Dyspnoea in patients with advanced cancer: incidence, causes and treatments

Enabling patients in effective self-management of breathlessness in lung cancer: the neglected pillar of personalized medicine

Globally, engagement of patients in the self management of disease and symptom problems has become a health policy priority to improve health outcomes in cancer. Unfortunately, little attention has been focused on the provision of self-management support (SMS)in cancer and specifically for complex cancer symptoms such as breathlessness. Current management of breathlessness, which includes treatment of underlying disease, pharmacological agents to address comorbidities and opiates and anxiolytics to change perception and reduce the sense of breathing effort, is inadequate. In this perspective paper, we review the rationale and evidence for a structured, multicomponent SMS program in breathlessness including four components: breathing retraining, enhancing positive coping skills, optimizing exertional capacity and reducing symptom burden and health risks. The integration of SMS in routine lung cancer care is essential to improve breathlessness, reduce psychological distress, suffering and improve quality of life.

Efficacy and Safety of Opioids in Treating Cancer-Related Dyspnea: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

BACKGROUND

Dyspnea is one of the most distressing symptoms encountered by advanced cancer patients. In this study, we aimed to evaluate the role of opioids in the management of cancer-related dyspnea.

METHODS

A systematic review and meta-analysis based on Randomized Controlled Trials was conducted in the databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials testing the effect of opioids in relieving cancer-related dyspnea. Subgroup and sensitivity analyses were performed to evaluate various types of opioids in dyspnea management and stabilization of the study respectively.

RESULTS

Eleven RCTs fulfilled the eligibility criteria and had a total of 290 participants. Nine of these studies were included in meta-analyses. Compared with control, opioid therapy showed a small positive effect in dyspnea, SMD-0.82 (95%CI = -1.54 to -0.10) and Borg score, WMD-0.95 (95%CI = -1.83 to -0.06); Opioid therapy did not increase the risk of somnolence, OR0.93 (95%CI = 0.34 to 2.58), whereas a negative effect on respiratory rate was observed,WMD-1.89 (95%CI = -3.36 to -0.43); Also, there was no evidence to suggest improved performance of the 6MWT test, WMD6.49 (95%CI = -34.23 to 47.21), or the level of peripheral oxygen saturation, WMD0.33 (95%CI = -0.59 to 1.24) after opioid therapy. Subgroup analysis yielded a small positive effect for morphine on dyspnea, SMD-0.78 (95%CI = -1.45 to -0.10), whereas fentanyl showed no improvement in dyspnea, SMD-0.44 (95%CI = -0.89 to 0.02). Sensitivity analysis showed no changes in the direction of effect when any one study was excluded from the meta-analyses.

CONCLUSIONS

Our systematic review and meta-analysis indicated low quality evidence for a small positive effect of opioids in cancer-related dyspnea. Evidence for safety is insufficient as comprehensive adverse events were not adequately reported in studies.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

"Whatever my mother wants": barriers to adequate pain management

Opioids are the preferred medications to treat cancer pain; however, several barriers to cancer pain management exist, including those related to the patient, health care provider, and family caregiver. We describe one such situation in which a family member prevents the patient from receiving adequate pain management at the end of life despite interdepartmental and interdisciplinary efforts. This case highlights the importance of understanding and addressing fears regarding opioid use and implementing an integrated approach including oncologists and palliative care physicians, along with early referrals to palliative care.

WITHDRAWN: Opioids for the palliation of breathlessness in advanced disease and terminal illness

BACKGROUND

Breathlessness is a common symptom in people with advanced disease. The most effective treatments are aimed at treating the underlying cause of the breathlessness but this may not be possible and symptomatic treatment is often necessary. Strategies for the symptomatic treatment of breathlessness have never been systematically evaluated. Opioids are commonly used to treat breathlessness: the mechanisms underlying their effectiveness are not completely clear and there have been few good-sized trials in this area.

OBJECTIVES

To determine the effectiveness of opioid drugs given by any route in relieving the symptom of breathlessness in patients who are being treated palliatively.

SEARCH METHODS

An electronic search was carried out of Medline, Embase, CINAHL, T he Cochrane L ibrary, Dissertation Abstracts, Cancercd and SIGLE. Review articles and reference lists of retrieved articles were hand searched. Date of most recent search: May 1999.

SELECTION CRITERIA

Randomised double-blind, controlled trials comparing the use of any opioid drug against placebo for the relief of breathlessness were included. Patients with any illness suffering from breathlessness were included and the intervention was any opioid, given by any route, in any dose.

