Symptom Control in Cancer Rehabilitation - TIRR …tirr.memorialhermann.org/uploadedFiles/_Library/TIRR... · 2016-05-13 · Cancer Patients’ Symptoms Pain- 90% of patients with

Symptom Control in

Cancer Rehabilitation Ying Guo, MD

Department of Palliative, Rehabilitation and Integrative Medicine

UT MD Anderson Cancer Center

Cancer Patients’ Symptoms

Pain- 90% of patients with advanced cancer

Fatigue–60-90% of cancer patients

Cachexia/Anorexia Syndrome-80% patients with advanced cancer

How to Assess Symptoms

Symptom During Inpatient

Rehabilitation

Patients who were admitted to an acute inpatient rehabilitation unit

(N=96). Patients’ median age was 64 years (range, 26–87y), and 49% were

women.

Cancer patient’s symptom intensity is high at admission

Symptoms with high intensity:

Pain

Fatigue

Anorexia

Insomnia

Symptom During Inpatient

Rehabilitation

0

1

2

3

4

5

Ave

rag

e V

AS

Admission

Discharge

Symptom During Inpatient

Rehabilitation

Significant improvements

Anxiety (P=.001)

Constipation (P=.001)

Fatigue (P=.002)

Pain (P=.003)

Appetite (P=.004)

Insomnia (P=.04)

Sense of well-being (P=.01)

Symptom During Inpatient

Rehabilitation

0%

10%

20%

30%

40%

50%

60%

70%

80%

Ana

lgesi

cs

App

etite

stim

ulant

Mirt

azapi

ne

Met

oclo

pram

ide

Ant

idep

ress

ants

Met

hylp

henida

te

Laxa

tives

Hyp

notic

s

Perc

en

tag

e o

f P

ati

en

ts

Symptom During Inpatient

Rehabilitation

The poor appetite at admission scores correlated positively with hospital

LOS (P<.001)

Depression at admission scores also correlated positively with hospital LOS

P=.05)

Average acute rehabilitation LOS was 9 days.

Symptom at Outpatient Rehabilitation

Clinic

Survivorship definition by NCI: In cancer, a person is considered to be a survivor from the time of diagnosis until the end of life.

Short-term survivor: ≤5 years since cancer diagnosis

Long-term survivor: ≥5 years since cancer diagnosis

Comparison of symptoms in short-term and long-term cancer survivor

Similar symptom pattern

Highest intensity symptoms are:

Pain

Fatigue

Anorexia

Insomnia

Characteristics of Patients in the Two Study

Groups <5 YSD (N=133) ≥5 YSD (N=67)

Age, Mean (SD) 53.4 (16.9) 57.8 (15.6)

Female 63 (47.4) 40 (59.7)

Weight (Kg), Mean (SD) 81.0 (22.2) 78.6 (21.9)

Height (cm), Mean (SD) 168.9 (10.5) 166.8 (11.1)

BMI, Mean (SD) 28.5 (8.3) 28.3 (8.1)

N (%)

N (%)

Race

Asian 7 (5.3) 7 (10.4)

Black 14 (10.5) 12 (17.9)

Hispanic 16 (12.0) 6 (9.0)

White 94 (70.7) 42 (62.7)

Unknown 2 (1.5) 0

Cancer Treatment History

Prior Chemotherapy 75 (56.4) 44 (65.7)

Prior Radiation therapy 74 (55.6) 44 (65.7)

Prior Surgery 115 (86.5) 59 (88.1)

Types of cancer

Brain/spinal 42( 31.6) 15 (22.4)

Breast 14 (10.5) 18 (26.9)

Gastroenterological 12 (9.0) 5 (7.5)

Head & Neck 10 (7.5) 4 (6.0)

Leukemia 9 (6.8) 3 (4.5)

Lung 7 (5.3) 3 (4.5)

Lymphoma 4 (3.0) 5 (7.5)

Melanoma 6 (4.5) 2 (3.0)

Prostate 3 (2.3) 2 (3.0)

Sarcoma 15 (11.3) 5 (7.5)

Other* 11 (8.3) 5 (7.5)

Comparison of Symptom based on ESAS in the Short-term and Long-term Survivor Groups

