What Are Palliative Care and

Hospice Care?
Lecturer: Nadia shamasnsh
• Doctors can provide treatment to seriously ill patients in the hopes of
a cure for as long as possible. These patients may receive medical
care for their symptoms, or palliative care, along with curative
treatment.
• A palliative care consultation team is a multidisciplinary team that
works with the patient, family, and the patient's other doctors to
provide medical, social, emotional, and practical support.
• The team is made of:
• palliative care specialist doctors
• and nurses,
• social workers,
• nutritionists, and chaplains.
• Palliative care can be provided in:
• hospitals,
• nursing homes,
• outpatient palliative care clinics
• and certain other specialized clinics,
• or at home.
• In palliative care, you do not have to give up treatment that might
cure a serious illness.
• Palliative care can be provided along with curative treatment and
may begin at the time of diagnosis.
• Over time, if the doctor or the palliative care team believes ongoing
treatment is no longer helping, there are two possibilities:
• Palliative care could transition to hospice care if the doctor believes
the person is likely to die within 6 months
• Or, the palliative care team could continue to help with increasing
emphasis on comfort care.
• Increasingly, people are choosing hospice care at the end of life.
Hospice can be provided in any setting—home, nursing home,
assisted living facility, or inpatient hospital.
• At some point,
• it may not be possible to cure a serious illness,
• or a patient may choose not to undergo certain treatments.
• Hospice is designed for this situation.
• The patient beginning hospice care understands that his or her illness
is not responding to medical attempts to cure it or to slow the
disease's progress.
• Like palliative care, hospice provides comprehensive comfort care as
well as support for the family,
• but, in hospice, attempts to cure the person's illness are stopped.
Hospice is provided for a person with a terminal illness whose doctor
believes he or she has 6 months or less to live if the illness runs its
natural course.
• Hospice care brings together a team of people with special skills—
among them nurses, doctors, social workers, spiritual advisors, and
trained volunteers. Everyone works together with the person who is
dying, the caregiver, and/or the family to provide the medical,
emotional, and spiritual support needed.
• A member of the hospice team visits regularly, and someone is always
available by phone—24 hours a day, 7 days a week.
• It is important to remember that stopping treatment aimed at curing
an illness does not mean discontinuing all treatment.
• A good example is an older person with cancer. If the doctor
determines that the cancer is not responding to chemotherapy and
the patient chooses to enter into hospice care, then the
chemotherapy will stop. Other medical care may continue as long as
it is helpful. For example, if the person has high blood pressure, he or
she will still get medicine for that.
• Families of people who received care through a hospice program are
more satisfied with end-of-life care than are those of people who did
not have hospice services.
• Also, hospice recipients are more likely to have their pain controlled
and less likely to undergo tests or be given medicines they don't need,
compared with people who don't use hospice care.
• National Hospice and Palliative Care Organization
What is cancer
Lecturer: Nadia shamasnah
• Cancer is the uncontrolled growth of abnormal cells anywhere in the
body.
• These abnormal cells are termed cancer cells, malignant cells, or
tumor cells. These cells can infiltrate normal body tissues.
• Many cancers and the abnormal cells that compose the cancer tissue
are further identified by the name of the tissue that the abnormal
cells originated from (for example, breast cancer, lung cancer, and
colorectal cancer).
• When damaged or unrepaired cells do not die and become cancer
cells and show uncontrolled division and growth - a mass of cancer
cells develop.
• Frequently, cancer cells can break away from this original mass of
cells, travel through the blood and lymph systems, and lodge in other
organs where they can again repeat the uncontrolled growth cycle.
This process of cancer cells leaving an area and growing in another
body area is termed metastatic spread or metastasis.
• For example, if breast cancer cells spread to a bone, it means that the
individual has metastatic breast cancer to bone.
What are risk factors and causes of cancer?

• Anything that may cause a normal body cell to develop abnormally

potentially can cause cancer.
• Some cancer causes remain unknown while other cancers have
environmental or lifestyle triggers or may develop from more than
one known cause.
• Some may be developmentally influenced by a person's genetic
makeup.
• Many patients develop cancer due to a combination of these factors.
RISK FACTORS

1. Heredity
2. Ionizing radiation
3. Chemical substances
4. Dietary factors – Meat, energy balance, fat, protein, alcohol, nitrates
5. Estrogens
6. Viruses
7. Stress
8. Age
1. Heredity:

• A number of specific cancers have been linked to human genes and are as
follows:
• breast, ovarian, colorectal, prostate, skin and melanoma.
• The higher the amount or level of cancer causing materials a person is
exposed to, the higher the chance the person will develop cancer.
• In addition, the people with genetic links to cancer may not develop it for
similar reasons (lack of enough stimulus to make the genes function).
• In addition, some people may have a heightened immune response that
controls or eliminates cells that are or potentially may become cancer cells.
2. Ionizing radiation:

• Uranium, radon, ultraviolet rays from sunlight, radiation from alpha,

beta, gamma, and X-ray emitting sources can predispose to cancer by
rupturing DNA strands, thus causing mutations.
3. Chemical substances:

• Chemical substances that can cause mutations are called carcinogens.

Example of carcinogens are –
• benzene, asbestos, nickel, cadmium, vinyl chloride, benzidine, N-
nitrosamines, tobacco or cigarette smoke (contains at least 66 known
potential carcinogenic chemicals and toxins).
4. Dietary factors – Meat, energy balance, fat,
protein, alcohol, nitrates:
• MEAT:
• Meat intake has been associated with risk of digestive tract cancers. Intake
of red meat and white meat known to increase the risk of colon cancer.
• High intake of fish sauce may be a risk factor for gastric cancer.
• ENERGY BALANCE:
• The relationship between body weight, body mass index, or relative body
weight and site specific cancer has been found to be positively associated
with the cancers of the breast, endometrium, gall bladder, and kidney.
• Physical inactivity, high energy intake, and large body mass are associated
with increased risk of developing colon cancer in both men and women.
• FAT:
• A high intake of saturated fat increases the risk of prostate cancer.
• PROTEIN:
• Increased meat intake has been found to be associated with an
increased risk of colon cancer and with advanced prostate cancer.
• ALCOHOL:
• Alcohol has a causal role in carcinogenesis, especially for the cancers
of the mouth, pharynx and esophagus. Alcohol has an increased
effect on those tissues that directly get exposed to it during its
consumption, and tends to act synergistically with tobacco.
• Beer consumption has been associated with an increased risk for
colorectal cancer.
• NITRATES:
• Nitrates are present in variety of foods, and the main dietary sources
are vegetables and drinking water.
• Sodium and potassium nitrates are used in the processes of salting,
pickling and curing foods.
• Nitrosamines are present in tobacco and tobacco smoke.
Nitrosamines related to nitrates and nitrates are potent carcinogens.
5. Estrogens:
• Estrogens have been given for the relief of post-menopausal symptoms and
for the prevention of osteoporosis.
• Estrogens may play role in the production of the breast and endometrial
cancer.
6. Viruses:
• Viruses may act as cofactors in the development of some malignant
diseases.
• There may be a possible role of hepatitis B virus in human primary liver
cancer. Human papillomavirus and the Epstein Barr virus are considered
oncogenic.
• 7. Stress
• Stress may cause damage to the thymus gland, and the immune
system and hormonal effects mediated through the hypothalamus,
pituitary and adrenal cortex.
• This may provide the neurologic currency that converts anxiety to
malignancy
• 8. Age
• The risk of developing colorectal cancer increases with age. The
incidence is 6 times higher among persons aged 65 years and older
than in comparison to persons aged 40-64 years.
• Increasing risk of cancer with age reflects the accumulation of critical
genetic mutations.
What are cancer signs and symptoms?

