V. Palliative care
The purpose of palliative care is to relieve symptoms, alleviate pain and improve quality of life. All lung cancer patients should receive symptom screening, evaluation and treatment in palliative medicine throughout the whole process. The symptoms to be screened include both common physical symptoms such as pain, dyspnea and fatigue, and also psychological problems such as sleep disorders and anxiety and depression. Kaihua Lu, Department of Oncology, The First Affiliated Hospital of Nanjing Medical University
Quality of life evaluation should be incorporated into the overall evaluation system of lung cancer patients and the efficacy evaluation of palliative care. The Chinese version of the Quality of Life Measurement Scale EORTC QLQ-C30 (V3.0) is recommended for overall assessment, and the Quality of Life Measurement Scale EORTC QLQ-LC13 can also be used to screen and assess common symptoms of lung cancer patients. Pain and dyspnea are the most common symptoms that affect the quality of life of lung cancer patients.
(i) Pain
1. Assessment: The patient’s complaints are the gold standard for pain assessment, and the intensity of the patient’s pain must be assessed before analgesic treatment. The numerical pain grading method is preferred, and the face-marking method can be used for children or elderly people with cognitive impairment. Pain intensity is divided into 3 categories, i.e. mild, moderate and severe pain; it is important to record not only the pain intensity at the time of the patient’s assessment, but also to know the worst, least and average pain intensity over the past 24 h. It is important to know the change in pain intensity at rest and during activity.
A comprehensive assessment of pain should be performed. The assessment should include the etiology, characteristics and nature of the pain, aggravating or relieving factors, the impact of the pain on the patient’s daily life, and the efficacy and side effects of analgesic treatment. A brief pain scale is recommended for assessment.
The assessment should also clarify whether the patient has pain due to oncologic emergencies so that relevant treatment can be given immediately. Common oncologic emergencies include pathologic fractures or preexisting fractures of weight-bearing bones; metastatic cancer of the brain parenchyma, dura or soft meninges; pain associated with infection; and visceral obstruction or perforation.
2. Treatment: The goal is to achieve an optimal balance between analgesic effects and side effects. Analgesic drugs can relieve cancer pain in more than 80% of patients. A small number of patients may need non-pharmacological analgesic means, including surgery, radiotherapy for pain relief or nerve block, so the analgesic effect should be dynamically evaluated and interdisciplinary collaboration should be actively carried out.
(1) Basic principles: WHO three-step analgesic principles are still the most basic principles of cancer pain treatment, which include the following five main aspects.
(1) Preferred oral administration: Non-invasive, simple and safe routes of administration should be chosen as far as possible; oral administration is the preferred route of administration, and transdermal absorption, subcutaneous injection or intravenous infusion can be considered as appropriate.
②Dosing by step: choose pain medication according to the degree of pain by step. For mild pain, choose acetaminophen or non-steroidal anti-inflammatory analgesics; for moderate pain, choose weak opioids, such as codeine and tramadol; for severe pain, choose strong opioids, such as morphine, oxycodone, fentanyl, etc. Low-dose strong opioids can also be used to treat moderate pain.
(3) Timely administration of drugs: if chronic persistent cancer pain occurs, patients should be given analgesic treatment in time after timely administration of drugs, and it is recommended to choose fast-acting immediate release drugs.
④Individualized treatment: Before formulating the pain relief plan, the general condition of the patient should be fully evaluated, such as underlying diseases, heart, liver and kidney functions, concomitant symptoms and combined medications, etc., and appropriate drugs and doses should be selected.
⑤ Attention to details: details during analgesic treatment refer to all factors that may affect the analgesic effect. It is important to pay attention to the information obtained from pain assessment, and to pay attention to factors such as the patient’s psychological, spiritual, economic status, family and social support.
(2) Opioids are the core drugs for cancer pain treatment: whether opioid tolerance exists in patients should be judged before opioid treatment. The determination of opioid tolerance is based on the standard of the U.S. Food and Drug Administration, that is, patients are currently taking at least 60 mg of morphine, 8 mg of hydromorphone, 30 mg of oxycodone, 25 mg of oxycodone, 25 μg/h of fentanyl transdermal patch or other equivalent opioid daily for at least one week; patients who do not meet this standard are considered opioid intolerant.