0

1

2

3

4

5

6

7

8

9

10

Pain Fatigue Nausea Depression Anxiety Drowsiness Appetite Feeling of

WellBeing

Shortness of

Breath

Sleep

Me

dia

ns

ESAS Symptoms

<5 Year Since Diagnosis

≥ 5 Year Since Diagnosis

Comparison of Medications Used for Symptom

Management in the Short-term and Long-term Survivor Groups

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<5 Years Since Diagnosis

≥ 5 Years Since Diagnosis

Comparison of Symptom Treatment in the Short-term and Long-term Survivor Groups

132/200 (66%) total patients had fatigue ratings of ≥3

Methylphenidate is the most studied pharmacological agent for the treatment of cancer-related fatigue.

11/133(8%) of short-term survivors uses Methylphenidate

9/67 (13%) of long-term survivors uses Methylphenidate

99/200 (49.5%) total patients had anorexia ratings of ≥3

Appetite stimulants were prescribed for 61 (46%) of short-term survivors

Appetite stimulants were prescribed for 27 (40%) of long-term survivors

Among those patients with poor appetite ratings of ≥3, only 51/100 (51%) had appetite stimulants in their medication lists.

110 (56%) total patients had poor sleep ratings of ≥3

Hypnotics were prescribed for 20 (15%) of short-term survivors

14 (21%) of long-term survivors.

Symptoms are Under-treated

Lack of effective and standardized treatment for these symptoms.

Lack of emphasis in symptom control in rehabilitation community.

Patient’s hesitation in taking additional medications.

Physician’s worry of polypharmacy, and side effect of the medication.

Finding Reversible Causes-Pain

Etiology of pain

Neuropathic pain:

Nociceptive pain:

Somatic:

Bony pain: bracing

Joint pain: bracing, joint injection

Myofascial pain: myofascial release, heat, cold, acupuncture, massage, stretching

Visceral: distention due to gas/constipation: proper bowel and bladder management

Secondary pain:

Central sensitization and a windup phenomenon: causing prolongation and amplification nociceptive activity even after the cessation peripheral input: medication, acupuncture

Spiritual pain: support from family, social worker, psychologist, chaplain, Priest

Case Report

Plantar fasciitis in a 60 year old female patient with metastatic renal cancer

0

5

10

15

20

25

30

35

40

45

0

1

2

3

4

5

6

7

8

9

10

1/2/2015 2/3/2015 3/2/2015 4/13/2015 7/6/2015

Oxycontin ER (mg/day)

Pain

Finding Reversible Causes-Fatigue

Central fatigue:

Depression: involve supportive care on psychiatry

Brain dysfunction due to brain metastasis/tumor

Paraneoplastic neurological syndrome

Peripheral fatigue:

Effect of inflammatory cytokines (TNF alpha, IL-6,IL 1,

IL-2): causing anorexia, progressive loss of muscle

mass.

Correct anemia: iron deficiency, Vitamin B12

deficiency, folate deficiency, GI bleed

Bed rest, immobility lead to low exercise tolerance:

endurance training and aerobic exercises

Hb

BUN

↑ Low Fe,

high retic

Finding Reversible Causes-Fatigue

Peripheral fatigue:

Respiratory related to reason: Pulmonary toilet, each patient abdominal /diaphragmatic breathing

Infections

Endocrine disorders: adrenal insufficiency; hypothyroidism; hypogonadism

Anticancer treatment related side effect, such as nausea and vomiting

Poor sleep: cluster care

Hypocalcemia

Calcium

Vit D

Finding Reversible Causes-Insomnia

Anxiety: Cognitive behavior therapy

Sun-downing/delirium

Circadian rhythm dysfunction: Melatonin; increase exposure to sun, sleep

hygiene

Symptom control: frequent urination, pain, shortness of breath, depression

and anxiety

High-dose steroid-induced insomnia: taper down steroid, may use short-

term hypnotics.

Finding Reversible Causes-Anorexia/

Poor Appetite

Medication caused:

Pain medication: opioids

Antibiotics

Constipation: laxative and bowel program

Disturbed GI function due to antibiotics treatment, chemotherapy,

radiation treatment: probiotics