Common symptoms

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 treatment while others will be caused by the cancer .

If you are 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, he or she does not have to put up with it: tell the doctor or nurse. It is important for them to identify the cause of nausea so the right treatment can be given. Treatments for nausea include:

• adjustment to the diet, for example, offering cold food rather than hot food
• anti-nausea medication taken regularly and before pain medication or in higher doses
• a drug which lowers calcium levels in the blood
• stress reduction techniques
• dry ginger ale or ginger tea. Some people say this helps.

Breathlessness

Some people with advanced cancer experience breathlessness. It can be very unpleasant and may be frightening for the person who is having trouble breathing and those around him or her. Breathlessness may be due to:

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

The treatment for breathlessness depends on the cause. Simple measures that may help include:

• reassurance: stay with the person if they are 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
• positioning: encourage the person with cancer 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
• taking medication to reduce anxiety: 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, demonstrating 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.

Tiredness

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

Tiredness can be caused by a range of things such as:

• progression of the cancer
• cancer treatment such as chemotherapy and radiotherapy
• inadequate nutrition due to illness, causing loss of weight and muscle tone
• anxiety
• inadequate sleep
• drugs such as analgesics, antidepressants and sedatives
• anaemia
• infection.

Unfortunately, treating tiredness successfully is not as straightforward as treating some of the other symptoms. It can be very difficult to describe: what one person experiences as extreme fatigue may be simple tiredness for another person. This makes it very difficult for carers to understand what it is like for the person experiencing it and to provide assistance.

I think tiredness is very hard for him and everyone. It is hard for me as well. I feel so frustrated because I can't help and people don't ask, but it is 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 are 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 that tiredness: understanding how it feels will help you both.
• Plan to do things at the time of day when tiredness is least severe. Morning is best for many people.
• Plan activities so that they conserve their energy for the things they really want or need to do.
• Encourage short naps during the day. Naps allow you to feel better, yet still sleep at night.
• Encourage gentle exercise, like walking to the letterbox or sitting out of bed for meals. This preserves muscle tone and a sense of normality.
• 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

Pain, and the fear of pain, can be frightening. Our fears and misunderstandings about cancer and pain can contribute to less effective pain control.

People with cancer do not necessarily experience severe pain as the cancer progresses. Pain depends on the location of the cancer and its size. If a person does experience pain, in most cases it can be controlled. It may take a little time to find the correct pain-control measure. Pain management is now recognised as 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 than others or it may be always present. Generally, pain can be controlled so that it has minimal impact.

There are many ways to manage pain, including:

• pain-relieving drugs like paracetamol, codeine and morphine
• a pain-relieving '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 medication has been taken and how effective it was. Regular review by pain-management experts will ensure the best results are achieved.

Pain-relieving drugs

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

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 in many different human societies 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 does not 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 does not 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 to carry on 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 is not present. It is better to stay pain free rather than waiting to treat the pain when it comes back.
• Some people cannot tolerate morphine because of side effects like nausea. 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 the 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 are unsuccessful. Nerve block is usually used in combination with medications like analgesics or antidepressants.

Chemotherapy, radiotherapy and surgery

Chemotherapy, radiotherapy and surgery are used to cure primary cancers. They are also used in advanced cancer to reduce symptoms such as pain.

Chemotherapy can shrink cancer that is 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 faced by people with cancer. 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 for various reasons. These phases may last a few days to weeks or it could become the 'norm' for that person. You are not failing the person in any way if you cannot provide him or her with three 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 is appealing and appetising. Advice can be obtained 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 does not 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.
• Don't underestimate the benefits of nutritious drinks. Adding an egg, icecream 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 does not appeal.
• Ask your dietitian if it is OK to serve commercially-prepared food supplements such as Sustagen, Polycose and Ensure. These can supplement solid food.
• Lemon juice and salt may give flavour when food tastes bland.
• Alcohol may improve the appetite and can be taken safely with painkilling drugs. Try stout or sherry.

Try not to worry if all the food you have prepared is not eaten. Perhaps next time a little more will be eaten.

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Updated March 2005