Managing symptoms

Thursday 1 December, 2016

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On this page:  PainFeeling sickLoss of appetiteShortness of breathFatigue | Key points


People experience many different symptoms when they have advanced cancer. Common symptoms include pain, nausea, loss of appetite, tiredness and breathlessness. While it may not be possible to control all symptoms, the suggestions in this chapter can help make you as comfortable as possible. As the disease progresses, these symptoms can vary in intensity and frequency, placing different limitations on your body.

The relief of symptoms is one of the aims of the palliative care team. Contact them to work out what you need and discuss suitable options.

Pain

Many people with advanced cancer worry they will be in pain, but not everyone with cancer has pain and many find the pain comes and goes. Whether you have pain depends on the location of the cancer and its size.

If you do experience pain, it can usually be controlled. Pain management is a specialised field for doctors and nurses, and palliative care services are specifically trained in pain management.

There are many ways to relieve pain, including:

  • pain medicines (see below)
  • pain-relieving procedures for nerve pain (see below)
  • complementary therapies such as massage, meditation, yoga,
  • hypnotherapy or cognitive behavioural therapy
  • chemotherapy, radiotherapy or surgery.

Everyone experiences pain differently, so it may take time to find the most effective pain relief or combination of treatments for you. To work out the best pain control method, your pain specialists will ask you to use a variety of tools, such as a pain scale or pain diary, to describe your pain.

How and where the pain is felt and how it affects your life can change. Regular reviews by pain management experts can help keep the pain under control. It’s better to take medicine regularly, rather than waiting for the pain to build up. This is called staying on top of the pain. Controlling the pain may allow you to continue with activities you enjoy for some time and offer a better quality of life.

Pain medicines

Medicines that relieve pain are called analgesics. Depending on the type of pain and how intense it is, you may be offered:

  • mild pain medicines, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs)
  • moderate pain medicine, such as codeine
  • strong pain medicine known as opioids, such as morphine, oxycodone and fentanyl.

Some people worry about becoming addicted to pain medicine, but this is unlikely when medicines are taken to relieve pain. Any side effects, such as constipation or drowsiness, can usually be managed. For more information about managing pain and answers to common concerns, see Overcoming Cancer Pain or call Cancer Council 13 11 20.

Other pain relief methods

You may also be given other types of medicine to take with the main pain medicine. These could include antidepressants and anticonvulsants for nerve pain; anti-anxiety drugs for muscle spasms; or local anaesthetics for nerve pain.

If the pain is hard to manage, a pain specialist may consider a nerve block. The type of nerve block you are offered will vary depending on the type of cancer you have. Delivering the pain medicine directly into the nerves in the spine via a tube (epidural) can cause fewer side effects, however this is usually temporary.

Cancer treatments for pain relief

Chemotherapy, radiotherapy and surgery may also be used to control pain.

Chemotherapy

This drug treatment can shrink cancer that is causing pain because of its size or location. It can also slow the growth of the cancer and help control symptoms, including pain, loss of appetite and weight loss.

Radiotherapy

This uses radiation such as x-rays, to shrink a tumour and reduce discomfort. For example, it may relieve headaches by shrinking cancer that has spread to the brain from another part of the body (brain metastasis).

Surgery

An operation can remove a single tumour in the soft organs; treat a bowel obstruction that is causing pain; or improve outcomes from chemotherapy and radiotherapy by reducing the size of a tumour.

Feeling sick

People with advanced cancer often have problems with feeling sick (nausea) or being sick (vomiting). These can be caused by treatment with chemotherapy or radiotherapy, cancer growth, blockage of the bowel or the location of the cancer. Nausea can usually be managed with medicines. You may need to try different types until you find one that works for you.

Many people talk about anticipatory nausea, the response your body learns when you know it is chemotherapy time again. Even if you are no longer having chemotherapy, you may still feel a surge of nausea if you’re going past the place where you were treated.

