Volume 2 No 6
June 2008
models for testing theories or interventions. The
Cancer-related Dyspnea
intensity of support and the specific interventions used
Several new review articles and treatment guidelines on
depend not only on symptom severity but also on where
cancer-related dyspnea have been published this year,
the patient is in the disease trajectory. For example,
which provides an opportunity to optimize care for
addressing the underlying cause of dyspnea may be
patients with this very distressing and debilitating
highly desirable in a patient with a prognosis of months
symptom. See the reference list on page 3.
to years, but a primary focus on comfort is more
Unfortunately there is nothing radically new to report, but
appropriate in a patient who is expected to die within
a systematic approach to assessment and treatment
days to weeks.
should improve the quality of care in these patients.
Oral, intravenous, and subcutaneous opioids are widely
Most succinctly, dyspnea is a subjective sense of
used for dyspnea relief and have more research support
breathlessness or difficulty breathing. As with other
compared to other interventions. Nebulized
symptoms it varies in severity and impact, generally
(aerosolized) opioids seem an attractive option, but have
worsens as disease progresses, and has physical,
thus far shown limited success and mixed results. This
psychological, social, functional, and spiritual/existential
lack of clear success may possibly be related to the
components. Along with pain, it is among the most
inefficiency of available nebulizers. As technology
feared symptoms in advanced cancer. 50-70% of
improves so that therapeutic doses can be consistently
people with advanced cancer report dyspnea, up to 79%
and reliably delivered to the lungs, this promising
in the last week of life.
approach may yet become standard treatment. When
bronchospasm contributes to dyspnea, aerosolized
Not surprisingly, there is a strong correlation between
furosemide may be helpful. Corticosteroids have not
dyspnea and anxiety; the two symptoms can drive each
been studied in cancer patients with dysnea.
other. Dyspnea has a major impact on quality of life. It
can prevent mobility and even basic activities of daily
The use of oxygen therapy is controversial. Studies
living. Communication and social interaction become
have produced mixed results when comparing oxygen to
very limited, leading to isolation, frustration and
air, or oxygen plus helium. However, when hypoxemia
increased anxiety for patient and family caregiver alike.
is a contributing factor, oxygen supplementation appears
Families find caring for a patient with severe dyspnea to
to be helpful.
be physically and emotionally taxing.
Benzodiazepines, particularly midazolam, can be used
There is no definitive treatment for dyspnea, in part
to ease the anxiety component of dyspnea. Non-
because the pathophysiological mechanisms underlying
pharmacologic approaches to dyspnea-related anxiety
dyspnea are poorly understood and there are no animal
management include cognitive-behavioral interventions,
To subscribe to YaleCares, send an email to [email protected]
emotional support, and environmental stress reduction.
Hand-held fans, cooler room temperatures, education,
pulmonary rehabilitation, stress/anxiety-reduction
Childhood Cancer. Journal of Pediatric
Oncology Nursing 2008;25(4):213-219.
•
training, noninvasive ventilatory assistance, and
emotional support for family caregivers have been found
to be helpful interventions at various disease stages and
symptom severity. Addressing the suffering or
Leib JR. The new genetic privacy law: how
GINA will affect patients seeking counseling and
testing for inherited cancer risk. Community
Oncology 2008;5(6):351-354 (free full text).
Connecticut Challenge Updates
•
There is still time to sign up as a rider or
volunteer or for registered riders to join a team.
be helpful for some patients.
•
Yale Cancer Center, Yale School of Nursing,
and the HEROS Clinic have team openings and
need donations to meet their pledged goals.
In the News
•
Practice/training ride—Sunday June 29. This is
your chance to ride the actual 25 or 50-mile
routes with other Challenge riders. Noncompetitive, beautiful ride. Note: no supported
rest stops. See more info at link, above.
•
Team Connecticut Challenge raced from
Oceanside, CA to Annapolis, MD in the Race
Across America and took the silver medal an
incredible 7 days, 7 hours and 7 minutes!
existential component through spiritual intervention may
•
Time to Talk is an initiative of the National
Center for Complementary and Alternative
Medicine (NCCAM). It provides tools and
resources for patients and professional
caregivers about the importance of discussing
complementary and alternative medicine or
health practices (CAM). According to a national
consumer survey conducted by NCCAM and
AARP, almost two-thirds of people age 50 or
older are using some form of CAM, yet less than
one-third of these CAM users talk about it with
their providers.
•
Zoledronic Acid (Aredia) Significantly Reduced
Relapse in Early Breast Cancer.
o ASCO Abstract
•
Acupuncture Effective in Reducing Pain and
Dysfunction After Neck Dissection.