In the selection of opioids, attention should be paid to: not using pethidine to control cancer pain; choosing pure receptor agonists as much as possible; avoiding morphine analgesia in patients with renal insufficiency. Opioid analgesic treatment is divided into short-acting titration phase and long-acting maintenance phase. Short-acting titration is the initial phase of opioid therapy, aiming to determine the opioid dose required for satisfactory analgesia as soon as possible. It is recommended that short-acting opioids be given on time, with the initial dose depending on whether the patient tolerates it or not. This phase should also be administered on an as-needed basis to relieve painful outbreaks, with a single dose calculated at 10% to 20% of the total daily opioid dose, or at the starting dose for those who are opioid intolerant.
After pain relief is achieved by opioid titration, short-acting opioids can be converted to controlled-release dosage forms to extend the dosing interval and simplify treatment. It is important to actively prevent and treat opioid adverse reactions. All opioid users need to prevent and control constipation, and the laxative composition should include at least ingredients that stimulate gastrointestinal motility, such as senna and bisacodyl.
(3) Treatment of neuropathic pain: analgesic drugs can only relieve part of the neuropathic pain. Treatment with strong opioids in combination with adjuvant medications is recommended. Potentially effective adjuvant medications include.
(i) Gabapentin: 100-300 mg orally once/d, gradually increasing to 300-600 mg three times/d, with a maximum dose of 3600 mg/d.
(ii) Pregabalin: 75 mg orally, 2 times/d, with the possibility of increasing the dose to 150 mg, 2 times/d, up to a maximum dose of 600 mg/d.
(3) tricyclic antidepressants: such as amitriptyline, 10-25 mg orally once a night, the usual dose is 25 mg, twice /d, can be gradually increased to the optimal therapeutic dose, the maximum dose of 150 mg /d; (4) methadone, ketamine is effective for some neuropathic pain.
3. Education for patients and their relatives: Patients and relatives should be told that analgesic treatment is an important part of overall tumor treatment, and pain tolerance is not beneficial to patients. Morphine and its similar drugs are commonly used in cancer pain treatment, and addiction is rare; analgesic treatment should be carried out under the guidance of medical personnel, and patients should not adjust the treatment plan and drug dose by themselves; the efficacy and side effects of drugs should be closely observed, and patients should communicate with medical personnel at any time and follow up regularly.
(2) Breathing difficulty
It is one of the most common symptoms of advanced tumor patients. Among advanced tumor patients, 70% of them may have dyspnea, and 90 010 of lung cancer patients have dyspnea before death. Dyspnea is a subjective discomfort of breathing, and the patient’s complaint is the gold standard for diagnosis. The clinical manifestation of dyspnea is the change of respiratory rate, rhythm and amplitude, and in severe cases, the feeling of near death, fear and anxiety can aggravate dyspnea.
The complexity of dyspnea in lung cancer patients should be fully recognized and the reversible causes should be eliminated as much as possible. Anti-tumor and anti-infection treatment can be given in a targeted manner; bronchodilators and glucocorticoids can be given for chronic obstructive lung disease; glucocorticoids, radiotherapy or stent placement can be applied for superior vena cava and bronchial obstruction; thoracentesis and drainage can be given for pleural effusion.
Non-pharmacological treatment includes oxygen, respiratory exercises, posture and position training, psychotherapy, etc., which should be implemented at the early stage of symptoms. Opioids are the most common drugs used to treat dyspnea in cancer patients. Early administration of opioids can reduce the physical and psychological burden of patients and prolong the survival period.
Morphine is the drug of choice and is used in the same way as analgesic treatment for dyspnea. It is recommended to start with small doses, give the drug on time, slowly increase the dose, closely observe and prevent side effects. Caution should be exercised in increasing the dose in elderly patients.
Sedation is an effective drug other than opioids to help relieve acute or severe dyspnea.
VI. Treatment flow and follow-up
(A) Treatment process of lung cancer
The general flow of diagnosis and treatment of lung cancer is shown in Figure 1.
(B) Follow-up
For new lung cancer patients, a complete case file and related information should be established, and regular follow-up and corresponding examination should be conducted after diagnosis and treatment. The specific examination methods include medical history, physical examination, blood biochemistry and blood tumor marker examination, imaging examination and endoscopy, etc., aiming at monitoring disease recurrence or treatment-related adverse effects and assessing the quality of life. The frequency of follow-up for postoperative patients is every 3-6 months for 2 years, every 6 months for 2-5 years, and every year after 5 years.
The formulation of this guideline has made reference to the international authoritative guidelines for the diagnosis and treatment of lung cancer and other tumors, while taking into account the actual situation in China. Some of the new drugs marketed abroad are not included because they have not been approved for clinical application in China. Since there are great individual differences in clinical practice, this specification is for reference only.