but also from other clinicians. While many GRACE members are familiar with palliative care, there still exists a lot of confusion out there about what palliative care exactly is. To be honest, back when I started medical school, I didn’t know what it was myself.
The World Health Organization (WHO) defines palliative care now 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 suffering by means of early identification and impeccable assessment of pain and other problems—physical, psychosocial, and spiritual.”
In the WHO definition, there is no mention of death and dying, because a patient does not have to be dying to receive palliative care. The overall philosophy of palliative care is the relief of suffering and the enhancement of quality of life. Most commonly, palliative care is practiced with a multidisciplinary team approach and focuses on the patient and the family as the unit of care. In the US, palliative care programs initially started out as hospital-based, or inpatient, programs but are now growing in the outpatient realm with clinics and other outpatient programs.
Posted in: Cancer Treatments, Pain and Symptom ManagementOne of the most common side effects of many different anti-angiogenic agents, which are felt to decrease the tumor’s blood supply, is high blood pressure, also known as hypertension. The cause of this isn’t really known, but most patients develop some degree of high blood pressure. What is interesting is that there is growing evidence that this may not just be an unwanted side effect, but rather a marker of a probability of doing better, similar to the correlation of rash with longer survival in patients receiving EGFR inhibitors.
For this, we can start by looking at results from a recent study of the anti-angiogenic agent sorafenib (nexavar) in renal cell carcinoma (kidney cancer). Here, patients were classified according to whether they demonstrated evidence of a high blood pressure, which was defined as a systolic blood pressure (the higher number) of 140 or greater, and/or a diastolic blood pressure (the lower number) of 90 or greater over the course of their treatment with sorafenib. The 441 of 534 (83%) who had hypertension had a remarkably higher response rate (54% vs. 10%, p < 0.0001), and a significantly longer median progression-free survival (12.5 vs. 2.5 months, p < 0.0001) and median overall survival (30.5 vs. 7.8 months, p < 0.0001) than the patients with advanced RCC who didn’t have hypertension on the study:
Chemotherapy is a common contributor to peripheral neuropathy, and because of this, there have been efforts to both prevent and treat chemo-induced peripheral neuropathy (CIPN). However, much of the work in this field has been hampered by difficulty in measuring this, as well as trials that are pretty small.
A couple have been the subject of trials that were negative, showing no benefit for the investigational agent, including the radioprotectant amifostine, the calcium channel blocker nimodipine, and some others.
A few have had some mixed and some positive results. Among these, vitamin E has been suggested in trials to reduce the frequency and severity of CIPN, but as an anti-oxidant, there is some concern that it may compromise the effectiveness of chemotherapy. Others that have looked favorable in small studies have included glutamine, glutathione, N-acetylcysteine, and calcium and magnesium infusions, though the last have raised some questions about being associated with reducing the efficacy of chemotherapy. Overall, with most of these being such small trials, and without establishing that prevention of neuropathy occurs without a compromise of the effectiveness of the chemotherapy, none of these has become a standard treatment. In the meantime, there are ongoing trials looking at whether certain approaches prevent CIPN, including acetyl-L-carnitine, vitamins B6 and B12, and alpha lipoic acid.
Posted in: Cancer Treatments, Pain and Symptom ManagementPeripheral neuropathy is a common complication of multiple widely used chemotherapy agents, and this symptom often limits our ability to have patients continue on the same treatment, even when it’s effectively treating the cancer. Typically, the symptoms are more sensory than motor, and the leading complaints are numbness and tingling, cold sensitivity, sometimes burning, electric, and sometimes normal pressure is perceived as painful. Diminished proprioception, the perception of a person’s body in space, can lead to balance problems and falls. And while dysfunction of autonomic nerves, which mediate the body’s automated body processes like temperature regulation, blood pressure and heart rate bowel fucntion, etc., is felt to be rare, this hasn’t been well studied. It’s possible that issues like difficulty regulating blood pressure, constipation, and urinary difficulties may in fact be related to neuropathy of autonomic nerve function.
The classical side effect of chemo-inducted peripheral neuropathy is sensory and symmetric, affecting both sides of the body relatively similarly, unlike nerve compression, which affects a single nerve and is not symmetric. Because neuropathy preferentially affects the longest nerves of the body first, and these are the nerves that run from the spinal cord to the tips of the feet and hands, a neuropathy in a stocking-glove distribution is what is typically seen.
