Common symptoms

Sunday 28 February, 2010

On this page: Nausea | Breathlessness | Tiredness | Pain | Lack of appetite

The person with advanced cancer may have different symptoms at different times. Some symptoms will be a side effect of cancer treatment while others will be caused by the cancer .

It's hard to cover all possible symptoms of advanced cancer, so we'll look at some common symptoms: nausea, breathlessness, tiredness, pain and lack of appetite. The person you're caring for may have some of these symptoms or none.

If you're concerned about a particular symptom, explain your concern to the treating doctors and nurses.

Nausea

Nausea is an unpleasant symptom that can be caused by:

  • treatment with chemotherapy or radiotherapy
  • the location of the cancer
  • stress or anxiety
  • an imbalance in the minerals in the blood, for example, calcium
  • drugs that control other symptoms, for example, morphine for pain
  • a bowel obstruction or blockage
  • increased pressure around the brain as a result of cancer in the brain or cancer affecting the fluid around the spinal cord.

If the person with cancer has nausea, they don't have to put up with it: tell the doctor or nurse. It's important the doctor identifies the cause so the right treatment can be prescribed. Treatments for nausea include:

  • changes to the diet, for example, offering cold food rather than hot food
  • anti-nausea drugs taken regularly and before pain drugs or in higher doses
  • a drug which lowers calcium levels in the blood
  • reducing stress, for example, with meditation or breathing exercises
  • dry ginger ale or ginger tea (some people say this helps).

Breathlessness

Some people with advanced cancer become breathless. It may be frightening for the person who is having trouble breathing and those around them. Breathlessness may be due to:

  • fluid around the lungs
  • cancer in the lung
  • low haemoglobin or anaemia
  • scarring around the lung from radiotherapy
  • a swollen abdomen causing pressure under the diaphragm
  • pre-existing lung problems like asthma or emphysema
  • chest infection
  • anxiety and fear.

The treatment depends on the cause. Simple measures include:

  • reassurance - stay with the person if they're afraid and encourage them to relax
  • keeping a personal fan nearby
  • a well-ventilated room - have a fan in the room or open a window
  • encouraging the person to sit in a forward-leaning position, for example supported by the back of a chair
  • oxygen - a supply for home can be organised by the hospital or local doctor
  • using a wheelchair at home and when going out if activity makes the breathlessness worse
  • a small dose of morphine and some other drugs can help if breathing is difficult
  • practising breathing techniques: you can try breathing with the person, showing how to slow the breathing rate. This can be done during a breathless episode and at other times. It is a good relaxation exercise for you both
  • if breathlessness is caused by fluid around the lungs, the fluid can be drained.

Your physiotherapist or occupational therapist can help with any equipment needed to make the person with cancer feel more comfortable.

Tiredness

For many people, extreme and constant tiredness (fatigue) can be a great problem. It can be very upsetting for the person and for those around them. Some people say their tiredness is worse than any pain or nausea.

Tiredness can be caused by:

  • progression of the cancer
  • cancer treatment such as chemotherapy and radiotherapy
  • poor nutrition due to illness, causing loss of weight and muscle tone
  • anxiety
  • not enough sleep
  • drugs such as analgesics, antidepressants and sedatives
  • anaemia
  • anaemia
  • infection.

Unfortunately, treating tiredness is not always straightforward. It can be very hard to describe: what one person says is extreme fatigue may be simple tiredness for another person. This makes it very difficult for carers to understand what it's like and to help. 

I think tiredness is very hard for him and everyone. It's hard for me as well. I feel so frustrated because I can't help and people don't ask, but it's so important to understand it. To know how everyone feels. It affects us all.

You may find yourself 'nagging' because you want your friend or relative to do things like they used to. But then when you stop nagging it feels like you're giving up.

'After a while I stopped nagging, I realised she couldn't do it anymore. She was just too tired all the time.'

Good things to do when the person with cancer is tired:

  • Encourage them to talk about the tiredness: knowing how it feels will help you both.
  • Plan to do things when tiredness is least severe. Morning is best for many people.
  • Encourage them to conserve their energy for the things they really want or need to do.
  • Encourage short naps during the day. Short naps will help them feel better yet still sleep at night.
  • Encourage gentle exercise, such as walking to the letterbox or sitting out of bed for meals. This is good for muscles and for feeling more normal.
  • Reorganise your home, for example, keep a commode by the bed.
  • Provide high-calorie, high-protein drinks. This may slow weight loss and help maintain muscle strength.
  • Tell the doctor or nurse if the person with cancer gets weaker or more fatigued. The cause may be something treatable, like anaemia or a mineral imbalance.

Pain

People with cancer don't always have severe pain as the cancer progresses. Pain depends on the location of the cancer and its size. If a person does have pain, in most cases it can be controlled. It may take a little time to find the correct pain-control measure.

Pain management is a specialised field for doctors and nurses. Palliative care services specialise in pain management.

Pain may come and go. It may be worse on some occasions or it may be always present. The person with cancer could keep a record of their pain. This can help their doctor work out the best way to relieve the pain. Is the pain worse at certain times? Does the pain relief work at all? How bad is the pain? Pain can be scored on a scale of one to 10, with one being no pain and 10 being the worst pain imaginable.

