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

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

3. Multidisciplinary Team Oncologist Radiation Oncologist SurgeonGastroenterologistsNurse Multidisciplinary Team Approach

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

5. Symptom Management Fatigue Fatigue Pain Pain Bowel Changes Bowel Changes  Diarrhea  Constipation Changes in Eating Changes in Eating Sleep pattern disturbance Sleep pattern disturbance Psychological/Emotional Issues 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 Most common and distressing symptom Multiple factors that can contribute to fatigue: exact pathophysiology unknown 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 No real test to measure fatigue Important to “maintain what you can, and if you can’t, minimize loss” Important to “maintain what you can, and if you can’t, minimize loss” Patterns of fatigue must be correlated with symptoms Patterns of fatigue must be correlated with symptoms Leads to decrease in quality of life and ability to participate in everyday activities Leads to decrease in quality of life and ability to participate in everyday activities Report symptoms to your medical provider 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 Detection and treatment of underlying problem Energy conservation: Pace activities Energy conservation: Pace activities  Basic activities of daily living: bathing, mobility, dressing  Household activities, shopping, work, leisure Exercise Exercise Keep record of fatigue pattern for a week 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. Pain Overview 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 Management Interventions Anticancer therapies Anticancer therapies Pharmacologic interventions are the cornerstone to cancer pain management Pharmacologic interventions are the cornerstone to cancer pain management Patients and caregivers should be educated about the purpose, optimal dose and schedule of medications 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 Improper dosage or schedule of medications may cause or exacerbate side effects May need bowel regimen to prevent constipation May need bowel regimen to prevent constipation

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

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

15. Diarrhea Carcinoid Syndrome: Associated with Chronic Diarrhea Can occurs in about 70-75% of patients with carcinoid syndrome Can occurs in about 70-75% of patients with carcinoid syndrome Usually secretory-type diarrhea: mild to severe 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 Somatostatin analogues Nonspecific Approaches 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. Constipation Management 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 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 Management Interventions Nutrition consult Nutrition consult Frequent small portions of food Frequent small portions of food Good oral hygiene Good oral hygiene Create a pleasant setting for eating Create a pleasant setting for eating Provide foods high in protein and calories Provide foods high in protein and calories Appetite stimulating medication if appropriate Appetite stimulating medication if appropriate

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

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

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

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

26. Sleep Pattern Disturbances: Interventions Institute regular sleep pattern times 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) Exercise on a consistent basis (4-7 hours before bedtime) Avoid stimulants Avoid stimulants Individualize the sleep environment Individualize the sleep environment Avoid CNS depressants Avoid CNS depressants Behavioral and cognitive techniques Behavioral and cognitive techniques Pharmacologic approaches Pharmacologic approaches (Yellan& Dyonzak, 1999)

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

28. Anxiety Interventions Pharmacologic treatment Pharmacologic treatment Nonpharmacologic 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)