Supportive Care & Quality of Life: Managing Cancer Symptoms

SUPPORTIVE CARE
&
QUALITY OF LIFE
By
Dr. Ayush Garg

SUPPORTIVE CARE
• According to the Multinational Association for Supportive Care in
Cancer, supportive care is the prevention and management of the
adverse effects of cancer and its treatment.
• This includes management of physical and psychological symptoms
and side-effects across the continuum of the cancer experience from
diagnosis through anticancer treatment to post-treatment care.
• Supportive care alleviates symptoms and complications of cancer,
reduces or prevents toxic effects of treatment.

PALLIATIVE CARE
Palliative care is an approach to
patient/family/caregiver-centred health care
that focuses on optimal management of pain
and other distressing symptoms, while
incorporating psychosocial and spiritual care
according to patient/family needs, values,
beliefs and cultures.

What is the difference between
Supportive Care and Palliative Care???

When comparing the terms palliative and supportive care, Morstad et
al found that the term palliative care evoked more negative emotions
and was less favored by patients
• Supportive care is one means
improving patients' quality of
life.
• Supportive care includes
symptom control, anti-
infective measures, nutritional
supplements and psychosocial
support.
• In 2009, colleagues from the
MD Anderson Cancer Center
discussed that referrals to
palliative care tended to occur
late in the trajectory of illness.
• Palliative care becomes the
main focus of care when
disease directed, life
prolonging therapies are not
longer effective, appropriate
or desired.

Advantages of Supportive Care
• Reduce polypharmacy
• Lessen drug side effects
• Produce pharmacoeconomic benefits

SYMPTOMS
Routinely Discussed
• Pain
• Xerostomia
• Oral Mucositis
• Nausea & Vomiting
• Diarrhoea
• Acute Dermatitis
• Urinary Symptoms
No Routinely Discussed
• Fatigue
• Mood Dysfunction
• Female Sexuality
• Male Sexuality
• Psychosocial Problems
Nutrition

Other Therapies
• Radiotherapy
• Psychosocial Counselling
• Cognitive/behavioral therapy
Alternative Therapies
• Acupuncture
• Meditation/relaxation
• Guided imagery
• Herbal preparations
• Magnets
• Therapeutic massage

XEROSTOMIA
THINGS I ALREADY KNOW
• It is the subjective experience of dry mouth
• 50% to 60% decrease in salivary flow occurs during the first week
• IMRT & IV Amifostine can be used for prevention
Clinical Features:
• Loss of appetite
• Chronic esophagitis
• Gastroesophageal reflux
• Sleep disruption
• Dental caries
• Periodontal diseases
• Atrophy and ulceration of mucosa

Treatment
• Dietary and oral hygiene, saliva substitution, or stimulation of
salivation by moistening agents or medications.
• Cold, tepid, soft food, and beverages are preferred.
• Hard, spicy foods should be avoided.
• Saliva Substitutes:
• Water
• Other types of mouthwash such as saline, bicarbonate or glycerol
• Artificial saliva agents:
• Carboxymethylcellulose
• Porcine
• Bovine mucin, or xanthan gum

• Natural saliva can be achieved by stimulation with :
• Chewing gum
• Sucking ointment
• Sugarless candies
• Menthol acid
• Vitamin C
• Lozenges

THINGS I LEARNED
• Sialogogues (systemic salivary gland stimulants):
• Muscarinic agonists such as pilocarpine, bethanechol, carbachol.
• Other agents: neostigmine, physostigmine, nicotinic acid, potassium
iodide, bromhexine (a mucolytic), and anethole trithione
• The most extensively studied is pilocarpine. Oral administration at 5
to 10 mg, 3 times daily, is the standard regimen.
• Several trials have shown clinical efficacy and safety of pilocarpine in
treating radiation-induced Xerostomia

THINGS I LEARNED
• Acupuncture has been shown to stimulate saliva production. It even
shows some benefit in pilocarpine-resistant xerostomia

Salivary gland transplantation
In several studies, surgical transfer of submandibular glands into the
submental space prior to radiation therapy resulted in prevention of
xerostomia. A 2-year follow-up showed that 83% to 92% of patients
reported no or minimal xerostomia.

