L6 Cancer-related symptom management & supportive care

Which types of pain does the following description refers to ?

• Sudden onset, short duration

• Etiology is often known

• Pain behaviors are more frequently exhibited

• e.g., surgery, childbirth

Actue pain

Which types of pain does the following description refers to ?

• Persistent, long-lasting, typically lasts > 3 months

• Etiology is often unknown with chronic pain (nonmalignant)

• Fatigue and depression are common

• e.g., arthritis, neuropathic pain

Chronic pain

Which types of pain does the following description refers to ?

• A flare in the pain pattern that occurs in conjunction with well-controlled background pain

Breakthrough pain (BTP)

Which types of pain does the following description refers to ?

• Transient pain precipitated by any movement or activity

Incident pain

(a subtype of breakthrough pain)

Which types of pain does the following description refers to ?

• Spontaneous pain that occurs without warning

Insidious pain

(a subtype of breakthrough pain)

Which types of pain does the following examples belongs to ?

• e.g., Spinal cord compression, bone pain,

Cancer pain

Which 4 domain should be included in total pain assessment ?

1. Physical domain

2. Psychological domain

3. Social domain

4. Spiritual / existential domain

Suggest examples of pain from the physical domain in total pain assessment

• Description of pain

• Caused by illness

• Caused by treatment

Suggest examples of pain from the psychological domain in total pain assessment

• Feeling about disease & death

• How pain affects the patient/family’s affect

• Beliefs about opioids/addiction

• Usual coping strategies

• Willingness to try complementary modalities, etc.

Suggest examples of pain from the social domain in total pain assessment

• How pain/pain medications affect activities of daily living

• Changes in family roles

• Financial impact of pain, etc.

Suggest examples of pain from the spiritual domain in total pain assessment

• Influence of spiritual/religious beliefs related to pain or illness

• Presence of spiritual support or community

• Use of traditional medicines, etc.

List the items / contents included in a thorough pain evaluation (8)

1. Detailed patient history gathering (current and prior oncologic treatment, other significant comorbidities, pre-existing chronic pain, medication history)

2. Conduct physical and neurologic examinations

3. Evaluation of imaging studies (X-rays, MRI, CT scan, bone scan) and laboratory values (tumor markers)

4. Utilizing validated pain assessment tools

5. Assess for alterations of body systems (e.g. respiratory status, CNS changes, etc.)

6. Assessing the patient's psychological and emotional well-being

7. Evaluating the impact of pain on the patient’s functional abilities and quality of life

8. Involving multidisciplinary collaboration

Suggest 4 types of pain assessment tools for adults

• Numerical Rating Scale (NRS)

• Verbal Rating Scale (VRS)

• Visual/Colour Analog Scale (VAS)

• Multidimensional Pain Assessment Tools, e.g. McGill Pain questionnaire

Which type of pain assessment tools is the most preferred for elderly or cognitively challenged patients ?

• Verbal Rating Scale (VRS)

  • Categories include none, mild, moderate, severe

List 3 types of cancer-related management

1. Pharmacological intervention

2. Non-pharmacological intervention

3. Other types of intervention

According to WHO, what are the 3 steps analgesic ladder for cancer pain management control ?

Step 1:

• mild to moderate pain by non- opioid analgesic

• +/- adjuvant analgesic

Step 2:

• moderate to severe pain by weak opioid

• +/- non- opioid analgesic

• +/- Adjuvant analgesics

Step 3:

• severe pain by strong opioid (when pain has not been well controlled with maximum doses of weak opioid)

• +/- non-opioid analgesic

• +/- Adjuvant analgesics

Adjuvant drugs are used to enhance analgesic effect at all levels

Suggest examples of non-opioids analgesics

Ibuprofen, or other NSAIDs, paracetamol (acetaminophen), or aspirin

Suggest examples of weak opioids analgesics (3)

• Codeine,

• tramadol,

• low-dose morphine

Suggest examples of strong opioids analgesics

Morphine, fentanyl, methadone, oxycodone, hydromorphone, buprenorphine

Suggest examples of adjuvants therapy (drugs) for pain management

• Antidepressant, anticonvulsant, antispasmodic, muscle relaxant, bisphosphonate, or corticosteroid

Which adjuvant drugs is the most commonly used to enhance analgesic effects ?