• Symptoms and signs of cancer depend on the type of cancer, where it

is located, and/or where the cancer cells have spread.
• For example, breast cancer may present as a lump in the breast or as
nipple discharge while metastatic breast cancer may present with
symptoms of pain (if spread to bones), extreme fatigue (lungs), or
seizures (brain).
• A few patients show no signs or symptoms until the cancer is far
advanced.
Seven warning signs and/or symptoms that a cancer may be
present, and which should prompt a person to seek medical
attention.
1. Change in bowel or bladder habits
2. A sore throat that does not heal
3. Unusual bleeding or discharge (for example, nipple secretions or a
"sore" that will not heal that oozes material)
4. Thickening or lump in the breast, testicles, or elsewhere
5. Indigestion (usually chronic) or difficulty swallowing
6. Obvious change in the size, color, shape, or thickness of a wart or
mole
7. Nagging cough or hoarseness
Other signs or symptoms may include the
following:
• Unexplained loss of weight or loss of appetite
• A new type of pain in the bones or other parts of the body that may
be steadily worsening, or come and go, but is unlike previous pains one
has had before
• Persistent fatigue, nausea, or vomiting
• Unexplained low-grade fevers with may be either persistent or come
and go
• Recurring infections which will not clear with usual treatment
What are the different types of cancer?

• Carcinoma: Cancer that begins in the skin or in tissues that line or cover
internal organs -- "skin, lung, colon, pancreatic, ovarian cancers," epithelial,
squamous and basal cell carcinomas, melanomas, papillomas, and
adenomas.
• Sarcoma: Cancer that begins in bone, cartilage, fat, muscle, blood vessels,
or other connective or supportive tissue -- "bone, soft tissue cancers,"
osteosarcoma, synovial sarcoma, liposarcoma, angiosarcoma,
rhabdosarcoma, and fibrosarcoma
• Leukemia: Cancer that starts in blood-forming tissue such as the bone
marrow and causes large numbers of abnormal blood cells to be produced
and enter the blood -- "leukemia”.
• Lymphoma and myeloma: Cancers that begin in the cells of the immune
system -- "lymphoma," T-cell lymphomas
• Central nervous system cancers: Cancers that begin in the tissues of
the brain and spinal cord -- "brain and spinal cord tumors”.
Types of Cancer Treatment
• There are many types of cancer treatment. The types of treatment
that one receive will depend on
• the type of cancer he/she have and how advanced it is. Some people
with cancer will have only one treatment. But most people have a
combination of treatments, such as surgery with chemotherapy
and/or radiation therapy.
• Surgery :
is a procedure in which a surgeon removes cancer from the body.
• RADIATION THERAPY:
Radiation therapy is a type of cancer treatment that uses high doses of
radiation to kill cancer cells and shrink tumors.
• CHEMOTHERAPY
Chemotherapy is a type of cancer treatment that uses drugs to kill cancer
cells.
• IMMUNOTHERAPY TO TREAT CANCER
Immunotherapy is a type of cancer treatment that helps the immune system
fight cancer.
• TARGETED THERAPY
Targeted therapy is a type of cancer treatment that targets the changes in
cancer cells that help them grow, divide, and spread.
• HORMONE THERAPY
Hormone therapy is a treatment that slows or stops the growth of breast and
prostate cancers that use hormones to grow
• STEM CELL TRANSPLANT
Stem cell transplants are procedures that restore blood-forming stem
cells in cancer patients who have had theirs destroyed by very high
doses of chemotherapy or radiation therapy.
• PRECISION MEDICINE
Precision medicine helps doctors select treatments that are most likely
to help patients based on a genetic understanding of their disease.
• Benign, or noncancerous, tumors do not spread to other parts of the
body, and do not create new tumors.
• Malignant, or cancerous, tumors crowd out healthy cells, interfere
with body functions, and draw nutrients from body tissues.
• Cancers continue to grow and spread by direct extension or through a
process called metastasis, whereby the malignant cells travel through
the lymphatic or blood vessels -- eventually forming new tumors in
other parts of the body.
• The term "cancer" encompasses more than 100 diseases affecting
nearly every part of the body, and all are potentially life-threatening.
Metastasis
What is Pain
Lecturer: Nadia shamasnah
The International Association for the Study of
Pain definition of pain
• “An unpleasant sensory and emotional experience associated with
actual or potential tissue damage.
Noxious stimuli and responses
• There are three categories of noxious stimuli:

• mechanical (pressure, swelling, abscess, incision, tumour growth);

• thermal (burn, scald);
• chemical (excitatory neurotransmitter, toxic substance, ischaemia,
infection).
• The cause of stimulation may be internal, such as pressure exerted by a
tumor or external, for example, a burn.
• This noxious stimulation causes a release of chemical mediators from the
damaged cells including:

• prostaglandin;
• bradykinin;
• serotonin;
• substance P;
• potassium;
• histamine.
• These chemical mediators activate and/or sensitize the nociceptors to
the noxious stimuli. In order for a pain impulse to be generated, an
exchange of sodium and potassium ions (de-polarisation and re-
polarisation) occurs at the cell membranes. This results in an action
potential and generation of a pain impulse.
Types of pain
Acute pain
• Acute pain is short-term pain that comes on suddenly and has a
specific cause, usually tissue injury. Generally, it lasts for fewer than
six months and goes away once the underlying cause is treated.

• Acute pain tends to start out sharp or intense before gradually

improving.
Common causes of acute pain include:

• broken bones
• surgery
• dental work
• labor and childbirth
• cuts
• burns
Chronic pain
• Pain that lasts for more than six months, even after the original injury has
healed, is considered chronic.

• Chronic pain can last for years and range from mild to severe on any given
day.
• While past injuries or damage can cause chronic pain, sometimes there’s
no apparent cause.

• Without proper management, chronic pain can start to impact the quality
of life. As a result, people living with chronic pain may develop symptoms
of anxiety or depression.
• Other symptoms that can accompany chronic pain include:

• tense muscles
• lack of energy
• limited mobility
• Some common examples of chronic pain include:

• frequent headaches
• nerve damage pain
• low back pain
• arthritis pain
Nociceptive pain
• Nociceptive pain is the most common type of pain. It’s caused by
stimulation of nociceptors, which are pain receptors for tissue injury.