Home Remedies
• Drink plenty of water
• Stop Medications
• Antihistamines
• Hormonal Medications
• Antihypertensives
• Bronchodilators
• Avoid Caffeine
• Stop Smoking and alcohol
• Avoid mouth breathing
• Aloe Vera
• Ginger
• Marshmallow
• Sweet Pepper
• Lemon
• Cardamom

MUCOSITIS
• When the injury occurs in nonoral alimentary tract mucosa, it
presents as esophagitis, gastritis, enteritis, colitis, or proctitis.
• These injuries manifest as pain, dysphagia, odynophagia, nausea,
vomiting, and diarrhea.
• Accelerated fractionation increases the risk.
• Topical benzydamine, a drug with anti-inflammatory, analgesic, and
antimicrobial effects, reduces the frequency and severity of oral
ulcers and pain.
• Protocols consisting of brushing, flossing, bland rinses, and
moisturizers should be implemented for all patients

THINGS I LEARNED
• Midline mucosa-sparing blocks were shown to protect the aerodigestive
tract and significantly reduce acute toxicity during RT for head and neck
cancer without compromising tumor control.
• Another technique is three-dimensional treatment planning with
conformational dose delivery. It reduces the volume of mucosa exposed to
irradiation.
• Chlorhexidine should not be used to prevent oral mucositis.
• An interdisciplinary approach to oral care is preferred
• Nurse
• Physician
• Dentist
• Dental hygienist
• Dietician
• Pharmacist

New classes of agents are being
investigated:
• Recombinant human
keratinocyte growth factor-1
(rhuKGF-1, palifermin)
• Epidermal growth factor,
• Transforming growth factor-β,
• Glucagon-like peptide-2,
• Lactoferrin,
• Anti-inflammatory amino acid
decapeptide,
• Recombinant human
interleukin-11, and
• Insulin-like growth factor-1.
Natural product and dietary
supplements such as:
• Glutamine,
• PV701 (milk-derived protein
extract),
• Several vitamins (A, B12, E),
• Folate,
• Aloe vera (a plant extract),
• Probiotics, and
• Curcumin

Home Remedies
• Drink plenty of water
• Honey
• Aloe vera
• Salt water rinses
• Baking soda + Salt water rinse
• Avoid
• Very hot foods
• Sugary foods
• Spicy foods
• Rough foods

GI MUCOSITIS
• External beam irradiation to the pelvis as part of treatment for
prostate, rectal, or cervical cancer produces lower GI injury.
• In a randomized, controlled trial of pelvic irradiation, sulfasalazine, 1 g
orally, twice daily, reduces GI toxicity from 93% to 80% and diarrhea
from 86% to 55%.
THINGS I LEARNED
• Agents that should not be used to prevent radiation GI toxicity:
glutamine, oral sucralfate, rectal administration of sucralfate, 5-
aminosalicylates, mesalazine, and olsalazine.

NAUSEA & VOMITING
Factors that influence radiation-induced emesis include
• Single And Total Dose Rate
• Fractionation
• Field-size And Irradiated Volume
• Site Of Irradiation And Organs Included In The Radiation Field
• Patient Positioning
• Radiation Technique, Energy, And Beam Quality
• Previous Or Simultaneous Influencing Therapy
• General Health Status Of The Patient
THINGS I LEARNED

Home Remedies
• Ginger
• Cloves
• Sugar & Salt water
• Lemonade
• Saunf
• Deep Breathing
• Wrist acupressure

DIARRHOEA
• Diarrhoea usually occurs during the third week of fractionated abdomen or
pelvic RT.
• For mild to moderate diarrhea, the initial management should include
dietary modifications.
• Patients should eat small, frequent, protein-rich meals.
• Adequate fluid intake (35 mL/kg/day) is necessary.
• Liquids should be taken primarily between meals.
• Soluble fibers such as oats, pectin, guar, and psyllium help retain stool
consistency.