• Gabapentin

According to NRS pain assessment tools, what is the score range that classified as Mild pain and require step 1 analgesic level management ?

0-4

According to NRS pain assessment tools, what is the score range that classified as Mild-Moderate pain and require step 2 analgesic level management ?

5-7

According to NRS pain assessment tools, what is the score range that classified as Moderate-severe pain and require step 3 analgesic level management ?

8-10

Suggest the pre-administration assessment / S/E for NSAID (3)

• GI bleed, perforation – supplementary PPI or H2 blocker, caution when concurrent use with steroid

• Avoid in renal impairment,

• Alert for thrombocytopenia

Suggest the pre-administration assessment / S/E for weak opioids (2)

• Weak opioids cause constipation →consider adding laxative

• 100mg Tramadol has 5mg of the potency of morphine→watch out for drug-drug interaction e.g., SSRI, TCA, warfarin

Suggest the pre-administration assessment / S/E for Morphine (1)

Adjust dose in renal impairment

Suggest the pre-administration assessment / S/E for Methadone (2)

• Caution in liver impairment

• Long half-life

Suggest the use of Fentanyl transdermal patch (2)

• Use if intolerable morphine S/E

• Reserved for patients require stable opioid

Suggest the use of Oxycodone (2)

• Use if intolerable morphine S/E

• Adjust dose in renal and/or liver impairment

Suggest the first line opioid choice for moderate to severe cancer pain

Morphine

Describe the starting dose regimen for oral Morphine

5mg Q4H

• Implement round-the-clock dosing for continuous or frequently recurring pain

• Reduce dose for elderly/frail/very cachectic patients (3mg)

Describe the Nocte dose regimen for oral Morphine

• Give QID + a double dose before sleep to allow skipping of 4 a.m. dose

• e.g., Morphine 5mg QID + 10mg Nocte

Describe the Breakthrough dose regimen for oral Morphine

• Give 1⁄2 or the same regular dose Q2H – Q4H for breakthrough pain

  • e.g., Morphine 10mg QID + 20mg Nocte + 5-10mg Q4H PRN

• Review total PRN doses used in the past 24 hours and add that to the regular

Describe the Dose escalation regimen for oral Morphine

• suggest a management precaution as well

• Stepwise increase by 30% to 50% each time

• Majority of pain can be controlled with daily morphine < 600mg

• If pain remains uncontrolled, review the cause of pain + psychosocial aspect

• Monitor RR 4 hourly during titration of dose

Suggest the pros of having Morphine Continuous Subcutaneous Infusion (CSCI) as pain management (5)

1. Suitable for patients unable to tolerate oral therapy

2. Increases comfort by avoiding repeated injections or excessive tablets

3. Ideal for very drowsy comatose 昏迷的 or semi- comatose patient

4. Beneficial for patients with poor venous access

5. Cannula can remain for 72 hours if no redness or inflammation occurs

Suggest the cons of having Morphine Continuous Subcutaneous Infusion (CSCI) as pain management (3)

1. Possible inflammation or irritation at the infusion site

2. Possible leakage at the subcutaneous site

3. Possible for allergic reactions

What are the indication of using Morphine Continuous Subcutaneous Infusion (CSCI) as pain management (8)

• Persistent severe nausea and vomiting

• Difficulty in swallowing

• High risk of aspiration

• Poor alimentary absorption

• GI obstruction

• Profound weakness

• Unconscious patients

What are the contraindication of using Morphine Continuous Subcutaneous Infusion (CSCI) as pain management (5)

• Emergency situations, e,g, shock, severe dehydration

• Obvious clotting disorders

• Fluid overload, e.g., CHF, marked oedema

• Requires IV treatment, e.g.,Hypercalcaemia

• Patients on renal dialysis

Suggest 4 sites that are suitable for Morphine Continuous Subcutaneous Infusion (CSCI)

• Anterior chest wall (avoid if patient very cachexic) 鎖骨低少少

• Lateral upper arm

• Anterior abdominal wall

• Anterior outer thigh

What are the sites that are NOT suitable for Morphine Continuous Subcutaneous Infusion (CSCI)