• You have nociceptors throughout the body, especially in skin and internal
organs. When they’re stimulated by potential harm, such as a cut or other
injury, they send electrical signals to the brain, causing the feeling of pain.

• This type of pain you usually feel when you have any type of injury or
inflammation. Nociceptive pain can be either acute or chronic. It can also
be further classified as being either visceral or somatic.
Visceral pain
• Visceral pain results from injuries or damage to the internal organs. You
can feel it in the trunk area of the body, which includes chest, abdomen,
and pelvis. It’s often hard to pinpoint the exact location of visceral pain.

• Visceral pain is often described as:

• pressure
• aching
• squeezing
• cramping
• You may also notice other symptoms such as nausea or vomiting, as
well as changes in body temperature, heart rate, or blood pressure.

• Examples of things that cause visceral pain include:

• gallstones
• appendicitis
• irritable bowel syndrome
Somatic pain

• Somatic pain results from stimulation of the pain receptors in tissues, rather than
internal organs.
• This includes skin, muscles, joints, connective tissues, and bones.
• It’s often easier to pinpoint the location of somatic pain rather than visceral pain.

• Somatic pain usually feels like a constant aching .

• It can be further classified as either deep or superficial:

• For example, a tear in a tendon will cause deep somatic pain, while a canker sore
on your inner check causes superficial somatic pain.
Examples of somatic pain include:

• bone fractures
• strained muscles
• connective tissue diseases, such as osteoporosis
• cancer that affects the skin or bones
• skin cuts, scrapes, and burns
• joint pain, including arthritis pain
 Neuropathic pain
• Neuropathic pain results from damage to or dysfunction of the nervous system.
This results in damaged or dysfunctional nerves misfiring pain signals. This pain
seems to come out of nowhere, rather than in response to any specific injury.
• Neuropathic pain is described as:
• burning
• freezing
• numbness
• tingling
• shooting
• stabbing
• electric shocks
• Diabetes is a common cause of neuropathic pain. Other sources of nerve injury or
dysfunction that can lead to neuropathic pain include:
• chronic alcohol consumption
• accidents
• infections
• facial nerve problems
• spinal nerve inflammation or compression
• carpal tunnel syndrome
• HIV
• central nervous system disorders, such as multiple sclerosis or Parkinson’s disease
• radiation
• chemotherapy drugs
• Pain is a very personal experience that varies from person to person.
What feels very painful to one person may only feel like mild pain to
another. And other factors, such as the emotional state and overall
physical health, can play a big role in how we feel pain.
Pain related questions

• how long you’ve had the pain

• how often your pain occurs
• what brought on your pain
• what activities or movements make your pain better or worse
• where you feel the pain
• whether your pain is localized to one spot or spread out
• if your pain comes and goes or is constant
WHO Analgesic Ladder
• The WHO analgesic ladder was a strategy proposed by the World
Health Organization (WHO), in 1986, to provide adequate pain relief
for cancer patients.
• The analgesic ladder was part of a vast health program termed the
WHO Cancer Pain and Palliative Care Program aimed at improving
strategies for cancer pain management through educational
campaigns, the creation of shared strategies, and the development of
a global network of support.
• This analgesic path, developed following the recommendations of an
international group of experts, has undergone several modifications
over the years and is currently applied for managing cancer pain but
also acute and chronic non-cancer painful conditions due to a broader
spectrum of diseases such as degenerative disorders, musculoskeletal
diseases, neuropathic pain disorders, and other types of chronic pain.
The original ladder mainly consisted of three
steps:

• First step. Mild pain: non-opioid analgesics such as nonsteroidal anti-

inflammatory drugs (NSAIDs) or acetaminophen with or without
adjuvants
• Second step. Moderate pain: weak opioids (hydrocodone, codeine,
tramadol) with or without non-opioid analgesics, and with or without
adjuvants
• Third step. Severe and persistent pain: potent opioids (morphine,
methadone, fentanyl, oxycodone, buprenorphine, tapentadol,
hydromorphone, oxymorphone) with or without non-opioid
analgesics, and with or without adjuvants
• The term adjuvant refers to a vast set of drugs belonging to different
classes. Although their administration is typically for indications other
than pain treatment, these medications can be of particular help in
various painful conditions.
• Adjuvants, also called co-analgesics, include:
• antidepressants including tricyclic antidepressants (TCAs) such as
amitriptyline and nortriptyline, serotonin-norepinephrine reuptake
inhibitors (SNRIs) such as duloxetine and venlafaxine,
• anticonvulsants like gabapentin and pregabalin,
• topical anesthetics (e.g., lidocaine patch), topical therapies (e.g.,
capsaicin), corticosteroids, bisphosphonates, and cannabinoids
• Interestingly, although adjuvants are coadministered with analgesics,
they are indicated as a first-line treatment option for the treatment of
specific pain conditions. For instance, the European Federation of
Neurological Societies (ENS) recommended the use of duloxetine, or
anticonvulsants, or a TCA for diabetic painful neuropathy treatment.
• The key concept of the ladder is that it is essential to have adequate
knowledge about pain, to assess its degree in a patient through
proper evaluation, and to prescribe appropriate medications.
• As many patients will receive opioids eventually, it is essential to
balance the optimum dosage with the side effects of the drug.
• Moreover, opioid rotation can be adopted to improve analgesia and
reduce side effects.
• patients should receive education about the uses and side effects of
drugs to avoid misuse or abuse without compromising their beneficial
aspects.
• The original WHO ladder was unidirectional, starting from the lowest step of
NSAIDs, including COX-inhibitors, or acetaminophen, and heading up towards the
strong opioids, depending on the patient’s pain.
• Scholars in the field suggested eliminating the second level as weak opioids
contribute very little towards pain control.
• In case of moderate pain, it might be more useful to prescribe third step opioids
although administered at reduced dosages (e.g., morphine 30 mg per day, orally).
• According to some authors, moreover, it should be necessary to distinguish
pathways for the treatment of acute pain, from more specific treatments for use
in long-lasting cancer pain.[4] However, the real limitation of the original scale
was the impossibility of integrating non-pharmacological treatments into the
therapy path. As a consequence, a fourth step was added to the ladder
• It includes numerous non-pharmacological procedures that are strong
recommendations for treating persistent pain, even in combination with
the use of strong opioids or other medications.
• This group of encompasses interventional and minimally invasive
procedures such as epidural analgesia, intrathecal administration of
analgesic and local anesthetic drugs with or without pumps, neurosurgical
procedures (e.g., lumbar percutaneous adhesiolysis, cordotomy),
neuromodulation strategies (e.g., brain stimulators, spinal cord
stimulation), nerve blocks, ablative procedures (e.g., alcoholization,
radiofrequency, microwave, cryoablation ablations; laser-induced
thermotherapy, irreversible electroporation, electrochemotherapy),
cementoplasty as well as palliation radiotherapy.
• This updated WHO latter focused on the quality of life, was intended
as a bidirectional approach, extending the strategy to treat acute pain
as well.
• For acute pain, the strongest analgesic (for that intensity of pain) is
the initial therapy and later toned down, whereas, for chronic pain,
employing a step-wise approach from bottom-to-top.
• However, clinicians should also provide de-escalation in the case of
chronic pain resolution.
Issues of Concern
• The design of the analgesic ladder was so that it could be easily used
even by non-pain medicine experts. However, the continued referral
of patients to pain specialists proves otherwise.
• The lack of proper knowledge of drugs, under dosing and wrong
timing of drugs, fear of addiction in patients, and lack of public
awareness are severe limitations that can come in the way of proper
implementation of the strategy.
• Another limitation concerns the placement of drugs.
• Placing NSAIDs at the bottom rung of the ladder could lead to a false
belief that this represents the most secure treatment.
• In daily clinical practice, it often happens that patients take these
drugs even for long periods. Also, long-term use of NSAIDs combined
with opioids for the treatment of moderate pain (second step) can
lead to much more serious side effects than those described for
opioids.
• A significant issue of concern regards the management of pure neuropathic pain.
• This type of pain has complex pathophysiology and mechanisms that involve
different regions of the central nervous system, or specific structures of the
peripheral nervous system.
• An injury in these regions can trigger a cascade of events culminating in the
phenomena of peripheral and central sensitization.
• In this context, opioids have little or no efficacy, and other strategies are
necessary.
• other clinical conditions are poorly manageable following ladder rules. For
example, in fibromyalgia, the drugs of the first two steps are often of poor
efficacy, whereas the use of opioids can induce dangerous, addictive phenomena
as well as being a treatment with little scientific evidence of efficacy.
• Experts in pain medicine found this approach one-dimensional as it concentrated
only on the physical aspect of pain. For this reason, other methods have been
proposed.
• For instance, the International Association For The Study Of Pain (IASP) suggested
adopting a therapeutic approach more focused on the type of pain (i.e.,
mechanism) and on the mechanism of action of the drugs used to treat it.
• Therefore, in the case of chronic nociceptive pain on an inflammatory basis, it
would be more appropriate to use steroids or NSAIDs. On the other hand, low-
inflammatory nociceptive pain should receive treatment with opioids and non-
opioid analgesics.
• Finally, neuropathic pain may require antidepressants or anticonvulsants, and
specific drugs in certain rheumatologic clinical conditions (e.g., colchicine to treat
gout).
• There have been other proposed suggestions in attempts to offer a more
precise methodology. Leung, for instance, suggested a new analgesic
model represented as a platform where pain management follows a three-
dimensional perspective that can combine with the classical analgesics,
based on the pain condition.
• More recently, Cuomo et al. proposed the so-called "multimodal trolley
approach," which gives importance to the physical, psychological, and
emotional causes of pain.
• The model underlies the need for personalized therapy and suggests that
pain is not merely a sensory discomfort experienced by the patient but also
incorporates the patient's perceptual, homeostatic, and behavioral
response to an injury or chronic illness.
• Through this approach, clinicians can dynamically manage pain by
combining several pharmacologic and non-pharmacologic strategies
according to the physiopathology of pain, pain features, and the
complexity of symptoms, the presence of comorbidity, and the physio
pathological factors and the social context.
• Consequently, a wide range of non-pharmacological approaches such
as yoga, acupuncture, psychotherapy, occupational therapy, are
present in specific 'drawers' of the trolley and can be used according
to the clinical needs and skills of the operator, as well as available
resources.
Clinical Significance
• Even with the drawbacks, the strategy includes a simple and effective
guideline on the administration of analgesics that is valid even today. The
main components include:

• Oral dosing of drugs whenever possible (as opposed to intravenous, rectal,

etc.)
• Around-the-clock administration rather than on-demand.
• The prescription must follow the pharmacokinetic characteristics of the
drugs.
• Analgesics must be prescribed according to pain intensity as evaluated by a
scale of pain severity. For this purpose, a clinical examination must
combine with an adequate assessment of the pain.
• Individualized therapy (including dosing) addresses the concerns of
the patient. This method presupposes is that there is no standardized
dosage in the treatment of pain.
• Probably, it is the biggest challenge in pain medicine, as the
medication must be continuously adapted to the patient, balancing
analgesic desired effects and the possible occurrence of side effects.
• Proper adherence to pain medications as any alteration in the dosing
can lead to a recurrence of pain.
• Pain accounts for one of the top five reasons for consultation. A
better understanding of the physiology and the psychological aspects
is necessary to come up with an ideal approach towards pain control.
The WHO analgesic ladder can remain a foundational treatment for
chronic pain, upon which clinicians can add new modalities.
• Nursing, Allied Health, and Inter professional Team Interventions
• The patients should be treated with the utmost respect and empathy to
make them as comfortable as possible.

• Opioids administration should only be when their benefits outweigh their

risks as it carries a considerable risk of dependence.
• Nurses should make sure they understand the physicians' directions
regarding the drug, its dosage, and side effects to provide the optimum
amount of medication.
• Any doubts regarding the drug should have clarification from the ordering
physician. The pharmacists should keep accurate track of all the
prescriptions, and report any suspicion of drug misuse.
• Nursing, Allied Health, and Interp rofessional Team Monitoring
• Pain management in chronic diseases may be time-consuming and boring
for the patient. It is essential to have regular follow-up visits to assess the
progression of the disease and the efficacy of therapy and to make any
necessary modifications. The patients should be encouraged to stay
motivated and appreciated for any improvement or progress.

• Hospitalized patients on opioids should be monitored regularly for their

vitals, especially respiratory rate, to check for any adverse effects. Bed-
ridden patients should receive proper care to maintain hygiene and avoid
complications like bedsores and deep vein thrombosis.
Symptom Assessment and
Management
Lecturer: Nadia shamasnah
Barriers to Optimal Pain
Assessment
Health care professional barriers

• Lack of identification of pain assessment and relief as a priority in patient

care
• Inadequate knowledge about the performance of a pain assessment
• Perceived lack of time to conduct and document a pain assessment and
reassessment
• Failure to use validated pain measurement tools
• Inability of clinician to empathize or establish rapport with patient
• Lack of continuity of care
• Lack of communication among the health care professional team
• Prejudice and bias in dealing with patients
Health care system barriers

• A system that fails to hold health care professionals accountable for

pain assessment
• Lack of criteria or availability of culturally sensitive instruments for
pain assessment in health care settings
• Lack of institutional policies for performance and documentation of
pain assessment
Patient/family/societal barriers
• The highly subjective and personal nature of the pain experience
• Lack of patient and family awareness about the importance of
speaking out about pain
• Lack of patient communication with health care professionals about
pain
Patient reluctance to report pain