• Spices, alcohol, caffeine, high osmolar beverages, and high-lactose
food should be avoided.
• Probiotic supplementation showed beneficial effect.
THINGS I LEARNED
• Loperamide remains the mainstay of pharmacologic treatment. It
should be started at 4 mg followed by 2 mg every 4 hours or after
every unformed stool (maximum, 16 mg per day).
• If diarrhea has not resolved after another 24 hours on the higher dose
of loperamide, the drug should be continued and a second-line agent,
such as tincture of opium (paregoric), an antimotility agent, can be
added.
• Diphenoxylate and atropine can also be used.
• Octreotide and glutamine have been studied and found of no benefit.

ACUTE DERMATITIS &
CHRONIC SKIN CHANGES
• Skin changes can occur at both the entrance and exit site of the
irradiation beam.
• Severity is determined by the dose, fractionation, beam, volume, and
surface area.
• Patient-specific factors also play a role, such as
• Poor nutrition status
• Pre-existing vascular condition or connective tissue disease
• Excessive skin folds, or genetics

Pathophysiology is a combination of direct radiation injury and a
subsequent inflammatory response
Free radicals from ionizing radiation cause alteration of
DNA, proteins, lipids, and carbohydrates
Epithelial basal cells, vascular endothelial cells, and
Langerhans cells are damaged.
A cascade of proinflammatory cytokines, thrombotic
factors, growth factors, and other molecules is activated

Acute skin changes may become visible after 10 to 14 hours.
Grade 1 changes include mild generalized erythema and dry desquamation,
pruritus, scaling, dyspigmentation, and hair loss.
After 4 or 5 weeks of radiotherapy and radiation doses to the skin of 40 Gy or
greater, grade 2 dermatitis may develop, with tender or edematous erythema, moist
desquamation in skin folds, and considerable pain.
They tend to peak 1 to 2 week after the last treatment and start healing 3 to 5
weeks after radiation. Complete healing may take 1 to 3 months.
In some patients, radiation recall dermatitis may occur. This happens when a patient
who has completed RT encounters a cytotoxic drug and develops skin reaction
similar to acute radiation dermatitis due to local cutaneous immunologic responses.

• Mild acute dermatitis is treated symptomatically.
• Washing with water, gentle cleansing with a mild agent, wearing
loose, nonbinding clothing, and avoidance of irritants,
antiperspirants, and ultraviolet exposure all help.
• When erythema and dry desquamation occurs, creams or ointments
(petrolatum based, castor oil, balsam of Peru, trypsin, trolamine) can
be used.
• Topical sucralfate or hyaluronic acid was shown to be efficacious in
some controlled studies.
• Other topical agents containing aloevera, d-panthenol, almond, or
chamomile can also be tried.

• When acute dermatitis becomes severe, usual wound care should be
applied to the erosions and ulcerations.
• Key measures are:
• Keeping the site clean and moist,
• Pain management,
• Protection from contamination,
• Debridement, and
• Infection control
• During radiation treatment, hydrogel dressings, hydrocolloid dressing,
burn pads, or foam dressings can be applied.
• Topical granulocyte-macrophage colony-stimulating factor, tacrolimus,
pimecrolimus, and platelet-derived growth factor also have some role

THINGS I LEARNED
• Chronic skin changes from radiation injury are harder to treat.
• Chronic fibrosis is associated with high incidence of skin breakdown
and infection.
• A team approach should be adopted to address cosmetic and quality
of life issues:
• Wound care,
• Physical therapy,
• Deep massage, and
• Pain management

• Pentoxifylline (Trental) appears to have an antifibrotic effect.
• Oral pentoxifylline (800 mg per day) and vitamin E (1,000 IU per day)
for 6 months significantly reduce radiation-induced fibrosis.
• Prophylactic use of pentoxifylline significantly reduces late skin
changes, fibrosis, and soft tissue necrosis in a randomized controlled
study, possibly through its protective effect against vascular
pathology.
• Intramuscular liposomal copper or zinc superoxide dismutase,
subcutaneous interferon-γ, or hyperbaric oxygen therapy has also
been used.

Home Remedies
• Avoid wearing tight clothes in radiation area
• Don’t touch/ rub the irradiated area
• Avoid scratching in the radiation area
• Avoid using blade in the radiation area
• Coconut oil
• Sunflower oil

URINARY SYMPTOMS
• THINGS I ALREADY KNOW
• Irradiation to the pelvic region as part of treatment for cancer of the
prostate, uterus, ovary, cervix rectum, or urinary bladder can cause
urinary problems due to injury to mucosa, vasculature, and smooth
muscles.
• Acute reactions occur within 3 to 6 months of treatment.
• Acute reactions present as dysuria, frequency, and urgency as a result
of radiation cystitis.