• Lymphedematous areas

• Bony prominences

• Previously irradiated skin

• Site near a joint

• Broken, inflamed or infected skin

• Skin folds area

• Scarring

List the nursing management for pharmacological pain management (12)

1. Regular pain screening for early identification and management

2. Individualized analgesic regimens (adherence to WHO analgesic ladder)

3. Begin with the least invasive route of administration to achieve optimal pain relief

4. Start with a small dose, then titrate against the patient’s pain till comfortable

   • Reassess and readjust the doses and schedules closely for severe pain

   • Taper daily dose by < 50% before complete cessation and discontinue opioids when no longer needed

5. Prescribe stronger opioids for patients presenting with severe pain initially

6. Time doses based on drug half-life (dose by the clock) and do not wait for the pain to recur

7. Avoid the combination of drugs within the same class to treat pain

8. Avoid multiple drug changes at one time

9. Administer drugs at intervals before anticipated painful activity for incident pain

10. Assess drug compliance and drug side effects

11. Implement strategies to minimize side effects of analgesic therapy: Bowel regimen that includes stool softener and stimulant, antiemetics, H2 antagonists, CNS stimulants to counteract sedation

12. Multimodal approach (pharmacological, non-pharmacological and psychological support)

What are the common S/E of opioid administration (7)

• Constipation

• Nausea & vomiting

• Respiratory depression

• Sedation

• Dizziness

• Physical dependence

• Tolerance

Suggest some non pharmacological management for cancer related pain (7)

• Manipulative and body-based practices

• Acupuncture (TCM)

• Transcutaneous Electrical Nerve Stimulation (TENS)

• Physiotherapy

• Relaxation techniques

• Music/Art therapy

• Cognitive-behavioural interventions

In Chemotherapy Induced nausea and vomiting (CINV), describe what is the phase: Anticipatory Emesis ?

24 hrs before chemotherapy

• Consider as conditioned response, after a negative experience with

  chemotherapy

• Psychological mechanism

• Antiemetics ineffective

What are the management for anticipatory CINV ? (3+)

• CBT

• Most effective treatment is to use optimal antiemetic therapy during every cycle

• Other treatment: Avoid strong smells, behavioral therapy with systematic desensitization, yoga, cognitive distraction, progressive muscle relaxation, hypnosis

In Chemotherapy Induced nausea and vomiting (CINV), describe what is the phase: Actue Emesis ?

Day 1 chemo (24 hrs)

• Serotonin dependent (Peripheral)

In Chemotherapy Induced nausea and vomiting (CINV), describe what is the phase: Delay Emesis ?

Day 2-7

• Substance P dependent mechanisms (central)

List 7 risk factors for Chemotherapy Induced nausea and vomiting (CINV)

• History and History of severity of CINV

• motion sickness

• Low alcohol use

• History of morning sickness

• Anxiety and depression

• Female sex

• Younger than 50 years of age

When consider chemotherapy drug emetogenicity, what is the % risk of emesis if the drug is “Highly emetic”

>90%

When consider chemotherapy drug emetogenicity, what is the % risk of emesis if the drug is “Moderately emetic”

>30-90%

When consider chemotherapy drug emetogenicity, what is the % risk of emesis if the drug is “Low emetic”

>10-30%

When consider chemotherapy drug emetogenicity, what is the % risk of emesis if the drug is “Minimally emetic”

<10%

Suggest an example of high emetic risk chemo drug

Cisplatin

What is the principle goal of antiemetic therapy ?

Prevention

When should antiemetic therapy be given ? (3)

After last dose of anticancer therapy

• At least 3 days for high emetic risk agents

• At least 2 days for moderate emetic risk agents

For multi-drug regimens, select antiemetic therapy based on the highest emetic risk

Optimal time for administration for 1st dose should be 30-60 mins prior chemotherapy

What are the potential causes of emesis that is not suitable / indicated to have antiemetic therapy (5)

• Partial or complete bowel

• Brain metastases

• Electrolyte imbalance: hypercalcemia/hyperglycemia/hyponatremia

• Excessive secretion (in H&N cancer)

• Rapid opioid withdrawal

Suggest 2 5-HT3 antagonists as antiemetic agent

• Granisetron (Kytril)

• Ondansetron (Zofran)

