Quality of Life Issues in Cancer

Factors Affecting Quality of Life in Cancer Patients

Cancer patients are confronted with a variety of physical, emotional, and social issues that, if left unchecked or ignored, can rapidly contribute to a diminished quality of life. In general, some of the more common problems encountered by cancer patients either as a result of the disease itself or as a side-effect of cancer treatments include:

• Sleep disorders
• Fatigue
• Diminished exercise capacity
• Unintentional weight loss
• Psychological stress
• Cancer-related pain

Sleep Disorders

Lack of adequate sleep due to anxiety, stress, pain, or treatment side-effects can lead to severe daytime fatigue that, in turn, can interfere with the ability to function and perform routine activities of daily living. Perhaps now, more than ever before, getting an adequate amount of sleep is critical to enable the body and mind to cope with the additional physical and emotional burdens resulting from cancer and its treatment. If sleep disturbances begin to affect your functional ability and diminish your quality of life, a variety of options are available to deal with the problem. These treatment options include learning new sleep habits (improved sleep hygiene practices); complementary therapies (e.g., relaxation techniques, biofeedback, meditation); and the use of prescription sleep medications. If lack of sleep is affecting your quality of life and interfering with your activities of daily living, talk with your doctor about developing an individualized treatment plan to help improve your quality of sleep.

Fatigue

Fatigue is perhaps the most common and potentially debilitating symptom experienced by cancer patients that can have a significant negative impact on routine activities of daily living and diminish quality of life. Fatigue may be attributed to a variety of causes including side-effects of cancer treatments (e.g., chemotherapy, radiation therapy), anemia, sleep deprivation resulting from insomnia, chronic pain, inadequate nutrition, and lack of physical exercise. In many cases, a combination of factors contributes to fatigue, exhaustion, and a general lack of energy. It is important to notify your cancer specialist or primary health care provider if you begin to experience bouts of fatigue lasting a few days or longer.

A variety of strategies are available to overcome the problem of fatigue in cancer patients. Fatigue related to anemia (low numbers of red blood cells) can be treated with blood transfusions and drugs, such as erythropoietin (e.g., Procrit) that promote the production of red blood cells. Fatigue not related to anemia may be managed with lifestyle modifications such as proper nutrition, regular exercise, and improved sleep hygiene practices.

Exercise

In the past, cancer patients were usually advised to "relax", "take it easy" and "don't overdo it". More recently, however, doctors are beginning to realize the potential benefits of physical exercise for cancer patients undergoing treatment as well as for cancer survivors. Researchers are continuing to explore the effect of physical exercise on survival rates for various types of cancers. In general, the potential benefits of physical activity for patients suffering from chronic diseases include enhanced physical and mental function and improved quality of life. For cancer patients, the potential benefits of exercise also include decreased fatigue, improved appetite, better toleration of side effects of chemotherapy and radiation therapy and improved quality of life.

It is important to speak to your cancer specialist about the types of exercises that may be appropriate at various stages of you cancer treatment and the types of physical activities that you should avoid.

Unintentional Weight Loss

One of the most common symptoms experienced by cancer patients is unintentional weight loss which can lead to malnutrition, increased susceptibility to infections, reduced quality of life, and shorter survival time. The underlying causes of unintentional weight loss in cancer patients may be attributed to a variety of factors including loss of appetite associated with chemotherapy and/or radiation therapy and psychological disturbances such as depression which has been found to affect up to 25% of cancer patients.

From a metabolic perspective, unintentional weight loss may be understood by the increased energy (calories) required by cancer cells to grow and spread as well as the increased energy requirements of the body to mount an effective response to fight the cancer. A net loss in weight occurs when the body uses more calories from stored energy reserves than is available from calories ingested from nutrients in the diet. Metabolic changes in cancer can also cause a condition called cachexia - a generalized wasting condition involving the loss of muscle mass and fat. Cachexia may develop even in people with good nutritional intake due to the failure of the body to absorb nutrients. Symptoms of cachexia, which affects about 50% of all cancer patients, include loss of appetite, weight loss, wasting of muscle mass, generalized fatigue, and significantly reduced capacity to perform routine activities of daily living.

The management of weight loss in cancer patients usually involves nutritional counseling to ensure an adequate intake of calories. Nutritional counseling can also help cancer patients develop new eating habits to prevent further weight loss including eating foods that are rich in calories or protein; eating smaller meals more frequently throughout the course of the day; "snacking" between meals; and drinking high-calorie liquid nutritional supplements (e.g., Boost, Ensure, Sustacal). In some cases, medications such as megestrol acetate (Megace) or dexamethasone (Decadron) may be prescribed to stimulate the appetite.

Your cancer specialist, working together with a nutritionist and a dietician, can help you develop and maintain a well-balanced diet to ensure that your body receives an adequate level of nutrition not only during the course of your cancer treatments but also during the recovery phase.