Generally, pain can be controlled. There are many ways, including:

  • drugs like paracetamol, codeine and morphine
  • anti-inflammatory drugs on their own or with other pain relievers
  • drugs that are usually used to treat seizures can help treat pain caused by nerve involvement
  • if tablets aren't working, you can use a small machine called a syringe driver that delivers it (usually over 24 hours) through a small needle that sits in the top of the skin
  • a ‘nerve block' procedure
  • treating the cause of the pain with chemotherapy, surgery and radiotherapy, alone or together.

A combination of these methods may achieve the best results. How and where the pain is felt, and how it affects one's life, can change. It may help to keep a record of what drug has been taken and how effective it was. Regular review by pain-management experts will give the best results.

Each method is briefly described below.

Pain-relieving drugs

Pain-relieving drugs (analgesics) may be mild, like aspirin or paracetamol; moderate, like codeine; or relatively strong, like morphine or oxycontin.

Pain-relieving drugs may be taken as tablets, other oral mixtures, suppositories, patches and injections.

Other drugs may also be prescribed, like non-steroidal anti-inflammatory drugs (NSAIDs) and antidepressants.

The doctor will aim to find the right drug, dose, frequency for taking the drug and way to take it (for example, tablet or injection), and to control any side effects. This may involve trying one drug at different doses and then trying another drug at different doses, over several days. 

Morphine

Morphine is one of the most common drugs used to control moderate to severe cancer pain. It comes in quick-acting and long-acting form.

Morphine has been used for centuries as a pain reliever. Unfortunately, morphine has an undeserved reputation, because some people associate it with drug addiction, and people often think that morphine is only used for people who are dying.

When the doctor said he was going to start my sister on morphine to help the pain I thought it was a gentle way of telling me she only had a short time left.

  • A person doesn't become addicted to morphine if he or she is taking it to relieve pain.
  • Morphine is a very effective pain reliever. It can be taken for a long time, in increasing doses if needed. It doesn't have to be kept for when the pain gets really bad.
  • The ‘drowsiness' effect of morphine decreases after a couple of days and people can continue their normal activities and be pain free.
  • Morphine causes constipation. Regular laxatives can relieve or prevent this.
  • Morphine is most effective when taken regularly, even if the pain isn't present. It's better to stay pain-free rather than waiting to treat the pain when it comes back.
  • Some people can't tolerate morphine because of side effects like nausea or hallucinations. There are other drugs available that can be just as effective.

Morphine causes confusion in some people. This can be very difficult for the carer, especially if the confusion comes on top of existing dementia. This may make caring for the person with cancer at home difficult. Speak to the doctors and nurses if you notice a change in the person's mental state.

Nerve block

This is used when the cancer affects a nerve. This is called neuropathic pain.

A specialist such as an anaesthetist usually does a nerve block procedure. The nerve is ‘blocked' - prevented from sending signals to the brain that cause pain to be felt. The nerve is injected with a drug such as local anaesthetic. The method used will depend on the nerve involved and its role in the body.

Nerve block may be used if other pain control methods don't work. Nerve block is usually used with drugs like analgesics or antidepressants. 

Chemotherapy, radiotherapy and surgery

Chemotherapy, radiotherapy and surgery are used in advanced cancer to reduce symptoms such as pain.

Chemotherapy can shrink cancer that's causing pain because of its size and location. Radiotherapy can relieve some symptoms, such as headaches caused by increased pressure in the brain due to brain metastases.

The number of treatments needed varies but may be fewer than when radiotherapy is used in the treatment of early cancer.

Surgery may be done to improve outcomes from chemotherapy and radiotherapy by reducing the size of the cancer, or it may be used to treat a serious condition like a bowel obstruction that is causing pain.

Lack of appetite

Lack of appetite is a common problem. It can result from the illness, treatment, tiredness, an altered sense of taste, pain, lack of activity, depression, nausea and vomiting.

The person with cancer will go through phases of not wanting to eat. These phases may last a few days to weeks or it could become the ‘norm' for that person. You're not failing the person in any way if you can't provide them with 3 meals a day that includes all the food groups. They may be just unable to eat the way they used to.

Aim to provide food that's appealing and appetising. Ask for advice from the hospital dietitian, doctor or nurse.

  • Serve small meals and snacks frequently.
  • Try to make the food look good.
  • Give favourite foods often. Don't worry too much about whether the diet is ‘balanced'.
  • Use a small plate so a small amount doesn't look lost. Dessert in a wineglass is another idea.
  • Serve moist food, for example scrambled eggs, which is usually easier to eat and is less irritating to a sore mouth.
  • Peppermints can help prevent a dry mouth if this is making food seem unappetising.
  • Adding ice cream or fruit to a drink can increase calories and nutrients.
  • Half fill the glass. It is more satisfying to empty a half-full glass than only half finish a full one.
  • Offer drinks frequently, especially if solid food doesn't appeal.
  • Ask the dietitian if it's okay to serve nutritional supplements. These can supplement solid food.
  • Lemon juice and salt give flavour when food tastes bland.
  • If your doctor allows, have a small glass of dry wine, beer or spirits about half an hour before a meal to help stimulate the appetite. Don't drink too much. For men, the recommended limit is no more than 2 standard drinks a day. For women, it's 1 standard drink per day.
  • Try not to worry if all the food you prepare isn't eaten. 

See Nutrition and Exercise.

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