How are symptoms managed?

Management of Cancer-Related Symptoms

Implement routine symptom screening at every clinic visit using validated questionnaires or patient-reported outcome measures (PROMs), followed by comprehensive investigation if empirical treatment fails within days, as most cancer patients have multiple concurrent causes requiring simultaneous treatment. 1

Systematic Assessment Framework

Routine Screening Protocol

• Use validated symptom questionnaires (such as the Gastrointestinal Symptom Rating Scale) or PROMs at every clinic visit to capture the full spectrum of symptoms that patients may not spontaneously report 1, 2
• Screen specifically for pain, depression, and fatigue using visual analog or numeric rating scales, as these are the most prevalent undertreated symptoms 1
• Perform comprehensive biopsychosocial assessment immediately after diagnosis and at key transition points: completion of treatment, disease progression, and new symptom onset 1

Critical Diagnostic Principle

• Clinical symptoms alone cannot reliably identify underlying causes in cancer patients—comprehensive investigation is required early if symptoms persist despite simple empirical intervention 1
• The majority of patients have more than one physiological cause for their symptoms; all must be diagnosed and treated simultaneously to achieve resolution 1, 2
• Common treatable causes include bile acid diarrhea, carbohydrate intolerance, pancreatic exocrine insufficiency, small intestinal bacterial overgrowth, and infections after immunosuppression 1

Symptom-Specific Management

Pain Management

• Follow the WHO three-step analgesic ladder: start with NSAIDs, add weak opioids if inadequate, then substitute strong opioids for persistent pain 1
• Prescribe around-the-clock dosing rather than as-needed to improve adherence and outcomes 1
• Add adjuvants for neuropathic pain and opioid side effects 1
• Consider external beam radiotherapy for localized pain and bisphosphonates for bone metastases pain 1

Depression and Anxiety

• Prescribe adequate doses and duration of antidepressants, as they demonstrate clear benefit in cancer-related depression 1
• Use sedating antidepressants (targeting both sleep and mood) over sedative-hypnotics (which only improve sleep) for insomnia 1
• Integrate cognitive-behavioral therapy and psychosocial interventions, which show modest benefit 1
• Consider anxiolytics and psychostimulants to decrease morbidity from anxiety and excessive daytime sedation 1

Breathlessness

• Implement interventions specifically designed for dyspnea using psychological coping and physical adaptation techniques, as these more effectively decrease distress than usual care 1
• Teach controlled breathing techniques: positioning, pursed-lip breathing, breathing exercises, and coordinated breathing training 1
• For patients with cough, advise avoiding lying supine as this makes coughing ineffective 1, 3
• Consider short-term codeine linctus, codeine phosphate tablets, or morphine sulfate oral solution for distressing cough 1

Fatigue

• Recognize that fatigue is the most prevalent cancer symptom but has limited evidence for effective pharmacologic therapies 1
• Consider psychostimulants to reduce morbidity from fatigue 1
• Implement psychoeducational interventions addressing fatigue, which can improve quality of life in physical and psychological domains 1

Psychological and Behavioral Interventions

Evidence-Based Approaches

• Offer one of several proven psychological interventions: psychoeducation, deep breathing, progressive muscle relaxation, guided imagery, cognitive behavioral therapy, or supportive psychotherapy 1
• Select interventions based on patient preference, healthcare team skill-set, and available evidence, as there is insufficient data to recommend one over another 1
• Integrate non-pharmacologic interventions with medication management rather than using either alone 1

Treatment Principles

• Effective interventions share common features: increased illness understanding, facilitation of meaning-making, opportunities for active coping, promotion of self-care skills, and provision of supportive therapeutic atmosphere 1
• Address symptoms rapidly as patients with lung cancer experience declining health and terminal illness, requiring timely flexible interventions 1

Gastrointestinal Symptom Management

Nutritional Support Strategy

• Target 25-30 kcal/kg/day for ambulatory patients and 20-25 kcal/kg/day for bedridden patients using actual body weight 2
• Provide minimum 1.0 g protein/kg/day, with optimal range of 1.2-1.5 g protein/kg/day to maintain fat-free mass 2
• Emphasize diet high in vegetables, fruits, whole grains with low saturated fat, focusing on micronutrient-rich and phytochemical-rich foods 2

Enteral Nutrition Indications

• Initiate tube feeding when oral intake is inadequate (<60% of estimated energy expenditure) for more than 10 days, or when undernutrition already exists 2
• Use nasogastric tubes for short-term feeding (<30 days) and percutaneous gastrostomy for longer-term feeding (>4 weeks) 2
• Avoid parenteral nutrition during chemotherapy or radiotherapy except in cases of malnutrition or starvation longer than one week where enteral support is not feasible 2

Critical Pitfalls to Avoid

• Do not rely on clinical acumen or symptom patterns alone to diagnose underlying causes—investigation is mandatory 1
• Avoid restrictive diets (ketogenic, fasting) in patients with or at risk of malnutrition, as they lack clinical evidence and may cause insufficient energy intake 2
• Do not assume medical investigations will reassure patients—they often have iatrogenic effects and fail to provide reassurance 1
• Avoid excessive calcium supplementation (>1200 mg/day) 2
• Do not delay psychological interventions until late in disease course—early integration improves outcomes 1

Healthcare System Requirements

Multidisciplinary Team Structure

• Ensure cancer care is delivered by specialized teams with access to rehabilitation specialists, psychologists, physiotherapists, and registered dietitians 2
• Designate a specialized nurse or healthcare practitioner as patient navigator throughout the cancer journey 2
• Train all healthcare professionals in psychological and physical symptom management of symptoms frequently associated with cancer diagnosis, treatment, and survivorship 1

Quality Improvement Framework

• Follow treatment algorithms with continuous quality-improvement interventions 1
• Perform regular reassessment and follow-up of symptom scores 1
• Ensure adequate reimbursement for symptom management and medications 1
• Consider inadequately treated pain as an indicator of poor quality of care 1

Treatment Planning Essentials

• Establish treatment escalation plans early, as patients may deteriorate rapidly and need urgent hospital admission 1
• Document advance care plans, advance decisions to refuse treatment, and do-not-attempt-resuscitation decisions clearly 1
• Provide clear instructions on when to seek emergency care: worsening breathlessness, persistent chest pain, confusion, or bluish lips 3