Suggest 1 NK-1 antagonists as antiemetic agent

Aprepitant (Emend Oral)

Suggest the 3 types of Oncologic Emergencies

1. Superior Vena Cava Syndrome/Obstruction (SVCS/SVCO)

2. Malignant Spinal Cord Compression (MSCC)

3. Febrile Neutropenia

Define what is Superior Vena Cava Syndrome / Obstruction (SVCS)

• Obstruction of blood flow by tumours or enlarged lymph nodes through SVC→venous pressure increases & cardiac output decreases→SVC Invasion or compression & thrombosis within SVC

List the s/s of Superior Vena Cava Syndrome / Obstruction (SVCS) (5)

• Dyspnea (most common),

• orthopnea,

• facial flushing & swelling,

• upper extremity swelling,

• neck & thoracic vein distention

List the possible cause of Superior Vena Cava Syndrome / Obstruction (SVCS) (6)

1. Cancer related

2. Thrombosis

3. Infection

4. Post radiation therapy stenosis

5. Benign cause

6. Vascular devices or interventional procedures, e.g. Placement of central venous catheters, or other vascular devices causing mechanical obstruction or thrombosis

Suggest a observable signs of Superior Vena Cava Syndrome / Obstruction (SVCS) through physical examination

Jugular Venous Distension at upright position

What is the golden standard to diagnose Superior Vena Cava Syndrome / Obstruction (SVCS)

Venography

List the nursing management / intervention / care for Superior Vena Cava Syndrome / Obstruction (SVCS) (9)

• * what medication with be given as well ?

1. Assess the vital signs, any signs of respiratory distress, JVP and neurological status.

2. Avoid venipuncture, blood pressure measurement, and intravenous therapy in the upper extremities.

3. Encourage and assist the patient (using extra pillows) to maintain an upright or semi-Fowler’s position to ease breathing.

4. Administer oxygen therapy as prescribed if respiratory distress or hypoxia is present.

5. Enforce bed rest as indicated and monitor the patient’s tolerance to
   activity.

6. Administer prescribed medications:

   • Steroids with gastric protection to reduce laryngeal or cerebral edema; use a short course and taper when definitive treatment is initiated.

   • Low-dose morphine for relief of dyspnea.

   • Anticoagulants for patients with venous stent placement or

     thrombosis.

7. Provide benzodiazepines and psychological support to manage anxiety.

8. Evaluate and reassess the effectiveness of interventions in improving symptoms and comfort.

9. Monitor for and promptly report any signs of clinical deterioration.

Define what is Malignant Spinal Cord Compression (MSCC)

Typically resulting from metastases, vertebral collapse or direct tumour extension, causing spinal cord or cauda equina compression

Can cause alterations in motor, sensory & autonomic functions or even complete paralysis in the worst situation

What are the s/s , clinical presentation & RED FLAGS of Malignant Spinal Cord Compression (MSCC)

• Early signs / first signs

• late signs

• Back pain: FIRST SYMPTOM

Referred or BAND LIKE pain

Escalating pain: Poor response to treatment
(Pain with) Different character or site than the previous

Funny or “odd sensations” or “heavy legs”
Lying flat increases pain Agonizing or severe back pain

Gait disturbance: Unsteady, stairs difficult
Sleep disturbance with night pain

• Established Motor/ Sensory/ Bladder/ Bowel disturbances are LATE SIGNS = poor functional outcome & Survival

Describe what is the GOOD standard for diagnose Malignant Spinal Cord Compression (MSCC)

MRI

• Discriminate metastatic disease from other pathologies

• Assess the extent for RT & help to plan surgery

Suggest an alternative investigation to diagnose Malignant Spinal Cord Compression (MSCC) when the GOOD standard method is not available or contraindicated

• what might be the contraindication of the GOOD standard investigation ?

