ONCOLOGY Vol 18 No 12

Delirium in the setting of terminalillness is common; moreover,it can create extremehardships for patients and their families,who are already facing the mostdifficult of circumstances. However,delirium that develops in the contextof comorbid medical conditions maybe readily reversible with thoughtfulevaluation and effective management.Friedlander, Brayman, and Breitbartdescribe important factors to considerwhen assessing and treating deliriumin the context of end-stage illness.We will elaborate on their discussionand emphasize some common pitfallsassociated with the management ofdelirium.

The Pharmacologic Managementof Cancer Pain” by NathanCherny is an excellent, comprehensive,yet concise paper on thetreatment of cancer pain. It even goesbeyond its stated intention of discussingpharmacologic treatment, as it ventures-in a very appropriate, balanced,and succinct manner-to delve intothe issues of psychological therapiesand physiatric and invasive analgesictechniques.

Fatigue, the most common symptomreported by people withcancer, is associated with functionalimpairments and decrements inquality of life. As Drs. Lipman andLawrence have pointed out, researchon the etiology of cancer-related fatigueis scant. Morrow et al[1] conducteda detailed review of theevidence to support four hypothesesfor cancer-related fatigue and highlightedindependent findings that implicatecytokines, 5-HT, and thehypothalamic-pituitary axis in the developmentof cancer-related fatigue.Additional research is needed in thisarea to articulate the pathophysiologyof fatigue and the associated clinicalimplications.

Depression is seen in many cancer patients. It is an especially importantissue in palliative care, as depression can be more common inpatients who are at the end of life. Accurate assessment and treatmentcan have a powerful impact on improving a patient's quality of life.This article reviews the definition and the differential diagnosis of depressionin cancer patients. It then focuses on some of the treatmentoptions available, including pharmacotherapy and psychotherapy.

Miriam Friedlander, YanaBrayman, and WilliamBreitbart have produced anexcellent review of delirium in thepalliative care setting. Their paper isthorough, readable, and thoughtful,and will be helpful to oncologists caringfor patients with advanced illness.I particularly like the fact that theauthors make it clear that delirium isnot only a very common complicationof advanced cancer, but that it isalso a major source of suffering anddistress for both patients and families.In view of the problems deliriumpresents and the frequency with whichdelirium arises as death approaches,this complication of advanced and terminalillness has received inadequateattention. My thanks and congratulationsgo to the authors for providingsuch a clear and helpful review of thischallenging clinical problem.

Drs. Jeremy Winell and AndrewRoth have provided a niceoverview of the diagnosis andtreatment of depression in cancer patients.The views they express are bothwidely accepted and applicable to otherserious medical illnesses as well.They remind us of the challenge ofmaking a valid diagnosis of depressionin cancer patients, since all of thesomatic symptoms of depression (eg,anorexia, fatigue, insomnia) may insome patients represent symptoms ofcancer or cancer treatment rather thandepression.

The term “supportive oncology” refers to those aspects of medical careconcerned with the physical, psychosocial, and spiritual issues facedby persons with cancer, their families, their communities, and their healthcareproviders. In this context, supportive oncology describes both those interventionsused to support patients who experience adverse effects caused by antineoplastictherapies and those interventions now considered under the broad rubric of palliativecare. At its core, palliative care is concerned with providing the maximumquality of life to the patient/family unit.

Dr. Cherny’s article on the managementof cancer pain is acomprehensive review thatshould prove to be a helpful resource.As physicians in a palliative care andoncology program, we discuss howwe utilize these principles and whatwe see put into practice by others.Cherny and Catane have already documentedthat the great majority ofoncologists do a substantial amountof palliative care, whether they call itthat or not, and that most oncologistswould be willing to work with palliativecare or symptom managementspecialists.[1] Knowledge is only onepart of the solution, and must be pairedwith better practice by health-care professionalsand help from our patients.Articles like this will only help if oncologistspay attention.

Delirium is highly prevalent in cancer patients with advanced disease.Frequently a preterminal event, the condition is a sign of significantphysiologic disturbance, typically involving multiple medical etiologiesincluding infection, organ failure, adverse medication effects,and in rare situations, paraneoplastic syndromes. Unfortunately, deliriumis frequently underrecognized or misdiagnosed and, therefore,inappropriately treated or untreated in terminally ill patients. The clinicalfeatures of delirium are numerous and encompass a variety of neuropsychiatricsymptoms common to other psychiatric disorders. Threeclinical subtypes of delirium, based on arousal disturbance and psychomotorbehavior, have been described: hyperactive, hypoactive, andmixed. The differential diagnosis for delirium includes depression,mania, psychosis, and dementia. Numerous instruments have been developedto aid the clinician in rapidly screening for the disorder. Standardmanagement requires an investigation of the etiologies, correctionof the contributing factors, and management of symptoms. Symptomaticand supportive therapies, including numerous pharmacologicapproaches, are important, but several aspects of the use of neurolepticsand other agents in the management of delirium in the dying patientremain controversial.

Severe, debilitating fatigue is common in cancer patients. For many,it is the symptom that interferes most with normal routines. Virtuallyevery modality used to treat cancer may cause fatigue, as can complicationsof the disease such as sleep disturbances, infections, malnutrition,hypothyroidism, and anemia. There is a significant overlap betweendepression and fatigue in many patients. Given the high prevalenceof cancer-related fatigue, frequent assessment of patients is essential.The evaluation should include an attempt to identify reversiblecauses of fatigue, and screening for depression. However, many cancerpatients suffer from fatigue even in the absence of any identifiable,reversible cause. For these patients, consideration can be given to suitableexercise programs, educational support and counseling, and energyconservation strategies. A trial of a stimulant medication is alsoreasonable. Given the heterogeneity of patients, individualized approachesare needed. For anemic patients undergoing chemotherapy,erythropoietic agents can increase hemoglobin levels. The impact ofthese drugs on fatigue and quality of life is uncertain. Recent reports ofincreased mortality and thrombotic events in cancer patients treatedwith epoetin require further investigation.

The management of cancer pain requires familiarity with a rangeof therapeutic strategies, including antineoplastic therapies, analgesicpharmacotherapy, and anesthetic, neurosurgical, psychological, andrehabilitation techniques. Successful pain management is characterizedby implementation of the techniques with the most favorable therapeuticindex for the prevailing circumstances, along with provision forrepeated evaluations, so that a favorable balance between pain reliefand adverse effects is maintained. For most patients, pain managementinvolves the administration of specific analgesic approaches. In all cases,these analgesic treatments must be skillfully integrated with the managementof other symptoms.