Dharamshila Narayana Superspeciality Hospital

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Palliative Care Support Programme

Introduction

Cancer of the female genital tract is a significant cause of morbidity and mortality worldwide. Cervical cancer is the third largest cause of cancer mortality in India after cancers of the mouth & oropharynx, and oesophagus, accounting for nearly 10% of all cancer related deaths in the country (WHO, 2009b).

When potentially curative treatment options are unavailable or have proven ineffective, the clinical goal changes from cure to palliation. The various gynaecological cancers, although arising from anatomically adjacent organs, have different natural histories. Symptoms of progressive disease vary depending upon the site of primary tumor origin. Therefore, strategies to palliate disease progression are tailored to the complications caused by the particular combination of local invasion and distant spread encountered with tumors arising from a given site of origin. For this reason, this review is organized by disease site of origin. The description of cervix cancer is subdivided into 3 parts, and information on certain issues of general relevance for all sites can be found in these sections.

Cervical Cancer I: Bleeding, Pain, Depression

Cervical cancer tends to spread locally before it metastasizes to distant organs. When cervical cancer is confined to the pelvis or regional lymph nodes, it may be cured with radical surgery, chemo-radiation, or both. When patients with cervical cancer have distant metastatic disease, the cancer generally is not curable. In this setting, any treatment administered is of palliative intent. As always, palliative treatment should be directed at symptom control. Patients with advanced or recurrent cervical cancer may have any of the following symptoms:

  • Vaginal bleeding or discharge
  • Pelvic or back pain
  • Urinary or bowel fistulas
  • Lower extremity edema
  • Deep venous thrombosis
  • Dyspnea from anemia or pulmonary involvement
  • Uremia from ureteral obstruction

Available interventions to control vaginal bleeding include vaginal packing, radiation therapy, embolization of the uterine arteries, or surgical resection or arterial ligation. Vaginal packing is usually a temporary measure. Potentially helpful radiation therapy approaches include trans-vaginal ortho-voltage treatment, high dose fraction tele therapy, or brachytherapy (see Radiation Therapy In Gynaecology).

Pain is often a very disabling symptom of advanced or recurrent cervical cancer. Regional nerve, muscle, and bone infiltration can cause severe discomfort. Narcotic analgesics are a fundamental component of cancer pain treatment. Recognizing that narcotics can be delivered via many different routes is important. Agents may be prepared for oral, rectal, vaginal, sublingual, intravenous, intramuscular, epidural, and topical administration. Unfortunately, narcotics are associated with some troublesome common adverse effects that also must be addressed. These include constipation, pruritus, nausea, drowsiness, and skin rash. Because constipation is almost universal with increasing doses of narcotics, a bowel stimulant should be prescribed simultaneously.

Nonsteroidal anti-inflammatory analgesics and certain antidepressant medications often can provide a favorable synergistic effect when prescribed concurrently with narcotics, especially for pain suspected to be of neuropathic origin. When pain is directly attributable to specific foci of disease, such as bone metastasis or para-aortic lymph node recurrence, a brief course of palliative radiation therapy yields substantial pain reduction in a high percentage of patients. Transdermal electrical nerve stimulation (TENS), massage therapy, and meditation or other biofeedback techniques are sometimes helpful adjuncts to narcotic therapy.

Anxiety and depression are common comorbidities in patients with malignancy of any type. Although these responses are not inappropriate in a patient diagnosed with a life-threatening condition, recognizing them and initiating intervention are important. Unless these conditions are treated adequately, patients might be noncompliant with other important therapies. Furthermore, efforts to control pain are particularly compromised. Fortunately, several effective medical therapies are available for both of these conditions. In addition to anxiolytics and antidepressants, supportive counseling, spiritual counseling, and family support can help counter feelings of depression and anxiety.

Cervical Cancer II: Fistulas, Edema, And Venous Thrombosis

Advanced cervical cancer may cause urinary fistulas, vesicovaginal fistulas more commonly, and, less commonly, ureterovaginal fistulas. Constant leakage of urine is extremely disturbing to many patients. Although not necessarily painful, fistulous drainage can have an extremely negative impact on quality of life. Patients with fistulas often may choose to avoid social and family encounters, ultimately becoming housebound.

Palliation of fistulas may be accomplished by either surgery to create an ureterointestinal conduit or by placing bilateral percutaneous nephrostomies and obstructing the ureters. Both procedures require an external appliance and maintenance. Functional status and operative risk should guide the selection of the means of palliation.

Although placement of nephrostomy tubes is a simpler procedure than surgical diversion of ureteral outflow, it is not necessarily a better choice for patients with a life expectancy of more than a few months. One disadvantage of percutaneous nephrostomies is the relative ease for these tubes to become kinked or dislodged. The tubes can be a source of infection and must be exchanged every few months. The use of external pads (diapers) to absorb drainage is the simplest option of all. However, in this author experience, unless the patient is confined to bed for other reasons, this is a choice of minimal benefit for most patients.

Occasionally, rectovaginal fistulas occur from primary tumor invasion of the adjacent rectum. More often, these fistulas result from radiation injury or tumor recurrence. Diverting colostomy is the surgical procedure of choice in someone with a limited lifespan. Diverting end colostomy is associated with less long-term complications than loop colostomy.

Edema may result from generalized anasarca from protein depletion and malnutrition. Alternatively, edema may be localized to the lower extremities as a consequence of lymphatic and/or venous obstruction due to a large tumor burden in the lymph nodes. Symptomatic relief of edema and leg discomfort may be obtained by the use of graded compression stockings, elevation of the extremities, and diuretics. Physical therapists with training and expertise in lymphedema management can facilitate fluid drainage with external massage maneuvers.

Deep venous thrombosis (DVT) may cause secondary edema. For DVT developing for any other reason, anticoagulation is standard treatment unless medically contraindicated. Conventional or low molecular heparin usually is followed by oral warfarin. Prolonged anticoagulation is usually necessary because DVT often recurs in terminally ill patients with recurrent cancer. Anticoagulation prevents further extension of the thrombus and promotes gradual recanalization of the vessel as the thrombus is resorbed. At the same time, collateral vessels enlarge to accommodate more flow, and the net result is relief of extremity swelling and improved comfort for the patient. Because anticoagulation might exacerbate hemorrhage from recurrent cancer in the pelvis or elsewhere, in some cases, vena caval filters are preferable to prevent pulmonary emboli.

 

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