Invasive Care Can Still Be Palliative Care in Patients With Advanced Cancer

Gabriel Aisenberg, MD
Gabriela Sanchez Petitto, MD
Volume 56 - Issue 2 - February 2016

Some patients with advanced cancer experience symptoms for which pharmacologic management, including cancer therapies, offers little or no relief. In such situations, physicians face the complicated decision of considering more-invasive interventions to improve their patients’ quality of life. The concepts of “invasion” and “palliation,” however, may appear contradictory.

Palliative care aims to improve the quality of life of patients (and their loved ones) who are facing life-threatening illness, through the prevention and relief of suffering, which is understood as pain or other physical, emotional, social, or spiritual impairment.1 Some symptoms at the end of life, such as fatigue, anorexia, confusion, depression, and pain, are treated mostly with pharmacologic interventions.2-8 On the other hand, when constipation is secondary to colonic obstructive masses, when dyspnea occurs in pulmonary embolism not responsive to anticoagulation, when superior vena cava syndrome leads to airway obstruction, when gastrointestinal obstructive tumors cause intractable vomiting, or when pulmonary or gastrointestinal tumors bleed, more-invasive interventions may be indicated.

Stent placement is more than 80% successful at relieving malignant biliary obstruction, with lower morbidity rates than surgical procedures.9 When gastric outlet or esophageal obstruction limit patients’ oral intake, self-expandable gastric or esophageal stents may solve the problem among those who are not candidates for surgical intervention.10,11 Gastrostomy or jejunostomy tube placement in advanced cancer, unlike the interventions mentioned above, is focused on meeting nutritional goals rather than on the improvement of quality of life; it is associated with numerous complications, and these tubes seldom accomplish the goal for which they are placed.12 Large-bowel obstruction from cancer usually is amenable to surgical correction or diversion. The use of stents in patients with advanced, incurable colon cancer, unlike those requiring surgery, allows those patients to reinstitute diet faster without the need for ostomy, and allows a shorter hospital stay.13 Obstructive tracheobronchial cancer usually defines incurability. Nonetheless, the frequently associated dyspnea can be treated with a variety of endobronchial or endotracheal stents or by electrosurgery.14,15 Even though up to 20% of inserted airway stents are complicated by endobronchial infections, the impact of stent placement on symptom control makes them appropriate in the management of mechanical obstructive dyspnea.16

In superior vena cava syndrome, blood flow blockage to the right heart could manifest with life-threatening airway and brain edema. While chemotherapy, radiotherapy, or both treat the cancer,17,18 endovascular stenting may offer immediate symptom relief, minimal complications, and no interference with antitumor drugs.19,20 Chemoembolization of hypervascular skeletal metastases produces a good and durable clinical response in patients with this painful condition. Bronchial artery embolization has a success rate of 86% in massive hemoptysis, with major complications seen in 3% of cases. Hematuria in renal or prostate cancer also responds well to embolization. Postembolization syndrome is an uncommon complication of those procedures; it is characterized by transient malaise, low-grade fever, nausea, and vomiting, all of which are managed conservatively.21

Venous thromboembolism occurs frequently in patients with cancer. When the patient is unresponsive to conventional anticoagulation, or when it is contraindicated, inferior vena cava (IVC) filter placement becomes necessary. IVC placement is highly effective in preventing pulmonary embolism, with low complication rates.22,23 Although widely accepted in settings outside of palliative care, the use of IVC filters in palliative care patients remains controversial.24

Several studies over the last decade have shown that the increased availability of palliative care and hospice services does not appear to have changed the focus on aggressive and curative care.25 However, the use of expensive resources for terminally ill patient remains debatable. In a group of 225 palliative care patients, the cost of percutaneous interventional procedures amounted to less than 12% of the cost of their hospitalization and allowed for rapid recovery and early discharge.21

Research has shown that patients’ goals and preferences change as their condition worsens; many patients want to face high-burden therapy even when the effect is not durable or when the success rate is low.25 The ethical principle of beneficence becomes essential in the care of these patients, although this principle remains subject to individual and cultural interpretation.26 The moral obligation to benefit others is limited by the patient’s desire to accept invasive interventions (ruled by the principle of autonomy), the coexistence of multiple serious symptoms that curtail the improvement expected from treating them individually, the costs associated with the intervention as well as its availability (ruled by the principle of justice), and the always uncertain life expectancy.

As with many other fields of medicine, the resource availability and scope of practice of palliative medicine have broadened. Now more than ever, a multidisciplinary approach to the care of patients with advanced cancer and their families becomes essential.

Gabriel Aisenberg, MD, is an assistant professor of medicine at the McGovern Medical School at the University of Texas Health Science Center at Houston and director of general medicine at Lyndon B. Johnson General Hospital in Houston, Texas.

