Applied Evidence

Primary care for the declining cancer survivor

J Fam Pract. 2019 October;68(8):448-450,452-455

References

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Most cancer pain is partially neuropathic, so anticonvulsant and antidepressant medications can help.³³ Gabapentin, pregabalin, and duloxetine are recommended based on evidence not restricted to cancer.³⁴ Cannabinoids have been evaluated in 2 trials of cancer pain with 440 patients and showed a borderline significant reduction of pain.³⁵

Some patients and providers resist palliative care due to a misconception that it requires abandoning treatment. Actually, palliative care can be given in concert with all active treatments.

Palliative radiation therapy can sometimes reduce pain. Bone metastases pain has been studied the most, and the literature suggests that palliative radiation provides improvement for 60% of patients and complete relief to 25% of patients.³⁶ Palliative thoracic radiotherapy for primary or metastatic lung masses reduces pain by more than 70% while improving dyspnea, hemoptysis, and cough in a majority of patients.³⁶

Other uses of palliative radiation have varied evidence. Palliative chemotherapy has less evidence of benefit. In a recent multicenter cohort trial, chemotherapy in end-stage cancer reduced quality of life in patients with good functional status, without affecting quality of life when function was limited.³⁷ Palliative chemotherapy may be beneficial if combined with corticosteroids or radiation therapy.³⁸

Treatment in the last weeks of life centers on opioids; dose increases do not shorten survival.³⁹ Cancer patients are 4 times as likely as noncancer patients to have severe or excruciating pain during the last 3 days of life.⁴⁰ Narcotics can be titrated aggressively near end of life with less concern for hypotension, respiratory depression, or level of consciousness. Palliative sedation remains an option for uncontrolled pain.⁴¹

Anorexia is only a problem if quality of life is affected. Cachexia is caused by increases in cytokines more than reduced calorie intake.⁴² Reversible causes of reduced eating may be found, including candidiasis, dental problems, depression, or constipation. Megestrol acetate improves weight (number needed to treat = 12), although it significantly increases mortality (number needed to harm = 23), making its use controversial.⁴³ Limited study of cannabinoids has not shown effectiveness in treating anorexia.³⁵

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