• INTERNATIONAL JOURNAL OF PHARMACEUTICAL MEDICINE 2000, 14:85-87 85

ORIGINAL ARTICLE

Recent progress in improvingquality of life in cancer patients

Peter Harper

Guy's Hospital, Department of Oncology, St Thomas Street, London SE1 9RT, UK

Received 4 February 2000; accepted 9 February 2000

SummaryThe importance of assessing and maintaining quality of life (QOL) in cancer patients is nowwell appreciated. The development of standardized instruments, such as the measurementsystem from the European Organization for Research and Treatment of Cancer (EORTC)QLQ-C30, the Functional Assessment of Chronic Illness Therapy (FACIT) scale and thevarious anaemia-specific questionnaires for quantifying patients' QOL, has led to theemergence of QOL measures in clinical studies to aid in assessing new treatments.Recommendations for appropriate management of common cancer-related symptoms, suchas pain, depression, fatigue, and nausea and vomiting, are described in this paper.Depression may be difficult to diagnose due to the overlap of symptoms from the cancer aswell as cancer therapy, but it does respond well to treatment. However, the single mostimportant cause of QOL deficit in cancer patients is fatigue. This is clearly multifactorial,but we are now able to assess the component associated with anaemia and its relief can leadto improvements in QOL in cancer patients. There are many potential causes of QOLdeficit in cancer patients and it is prudent that clinicians frequently monitor QOL duringthe course of the disease and treatment, while actively preventing and treating the relevantsymptoms.

Keywords: cancer, quality of life, depression, fatigue, anaemia.

Introduction

Measurement of quality of life (QOL) is important for thesuccessful management of cancer. It involves treating both thedisease itself and the side effects associated with cancer therapy.Patients who receive effective cancer treatment expect to havedisease regression and alleviation of cancer-related signs andsymptoms (e.g. ascites in ovarian cancer, dyspnoea in lungcancer, pain in most forms of cancer). However, these patientsare often then faced with an array of side effects caused bycancer therapy, including nausea and vomiting, alopecia,mucositis, and loss of appetite. They may also develop anaemiawith a worsening of fatigue and the depression and anxiety thatso frequently accompany both the disease and its treatment. Allof these may counteract the benefits obtained by treating thecancer. Fortunately, appropriate management of symptoms canresult in substantial improvements in the patient's QOL. Thispaper provides an overview of the management issues related toeach symptom.

Management of symptoms affecting QOL

In managing cancer patients, clinicians often focus on determin­ing the presence of signs and symptoms. However, they veryoften fail to address patient fears regarding what is in many casesa terminal illness. Although cancer patients with widespreaddisease understand that death is inevitable, they fear death andthe idea of leaving their loved ones behind due to cancer. Cancerpatients also fear the disease process. For example, patients maybe unsure about their ability to cope with certain cancer-relatedsymptoms, including pain. In addition, cancer patients maydevelop the fear of becoming dependent on others due to theirinability to maintain normal daily activities. Such patients maybelieve that such dependence may overwhelm the caregiversleading to inadequate support from them, which then results infear of being deserted by their family. These fears can precipitatedepression with a consequent diminution in QOL. Cliniciansneed to be sensitive to the patient's ability to cope with thedisease and treatment associated side effects when making

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86 HARPER

therapeutic decisions. Some of the methods of helping thepatients cope with these fears include use of humour whenconsulting with them and assuring them of a genuine interest intheir well-being, not just treating the symptoms. Clinicians alsoneed to show optimism and hope for improved survival. Ifinducing remission alleviates the immediate fear of death,patients tend to live a happier and active life. Therefore,management of cancer patients needs to take into account bothphysical and psychosocial considerations.

PainPain is an extremely common symptom in cancer patients,however, the prevalence and severity of pain in cancer patientsdepends on the stage and site of disease. For example, less than15% of patients with a non-metastatic tumour experience pain,while pain occurs in as many as 60-90% of patients withadvanced disease [1]. The site of disease is also a significantfactor: pain is more prevalent in patients with tumours that tendto metastasize to bone (e.g. breast, prostate) and in cancers thatare in close proximity to neural structures such as the pelvic painassociated with gynaecological malignancies [1]. In addition,cancer patients have a fear of suffering from pain as the diseaseprogresses. Although pain is controllable with suitable medica­tion, it remains very prevalent. In one survey of outpatients whohad recurrent or metastatic cancer, 56% of patients reportedsuffering substantial pain (defined as 5 or greater on the BriefPain Inventory) [2].

QOL is further impacted by the inadequate treatment of painin cancer patients. Many patients reported inadequate control ofpain. Forty-two percent of patients had a negative score on thePain Management Index (i.e. their pain was greater than wouldbe predicted by their prescribed pain medications) [3]. This isdue to a lack of knowledge by the treating physicians regardingthe appropriate management of pain [1] and patients' resistanceto pain treatment due to the fear of becoming addicted tonarcotic analgesics. Furthermore, inadequately controlled severepain can interfere with a patient's QOL, including the activitiesof daily living (ADL), sleep, and social interactions [1].

There are two treatment strategies to pain management incancer patients: amelioration of the disease process andanalgesic pain relief. Chemotherapy and radiotherapy areusually regarded as therapies for achieving remission or cureof malignancy, not as treatments for symptom control. However,they can be highly effective in a palliative role because byshrinking the tumour they can alleviate pain caused by themalignancy. Adjunctive cancer therapies, such as bisphospho­nates for bone metastases and surgical relief of neurologicalcompression, can provide excellent pain relief where relevant.However, pain relief achieved from these therapies is limitedsince they are not specifically targeted to alleviate pain. Henceanalgesics, including both opioids and non-opioids, are widelyused in cancer patients to relieve pain. Some patients may alsobenefit from invasive analgesic techniques such as coeliac plexusblock.

