From the Guidelines
The best next step is to refer the patient to palliative care. This patient has newly diagnosed stage IV colon cancer with manageable pain and an ECOG performance status of 2, indicating he is still relatively functional despite his disease. Since he and his wife explicitly want to pursue chemotherapy, hospice care would not be appropriate at this time as hospice typically focuses on comfort measures rather than disease-directed therapy.
Key Considerations
- Palliative care can provide symptom management, including pain control, while allowing the patient to simultaneously receive cancer treatment 1.
- Palliative care specialists can help address his pain issues, decreased appetite, and other symptoms while he undergoes chemotherapy.
- They can also facilitate goals of care discussions as his disease progresses.
- An interventional pain clinic would be too narrowly focused on pain management alone when this patient has multiple needs including nutritional support and comprehensive cancer care coordination.
- The patient's desire for chemotherapy is consistent with the recommendation for palliative chemotherapy in patients with inoperable cancers of the colon, as stated in the study published in the British Journal of Cancer 1.
Treatment Approach
- The study suggests that chemotherapy is recommended for the palliative treatment of inoperable cancers of the colon, with options including 5-FU/FA and 5-FU/methotrexate ± FA combinations 1.
- Palliative care offers the most comprehensive approach that aligns with the patient's current goals for treatment, allowing for both symptom management and disease-directed therapy.
From the Research
Patient's Situation
The patient is a 66-year-old man with stage IV colon cancer, experiencing abdominal pain and diminished appetite. He has an Eastern Cooperative Oncology Group performance score of Grade 2, indicating he is ambulatory and capable of self-care but unable to work.
Treatment Options
The patient's pain is better controlled after hospital care, and he is ready for discharge. His sister-in-law, a home hospice nurse, suggests enrolling him in home hospice care, but the patient and his wife want him to receive chemotherapy.
Best Next Step
- Refer to palliative care: This option is recommended because palliative care can be utilized concurrently with disease-modifying or curative therapies, such as chemotherapy 2, 3. Palliative care focuses on improving the quality of life of patients with life-threatening illnesses, including pain and symptom management, and emotional and spiritual support 3, 4.
- The patient's performance status, as assessed by the Eastern Cooperative Oncology Group, may be rated differently by palliative care specialists, nurses, and medical oncologists, highlighting the importance of interdisciplinary communication 5.
- While interventional pain management techniques can provide satisfactory pain relief for patients with advanced cancer, palliative care is a more comprehensive approach that addresses the patient's physical, psychological, and spiritual needs 6.
Considerations
- The patient's desire to receive chemotherapy suggests that he is not ready for hospice care, which is typically reserved for patients with a prognosis of 6 months or less 4.
- Palliative care can help guide treatment decisions and improve the patient's quality of life, making it an appropriate next step 2, 3.