From the Guidelines
For a patient with lung cancer, poor prognosis, and ineligibility for palliative chemotherapy, the next step should be a comprehensive palliative care approach focused on symptom management and quality of life. This approach is supported by the American College of Chest Physicians evidence-based clinical practice guidelines 1, which emphasize the importance of palliative care in reducing symptom burden, enhancing quality of life, and increasing survival benefit. The guidelines recommend that all physicians caring for patients with advanced lung cancer should initiate conversations about the goals of care, the pros and cons of life-sustaining treatment, and end-of-life care options 1.
The comprehensive palliative care approach would include:
- Optimizing pain control with medications such as morphine (starting at 5-15mg oral every 4 hours as needed, with a long-acting formulation like MS Contin 15-30mg twice daily once pain patterns are established)
- Managing dyspnea with opioids and possibly oxygen therapy
- Addressing other symptoms like cough, fatigue, and anxiety
- Consultation with a specialized palliative care team to coordinate care across multiple domains
- Psychological support for both the patient and family, along with discussions about goals of care and advance directives
- Hospice referral should be considered if the prognosis is estimated to be six months or less, as indicated by the National Comprehensive Cancer Network guidelines 1.
This approach is further supported by studies that demonstrate an increase in life expectancy and quality of life when palliative care is introduced early in the illness 1. The goal of palliative care is to relieve suffering and, if possible, to prolong life, with a focus on hope and control of the disease and its symptoms, as well as its impact on families 1.
By prioritizing palliative care, healthcare providers can improve the quality of life for patients with lung cancer and poor prognosis, even when disease-modifying treatments are no longer appropriate. As recommended by the guidelines, clinicians should discuss the prognosis with patients and their families clearly and consistently to help them develop realistic expectations 1.
From the Research
Next Steps for Patients with Lung Cancer and Poor Prognosis
For patients with lung cancer, poor prognosis, and not eligible for palliative chemotherapy, the next steps focus on symptom management and improving quality of life.
- Symptom Management: The primary goal is to alleviate symptoms such as dyspnea, chronic cough, severe pain, exhaustion, cachexia syndrome, fear, and depression 2, 3, 4.
- Palliative Care: Palliative care is crucial for these patients, providing comprehensive support to address emotional, physical, and spiritual suffering 4, 5.
- Multidisciplinary Approach: A multi-level approach involving interventions at the patient, health professional, and health service level is recommended for optimal outcomes from supportive and palliative care interventions 2.
- Non-Pharmacological Interventions: Non-pharmacological interventions such as pursed lip breathing, diaphragmatic breathing, positioning, and pacing techniques can improve breathing efficiency and manage dyspnea 2.
- Psychosocial Interventions: Psychosocial interventions can reduce anxiety and distress, further improving the management of breathlessness, although more studies are needed to fully understand their effectiveness 2.
- Case Management and Nurse-Led Follow-Up: Case management approaches and nurse-led follow-up programs have been shown to be effective in reducing breathlessness and psychological distress, providing a useful model for supporting the implementation of evidence-based symptom management strategies 2.
- Early Palliative Care Referral: Early referral to palliative care can improve quality of life, decrease symptom burden, and help patients better understand their illness 5.
- Primary Palliative Care Skills: Developing primary palliative care skills among all providers caring for patients with lung cancer can benefit more patients by providing better symptom management, communication, support, and quality of life 5.