Gabriela Sánchez Petitto, MD, is an internal medicine resident at the McGovern Medical School at the University of Texas Health Science Center at Houston in Houston, Texas.

 

References:

  1. Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization’s global perspective. J Pain Symptom Manage. 2002;24(2):91-96.
  2. Conill C, Verger E, Henriquez I, et al. Symptom prevalence in the last week of life. J Pain Symptom Manage. 1997;14(6):328-331.
  3. Portenoy RK, Ahmed E. Principles of opioid use in cancer pain. J Clin Oncol. 2014;32(16):1662-1670.
  4. Mücke M, Mochamat, Cuhls H, et al. Pharmacological treatments for fatigue associated with palliative care. Cochrane Database Syst Rev. 2015;(5):CD006788. doi:10.1002/14651858.CD006788.pub3.
  5. Lawlor PG, Bush SH. Delirium in patients with cancer: assessment, impact, mechanisms and management. Nat Rev Clin Oncol. 2015;12(2):77-92.
  6. von Gunten CF, Gafford E. Treatment of non-pain-related symptoms. Cancer J. 2013;19(5):397-404.
  7. Holmes S. Xerostomia: aetiology and management in cancer patients. Support Care Cancer. 1998;6(4):348-355.
  8. Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009;190(7 suppl): S54-S60.
  9. Dumonceau JM, Tringali A, Blero D, et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 2012;44(3):277-298.
  10. Kumagai H, Nio K, Shirakawa T, et al. Improvement of quality of life and survival using self-expandable metal stent placement for severe malignant stenosis of the gastric body: a case report. J Med Case Rep. 2012;6:315. doi:10.1186/1752-1947-6-315.
  11. Martinez JC, Puc MM, Quiros RM. Esophageal stenting in the setting of malignancy. ISRN Gastroenterol. 2011;2011:719575. doi:10.5402/2011/719575.
  12. Keung EZ, Liu X, Nuzhad A, Rabinowits G, Patel V. In-hospital and long-term outcomes after percutaneous endoscopic gastrostomy in patients with malignancy. J Am Coll Surg. 2012;215(6):777-786.
  13. Young CJ, De-loyde KJ, Young JM, et al. Improving quality of life for people with incurable large-bowel obstruction: randomized control trial of colonic stent insertion. Dis Colon Rectum. 2015;58(9):838-849.
  14. Folch E, Mehta AC. Airway interventions in the tracheobronchial tree. Semin Respir Crit Care Med. 2008;29(4):441-452.
  15. Kazi AA, Flowers WJ, Barrett JM, O’Rourke AK, Postma GN, Weinberger PM. Ethical issues in laryngology: tracheal stenting as palliative care. Laryngoscope. 2014;124(7): 1663-1667.
  16. Agrafiotis M, Siempos II, Falagas ME. Infections related to airway stenting: a systematic review. Respiration. 2009;78(1):69-74.
  17. Urban T, Lebeau B, Chastang C, Leclerc P, Botto MJ, Sauvaget J. Superior vena cava syndrome in small-cell lung cancer. Arch Intern Med. 1993;153(3):384-387.
  18. Lanciego C, Chacón JL, Julián A, et al. Stenting as first option for endovascular treatment of malignant superior vena cava syndrome. AJR Am J Roentgenol. 2001;177(3):585-593.
  19. Smayra T, Otal P, Chabbert V, et al. Long-term results of endovascular stent placement in the superior caval venous system. Cardiovasc Intervent Radiol. 2001; 24(6):388-394.
  20. Nicholson AA, Ettles DF, Arnold A, Greenstone M, Dyet JF. Treatment of malignant superior vena cava obstruction: metal stents or radiation therapy. J Vasc Interv Radiol. 1997;8(5):781-788.
  21. Hague J, Tippett R. Endovascular techniques in palliative care. Clin Oncol (R Coll Radiol). 2010;22(9):771-780.
  22. Kirkova J, Fainsinger RL. Thrombosis and anticoagulation in palliative care: an evolving clinical challenge. J Palliat Care. 2004; 20(2):101-104.
  23. Johnson MJ. Problems of anticoagulation within a palliative care setting: an audit of hospice patients taking warfarin. Palliat Med. 1997;11(4):306-312.
  24. Noble SIR, Shelley MD, Coles B, Williams SM, Wilcock A, Johnson MJ; Association for Palliative Medicine for Great Britain and Ireland. Management of venous thromboembolism in patients with advanced cancer: a systematic review and meta-analysis. Lancet Oncol. 2008;9(6):577-584.
  25. Jenq G, Tinetti ME. Changes in end-of-life care over the past decade: more not better. JAMA. 2013;309(5):489-490.
  26. Stanley JM. The Appleton Consensus: suggested international guidelines for decisions to forego medical treatment. J Med Ethics. 1989;15(3):129-136.