Palliative care in advanced cancer patients in a tertiary care hospital in Uttarakhand
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.45449
Source of Support: None, Conflict of Interest: None
Aim: Advanced cancer, irrespective of the site of the cancer, is characterized by a number of associated symptoms that impair the quality of life of patients. The management of these symptoms guides palliative care. The present study aims to describe the symptoms and appropriate palliation provided in patients with advanced cancer in a tertiary care hospital in Uttarakhand.
Keywords: Advanced cancer, polypharmacy, symptoms in cancer
The last few days of the cancer patient's life are impaired by a large number of debilitating symptoms related not just to illness but also to the often brutal treatment regimens. These symptoms increase the burden of morbidity, impair the quality of life and adversely impact the prognosis.  It is now widely recognized that palliative care should be instituted as early as possible in all chronic and ultimately fatal diseases. In advanced cancer, patients require supportive care apart from chemotherapy, which may be undertaken with the goal of palliation. Improved treatment of symptoms has been associated with an enhancement of patient and family satisfaction, functional status, quality of life and other clinical outcomes. , Supportive care is defined as any treatment given to prevent, control or relieve complications and side effects and to improve the patient's comfort and quality of life in people who have cancer.  Advanced cancer patients require a variety of drugs to tackle the multiple symptoms, therefore, predisposing them to other drug-related problems. The present study was carried out with two main intentions: firstly, to identify the main symptom concerns during the terminal stages of cancer and secondly, to count the number of drugs received by these patients with the ultimate aim of making recommendations toward rationalizing pharmacotherapy.
This was an observational cohort, prospective/follow-up study of patients with advanced cancer undergoing palliative treatment. One hundred patients with previously diagnosed advanced cancer, attending the oncology service, department of surgery at a tertiary care hospital in the state of Uttarakhand between May 2004 and May 2005 were included in the study. The patients were followed-up for 2 months.
Symptoms reported and treatments received by the patients at any point of time during the follow-up period were recorded. The medications used were recorded in detail and included dosage, route, frequency and duration of use. All drugs consumed by patients were classified according to the Anatomical Therapeutic Chemical (ATC) classification categories.  The drugs received by the patients were further grouped into three categories:
Any other therapeutic strategy, apart from pharmacological approaches, such as surgery, radiotherapy and relaxation therapy/yoga received by the patients was also documented.
Data were presented as mean ± SD.
Between May 2004 and May 2005, 100 patients were enrolled in the study. [Table 1] shows the demographic profile of these patients. Of the 100 patients, 60 (60%) were men and 40 (40%) were women. The median age was 55 years (range 13-80) and the mean ± SD karnofsky index was 64.44 ± 12.39 (range 40-90). The cancer classification by site for these patients is illustrated in [Figure 1]. The most common cancer represented in our study was lung cancer (34%), followed by gastrointestinal tract (25%) and breast cancer (10%). Lung and breast cancers were the most common malignancies in male and female patients, respectively.
The main symptoms reported by these patients at any point of time during the follow-up are shown in [Figure 2]. The most common symptoms were pain, weakness/fatigue, anorexia, insomnia, nausea/vomiting, dyspnea, constipation and cough. The average number of symptoms reported per patient was 5.33 ± 0.67 (mean ± SD). Pain was the most frequent symptom occurring in 95% of the patients. Psychological symptoms were not reported by the patients in this study.
The number of patients for the main ATC classification categories and some subcategories are reported in [Table 2]. A total of 91 different products, representing 11 of the ATC's main groups, were consumed. Fifty ATC subcategory drugs were used for the treatment of side effects, fifty drugs were used for relieving tumor-related symptoms and three products to treat concomitant diseases. In addition, five products were vitamins and mineral supplements. Polypharmacy was commonplace. Patients consumed approximately 8.7 ± 0.38 (mean ± SE) drugs on average during the 2-month period of follow-up. Gastrointestinal drugs (A, 99%), analgesics (N, 92%), systemic antibiotics (J, 41%) and drugs for the respiratory system (R, 20%) were the most frequently used ATC category drugs. Overall, 94 (94%), 94 (94%) and four (4%) patients had taken at least one drug against tumor symptoms, treatment side effects and concomitant disease, respectively.