DATA COLLECTION AND ANALYSIS

Studies identified by the search were imported into a reference manager database. The full texts of the relevant studies were retrieved and data were independently extracted by two review authors. Studies were quality scored according to the Oxford Quality scale. The primary outcome measure used was breathlessness and the secondary outcome measure was exercise tolerance. Studies were divided into non-nebulised and nebulised and were analysed both separately and together. A qualitative analysis was carried out of adverse effects of opioids. Where appropriate, meta-analysis was carried out.

MAIN RESULTS

Eighteen studies were identified of which nine involved the non-nebulised route of administration and nine the nebulised route. A small but statistically significant positive effect of opioids was seen on breathlessness in the analysis of studies using non-nebulised opioids. There was no statistically significant positive effect seen for exercise tolerance in either group of studies or for breathlessness in the studies using nebulised opioids.

AUTHORS' CONCLUSIONS

There is evidence to support the use of oral or parenteral opioids to palliate breathlessness although numbers of patients involved in the studies were small. No evidence was found to support the use of nebulised opioids. Further research with larger numbers of patients, using standardised protocols and with quality of life measures is needed.

Symptom management in metastatic breast cancer

Approximately 40,000 women die as a result of breast cancer each year and many more live with advanced disease. When breast cancer recurs, the goals of treatment often shift from one of cure to controlling the disease for as long as possible while palliating symptoms interfering with the patient's functional status and quality of life. This requires ongoing discussions with the patient and family about the goals of care. Many symptoms depend on the site of metastasis, with bone being the most frequent, and commonly occur with fatigue, depression, insomnia, and pain. The purpose of this paper is to identify and provide an overview of the management of the most common symptoms in patients with breast cancer metastases.

Endobronchial tumor migration presenting with acute breathlessness and stridor

We describe a case of known lung malignancy presenting acutely with bronchial obstruction. A piece of tumor from the left main bronchus (occluded by primary tumor) had been aspirated into the previously patent right main bronchus, leading to acute respiratory distress. The obstruction was cleared before intervention by expectoration.

Nebulized versus subcutaneous morphine for patients with cancer dyspnea: a preliminary study

This study compared the effects of nebulized versus subcutaneous morphine on the intensity of dyspnea in cancer patients. Patients with a resting dyspnea intensity > or =3 on a 0-10 scale (0=no dyspnea, 10=worst possible dyspnea) who received regular oral or parenteral opioids were included. On day 1, patients received either subcutaneous (SC) morphine plus nebulized placebo or nebulized morphine plus SC placebo. On day 2, a crossover was made. Dyspnea intensity, side effects, and blinded preference of treatment were assessed. Eleven patients completed the study. Dyspnea decreased from a median of 5 (range, 3-8) to 3 (range, 0-7) after SC morphine (P=0.025) and from 4 (range, 3-9) to 2 (range, 0-9) after nebulized morphine (P=0.007). There was no significant difference in dyspnea intensity between nebulized and subcutaneous morphine at 60 minutes. Unfortunately, due to limited sample size, there was insufficient power to rule out a significant difference between both routes of administration. Nebulized morphine offered dyspnea relief similar to that of SC morphine. Larger randomized controlled trials in patients with both continuous dyspnea and earlier stages of dyspnea are justified.

A randomized controlled trial of supplemental oxygen versus air in cancer patients with dyspnea

CONTEXT

The symptomatic benefits of oxygen in patients with cancer who have nonhypoxic dyspnea are not well defined.

OBJECTIVE

To determine whether or not oxygen is more effective than air in decreasing dyspnea and fatigue and increasing distance walked during a 6-minute walk test.

PATIENTS AND METHODS

Patients with advanced cancer who had no severe hypoxemia (i.e., had an O2 saturation level of > or = 90%) at rest and had a dyspnea intensity of > or = 3 on a scale of 0-10 (0 = no shortness of breath, 10 = worst imaginable shortness of breath) were recruited from an outpatient thoracic clinic at a comprehensive cancer center. This was a double-blind, randomized crossover trial. Supplemental oxygen or air (5 L/min) was administered via nasal cannula during a 6-minute walk test. The outcome measures were dyspnea at 3 and 6 minutes, fatigue at 6 minutes, and distance walked. We also measured oxygen saturation levels at baseline, before second treatment phase, and at the end of study.

