Robin Sommers MS, ANP-BC, AOCNP Division of Gastrointestinal Oncology

1. Robin Sommers MS, ANP-BC, AOCNP Division of Gastrointestinal Oncology Dana Farber Cancer Institute Understanding Symptom Management

2. Overview • Cancer can cause a multiple of symptoms • Physical • Psychological/Emotional Issues • Comprehensive management of patients with cancer: Multidisciplinary Approach • Disease Oriented • Symptom Oriented • Individualized

3. Multidisciplinary Team Approach

4. Professional Support Staff • Nurses: research, program, infusion room • Nurse Practitioners/Physician Assistants • Social Workers • Nutritionists • Genetic Counseling • Pharmacists • Chaplain • Pain and Palliative Care Team • Resource Specialist • Other support staff

5. Symptom Management • Fatigue • Pain • Bowel Changes • Diarrhea • Constipation • Changes in Eating • Sleep pattern disturbance • Psychological/Emotional Issues • Anxiety • Depression

6. Fatigue “Often described as an unusual or excessive whole-body tiredness, disproportionate to or unrelated to exertion” “ No definition that satisfies all the clinical observations and subjective experiences associated with it”

7. Fatigue • Most common and distressing symptom • Multiple factors that can contribute to fatigue: exact pathophysiology unknown • Cancer • Cancer treatments • Loss of weight • Loss of appetite • Decrease nutritional status • Sleep disturbances • Changes in activity/rest patterns • Drug side effects • Stress, anxiety, and depression

8. Fatigue • No real test to measure fatigue • Important to “maintain what you can, and if you can’t, minimize loss” • Patterns of fatigue must be correlated with symptoms • Leads to decrease in quality of life and ability to participate in everyday activities • Report symptoms to your medical provider • Description of fatigue • How do you feel? • How does it affect your quality of life? • What does fatigue mean to you?

9. Management of Fatigue • Detection and treatment of underlying problem • Energy conservation: Pace activities • Basic activities of daily living: bathing, mobility, dressing • Household activities, shopping, work, leisure • Exercise • Keep record of fatigue pattern for a week • Identify time of day when you are most fatigued • Identify any activities or situations in which fatigue is worse • Use a scale of 1-10 to assess levels of fatigue

10. Pain “Pain is whatever the experiencing person says it is, existing whenever he or she says it does”

11. PainOverview • One of the most major fears of patients • Much remains unknown regarding the pathophysiology of cancer pain, specifically in regards to chronic pain • Fear of addiction is often a barrier to pain management • Pain assessment often difficult as it is a subjective experience • Types of pain • Acute • Chronic

12. Pain ManagementInterventions • Anticancer therapies • Pharmacologic interventions are the cornerstone to cancer pain management • Patients and caregivers should be educated about the purpose, optimal dose and schedule of medications • Misunderstandings about side effects can serve as an obstacle to adequate pain relief • Improper dosage or schedule of medications may cause or exacerbate side effects • May need bowel regimen to prevent constipation

13. PainNonpharmacological Interventions • Valuable adjuncts to pain management • Physical techniques • Massage • Acupuncture • Positioning • Cognitive-behavioral techniques • Education and reassurance • Diversion of attention • Relaxation, breathing, hypnosis • Psychological and spiritual counseling

14. Diarrhea Acute Diarrhea Chronic Diarrhea Neoplasms such as neuroendocrine tumors or intestinal cancers Food allergies Lactose intolerance Malabsorption syndromes Hyperthyroidism Diabetes Laxative abuse Other • Infection • Drug reactions • Dietary alterations • Inflammatory bowel disease • Diverticulitis • Gastroenteritis • Fecal impaction • Other

15. Diarrhea Carcinoid Syndrome: Associated with Chronic Diarrhea • Can occurs in about 70-75% of patients with carcinoid syndrome • Usually secretory-type diarrhea: mild to severe • Watery • Can occur several times per day • Impact quality of life • Abdominal pain may accompany diarrhea, but diarrhea also occurs alone • Can lead to dehydration and electrolyte loss

16. Diarrhea Management:Pharmacologic Interventions • Somatostatin analogues • Nonspecific Approaches • Loperamide • Lomotil • Tincture of opium • Pancreatic Enzymes • Cholestyramine

17. Constipation • Defined as the passage of hard stools, which may be decreased in frequency from baseline pattern • Related to Cancer or Cancer Therapy • Primary Causes • Decrease in dietary intake of fluid and fiber • Decrease in mobility and exercise • Bedrest • Changes in usual patterns of elimination and bowel routine • Narcotics • Medications

18. ConstipationManagement of Symptoms • Prevention: Identification of person at risk • Monitoring bowel function • Increase dietary fiber and fluid intake • Exercise • Stool softener and peristaltic stimulators • Laxatives if indicated

19. Alterations in Nutrition • Causes of eating changes • Psychological abnormalities • Side effects of treatment and disease related • Anorexia • Altered taste • Mucositis • Alterations in gastrointestinal function • Metabolic abnormalities

20. Symptom ManagementInterventions • Nutrition consult • Frequent small portions of food • Good oral hygiene • Create a pleasant setting for eating • Provide foods high in protein and calories • Appetite stimulating medication if appropriate

21. DepressionOverview • Some degrees of sadness expected • Distinguishing sadness from clinical depression • Treatable • Interventions • Adopt calm, reassuring approach • Identify support systems

22. Signs of Depression • Persistent sad or “empty mood” • Loss of interest in ordinary activities • Fatigue or decrease energy • Sleep pattern disturbances • Difficulty concentrating • Feelings of guilt • Irritability • Excessive crying • Chronic unexplained aches or pains

23. DepressionOverview • Some degree of sadness expected • Distinguishing sadness from clinical depression • Treatable • Interventions • Adopt a calm reassuring approach • Identify support systems

24. Interventions for Depression • Report to your medical provider • Contact mental health provider • Avoid alcoholic beverages • Participation in support groups • Prayer or spiritual support if this is comfort to an individual • Supportive atmosphere

25. Sleep Pattern Disturbance • Frequent problem for cancer patients • Causes of sleep disturbance • Physical illness • Associated anxiety and/or depression • Side effects of disease and/or treatment • Classification • Difficulty falling asleep • Difficulty staying asleep • Early morning awakening

26. Sleep Pattern Disturbances: Interventions • Institute regular sleep pattern times • Establish a bedtime and wake time and maintain them • Set alarm clock but then hide it. • Stay in bed only for the hours intended for sleeping • Exercise on a consistent basis (4-7 hours before bedtime) • Avoid stimulants • Individualize the sleep environment • Avoid CNS depressants • Behavioral and cognitive techniques • Pharmacologic approaches (Yellan& Dyonzak, 1999)

27. Anxiety • Definition: Dominant psychophysiologic state of worry, autonomic hyperactivity, muscle tension, and hypervigilance • Common response to cancer experience • Poorly controlled can lead to ineffective coping and can be disruptive • Classification • Acute • Chronic (Clinical Manual for the Oncology Advance Practice Nurse, 2000)

28. Anxiety Interventions • Pharmacologic treatment • Nonpharmacologic treatment • Support from family, friends, and significant others • Patient education • Psychotherapy • Counseling • Support Groups (Clinical Manual for the Oncology Advance Practice Nurse, 2000)