CT myelogram with IV & intrathecal contrast injection

Contraindication of using MRI: e.g., pacemaker, severe claustrophobia

List the Definitive treatment / nursing management for Malignant Spinal Cord Compression (MSCC) (12)

1. Start the treatment before any further neurological deterioration occurs, ideally within 24 hours of a confirmed diagnosis of MSCC

2. Relieve spinal cord compression

3. Reserve and restore neurological function

4. Initial immobilization for unstable spine until stability is confirmed, e.g. On flat bed rest & log roll

5. Need an immediate high initial dose of steroid to ↓ vasogenic oedema of the spinal cord:

6. Give analgesics based on the WHO analgesic ladder and monitor its effects and S/E

7. Assess bladder & bowel function on initial presentation & at least daily thereafter

8. Prevention of chest infection, e.g. encourage breathing & coughing exercises, early mobilization, and suctioning as necessary

9. Prevent pressure injury, e.g., encourage early remobilization if condition allows, use a low air loss mattress, etc.

10. Prevention of venous thromboembolism, e.g., active limb exercise 2x/day, anti-embolism stockings, intermittent pneumatic compression devices, anti-coagulant therapy if indicated

11. Wear well-fitted orthosis for physical support as prescribed (24 hours vs during ambulation)

12. Protect the pressure points & check skin daily
    

Define what is Febrile Neutropenia ?

Common complication of chemotherapy

Normal absolute neutrophil count (ANC) ranges from 1,500 to 8,000 cells per microliter of blood

• Diagnosed when that count drops below 1,500 cells/μL, categorized by severity

What are the potential causes of Febrile Neutropenia (4)

• Cancer Treatments: Chemotherapy and radiation can lead to neutropenia.

• Bone Marrow Disorders: Conditions like leukemia or aplastic anemia.

• Infections: Viral or bacterial infections that affect blood cell production.

• Medications: Certain drugs can cause bone marrow suppression.

Suggest the management for Febrile Neutropenia (3+)

1. Require 2 sets of blood cultures & routine blood test for assessment

2. Start antibiotics within 1 hour

   • Medications e.g. Granulocytes colony stimulating factor(G-CSF) to stimulate neutrophil production.

3. Supportive Care: Hydration, monitoring, and management of complications

List the neutropenic precautions (Febrile Neutropenia) (5)

1. Use positive pressure rooms to reduce the risk of airborne pathogens.

2. Prohibit visitor to bring fresh flowers and plants in the patient’s room to reduce the risk of mold and bacteria.

3. Ensure all healthcare staff wear appropriate PPE (masks, gloves, gowns) & strict hand hygiene when caring for the patient.

4. Conduct regular temperature checks and monitor for any signs of infection.

5. Educate the patient about the importance of precautions and signs of infection to watch for.

What are the 7 stage of Grief ?

1. Shock

2. Denial

3. Anger

4. Bargaining

5. Depression

6. Reconstruction / Testing

7. Acceptance

Which stage of grief does the following statement refers to:

• “This can’t be happening!!”

Stage 1 Shock

Which stage of grief does the following statement refers to:

• "It must be a mistake."

Stage 2 Denial

Which stage of grief does the following statement refers to:

• “Why is this happening to me?”

Stage 3 Anger

Which stage of grief does the following statement refers to:

• “If you make this go away, I promise I will be more patient/kind/compassionate.”

Stage 4 Bargaining

Which stage of grief does the following statement refers to:

• “It’s no use. This pain will never go away.”

Stage 5 Depression

Which stage of grief does the following statement refers to:

• “I can find ways to keep their memory alive.”

Stage 6 Reconstruction / Testing

Which stage of grief does the following statement refers to:

• “Every occurrence has a purpose behind it.”

Stage 7 Acceptance

According to the Total Pain assessment domain, what are the signs of anticipatory grief in the physical domain ?

• Sleep disturbance

• Poor appetite

• Headache

• Nausea

• Fatigue

According to the Total Pain assessment domain, what are the signs of anticipatory grief in the psychological domain ?

• Anxious

• Sad

• Helpless,

• Disorganized

• Forgetful

• Angry

According to the Total Pain assessment domain, what are the signs of anticipatory grief in the social domain ?

Difficulty in Connecting emotionally with others

According to the Total Pain assessment domain, what are the signs of anticipatory grief in the spiritual domain ?

Doubting one’s faith or questioning the existence of God

How can CBT act as an intervention to for Grief in order to minimize psychological distress & psychiatric comorbidities (ADAPT)

• To adopt a positive problem solving attitude

• To define the problem and set realistic goals

• To explore alternatives and make use of the patient’s strengths and resilience

• Predict the consequences and develop a solution plan

• Try out the solution plan