Psychological Stress

The diagnosis of cancer is a life-altering event that may evoke feelings of anxiety, fear, depression, hopelessness, and severe psychological stress in many patients. Studies have shown that about 25% of cancer patients suffer from depression. Conventional treatments for anxiety, stress, and depression may involve the administration of prescription anti-anxiety medications or antidepressants which may cause undesirable side-effects in some patients. Specific types of psychotherapy or "talk therapy" can also help relieve depression in cancer patients.

Studies have shown that a variety of complementary and alternative medicine (CAM) therapies are useful for controlling anxiety and other mood disturbances when used in conjunction with conventional treatments. These include:

• Mind-body interventions - relaxation techniques, guided-imagery, meditation, hypnosis
• Acupuncture
• Massage therapy
• Music therapy

In general, patients with severe mood disturbances (e.g., panic attacks; suicide ideation) require immediate psychological evaluation and treatment to stabilize their acute condition before CAM therapies may be considered. For most patients with mild to moderate anxiety and mood disturbances, CAM therapies are a useful adjunct to conventional treatments for managing psychological distress. Techniques such as mind-body interventions, acupuncture, and music therapy are generally safe when performed by qualified, experienced practitioners and can help cancer patients better cope with feelings of anxiety, fear, hopelessness, and depression. Although some herbs and dietary supplements (e.g., Kava Kava; St. John's Wort; Passionflower) have been reported to relieve anxiety and mood disturbances, some experts have discouraged the use of these products in cancer patients because they may interfere with drugs used to treat cancer (chemotherapeutic agents) and/or other medications that patients may be taking. Patients should discuss the risks and benefits of using any herbal medications/dietary supplements with their oncologist before taking any of these products, particularly if they are undergoing chemotherapy, radiation therapy, or surgery.

Cancer-Related Pain

Pain is a relatively common symptom that is experienced by many cancer patients. In recent years, increased awareness about this problem has led to important advances in the management of patients with cancer-related pain. In fact, today most major cancer centers in the United States have established pain management clinics, usually located within the Anesthesiology department of a hospital, that specialize in helping patients to better control their cancer-related pain.

Most often, the source of cancer-related pain is the tumor itself. This can occur when a tumor spreads and invades other tissues or organs of the body; when a tumor compresses a nearby nerve or the spinal cord; or when a tumor causes intestinal obstruction. Cancer-related pain may also be caused by some procedures that are used for the diagnosis and treatment of cancer. Examples include tissue biopsy; placement of a central line catheter; bone marrow aspiration; and spinal tap.

Irrespective of the source of your cancer pain, it is important to notify your oncologist or primary care doctor about any pain or discomfort that you may be experiencing so that appropriate measures can be taken to eliminate or better control the pain. In developing an individualized pain control strategy, your doctor will want to learn as much as possible about the pain you are experiencing, including:

• When did the pain start?
• How long does the pain last (acute or chronic)?
• Is the pain minor, moderate, or severe?
• Is the pain localized to a particular area of the body?
• Are there any specific activities or events that either "trigger" the pain or help to alleviate the pain?
• To what extent does the pain interfere with your quality of life and activities of daily living?
• Are you currently taking any pain medications?

Drug Therapy for Cancer-Related Pain

A wide range of pain medications is available for helping patients better cope with cancer-related pain. Your doctor will determine the specific type of medication that is most suitable for you based on the information you provide including the severity of the pain (e.g., mild, moderate, or severe) and the duration of the pain. You can help your doctor in selecting the most appropriate pain medication for your specific type of cancer pain by providing him/her with as much information as possible about the nature and characteristics of the pain. Be sure to also notify your doctor if:

• You are allergic to any medications
• You have previously experienced any serious side-effects from pain medications (e.g., gastrointestinal bleeding)
• You have a current or past history of stomach ulcers
• You are taking any other pain medications including herbal products or medications.

In general, the following pain medication treatment options are available in the management of cancer-related pain based upon the severity of the pain:

• Non-Steroidal Anti-Inflammatory Drugs - Mild cancer-related pain can usually be managed with a variety of pain medications that belong to the general family of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). Examples of NSAIDs that are available "over-the-counter" include:

  • aspirin (e.g., Bayer)
  • acetaminophen (e.g., Tylenol)
  • ibuprofen (e.g., Motrin)
  • naproxen (e.g., Aleve)

Some NSAIDs used for the treatment of pain, including cancer-related pain, are availalble by prescription only. Examples include diclofenac (e.g., Voltaren); indomethacin (Indocin); ketoprofen (e.g., Orudis); and Cox-2 inhibitors (e.g., Celebrex), among others.

• Narcotic (Opioid) Analgesics - If you are experiencing mild to moderate cancer-related pain, your doctor may prescribe a medication that belongs to a family of drugs known as narcotic analgesics. Examples include:

  • codeine
  • morphine
  • buprenorphine (e.g., Subutex; Suboxone)
  • fentanyl (e.g., Duragesic)
  • oxycodone (e.g., OxyNorm; OxyContin)
  • hydrocodone (e.g., Vicodin; Lortab)
  • hydromorphone (e.g., Dilaudid)

In some cases, combination pain medication tablets containing an NSAID plus a narcotic analgesic may be prescribed for the management of mild to moderate cancer-related pain. Examples of combination pain medication tablets include Percodan (aspirin plus oxycodone); Percocet (acetaminophen plus oxycodone); Co-codamol (acetaminophen plus codeine); and Co-codaprin (aspirin plus codeine).