THINGS I LEARNED
• Phenazopyridine (Pyridium) is usually the first-line treatment for
acute symptoms. It is given at 200 mg orally, 3 times a day.
• Phenazopyridine accumulates in the urine essentially unchanged and
acts as a topical analgesic within the bladder. Patients should be
warned that phenazopyridine turns the urine into a bright orange
color and can stain clothing.
• Oxybutynin or flavoxate help relax the smooth muscles and reduce
urinary urgency and frequency.
• Tolterodine is a cholinergic antagonist that is also effective for
overactive bladder.
• Trospium (Sanctura) was documented to improve symptoms in
radiation-induced cystitis and is significantly better tolerated than
immediate-release oxybutynin

Pentosan Polysulfate Sodium
• MOA in cystitis unknown; drug appears to attach to the bladder wall
mucosa where it may act as a buffer to protect tissues from irritating
substances in the urine
• It is a weak anticoagulant (blood thinner) which may increase
bleeding.
• Indicated for bladder pain associated with interstitial cystitis
• 100 mg PO q8hr
• Administration: 1 hour before or 2 hours after meals with water
• Reassess every 3 Months

• Intravesical infusion of hyaluronic acid or chondroitin sulfate,
injection of botulinum toxin A into bladder wall, and hyperbaric
oxygen therapy have shown benefit.
• IV WF10 (tetrachlorodecaoxide), an immunomodulator, was reported
to be beneficial.
• In chronic changes dilatation or placement of a permanent catheter
may be required for significant obstruction.
• Reconstructive surgery to repair the stricture, sphincter failure, or
fistula can also be done.

Home Remedies
• Water Intake (2-3L/day)
• Frequent urination
• Vitamin C- specially
from green leafy vegetables and tomatoes
• Garlic
• Parsley
• Cranberry juice
• Avoid drinking
• Alcohol
• Coffee
• Citrus juices

FATIGUE & MOOD DYSFUNCTION
• RT-produced fatigue typically is short lived and far less severe than
chemotherapy-generated fatigue.
• One of the most common causes of fatigue is inadequate amount and poor
quality of sleep.
• In a prospective study of 28 men receiving radical external beam RT for
prostate cancer, the prevalence of moderate to severe fatigue increased
from 7% at baseline to 32% at RT completion. Fatigue significantly
interfered with walking ability, normal work, daily chores and enjoyment of
life, but at 6.5 weeks of follow-up remained higher than at baseline.
• In a study, during and for 3 months after primary RT for breast cancer,
fatigue increased from 33% to 93%, and gradual improvement occurred
during the following 3 months

• Cancer related fatigue is defined as a distressing, persistent,
subjective sense of physical, emotional, and/or cognitive tiredness or
exhaustion related to cancer or cancer treatment that is not
proportional to recent activity and that interferes with usual function.
• Management approach:
• Education
• Behaviour changes
• Pharmacologic interventions
• Non pharmacologic interventions

• Education of patient and family members should form the foundation
of CRF management. Patient should be counseled on self-monitoring
of fatigue levels, energy conservation techniques, and the use of
distraction.
• Simple behavioral changes in daily life, such as
• Setting priorities,
• Pacing daily activities,
• Delegating as much as possible,
• Scheduling activities at times of peak energy, and
• Structuring a daily routine to promote quality of sleep
• Psychostimulants, such as methylphenidate or modafinil are being
studied.

Non Pharmacologic Interventions
• Initiation of an exercise program
• Referral to physical therapy, occupational therapy, or rehabilitation
medicine may help enhance activity levels.
• Psychosocial interventions can be implemented to address
depression, anxiety, and adjustment disorders:
• Cognitive behavioral therapy,
• Educational therapy, and
• Supportive expressive therapy
• Massage therapy to reduce tension and stress is often helpful.