RESULTS

In 33 evaluable patients (31 with lung cancer), no significant differences between treatment groups were observed in dyspnea, fatigue, or distance walked (dyspnea at 3 minutes: P = 0.61; dyspnea, fatigue, and distance walked at 6 minutes: P = 0.81, 0.37, and 0.23, respectively).

CONCLUSIONS

Currently, the routine use of supplemental oxygen for dyspnea during exercise in this patient population cannot be recommended.

Nebulized furosemide as a novel treatment for dyspnea in terminal cancer patients

Three terminal cancer patients with severe dyspnea were treated with nebulized furosemide. The underlying causes of dyspnea varied. Twenty milligrams of furosemide was nebulized and inhaled four times each day. Dyspnea dramatically improved and could be controlled for weeks. No noticeable side effects were observed. Inhalation of nebulized furosemide seems to be an effective and useful treatment for dyspnea in terminal cancer patients, but these observations need to be confirmed in a randomized controlled trial.

Opioids for the palliation of breathlessness in terminal illness

BACKGROUND

Breathlessness is a common symptom in people with advanced disease. The most effective treatments are aimed at treating the underlying cause of the breathlessness but this may not be possible and symptomatic treatment is often necessary. Strategies for the symptomatic treatment of breathlessness have never been systematically evaluated. Opioids are commonly used to treat breathlessness: the mechanisms underlying their effectiveness are not completely clear and there have been few good-sized trials in this area.

OBJECTIVES

To determine the effectiveness of opioid drugs given by any route in relieving the symptom of breathlessness in patients who are being treated palliatively.

SEARCH STRATEGY

An electronic search was carried out of Medline, Embase, Cinahl, the Cochrane library, Dissertation Abstracts, Cancercd and SIGLE. Review articles and reference lists of retrieved articles were hand searched. Date of most recent search: May 1999

SELECTION CRITERIA

Randomised double-blind, controlled trials comparing the use of any opioid drug against placebo for the relief of breathlessness were included. Patients with any illness suffering from breathlessness were included and the intervention was any opioid, given by any route, in any dose.

DATA COLLECTION AND ANALYSIS

Studies identified by the search were imported into a reference manager database. The full texts of the relevant studies were retrieved and data were independently extracted by two reviewers. Studies were quality scored according to the Jadad scale. The primary outcome measure used was breathlessness and the secondary outcome measure was exercise tolerance. Studies were divided into non-nebulised and nebulised and were analysed both separately and together. A qualitative analysis was carried out of adverse effects of opioids. Where appropriate, meta-analysis was carried out.

MAIN RESULTS

Eighteen studies were identified of which nine involved the non-nebulised route of administration and nine the nebulised route. A small but statistically significant positive effect of opioids was seen on breathlessness in the analysis of studies using non-nebulised opioids. There was no statistically significant positive effect seen for exercise tolerance in either group of studies or for breathlessness in the studies using nebulised opioids.

REVIEWER'S CONCLUSIONS

There is evidence to support the use of oral or parenteral opioids to palliate breathlessness although numbers of patients involved in the studies were small. No evidence was found to support the use of nebulised opioids. Further research with larger numbers of patients, using standardised protocols and with quality of life measures is needed.

Nebulized hydromorphone for dyspnea in hospice care of advanced cancer

This case report describes the use of nebulized hydromorphone for management of dyspnea in advanced cancer in home hospice care. The patient was intolerant of morphine; nebulized hydromorphone was used as an alternative to nebulized morphine for dyspnea and found to be both safe and effective.

Pain and symptom control in terminally ill children

The management of pain in terminally ill pediatric patients has incalculable benefits to patients, their families, and physicians and nurses. A therapeutic management plan is dependent on a thorough understanding of the causes of pain in these patients, on pain assessment, and on the myriad drugs and drug strategies that are essential in pain treatment. Aggressive symptom control of treatment-related side effects can ensure successful implementation of such a plan.

Palliative management of dyspnea in advanced cancer

Dyspnea is a common and devastating symptom of life-threatening disease. Approximately 90% of non-small cell lung cancer patients experience moderate to severe dyspnea by death. Currently, the pathology is ill-defined and measurement of this subjective symptom is imprecise. The treatment is directed at the underlying cause when appropriate. When specific therapies no longer exist, palliative interventions are necessary. This article outlines the current state of knowledge and standards of care for palliative interventions in dyspnea. These include nonpharmacologic interventions, oxygen supplementation, and medications. Further research is needed to clarify the role of each and to develop better pathophysiologic understanding.