Patient not wanting to bother staff

Patient fears of not being believed
Patient age-related patience
Patient doesn’t report pain because “nothing helps”
Patient concern that curative therapy might be reduced with pain and
palliative care
Lack of a common language to describe pain
Presence of unfounded beliefs and myths about pain and its treatment
Multifactorial Pain Assessment
• Physiologic/ sensory
• What is causing the patient’s pain?
• How does the patient describe his/her pain?
• Affective
• How does the patient’s emotional state affect his/her report of pain?
• How does pain influence the patient’s affect or mood?
• Cognitive
• How do the patient’s knowledge, attitudes, and beliefs affect their
pain experience?
• What is the meaning of the pain to the patient?
• How does the patient’s past experience with pain influence the pain?
• Behavioral
• How do you know the patient is in pain?
• What patient pain behaviors or nonverbal cues inform you that pain is
being experienced?
• What is the patient doing to decrease his or her pain?
• Sociocultural
• How does the patient’s sociocultural background affect the pain
experience, expression, and coping?
• Environmental
• How does the patient’s environment affect the pain experience or
expression?
Common Patient Concerns and
Misconceptions about Pain and Analgesia
• Pain is inevitable. I just need to bear it.
• If the pain is worse, it must mean my disease (cancer) is spreading.
• I had better wait to take my pain medication until I really need it or
else it won’t work later.
• My family thinks I am getting too “high” on pain medication; I’d better
hold back.
• If it’s morphine, I must be getting close to the end.
• If I take pain medicine (such as opioids) regularly, I will get “hooked”
or addicted.
• If I take my pain medication before I hurt, I will end up taking too
much. It’s better to “hang in there and tough it out.”
• I’d rather have a good bowel movement than take pain medication
and get constipated.
• I don’t want to bother the nurse or doctor; they’re busy with other
patients.
• If I take too much pain medication, it will hasten my death.
• Good patients avoid talking about pain.
Barriers to Cancer Pain
Management
Problems related to health care professionals

• Inadequate knowledge of pain management

• Poor assessment of pain
• Concern about regulation of controlled substances
• Fear of patient addiction
• Concern about side effects of analgesics
• Concern about patients’ becoming tolerant to analgesics
Problems related to the health care system

• Low priority given to cancer pain treatment

• Inadequate reimbursement
• Restrictive regulation of controlled substances
• Problems of availability of treatment or access to it
Problems related to patients

• Reluctance to report pain

• Concern about distracting physicians from treatment of underlying
disease
• Fear that pain means disease is worse
• Concern about not being a “good” patient
Reluctance to take pain medications

• Fear of addiction or of being thought of as an addict

• Worries about unmanageable side effects
• Concern about becoming tolerant to pain medications
Common symptoms
Fatigue
• Fatigue is Unusual, Abnormal, or Excessive Whole body Tiredness
disproportionate to or unrelated to activity or exercise
• Prevalence rates of cancer-related fatigue vary depending on cancer
type and stage
• One study indicated that over 80% of patients receiving radiotherapy
experience fatigue, as did up to 90% of incurable cancer patients.
• Fatigue is also the most common and distressing symptom
experienced by pediatric cancer patients.
• In some cancer survivors, fatigue persists months or even years after
treatment
Incidence of fatigue among cancer
pateints

80
60 fatigue
anxiety
40
sleep dis
20 nausea
0 hair loss

pain
anxiety

nausea
fatigue

sleep dis

hair loss
pain
 Manifestations of fatigue

First : Subjective manifestations

Second : Objective manifestations

Subjective manifestations
• Physical manifestations (physical exhaustion, tiredness in
arms, legs, …

• Emotional manifestations ( fatigue described as

unpleasant, irritability, lack of motivation)

• Behavioral manifestations ( take longer to do things, more

effort is required, need for sleep, more naps)

• Cognitive & mental manifestations (difficult

concentration, memory)
Factors Associated with Fatigue
Development
Classifications of fatigue
• Acute  Chronic
 Last less than 1 month  Last 1 – 6 months or longer
 Relieved by rest  Not relieved by rest

 Chronic Fatigue Syndrome

Impact on life
It has profound negative effect on the quality of life, like:
• Interfere with the ability to work
• Interfere with their role in homes & families
• Difficult in concentration
• Interfere with engaging usual level of physical activity
• Can cause stress, cachexia, nausea, vomiting, dyspnea,, &
insomnia
 Risk Factors

Situational Clinical
Age Sex Race
stressors states
1. Age
Premature infants & elderly are at risk for respiratory muscle fatigue
more than adults

This is due to changes in the muscle fibers in these two groups

2. Sex
Women are twice likely to develop fatigue as men.

May be due to menstrual cycle, pregnancy, & post partum states

3. Race

Non white persons report fatigue more than

whites.
4. Situational stessors
Environmental factors (high temperature)

Alteration in sleep & rest pattern

Alteration in nutritional pattern

Workload & other activities

Alteration in socioeconomic status

5. Clinical status
Cancer & related treatment
Multiple sclerosis
SLE
Neuromuscular, cardiac, & respiratory diseases
Depression
Stress, pain, & anemia
Hypothyroidism
Benefit of fatigue
Some consider fatigue as a protective mechanism

It is usually occur before ATP is depleted & muscle contraction

occur.

It prevent person from engaging in excessive physical or mental

activities
 Manifestations of fatigue

First : Subjective manifestations

Second : Objective manifestations

Subjective manifestations
• Physical manifestations (physical exhaustion, tiredness in
arms, legs, …

• Emotional manifestations ( fatigue described as

unpleasant, irritability, lack of motivation)

• Behavioral manifestations ( take longer to do things, more

effort is required, need for sleep, more naps)

• Cognitive & mental manifestations (difficult

concentration, memory)
Objective manifestations
• Physiological indicators (decrease PCV (PACKED CELL VOLUME),
decrease blood sugar, decrease O2 saturation, alteration in pH,
electrolytes imbalance…)

• Behavioral indicators (change in physical appearance, affect,

attitude)
 Causes of fatigue among cancer’s
patients
The exact cause is unknown, but may be due to:
1) Disease process
2) Cancer treatment
3) Other factors
Disease process
Tumor-induced hyper metabolic state
Causing anemia
Forming toxic substances that interfere with normal cell function
Releasing TNF (Tumor necrosis factor ), which deplete the protein
stores in muscles
Cancer’s treatments
Chemotherapy : fatigue is a common side effect
Radiation : cause cumulative fatigue. It can be predicted
Biotherapy : fatigue described as the most important dose – limiting
side effect of interferon
Surgery : due to direct tissue damage
Other factors
Loss of appetite, diarrhea, nausea, vomiting. These cause
nutritional depletion and weight loss
Psychological distress & sleep disturbances (40%-60% of fatigue
caused by anxiety & depression)
Inactivity
Difficult breathing
Pain
Infection
Non-chemotherapy medication
Measurement

• Subjective measurement

• Objective measurement
Subjective measurements
• Text books mentioned many scales to measure fatigue, but without
mentioning the items. Some of these are:
• Pearson-Byars Fatigue Feeling Tone checklist (PBF)
• Fatigue severity scales
• Fatigue symptoms checklist (FSCL)
• Piper fatigue scale
• VAS
Objective measurements

