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The Evolving Face of Palliative Care in Cancer Medicine

Clinical Director Oncology Program National Cancer Institute Bethesda, Maryland

When cancer medicine was in its infancy, the meaning of "palliative care" was clear and fairly uniform. During cancer treatment, nausea and vomiting topped the list of chief complaints, adversely affecting the patient's quality of life. Most drugs caused hematologic cytopenia as their limiting toxicity. Following treatment, for patients with progressive disease, pain management and hospice care became the more urgent priorities. These facts have dominated our attitudes toward palliative care for the last two decades, but these attitudes are no longer consistent with the realities of cancer treatment. What has changed?

First, there are much better tools today for managing nausea, vomiting, neutropenia, and pain. As these problems have been solved or mitigated, other symptoms have risen to dominance. Cancer fatigue has now become the chief complaint of many cancer patients. Interestingly, as cancer patients survive longer, this problem has become even more dominant, since often cancer fatigue does not subside over time. Cancer fatigue is experienced by most cancer patients to the degree where it affects the patient's ability to work, enjoy life, and interact with family and friends.

Oddly, this state of affairs has caught the oncologist largely unawares. Fatigue has either been considered a necessary sequela of cancer and its treatment or an amorphous and complex condition not amenable to differential diagnosis and treatment. However, as Drs. Portenoy and Itri report in this issue of The Oncologist, fatigue is a common and important symptom in cancer patients and cancer survivors, and often has an etiology amenable to treatment.

Fatigue can be metabolic (electrolyte imbalance, hypothyroidism), cognitive (opioid usage or sleep deprivation), psychologic (depression), or physiologic (anemia). In each case, a careful history and physical exam, coupled with selected screening tests, can identify the cause of fatigue which can be improved by treatment.

The need for expertise in symptom management is likely to increase in cancer medicine. The next generation of cancer drugs will focus on cancer cell features other than uncontrolled growth—such as differentiation, angiogenesis, drug resistance, immune recognition, oncogene expression, and metastasis. The emerging evidence from Phase 1 trials with these agents predicts an array of side effects much different than nausea, vomiting, and cytopenia. For example, the taxanes are limited by neuropathy and some antisense compounds by fatigue. Drugs which interfere with cell cycle check points can cause hyperglycemia (UCNO1) or diarrhea (flavopiridol). Both UCNO1 and flavopiridol can also cause a proinflammatory syndrome. COL-3, an antimetastatic compound, causes photosensitization as its toxicity endpoint.

One of the major long-term goals of cancer medicine has always been to maintain the patient's overall quality of life during and after treatment. In the future, this is likely to become an even more important priority as more and better tools are developed for symptom management and patients justifiably expect to live as fully and productively as possible. Palliation will mean more than hospice care and pain management. Instead, oncologists (or perhaps a new set of oncology subspecialists) will need to become skilled in symptom management. Indeed, farsighted hospitals, such as Dr. Portenoy's, are beginning to establish new departments in this emerging area of clinical need and patient expectation. These departments will have several important missions: First, they will begin to use the symptom management tools currently available in the most effective ways. Second, they will conduct the research needed to develop new palliative care approaches as well as the algorithms which will translate into their usage by the broader oncology community. And last, and most importantly, they will begin to train tomorrow's leaders in this important and evolving area of cancer medicine.

Fatigue is a common and important symptom in cancer patients and cancer survivors, and often has an etiology amenable to treatment.

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