US cancer patients still plagued by undertreated
pain.
•
Journal Watch
•
Pal S. Oncologists must make time for fertility
issues. Oncology News International.
2008;17(5):26-27 (free full text).
•
Anderson J, Michaud LB. Cancer treatment–
induced bone loss and the role of zoledronic
acid. HemOncToday 2008;9(9):6-9 (free full
text).
•
Aguirre LL,et al. Pain diaries. For providers,
nuanced data; for patients, a sense of control.
American Journal of Nursing. 2008 Jun;108(6):
36-9.
•
Hesketh PJ. Chemotherapy-induced nausea and
vomiting. New England Journal of Medicine.
2008 Jun 5;358(23):2482-94.
•
The journal Cancer has published a free
supplement, Survivorship: Embracing the
Future.
•
Meeske KA, Nelson MB. The Role of the LongTerm Follow-up Clinic in Discovering New
Emerging Late Effects in Adult Survivors of
Online Fertility Resources
•
•
•
•
•
Resources from the American Society of Clinical
Oncology.
American Society for Reproductive Medicine
Fertile Hope
Lance Armstrong Foundation
Oncofertility Consortium
Books of Note
Loscalzo M, Heyison M. (2007). For the Women We
Love: A Breast Cancer Action Plan and Caregiver’s
Guide for Men. Baltimore: Bartleby Press. For purchase
($10) or free download from Men Against Breast Cancer.
Continuing Education
Yale
•
•
Schwartz Rounds resumes in September
Oct. Oncology Nursing Council Symposium
Elsewhere • Sep 4 – 7. PainWeek National Conference. Las
Vegas.
•
Sep 12. Eastern Pain Association Annual
Meeting
Online
• Jul 31, 1:30 – 2:30pm. APN Billing for Palliative
Care Services. (CAPC web/audio conference;
CNE).
•
The Etiology and Management of Intractable
Breathlessness in Patients With Advanced
Cancer: A Systematic Review of
Pharmacological Therapy (Medscape; CME)
To subscribe to YaleCares, send an email to [email protected]
Dyspnea
References
Abernethy AP, Wheeler JL. Total Dyspnoea. Current Opinion in Supportive and Palliative Care.
June 2008;2(2):110-113.
Bausewein C, et al. Measurement of dyspnea in the clinical rather than the research setting.
Current Opinion in Supportive and Palliative Care. June 2008;2(2):95-99.
Bausewein C, et al. Non-pharmacological interventions for breathlessness in advanced stages of
malignant and non-malignant diseases. Cochrane Database of Systematic Reviews. 2008
Apr 16;(2):CD005623.
Ben-Aharon I, et al. Interventions for alleviating cancer-related dyspnea: a systematic review.
Journal of Clinical Oncology. 2008 May 10;26(14):2396-404.
Booth S, et al. The etiology and management of intractable breathlessness in patients with
advanced cancer: a systematic review of pharmacological therapy. Nature Clinical Practice
Oncology. 2008 Feb;5(2):90-100.
Charles MA, et al. Relief of Incident Dyspnea in Palliative Cancer Patients: A Pilot, Randomized,
Controlled Trial Comparing Nebulized Hydromorphone, Systemic Hydromorphone, and
Nebulized Saline. Journal of Pain & Symptom Management. 2008 Mar 19. [Epub ahead of
print]
Clemens KE, Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with
dyspnea. Supportive Care in Cancer. 2008 Jan;16(1):93-9.
DiSalvo WM, et al. Putting evidence into practice: evidence-based interventions for cancerrelated dyspnea. Clinical Journal of Oncology Nursing. 2008 Apr;12(2):341-52. Review.
National Comprehensive Cancer Network (NCCN). 2008. Clinical Practice Guidelines in
Oncology: Palliative Care, V.1.2008.
http://www.nccn.org/professionals/physician_gls/PDF/palliative.pdf. Accessed June 26,
2008.
Oncology Nursing Society. Dyspnea: Clinical Practice Guidelines Table.
http://www.ons.org/outcomes/volume2/dyspnea/Guidelines_dyspnea.shtml. Accessed June
26, 2008.
Uronis H, Abernethy AP. Oxygen for relief of dyspnea: what is the evidence? Current Opinion in
Supportive and Palliative Care. June 2008;2(2):89-94.
Viola R, et al. The management of dyspnea in cancer patients: a systematic review. Supportive
Care in Cancer. 2008 Apr;16(4):329-37.