• blood tests (glucose, thyroid hormones, ABGs…)

Management
• The best way to manage fatigue is to treat the underlying
cause.
• Assessment is important, especially for:
1. Fatigue pattern (when started, when finished)
2. Severity of fatigue, & what is other accompanied side
effects
3. Treatment history, current medication
4. Sleep/rest pattern
5. Nutritional status (appetite, weight change, …)
6. Effect of fatigue on life style
7. Result of physical examination
8. Job performance
9. Financial resources
Management continue
1) Acid-base modulation
2) Aerobic exercise
3) Diversional-distraction activities
4) Drug therapies
5) Energy-consuming activities
Management continue
5) Nutritional intervention
6) Psychological support
7) Rest
8) Sleep-nap pattern
9) Breath effectively
10) Treating anemia
Disease-related factors

• Stage and extent of disease Co-morbidities

• Anemia
• Pain
• Dyspnea
• Nutritional changes (weight loss, cachexia, electrolyte imbalance)
• Sleep patterns/interruptions
Treatment-Related factors

• Any treatment-related effect from surgery, chemotherapy

or radiation (skin reaction, temporary altered energy level,
urinary/bowel changes, pain)
• Medication issues (side effects, polypharmacy, taste changes, OTC’s)
• Permanent physiologic changes
• Fatigue in patients undergoing cancer treatment has been closely
linked with other distressing symptoms, such as:
• pain,
• dyspnea,
• anorexia,
• constipation, sleep disruption, depression,
• anxiety, and other mood states.
• Research on patients with advanced cancer has demonstrated that
fatigue severity was significantly associated with similar symptoms.
• The value of assessing the “most troublesome” symptom when
symptom clusters are identified, was examined. In 146 palliative care
patients, Among all of the symptoms reported, fatigue and pain were
reported most frequently as the “most severe” and the “most
troublesome.”
• Like patients with cancer, patients with end-stage renal disease on
chronic dialysis complained of a high level of fatigue that was
associated with other symptoms.
• The other symptoms identified were headaches, cramps, itching,
dyspnea, sleep disruption (highest mean score), nausea, chest pain,
and abdominal pain.
Management/Treatment of Fatigue
• When considering palliative care, the management of fatigue is
extremely challenging. By its very definition, palliative care may
encompass a prolonged period before death, when a person is still
active and physically and socially participating in life, to a few weeks
before death, when participatory activity may be minimal.
• With fatigue interventions, the wishes of the patient and family are
paramount.
• One must consider management in the context of:
• the extent of disease,
• other symptoms (pain, nausea, diarrhea, etc.),
• whether palliative treatment is still in process,
• age and developmental stage,
• and the emotional “place” of the patient.
• Barriers to fatigue assessment as well as intervention exist and must
be considered in the context of the patient, health care provider, and
within the health care system itself.
Patients may feel that their fatigue is not a paramount problem
compared to other disease and treatment-related side effects unless
their physician asks.
Health care providers and their systems may not have the time/staff to
routinely assess fatigue, and may believe that disease-related fatigue
has no concrete solution potential.
• Interventions for fatigue have been suggested to occur at two levels:
• the management of symptoms that contribute to fatigue,
• and the prevention of additional or secondary fatigue
• by maintaining a balance between restorative rest and restorative
activity.
• Fatigue interventions have been grouped into two broad categories:
• pharmacologic interventions
• and nonpharmacologic interventions.
 the Prevention of
the management of additional or
symptoms that Secondary
contribute to fatigue
fatigue
Pharmacologic Intervention
• Pharmacologic therapies include:
• antidepressants,
• psychostimulants,
• progestational steroids,
• tumor necrosis factor alpha,
• micronutrients such as L-carnitine
• and various other classes of drugs.
• Methylphenidate, a psychostimulant, has been shown to improve
quality of life when given to depressed, terminally ill patients. It has
also been shown to counteract opioid somnolence, enhance the
effects of pain medication, improve cognition, and increase patient
activity level.
• Appropriate initial dosing for this drug is between 5 mg–10 mg orally
at breakfast
• and 5 mg at lunch daily.
• Some patients require higher doses. The elderly may require a
downward dose adjustment.
• Dextroamphetamines, a potent CNS stimulant, may also be used.
They are quickly absorbed from the gastrointestinal tract with high
concentrations in the brain.
• Antidepressants have shown some effectiveness when a patient
experiences both fatigue and depression. Efficacy has been shown
with both nortriptyline and amitriptyline.
• The use of Sertraline in advanced cancer patients has shown no
significant effect on fatigue,
• whereas Bupropion, used with cancer patients with a concomitant
psychiatric diagnosis, showed improvement in fatigue.
• Corticosteroids have been used to increase energy levels at a dose of
about 20 mg–40 mg/day.
• Prednisone has been shown to decrease the degree of fatigue
experienced in some patients. Results from one study indicated an
increase in activity level when palliative care patients were treated
with methylprednisolone.
• Anemia as a result of chemotherapeutic regimens has been very
responsive to interventions. Erythropoietin alpha has been important
in increasing hemoglobin levels for some cancer patients to improve
quality of life.
• Doses varying from 10,000U subcutaneously given three times per
week, to 40,000U given once a week, have resulted in a similar
increase in hemoglobin level.
• In one study of 4382 anemic cancer patients, the highest quality of
life was experienced when hemoglobin was maintained between 11
g–13 g/L with the use of epoetin alfa.
• Although results suggest that erythropoietin has a positive effect on
fatigue, two studies terminated their drug trials early due to safety
concerns over possible thromboembolic events.
Non-pharmacological Interventions
ETHICS IN PALLIATIVE CARE
Lecturer: Nadia shamasnah
• Physicians and nurses encounter difficulties in their practice of
palliative Care. They do need a good understanding of ethical
principles
• There are a wide range of medical issues and ethical dilemmas that
arise in the provision of palliative care.
• It is now realized that a good understanding of medical ethics will
contribute to the health professional's decision-making and day-to-
day practice of medicine for a terminally ill patient.
• The foundation of medical ethics is supported by four pillars:

• Autonomy - patient has the right to choose or refuse the treatment

• Beneficence - a doctor should act in the best interest of the patient

• Non-maleficence - do no harm

• Justice - it concerns the distribution of health resources equitably.

• Added to the above four, are two more aspects which form the
cornerstones of medical practice:

• Dignity - the patient and the persons treating the patient have the
right to dignity

• Truthfulness and honesty - the concept of informed consent and truth

telling

• All these together constitute the six values of medical ethics.

