P39. Management of respiratory symptoms in patients with advanced lung cancer

Abstract: Lung cancer is the most common cancer worldwide in terms of both incidence and mortality. Prognosis is generally poor. Of all patients with lung cancer, approximately 15% survive for 5 years after diagnosis while 80% die within 1 year.

Respiratory symptoms observed in patients with lung cancer (dyspnea, cough, haemoptysis) are determined by cancer’s histologic type, biological properties, and anatomic location. They may be caused either by the primary tumour itself or by locoregional metastases within the thorax. Respiratory symptoms can result from immediate mechanical effects of cancer spread, such as localized obstruction of large airways, postobstructive pneumonia, formation of fistulae between airways and other intrathoracic structures, pleural effusion, and paresis of diaphragm or vocal cords due to encroachment upon respective nerves. In such patients, noninvasive therapies may be insufficient to palliate respiratory symptoms. Invasive techniques are available to benefit this group of patients. Respiratory symptoms can be caused by chemotherapy, or complications of radiotherapy (airway stenosis and necrosis, fistula formation, haemoptysis). Moreover, comorbid conditions such as chronic obstructive lung disease (COPD), heart failure, pulmonary embolism, previous lung resection or malnutrition likewise contribute to respiratory symptoms.

Dyspnea is the most frequently reported symptom in lung cancer patients: over of 65% patients have this symptom at some time during the course of their illness. In management of cancer-related dyspnea, opioids will remain the mainstay of therapy for the foreseeable future. Further studies will also be needed to identify the target populations who would benefit from oxygen, benzodiazepines, and the wide spectrum nonpharmacological interventions to relieve dyspnea. The design of these studies should respect the difference between cancer-related dyspnea and dyspnea from other causes. Suppression of cancer-related cough should also be addressed in future randomized studies.

Current recommendations for palliative care in patients with advanced lung cancer, organized according to salient respiratory symptoms: Dyspnea: opioids; supplemental oxygen; other pharmacological interverventions; nonpharmacological interventions; dyspnea due to comorbidities and its treatment. Cough: opioids, non-opioid cough supressants, chemotherapy. Haemoptysis: pharmacologic treatment, bronchoscopic management, palliative thoracic radiotherapy. Malignant pleural effusion: thoracocentesis, chest tube dranaige, pleurodesis, and pleuroperitoneal shunting.

Keywords: Symptoms; palliation; dyspnea; cough; haemoptysis