As a general "rule of thumb", cancer patients with mild to moderate pain are usually started on "weaker" opioid-based medications (e.g., codeine) and, if necessary, are switched to stronger opioid medications (e.g., fentanyl, oxycodone, morphine).

Common side-effects of narcotic analgesics include constipation, lethargy, drowsiness, nausea/vomiting, and sleepiness. In addition, a major concern with the use of narcotic analgesics is the possibility of addiction to the medications. Be sure you notify your doctor if you have a current or past history of drug and/or alcohol abuse before taking narcotic analgesics. Also speak with your doctor about strategies that can be used to manage the side-effects of narcotic analgesics. For example, constipation may be managed by taking a stool softener (e.g., Colace; Senokot). If you experience drowsiness or sleepiness when you take your pain medication, you should avoid any activities that may pose a danger to yourself or others (e.g., driving a car; mowing the lawn).

• Adjuvant Pain Medications - Some drugs that are primary used to treat conditions other than pain also possess analgesic (pain-relieving) properties. These drugs are known as adjuvant pain medications and are sometimes prescribed, alone or in combination with other medications, for the management of cancer-related pain. Examples include:

  • Anticonvulsants - This class of drugs is used primarily to treat seizures. Examples of anticonvulsants that may also be used to treat cancer pain include: gabapentin (e.g.,Neurontin); carbamazepine (e.g., Tegretol); phenytoin (e.g., Dilantin); and topiramate (e.g., Topamax)

  • Antidepressants - This class of drugs is used primarily to treat depression. Examples of antidepressants that may be also be used to treat cancer pain include: amitriptylene (e.g., Elavil); desipramine (e.g., Norpramin); doxepin (e.g., Sinequon); and impipramine (e.g., Tofranil).

  • Bisphosphonates - This class of drugs is used primarily for the treatment of osteoporosis. Studies have also demonstrated that bisphosphonates may relieve bone pain in cancer patients. Examples include: alendronate (e.g., Fosamax); pamidronate (Aredia); and etidronate (e.g., Didronel).

  • Corticosteroids - This class of drugs is used primarily to treat inflammatory conditions such as rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis. By reducing inflammation, corticosteroids also reduce pain. A common type of corticosteroid drug used for the management of cancer pain is dexamethasone (e.g., Dexmethsone).

• Breakthrough Cancer Pain - Despite the regular use of pain medications on a fixed schedule, many cancer patients (estimates range from 50% to 65%) experience a type of pain known as breakthrough cancer pain. This type of pain is characterized by a sudden onset, may last from minutes to hours, and is usually severe in nature. Breakthrough cancer pain occurs most often in patients who are experiencing persistent or chronic cancer pain who notice a sudden, periodic "flare-up" of severe pain even though they are taking pain medication on a regular schedule.

Breakthrough cancer pain is most often treated with opioid medications that act quickly, such as immediate release morphine tablets or capsules, but are rapidly eliminated from the body so that they cause less side-effects. The U.S. Food and Drug Administration (FDA) has also approved a drug called ACTIQ (Oral Transmucosal Fentanyl Citrate) in the form of a lozenge on a stick that dissolves slowly in the mouth for the treatment of breakthrough cancer pain. Be sure to notify your doctor if you think you may be experiencing breakthrough pain that is not controlled with your regular fixed-schedule pain medications so that he/she may determine the best course of treatment to alleviate your pain.

For more information about cancer-related pain and the treatment options, please click on the following link: http://www.cancer-pain.org

The Role of Complementary and Alternative Medicine Therapies in Cancer-Related Pain

As a general rule, complementary and alternative medicine (CAM) therapies are usually not considered as a viable treatment option for the management of acute cancer-related pain. Acute cancer-related pain usually responds best to conventional drug therapy (e.g., NSAIDs; narcotic analgesics; adjuvant pain medications). Surgery may also be necessary for the treatment of some types of acute cancer pain such as when a tumor compresses a nearby nerve or the spinal cord or if the tumor is causing abdominal or intestinal obstruction. Once the acute pain has been brought under control by conventional treatment modalities, CAM therapies may be considered in the management of chronic (persistent) cancer-related pain. A potential benefit of using CAM therapies in conjunction with conventional treatments for the management of chronic cancer-related pain is that they may reduce the dosage of conventional pain medications that may be required to achieve chronic pain control and, therefore, also potentially reduce the side-effects that may be associated with conventional pain medications.

A variety of CAM therapies, when used in conjunction with conventional treatments, may be beneficial for the management of chronic cancer-related pain, including:

• Meditation
• Guided imagery
• Hypnosis
• Relaxation techniques
• Massage therapy
• Reflexology
• Acupuncture
• Yoga
• Aromatherapy