INTEGRATING MEDICAL ETHICS INTO
PALLIATIVE CARE
• ‘A 60-year-old lady with relapsed ovarian cancer, with ascites and
profound dyspnea, is in her terminal stage of disease. She has this
disease progression one year after her surgery and six months after
chemotherapy. Her husband is a retired 65-year-old teacher with
chronic heart disease. The son and daughter stay at distant places and
can only visit frequently’.
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902121/
Difficult Decisions in End-of-life care
• Regardless of the intervention or treatment, the nurse should focus
on helping the patient weigh the benefits and burdens of the
intervention, rather than focus on the intervention itself .
• Now we will discuss some of the difficult decisions that patients
often need to make in end-of-life care.
Withholding/withdrawing of medical
interventions
• One of the dilemmas that can occur relates to the cessation of
medical interventions in patients. Sometimes these interventions
range from minor, such as a non-life sustaining medication, to more
complex, such as mechanical ventilation. The rationale for stopping
these interventions is often based on the fact that the burdens are
outweighing any benefits the patient may get from it.
• Sometimes life-sustaining therapies may prolong suffering at the cost
of decreasing the patient’s quality of life. Patients and their family
often decide to stop medical interventions based on some of these
factors. One of the most heart-wrenching decisions that family
members often have to make is about withdrawing life sustaining
treatments (life support) from patients. This is why advance directives
are so important. Advance directives are documents that enable
patients to make their decisions about medical care known to their
family and health care providers, in the event that they are unable to
make those decisions themselves (National Cancer Institute, 2013).
• If a family member knows for sure that their loved one would not
have wanted a particular medical intervention done, it may help to
alleviate some of the burden they may feel about making the
decision.
• It also helps prevent the initiation of some life sustaining treatments
beforehand, in which case no decision will be need to be made to
withdraw that intervention.
• It also can help reduce overall costs of useless medical care (Coyne,
Smith, & Lyckholm, 2010).
Do not attempt resuscitation (DNAR)
• In 2005, the American Heart Association has changed from the more
recognized acronym for do not resuscitate (DNR) to DNAR (Breault,
2011); however, depending on the location, the more traditional DNR
terminology may still be used. If a patient has an order for a DNR or
DNAR, it means that the patient has elected for cardiopulmonary
resuscitation (CPR) to not be initiated or administered in the event of
a cardiac arrest.
• CPR could include the use of chest compressions, cardiac drugs, and
the placement of a breathing tube. Electing to have or not to have
CPR is a difficult but common medical decision that patients nearing
the end of life often make.
• A “do not intubate” (DNI) order often accompanies a DNR order,
which states that the patient elects not to be intubated with a
breathing tube if they go into cardiac arrest.
• Chest compressions and the use of cardiac medications could still be
used.
Allow natural death (AND)
• Allow natural death is a more recent terminology some health care
institutions have adopted to use instead of the traditional DNR
orders.
• Whereas a DNR order states that no attempts should be made to start
CPR in a patient, an AND order states that only comfort measures are
taken to manage symptoms related to comfort.
• An AND order simply allows the patient to remain comfortable while
not interfering with the natural dying process.
Medical order for life sustaining treatment
(MOLST)
• Sometimes also referred to as physician order to life-sustaining
treatment (POLST), these newer forms of advance directives were
developed in order to improve the communication of a patient’s
wishes about life-sustaining treatments among healthcare providers
and settings.
Hastening death (Principle of double effect)
• The principle of “double effect” refers to some decisions that clinicians
have that will produce both desirable and undesirable effects .
• The example in which the nurse administers a pain medication in order to
alleviate a patient’s pain and suffering but this same intervention may also
contribute to a hastened death, is also an example of “double effect.”
• The medication will reduce the pain but also further reduce the patient’s
respiratory rate to a level that is inconsistent with life. In the case of double
effect, the nurse or clinician should always consider what the intended
effect of the intervention is.
• Is the pain medication being administered to reduce pain and suffering, or
is it being given to further reduce the patient’s respirations?
Terminal/palliative sedation
• Terminal sedation (more recently called “palliative sedation”) is an
intervention used in patients at the end of life, usually as a last effort
to relieve suffering.
• It involves sedating the patient to a point in which refractory
symptoms are controlled.
• The goal is to control symptoms, and the patient is sedated to varying
degrees of consciousness to achieve this. The intent is not to cause or
hasten death, but rather to relieve suffering that has not responded
to any other means. Often the patient is sedated to a point at which
they are unconscious.
Criteria Required for Palliative Sedation
• Patient has a terminal illness
• Severe symptoms present are not responsive to treatment and
intolerable to patient
• A “do not resuscitate” order is in effect
• Death is imminent (hours to days)
• The fourth criteria is the most difficult to determine; however, one study
found that the mean time between initiation of terminal sedation and
death ranged from 1.9 to 3.2 days .
• Terminal sedation has been compared with slow euthanasia and assisted
dying; however, they are not the same thing. The key difference is based on
the intent or purpose of the intervention. The intent is not to hasten death
but to relieve suffering that cannot be relieved by any other available
method.
• In assisted dying or physician assisted euthanasia, the intent is to produce
death in order to relieve suffering. Palliative sedation has been supported
as a means to alleviate suffering by the United States Supreme Court, and
the Hospice and Palliative Nurses Association is in favor of its use (Hospice
and Palliative Nurses Association, 2003).
Assisted dying
• Assisted dying is defined as “an action in which an individual’s death
is intentionally hastened by the administration of a drug or other
lethal substance”
• Under this general definition, there are two distinct subcategories
that include assisted suicide and active euthanasia.
• In assisted suicide, the patient is provided with the means to carry
out suicide, such as providing a lethal dose of a medication. In active
euthanasia, someone other than the patient is the one who carries
out the action that ends the patient’s life (Volker, 2010).
Anorexia and Cachexia
Lecturer: Nadia shamasnah
• Anorexia is defined as the loss of desire to eat and is a symptom which
accompanies many common illnesses.
• In acute events, anorexia usually resolves with resolution of the illness, and
any weight lost may be replaced with nutritional supplements or increased
intake.
• Anorexia leads to insufficient caloric intake and protein-calorie
malnutrition.
• Weight loss from this starvation phenomenon usually involves loss of fat,
rather than muscle tissue.
• Anorexia is common among patients with advanced cancer and acquired
immune deficiency syndrome (AIDS), but also characterizes the clinical
course of patients with other chronic progressive disease, such as COPD,
CHF, and end-stage renal disease
• Cachexia is a complex syndrome that usually involves anorexia, along
with significant weight loss, loss of muscle tissue as well as adipose
tissue, and generalized weakness.
• The word “cachexia” is derived from the Greek kakos, meaning bad,
and hexis, meaning condition or appearance;
• throughout medical history, cachexia has been associated with the
gravely ill.
• The first clinical definition can be traced to Hippocrates earlier than
400 BC: “The flesh is consumed and becomes water . . . the abdomen
fills with water, the feet and legs swell, the shoulders, clavicles, chest
and thighs melt away . . . the illness is fatal.”
• Cachexia is defined as a state of “general ill health and malnutrition,
• marked by weakness and emaciation”; it occurs in more than 80% of
patients with cancer before death and is the main cause of death in
more than 20% of such patients
• Research has shown that over 50% of patients with advanced cancer
experience nausea and/or vomiting.
• These symptoms are more common in:
• patients under 65 years old,
• in women,
• and in patients with cancer of the gastro-intestinal tract or breast.
Management