Blockage in the bowel

Sometimes cancer in the abdominal area can cause the bowel to become blocked. This is called bowel obstruction. Because waste matter (faeces) cannot pass through the bowel easily, symptoms may include feeling sick or vomiting. To relieve these symptoms, you may have a small tube (stent) put in to keep the bowel open. The stent is inserted through the rectum using a flexible tube called an endoscope.

High levels of calcium in the blood

Feeling nauseous may be a symptom of high levels of calcium in your blood (hypercalcaemia). If the cancer spreads to the bones, the cancer cells make the bone break down and release calcium into the blood, causing you to feel tired and drowsy. Hypercalcaemia is more common in some types of advanced cancer. You may be given drugs to lower high calcium levels. These are called bisphosphonates, and are usually given through a drip into a vein.

Tips on managing nausea and vomiting
  • Eat small meals or snacks 5–6 times during the day. Going without food for long periods can make nausea worse.
  • Choose cold foods or foods at room temperature, such as sandwiches, salads, stewed fruit or jelly.
  • Have food or drink with ginger, e.g. ginger ale, ginger tea or ginger biscuits.
  • Take anti-nausea medicines as prescribed. Let the doctor know if the medicines don’t seem to be working.
  • Avoid fried, greasy or spicy foods or those that have strong smells.
  • Use stress reduction techniques, such as meditation.

Loss of appetite

People with advanced cancer often notice changes in their appetite. This may be because of the cancer itself, treatment, or other side effects such as tiredness, nausea or vomiting, change in sense of taste, pain, lack of activity, or depression.

A loss of appetite often leads to weight loss and malnutrition. By controlling appetite, your strength, function and quality of life can be maintained. However, it’s not necessary to force yourself to eat; this may only make you feel uncomfortable and cause vomiting and stomach pain. See below for suggestions.

Food-type nutritional supplements can increase nutrient intake. These are used as snacks between meals. Many pharmacies and supermarkets sell these specially formulated nutritional supplements. You do not need a prescription from your doctor or dietitian to buy them.

Many people with advanced cancer develop wasting syndrome (cachexia). This means the body isn’t using protein, carbohydrates and fats properly. Your doctor or dietitian will discuss ways to control cachexia, which may include nutritional supplements.

See Nutrition and Cancer for more details on malnutrition and wasting syndrome (cachexia) or call Cancer Council 13 11 20.

Tips on managing loss of appetite
  • Eat what you feel like, when you feel like it, e.g. have cereal for dinner or a main meal at lunch.
  • Use a smaller plate – a big plate full of food may put you off eating.
  • Relax dietary restrictions. During treatment, maintaining your weight is more important than avoiding full-fat foods.
  • Add flavour to foods with lemon juice, herbs and spices.
  • Add ice-cream or cream to fruit or a smoothie to increase kilojoules and nutrients.
  • Sip on juice, cordials, soft drinks and sports drinks during the day to keep hydrated.
  • Make meals as enjoyable as possible, e.g. play music, light candles or eat with friends.
  • Gentle physical activity can stimulate appetite, e.g. take a short walk around the block.

Shortness of breath

People with advanced cancer often experience shortness of breath (breathlessness). This is also called dyspnoea.

Breathlessness can occur for different reasons, including:

  • fluid surrounding the lungs
  • having an infection
  • the cancer itself
  • scarring from radiotherapy
  • pressure from a swollen abdomen
  • anaemia (low red blood cell levels)
  • underlying chronic breathing disorders, such as asthma or emphysema.

Symptoms of breathlessness include difficulty catching your breath, noisy breathing or very fast, shallow breaths. Although breathlessness can make you feel distressed and anxious, there are surgical and non-surgical ways to prevent or reduce its impact on your quality of life.