Other treatments received by the patients
Fifty-five percent of the patients received palliative chemotherapy. Palliative surgery was performed in 23% and blood transfusion was given to 13% of the patients.
Patients with advanced cancer often report multiple symptoms that require comprehensive treatment. One of the key tenets of palliative medicine is symptom management and documentation of these is the first step for effective treatment. Physical symptoms are more often treated than psychological symptoms. Guidelines for management of many of these symptoms such as pain and vomiting are already available. , Improved treatment of symptoms is associated with enhanced quality of life and patient satisfaction. , This study found that the most common cancers among men and women was lung cancer and breast cancer, respectively. This is similar to the distribution of cancers according to the world census. 
Most common symptoms encountered in the study were mainly physical symptoms like pain, fatigue, nausea and vomiting. This confirms previously published information on the prevalence of symptoms at the end of life in cancer patients.  The number of symptoms in patients was 5.33 ± 1.66 in contrast to a larger study of 480 patients where it was nearly double of this study, with a figure of 10.2 ± 5.8.  This is probably best explained by the fact that in this study symptoms were not actively elicited, only those reported by the patients themselves were recorded. Thus, the symptoms reported were mainly physical and none reported any psychological symptoms. One reason for this could be that psychological symptoms like anxiety and depression are difficult to elicit and are less well recognized unless they are very severe in intensity. Psychological symptoms are often accorded far less importance by patients and their relatives and are hence underreported. In accordance with previous studies, pain was the most common symptom reported. 
Since multiple symptoms are being targeted, patients with advanced cancer are often the recipients of polypharmacy. Patients may receive 2.43 supportive drugs on an average.  In this study, patients received 8.7 ± 0.38 (mean ± SE) drugs on an average during the observation period of 2 months, although not receiving more than two to three drugs at any given time. Polypharmacy, defined as the simultaneous consumption of many drugs, can produce adverse effects.  These patients are therefore at increased risk of having drug interactions, developing toxicity and jeopardizing adherence to drug therapy.
Drugs in this study were divided into three categories: drugs for treatment of side effects, drugs for management of tumor-related symptoms and drugs for concomitant diseases. More than half of the patients consumed drugs against the first two groups while only 4% consumed drugs against concomitant disease, making the category an insignificant contributor to drug therapy. This classification does not hold true for some drugs that have different and often simultaneous utility, e.g. antiemetics can be given for prophylaxis against nausea before chemotherapy as well as treatment of vomiting due to tumor-related issues. Apart from drugs for treatment of disease, advanced cancer patients also require drugs for combating side effects. Antacids were prescribed to most of the patients mainly for the prevention of gastritis, suggesting an indiscriminate use of these drugs. Cancer patients are more vulnerable to gastritis for a host of reasons that include underlying stress and the combined use of chemotherapeutic agents and non-steroidal anti-inflammatory drugs. More than 50% of the patients in this study received vitamins, which was in stark contrast to only 6% patients receiving them in another study.  This suggests an excessive use of these drugs, probably for a placebo effect. Oral vitamins were most commonly prescribed, although intravenous multivitamins were occasionally given to patients on parenteral nutrition. Apart from palliative drug therapy, the patients were also subjected to palliative chemotherapy and surgery, with many receiving blood transfusions. Radiotherapy was not provided to any patient as the hospital did not have these facilities. The patients requiring radiotherapy were invariably referred to other hospitals, resulting in a skewed sample. Palliative chemotherapy is effective in some cancers and is often undertaken to palliate tumor-related symptoms. It, however, carries the disadvantage of increasing the cost of therapy. More than 50% of the patients were given chemotherapy in this study.
In conclusion, cancer patients often suffer from many symptoms, all of which may not be directly related to the tumor. Pain was the most common symptom present in almost all the patients, with the majority reporting severe pain. Polypharmacy was quite common in advanced disease, predisposing them to various drug interactions and adverse drug reactions. More studies focusing on the drug interaction between chemotherapeutic agents and drugs used in supportive care are needed. Some of the limitations of this study were the relatively short duration of follow-up and comparatively smaller numbers enrolled. The results of this study therefore need to be interpreted with caution and may not be entirely reflective of trends elsewhere.
[Figure 1], [Figure 2]
[Table 1], [Table 2]