• The nutritional quality:

• Patients may benefit from supplementary sources of protein and
calories.
• Nurses should determine the meaning to the patient and family of
giving, taking, and refusing food.
• families require education and frequent support in the face of
helplessness and frustration related to ever-diminishing intake.
• Culturally appropriate or favored foods should be encouraged.
Preserving cultural or social traditions around meals may also be
helpful.
• Families should be encouraged to share mealtime with patients or
continue habits such as a glass of wine with meals, if medically
appropriate.
• Small meals, on the patient’s schedule and according to the taste and
whims of the patient, are helpful, at least emotionally.
• Foods with diffrent tastes, textures, temperatures, seasonings,
degrees of spiciness, degrees of moisture, and colors.
• less spicy foods are preferred by many patients.
• Different liquids should also be tried. Cold, clear liquids are usually
well tolerated .
• Patients who experience early satiety, for example, should take the
most nutritious part of the meal first.
• Filling fluids without nutritional value (such as carbonated soda)
should be avoided at mealtime Oral
• The nutritional quality of intake should be evaluated and, if possible
and appropriate, modified to improve the quality.
• Patients who are not dying may benefit from supplementary sources
of protein and calories.
• Hygiene and management of any oral pain are essential in nutritional
support. Procedures, treatments,
• psychological upsets (negative or positive), or other stresses or
activities should be limited prior to meals.
Which Cancer Is the Most
Painful?
Lecturer: Nadia shamasnah
• cancer spreading to the bone is the most painful type of cancer.
• Pain can be caused by a tumor pressing on the nerves around the
bone.
• As the tumor size increases, it can release chemicals that irritate the
area around the tumor. Cancer may either start or spread to the
bone.
 The degree of pain depends on different factors
such as follows:
• Type of cancer
• Stage of cancer
• Tolerance for pain
• People with stage IV cancer have the highest degree of cancer pain.
Additionally, cancer surgery, treatments, or tests cause cancer pain.
Spinal cord compression
• When a tumor spreads to the spine, it can press on the nerves of the
spinal cord leading to spinal cord compression.
• The symptoms generally include back or neck pain. Pain, numbness,
or weakness may also follow.
• Cancer surgery can also result in pain. Most pain resolves after a
while. However, some people may have pain that lasts for months or
years.

• Radiation therapy causes pain, which resolves after sometimes.

Chemotherapy may cause pain and numbness in the fingers and toes
called peripheral neuropathy.
Other causes of cancer pain include:

• Arthritis
• Chronic low back pain
• Phantom pain (longer-lasting effect of surgery, beyond the usual
surgical pain)
• Spasms, pain, stinging, and itching caused by intravenous
chemotherapy
What are the different types of cancer pain?

• Cancer pain can be felt in one of three ways:

• Acute pain: It is severe in the beginning and then eases off immediately. It
may be due to an ulcer-like sore on the skin and inside the body that is
cancerous.
• Chronic pain: It is a low throbbing or sharp pain that hangs around for a
long time. It can be managed with pain medications but cannot completely
disappear. It may be due to the destruction of the normal tissue by cancer
cells.
• Breakthrough pain: If you treat chronic pain with medications, you may feel
a flash of pain every once in a while. This is called “breakthrough pain”
because it breaks through the effects of medications.
• Fastest- and slowest-spreading cancers
• Cancer cells that have more genetic damage (poorly differentiated) usually
grow faster than cancer cells with less genetic damage (well differentiated).
Based on how abnormal they appear under a microscope, tumors are
graded as follows:

• GX: undetermined
• G1: well-differentiated or low-grade
• G2: moderately differentiated or intermediate-grade
• G3: poorly differentiated or high-grade
• G4: undifferentiated or high-grade
• Some cancers that are generally slower growing are:

• breast cancers, such as estrogen receptor-positive (ER+) and human

epidermal growth factor receptor 2-negative (HER2-)
• chronic lymphocytic leukemia (CLL)
• colon and rectal cancers
• most types of prostate cancer
• Some cancers, such as prostate cancer, can grow so slowly that your doctor may recommend a “watchful
waiting” approach rather than immediate treatment. Some may never require treatment.

• Examples of fast-growing cancers include:

• acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML)

• certain breast cancers, such as inflammatory breast cancer (IBC) and triple-negative breast cancer (TNBC)
• large B-cell lymphoma
• lung cancer
• rare prostate cancers such as small-cell carcinomas or lymphomas
• Having a fast-growing cancer doesn’t necessarily mean you have a poor prognosis. Many of these cancers
can be effectively treated. And some cancers don’t necessarily grow faster, but are less likely to be detected
until they have metastasized.
What stages have to do with cancer spread
• Cancers are staged according to tumor size and how far it has spread at the time of diagnosis.
Stages help doctors decide which treatments are most likely to work and give a general outlook.

• There are different types of staging systems and some are specific to certain types of cancer. The
following are the basic stages of cancer:

• In situ. Precancerous cells have been found, but they haven’t spread to surrounding tissue.
• Localized. Cancerous cells haven’t spread beyond where they started.
• Regional. Cancer has spread to nearby lymph nodes, tissues, or organs.
• Distant. Cancer has reached distant organs or tissues.
• Unknown. There’s not enough information to determine the stage.
• Or:
• Stage 0 or CIS. Abnormal cells have been found but have not spread
into surrounding tissue. This is also called precancer.
• Stages 1, 2, and 3. The diagnosis of cancer is confirmed. The numbers
represent how large the primary tumor has grown and how far the
cancer has spread.
• Stage 4. Cancer has metastasized to distant parts of the body.
• Your pathology report may use the TNM staging system, which
provides more detailed information as follows:
• T: Size of primary tumor

• TX: primary tumor can’t be measured

• T0: primary tumor can’t be located
• T1, T2, T3, T4: describes the size of the primary tumor and how far it
may have grown into surrounding tissue
• N: Number of regional lymph nodes affected by cancer

• NX: cancer in nearby lymph nodes can’t be measured

• N0: no cancer is found in nearby lymph nodes
• N1, N2, N3: describes the number and location of lymph nodes
affected by cancer
• M: Whether cancer has metastasized or not

• MX: metastasis can’t be measured

• M0: cancer hasn’t spread to other parts of the body
• M1: cancer has spread
• So, your cancer stage might look something like this: T2N1M0.
• Tumor growth and spread
• Benign tumors
• Benign tumors are noncancerous. They’re covered with normal cells and
aren’t able to invade nearby tissue or other organs. Benign tumors can
cause a few problems if they:

• are large enough to press on organs, cause pain, or are visually bothersome
• are located in the brain
• release hormones that affect body systems
• Benign tumors can usually be surgically removed and are unlikely to grow
back.
• Malignant tumors
• Cancerous tumors are called malignant. Cancer cells form when DNA
abnormalities cause a gene to behave differently than it should. They
can grow into nearby tissue, spread through the bloodstream or
lymph system, and spread through the body. Malignant tumors tend
to grow faster than benign tumors.