FEMALE SEXUALITY
• High-dose radiation to the pelvis causes varying degrees of sexual
dysfunction related to injury to the ovaries and vagina.
• Acute injury presents as vaginal and vulval mucositis, pain, and ulceration.
• Chronic changes include
• Fibrosis
• Loss of elasticity and sensation
• Susceptibility to trauma and infection
• Postcoital bleeding
• Dyspareunia

THINGS I LEARNED
• Maintenance of local hygiene, aggressive treatment of infection, and
regular dilatation of the vaginal canal help reduce the acute reaction.
• Hormone replacement therapy and application of lubricants for mucosal
dryness can be used to treat acute injury.
• Use of vaginal dilators, lubricants, and supplemental estrogen to prevent
chronic changes.
• Hyperbaric oxygen therapy or surgical reconstruction can be used in severe
cases.
• Topical estrogen showed benefit and promotes epithelial regeneration.
• Benzydamine is an anti-inflammatory that also has analgesic, local
anesthetic, and antimicrobial effects.
• Reconstructive surgery in cases of perineal defect or obliteration of vagina

MALE SEXUALITY
• When planning RT for prostate cancer, its effect on male sexual
function must be discussed with the patient.
• A survey showed that 68% of men aged 45 to 70 years were willing to
trade off a 10% or greater advantage in 5-year survival to maintain
sexual potency.
• RT does not reduce testosterone production or cause pelvic nerve
injury.
• Diminished sexual desire, decreased orgasmic pleasure, and a
reduced ejaculation volume are reported problems.

Non Pharmacologic Interventions
THINGS I LEARNED
• A multidisciplinary approach, including psychosocial evaluation and
counseling, pharmacologic intervention, and exploration of the use of
mechanical devices should be done
• The mainstay of pharmacologic treatment is phosphodiesterase
inhibitors like sildenafil and Tadalafil
• Implantation of a penile prosthesis can be considered.
• Vacuum devices are another option
• Intracavernosal injection of prostaglandins or phentolamine
papaverine is also effective.

PSYCHOSICAL PROBLEMS
• Coping, distress, and support are crucial psychological issues that
need to be discussed with patient and their attendants.
• Coping with a serious medical illness can be very challenging for a
patient.
• Common reactions at various stages of illness
At the time of Diagnosis Advanced Stage Terminal Stage
Shock Fear Regret
Emotional Numbness Sadness Guilt
Disbelief Guilt Hopelessness
Denial & Anger Helplessness

Stage-Specific Coping Challenges and Medical Responses
Stage of Cancer Coping Challenge Physician Response
Initial Diagnosis Existential anxiety Rapid and clear evaluation
Acute Treatment Helplessness Invite participation in treatment
decisions
Fatigue/ disruption of social rules Invite involvement of family/
friends
End of acute
treatment
Increased sense of vulnerability/ anxiety about
relapse and long term treatment effects
Treatment summary and long
term follow up plan
Medical Isolation Survivorship program
Relapse Anxiety about disease progression/ treatment
effects
Clear communication
compassion
Truncated future Commitment to providing care
Loss of social contacts Reordering priorities group and
other support

THINGS I LEARNED
• Psychoeducational Interventions
• Coping skills training
• Mindfulness training
• Electronic Technology-Based Interventions
• Cognitive-Behavioral Therapy
• Group Psychotherapy
• Psychotropic Medication
• Antidepressants
• SSRIs
• Antiaxiety agents

NUTRITION
• Integrate Nutrition into the overall treatment plan
• Nutritional recommendations include a high fat and low carbohydrate feed
• High caloric density feeding
• Improve lean body mass
• Low carbohydrate content
• “Starve the tumor, feed the patient”
• Suggested composition:
• High energy >1.2 – 1.5 kcal /ml
• High fat 45 - 50 % and low CHO
• High protein 18 - 20 %
(50% - Fat, 20% - Protein, 30% - CHO)

Incidence Of Malnutrition In Different Tumor Sites
Tumor Site % Malnutrition
Advanced Stage Patients 60%
Oesophagus 79%
Breast 9%
Gastric 83%
Lung (small cell) 50%
Head and Neck 72%
(Adapted from Freeman 2004)

Supportive Care & Quality of Life: Managing Cancer Symptoms

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