Neuropathy, also known as peripheral neuropathy, is a common medical problem caused by damage and dysfunction to one or more peripheral nerves, which are the nerves connecting the brain and spinal cord to the rest of the body. There are three different types of nerves: sensory, motor, and autonomic (controlling reflexive/automatic body processes like blood pressure, heart rate, temperature regulation, sweating, etc.).
It is a very common problem, seen in about 3-4% of people, and it’s particularly common in people over 55. About one third of cases are due to diabetes, and another third are termed idiopathic, a fancy sounding term just meaning that we can’t determine that cause of the problem (though a medical school professor of mine uncharitably suggested that it came from the idea that your doctor is an idiot, and that’s pathetic). The remaining third are from a range of identified causes such as chemotherapy or other medications, autoimmune diseases, infections, nutritional deficiencies, metabolic disorders, or genetic-mediated nerve damage.
Posted in: Cancer Treatments, Pain and Symptom ManagementBone pain is a specific cancer pain syndrome that also happens to be the most common cause of cancer pain. Cancer involvement of bone is also something that can be seen with numerous types of cancer. It is a type of somatic pain, which is “body-related” pain, as I mentioned in my Pain 101 post.
The more common bone sites for metastases include the spine, skull, humerus (upper arm), ribs, pelvis, and femur (hip bone). The more common cancers that cause bony metastases include lung, breast, prostate, and multiple myeloma. The incidence of bone involvement varies among these different cancers, but for example in lung cancer, up to 24% of patients have bony metastases. Bone pain in cancer also occurs as a complication of certain treatments, such as avascular necrosis (bone death in the large hip or shoulder bones) due to steroid treatments or osteoradionecrosis (bone death after radiation, particularly in the jaw bone). I will focus primarily on bone pain from metastases in this post.
Why do bone metastases cause pain? While the mechanisms are not completely understood, it is thought that cancer metastases disrupt the normal balance of bone building and bone resorption (bone breakdown); this imbalance contributes to the pain. The pain is usually constant and localized; it can sometimes “refer” or be felt in other adjacent locations. Patients often describe bone pain as an ache, versus the shooting electrical qualities of neuropathic pain, and it often gets worse with certain activity. Should the bone metastasis cause a fracture or damage a nerve, then the pain can become more complex and severe, with qualities of both somatic pain and neuropathic pain.
Posted in: Pain and Symptom Management, Supportive careNeuropathic pain is a common pain syndrome for patients with cancer. As I mentioned in my introductory pain post, neuropathic pain is one of the three main types of pain (somatic, visceral, and neuropathic). It is nerve-related and is typically described as an electrical or burning sensation; it can occur both due to damaged peripheral nerves (outside of the spinal cord and the brain) or damage within the central nervous system (CNS, which includes the spinal cord and brain). Because of associated nerve injury, some patients can develop decreased sensation or actual muscle weakness. While there are certainly isolated instances of pure neuropathic pain, often neuropathic pain is part of a “mixed” syndrome in which a patient can have neuropathic pain in conjunction with the other types of pain as well.
Why does this pain develop when a nerve is damaged, even after the injury has occurred? Nerves that are damaged can begin to have abnormal sensing—the pain fibers in the nerves can become more sensitive due to damage and can also trigger pain spontaneously. In the spinal cord, the signals from pain can be amplified by nerve damage—this causes the pain response to be much higher than expected to minor stimuli (a bedsheet touching the feet or something cold hitting the skin).
In hearing about neuropathic pain, we often think of the hands and feet being affected and feeling paresthesias (pins and needles) there, but neuropathic pain can occur anywhere there are nerves. In cancer, the mechanism of nerve injury can occur through three main ways:
1) direct pressing on the nerve by tumor
2) cancer treatments toxic to nerves
3) paraneoplastic syndromes where the cancer causes an abnormal reaction from the body’s autoimmune system against the nerves. Paraneoplastic syndromes are much less common, so I won’t be discussing this.
Posted in: Cancer Treatments, Pain and Symptom Management
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