Treatment will depend on the cause of the breathlessness. You may need your lungs drained or medicine prescribed to treat an infection or other lung problem. If breathlessness is caused by the lungs not supplying enough oxygen to your blood, your doctor can arrange a portable oxygen cylinder.

See below for ways to improve breathlessness without surgery. Ask your doctor or nurse about medicines, such as a low dose of morphine, to manage feelings of distress.

Tips on managing breathlessness
  • Use a fan or open a window to increase airflow near your face.
  • Sit up or lean forward on a table with an arm crossed over a pillow to allow your breathing muscles to relax.
  • Wear loose-fitting clothing around your waist and chest.
  • Drink plenty of fluids. Being dehydrated can increase breathlessness.
  • Place chairs around the house so that you can sit down between activities or when moving from room to room.
  • Try to relax or practise breathing techniques.
  • Use a walking frame or lean on the shopping trolley when at the supermarket, as the position or pace can ease your breathing.
  • Spread out activities during the day or break them up into smaller tasks.

Fatigue

For many people, extreme or constant tiredness (fatigue) can be a major problem, particularly as the cancer advances. You may find feeling fatigued distressing and frustrating. Some people say the fatigue is worse than any pain or nausea they’ve experienced.

Fatigue can be caused by a range of things, such as:

  • anxiety or depression
  • poor sleep
  • infection
  • progression of the cancer
  • anaemia (low red blood cell levels)
  • cancer treatment such as chemotherapy or radiotherapy
  • loss of weight and muscle tone
  • drugs such as analgesics, antidepressants and sedatives.

Tell the doctor or nurse if you think you are becoming weaker or more fatigued. If anaemia is making the fatigue worse, it can be managed. You may be referred to an occupational therapist who can teach you techniques for conserving your energy.

Tips on managing fatigue
  • Plan activities for the time of day when you feel less tired, and include rest times.
  • Do regular gentle activities, such as walking to the letterbox, doing stretches or getting out of bed for meals.
  • Avoid stress where possible – relaxation techniques or meditation can help.
  • Have several short naps rather than one long rest period.
  • Limit visitors if you find they are tiring you.
  • Limit the amount of alcohol you drink. Alcohol can cause tiredness and energy loss.
  • Use Meals on Wheels or other home delivery meal companies that bring prepared food to you.

Key points

  • People with advanced cancer tend to experience a range of symptoms, which may change over time.
  • You may experience pain, but it will depend on the size and location of the cancer and it can usually be controlled.
  • Pain-relieving medicines (analgesics) can be mild, like paracetamol, moderate like codeine, or strong like morphine.
  • Palliative care services are specifically trained in pain management. They can assess your needs to work out the most effective drug, dose and mode of delivery.
  • It is better to treat the pain early than wait to treat the pain when it builds up.
  • Chemotherapy, radiotherapy and surgery can be used to control pain.
  • A nerve block can relieve pain if cancer is affecting the nerves, but the pain relief from this is usually only temporary.
  • Cancer treatments, cancer growth or the location of the cancer can make you feel sick (nauseated). This can usually be controlled with medicines.
  • You may also experience a loss of appetite. Eat what you feel like when you feel like it, and relax dietary restrictions.
  • If you experience trouble breathing or breathlessness, let your doctor know, as there may be treatment that helps.
  • Constant tiredness can be distressing. If you feel it is getting worse, tell your doctor. It may be caused by something that can be treated.

Reviewed by: Dr Maria Ftanou, Lead Clinical Psychologist, Peter MacCallum Cancer Centre and Research Fellow, Melbourne School of Population and Global Health, University of Melbourne, VIC; Dr Kathryn Dwan, Senior Policy Officer, Palliative Care Australia; Alison Hocking, President-Elect, Oncology Social Work Australia, VIC; Philippa Kirkpatrick, National Policy Manager, Palliative Care Australia; Prof Liz Lobb, Professor of Palliative Care (Allied Health), Calvary Health Care, Kogarah, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; Hamish Park, Consumer.