Severe cancer pain can be treated with opioids, with orwithout non-opioids (e.g. non-steroidal anti-inflammatory drugsor NSAIDs) and other adjuvant therapies. Patients with mild-to­moderate pain can be treated with less potent opioids, such ascodeine, oxycodone, hydroxycodone and propoxyphene; how­ever, severe pain may require the use of more potent opioidsincluding morphine, hydromorphone, levorphanol, and trans-

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dermal fentanyl. The choice of specific agents can be based onpatient preference and QOL considerations. For instance,although both transdermal fentanyl and morphine are equallyefficacious for pain relief, significantly more patients prefer thetransdermal fentanyl despite having a greater incidence of sleepdisturbances with this agent [4]. This preference is probably dueto a lower incidence of drowsiness and constipation and possiblyalso the greater convenience of only having to administer thetransdermal fentanyl patch once every 72 hours.

In conclusion, the inadequate treatment of pain is still aproblem in cancer patients. It is important for clinicians tocontrol the pain adequately with available therapeutic interven­tions that minimize the adverse impact of pain on QOL. At thesame time adverse effects of the pain medications may also needto be minimized. For further discussion of this topic see thearticle by Charles Cleeland in this issue.

DepressionUp to 50% of hospitalized cancer patients have been reported tobe affected by depression, yet it often remains underdiagnosedand undertreated [5]. However, the overall incidence ofdepression in cancer patients is generally similar to that foundin hospitalized patients with physically debilitating illnessesother than cancer, suggesting that depression occurs due to thechronic debilitating nature of the illness and not due to canceritself. Patients with pancreatic and head-and-neck cancersappear to have a higher incidence of depression than patientswith other cancers. What should be stressed is that the diagnosisof depression must be based on the psychological symptoms,since the somatic symptoms are often indistinguishable from thesymptoms of cancer. In general, depression is a treatablecondition and most antidepressants that are used to treatdepression in the general population can also be used in cancerpatients. However, the doses required for controlling depressionin cancer patients are often less than those for physically healthyindividuals. Currently available antidepressants include tricyclicantidepressants (TCAs), monoamine oxidase (MAO) inhibitors,selective serotonin reuptake inhibitors (SSRIs), and sympatho­mimetic agents. Both fluoxetine (a SSRI) and desipramine (aTCA) are effective and safe in improving depressive symptomsin cancer patients; however, there is some evidence thatfluoxetine may provide greater improvements in QOL measures[5]. Patients may also benefit from adjuvant psychologicaltherapy that includes a cognitive-behavioural treatment pro­gramme specifically designed for the needs of cancer patients.Such therapy has been shown significantly to improve psycho­logically-related QOL measures in cancer patients [6]. Insummary, depression in cancer patients can be effectivelytreated with antidepressants in combination with adjuvantpsychological therapy.

FatigueDepression and fatigue are usually considered interrelated in thegeneral population, but in cancer patients they appear to belargely independent of each other. This is also evident from thedistinct time courses of the two symptoms. In cancer patients,fatigue is an important independent predictor of QOL. Fatigue isalso the most commonly reported symptom of cancer and cancertherapy [7]. Seventy-eight percent of cancer patients reportbeing fatigued during the course of the disease and treatment[7], with about 32% complaining of fatigue daily [8]. One of the

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underlying causes of fatigue is anaemia, which occurs in over60% of cancer patients [9, 10]. Approximately 33% of cancerpatients require blood transfusion [9, 10]. The management ofanaemia is discussed extensively in the article by Paul Sabbitiniin this issue.

Nausea and vomitingChemotherapy-induced nausea and vomitmg are common incancer patients, especially those receiving cisplatin and cyclo­phosphamide. More than 75% of patients receiving combinedchemotherapy are affected [11]. Selective serotonin receptor (5­HT3) antagonists (e.g. ondansetron and granisetron) are potentantiemetic agents with a low incidence of side effects. Theefficacy of ondansetron was demonstrated in a large comparativetrial of 259 breast cancer patients [12]. Ondansetron was foundto be significantly superior to alizapride (the mechanism ofaction is similar to metoclopramide) in reducing both nauseaand vomiting as well as improving overall QOL as related toemesis [12]. Other agents for controlling nausea and vomitinginclude metoclopramide, corticosteroids (e.g. dexamethasone),phenothiazines, cannabinoids, and haloperidol. However, thelatter three categories have low antiemetogenic activity. Ingeneral, nausea and vomiting in cancer patients are most safelyand effectively treated with 5-HT3 antagonists while the delayednausea is best treated with prolonged (2-4 days) corticosteroids.

Conclusions

QOL in cancer patients can be significantly improved by prompttreatment of the most common causes of QOL deficit (i.e. pain,depression, anaemia, and fatigue). Although cancer-related painis almost always controllable, especially with the use of newertherapies, it is often undertreated. Depression is generallydifficult to diagnose due to the overlap of symptoms from thecancer as well as the therapy (chemotherapy and radiotherapy),but responds well to treatment. While both pain and depressioncan compromise patient QOL, the single most common cause ofQOL deficit in cancer patients is fatigue. Fatigue is oftensecondary to anaemia and difficult to treat. Relieving the

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RECENT PROGRESS IN IMPROVING QUALITY OF LIFE 87

contributing anaemia can lead to improvements in the QOL ofcancer patients. There are many potential causes of QOL deficitin cancer patients and it is prudent that clinicians frequentlymonitor QOL during the course of the disease and treatment,while actively preventing and treating symptoms that impairQOL.

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