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Levy MH , Rosen SM , Ottery FD , Hermann J
Supportive Care in Oncology
Current Problems in Cancer. 1992 Nov-Dec;16(6) :329-&
PMID: ISI:A1992JZ78300001   
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Abstract
Pain management, nutritional support, and psychosocial support are fundamental services that enhance patients' ability to cope with their cancer and its therapy. The common goal of symptom prevention mandates that each of these supportive services be provided to all patients throughout their cancer experience. Comprehensive cancer pain management begins with identifying the origin of all of the patient's pains and treating each one specifically. Pain prevention can be achieved through around- the-clock opioid administration with as-needed supplements for breakthrough pain and dose titration. Common narcotic side effects such as constipation and nausea also must be prevented. Successful opioid analgesia requires that patient and family concerns regarding addiction and tolerance be dispelled at the outset. Cancer pain prevention can be further optimized with the use of appropriate coanalgesics in response to the pathophysiology of the patient's pains. Cognitive and behavioral therapies may also be useful adjuncts to reduce both pain and suffering. Procedure-oriented pain control should be considered when systemic pharmacologic therapy does not provide adequate pain relief or is associated with intolerable side effects. The only absolute contraindications for pain-relieving procedures are untreatable coagulopathy and a decrease in mental status not related to medical pain management. Useful neurodestructive techniques include radiofrequency lesioning, cryoanalgesia, and chemical neurolysis with agents such as phenol, alcohol, and hypertonic saline. The most beneficial pain-relieving procedures and percutaneous cordotomy, spinal narcotics, celiac and hypogastric plexus ablation, spinal neurolysis, and epidural injection of steroids and hypertonic saline. Procedure selection depends on the cause of the pain and the patient's prognosis. Common indications for pain- relieving procedures include unilateral pain below the shoulder, upper abdominal visceral pains, pelvic visceral pain, perineal pain, vertebral body metastasis, discogenic pain, and spinal stenosis. As results of well-conducted scientific trials begin to appear in the literature, the indications for these procedures will be better understood, resulting in their more appropriate use. Principles of nutritional support in patients with cancer include an awareness of the problem of malnutrition and its impact on performance status, quality of life, prognosis, and treatment; identification of those patients at risk; prophylactic versus therapeutic intervention; and analysis and management of the specific impediment(s) to adequate nutrient intake and absorption. The primary goals for nutritional support in cancer patients are prevention of weight loss and maintenance of adequate protein status. Appreciation of practical issues of nutritional support will enable the practicing physician to achieve these goals using primarily oral nutrition options. General indications for parenteral nutrition include significant malnutrition, a nonfunctional gastrointestinal tract, and active oncologic treatment options. Prevention of psychosocial distress is also crucial to effective supportive care in oncology. The quality of the physician-patient relationship is crucial to its success and a primary component of patient mastery of the cancer experience. Factors that affect this relationship include physician practice structure, communication techniques, family-oriented care, ancillary support services, and physician well-being. Differences between individual and group counseling modalities must be appreciated to optimize their benefit. Improvements in survival mandate that physicians meet their responsibility to help patients cope most effectively with their cancer. Effective pain management, nutritional support, and psychosocial support complement effective cancer therapy and must be integrated into each patient's comprehensive cancer care. Such total care will enhance survival and reduce the burden of cancer for patients and their caregivers.
Notes
English Review JZ783 CURR PROB CANCER