Edited by B. Ye. Peterson, Doctor of Medicine.
Publishing house "Medicine", Moscow, 1964
Provided with some abbreviations
Symptomatic treatment of tumors becomes the only and necessary when it is impossible to perform a radical operation or to carry out any other antitumor treatment. With advanced diseases, a number of severe disorders appear that require treatment, specific for each type of tumor. In the later stages of cancer, pains associated with compression of the nerve trunks appear, in which one should resort to various novocaine blocks and pain relievers, ranging from promedol to morphine, without fear of causing the patient to become addicted.
With insomnia and loss of appetite, the patient should be given sleeping pills and appetite-increasing agents. Patients, especially in the terminal stages of the disease, develop complications from the cardiovascular system and lungs. Edema, pneumonia appear, which requires appropriate treatment.
A good pain reliever and sedative medicine is the following:
Rp. Sol. Chlorali hydrati 0.6-200.0 Natrii bromati 6.0 Tinct. Valerianae 8.0 Tinct. Convallariae majalis 8.0 Pantoponi 0.04 Luminali 0.5
DS. 1 tablespoon 3 times a day
Thrombophlebitis are not uncommon in severe cancer patients, which should be treated with an elevated position of the limb, bandages with Vishnevsky's ointment. The use of anticoagulants in oncological inoperable patients is contraindicated.
In case of frequent secondary inflammatory phenomena that join the tumor process (especially in lung cancer), the entire arsenal of anti-inflammatory drugs should be used, primarily antibiotics: penicillin 100,000-200,000 units, streptomycin, terramycin, etc. With the development of tumor metastases in the bone or in the case of inoperable bone tumors, an appropriate immobilization of the limb should be carried out. With the development of jaundice due to damage to the liver or the gate of its metastases, therapy is necessary to maintain liver function (intravenous infusion of glucose, vitamins, etc.).
Glucose should be administered to an inoperable cancer patient as an energy and detoxification agent. With the development of anemia, it is advisable to use iron preparations, hemostimulating therapy. Each patient should receive a complex of vitamins. Blood transfusion is indicated for increasing anemia caused by blood loss. Different localization of the tumor in each organ requires specific symptomatic therapy. In case of stomach cancer, it is necessary to carry out treatment in connection with constipation (proserin), with salivation, give atropine, with ascites, do paracentesis and give mild diuretics (novurit, fractional doses of mercusel, etc.).
With lung cancer, anti-inflammatory therapy should be carried out, with pleurisy - puncture with pumping out exudate. With advanced tumors of the female genital area, often occurring rectovaginal and cystovaginal fistulas require careful local care, etc.
There are special symptomatic remedies for the treatment of malignant tumors (neocide, chaga, crucine). These drugs have no effect on the tumor, but in some cases they improve the general condition of the patient, relieve secondary inflammation. Chaga is an old folk remedy for cancer. Neocide is an antibiotic applied orally before meals 3 times a day. Crucine is also an antibiotic. It is administered intramuscularly (see Antineoplastic drugs).
In the treatment of an oncological patient, psychotherapeutic influence should play an important role. Many patients guess about a serious illness, are worried about sending them to a special oncological institution. Therefore, the cancer patient needs to be instilled with confidence in the good success of the treatment. In the wards where patients awaiting treatment are located, patients who have undergone surgery well or are being examined after previous treatment with good long-term results should be placed. There is no single point of view on the question of whether to hide the true diagnosis of the disease from patients or declare it to them. But it would be more correct not to disclose to patients the true position and not to report the diagnosis of a malignant tumor. This should be done for a number of reasons.
1. Unfortunately, for some types of malignant tumors, there is still no sufficiently effective remedy, and the patient with this form of the disease will naturally feel doomed.
2. With some types of tumor, good long-term results of treatment are mainly observed within 2-5 years. After the expiration of this period, many patients have relapses, and the inevitable deterioration of the patient's health will be accompanied by severe mental depression.
3. It should be borne in mind that in each individual case, while carrying out treatment, the doctor does not know for how long the patient has been cured. If the patient's condition worsens, the patient must believe in his recovery and be convinced that the deterioration is temporary. The more the patient assures the doctor that he knows about his illness and is ready for inevitable death, the more he expects the doctor to refute his gloomy thoughts. Belief in the recovery of even a hopeless patient is an important background for treatment. It makes the last days of the patient's life easier.
Symptomatic therapy is a method of using therapeutic agents aimed at eliminating or weakening the adverse symptoms of the disease. It is not used as an independent method, since the elimination of any symptom is not yet an indicator of recovery or a favorable course of the disease, on the contrary, it can cause undesirable consequences after stopping treatment. This method is used only in combination with others, mainly with pathogenetic therapy. Examples of symptomatic therapy include: the use of antipyretic drugs for very high fever, when fever can be life-threatening; the use of cough suppressants when it is continuous and can cause oxygen starvation; the use of astringents for profuse diarrhea, when life-threatening dehydration develops; giving irritating respiratory center and cardiac drugs with a sharp decrease in respiratory movements and heartbeats. Many researchers consider symptomatic therapy as a kind of pathogenetic, in some cases it can become one of the decisive factors in the recovery of animals against the background of complex treatment.
Despite the fact that the use of therapeutic agents and pharmacological drugs, taking into account their prevailing action in the directions (etiotropic, pathogenetic, neurotrophic functions, substitution and symptomatic therapy), is conditional, it justifies itself in clinical veterinary practice when developing a plan of reasonable treatment. An example would be the planning of treatment measures for the most widespread diseases: gastrointestinal and respiratory.
So, for the treatment of patients with lesions of the mucous membranes of the stomach and intestines (gastroenteritis), all methods of therapy should always be provided in the treatment plan: etiotropic (antibiotics, sulfa drugs), pathogenetic (diet, washing, laxatives, enhancing or weakening peristalsis, improving secretion) , regulating neurotrophic functions (novocaine blockade), substitutional (administration of isotonic fluids for dehydration, gastric juice, pepsin or intestinal enzymes), symptomatic (astringents).
With bronchopneumonia, all means and methods of therapy are also used: antibiotics or sulfa drugs - as antimicrobial etiotropic agents; physiotherapeutic and expectorant - as pathogenetic; novocaine blockade of stellate sympathetic nodes - as regulating neurotrophic functions; oxygen (subcutaneously or by inhalation) - as replacement therapy; antitussives - as symptomatic therapy.
Thus, the main condition for conducting evidence-based therapy is its complexity and the correct use of therapy methods.
For citation: Isakova M.E. Symptomatic treatment of cancer patients in the late stages of the disease // BC. 2003. No. 11. P. 653
Russian Cancer Research Center. N.N. Blokhin RAMS
V The World Health Organization (WHO) is a specialized agency of the United Nations whose main function is to solve international health problems and protect public health. Through this organization, health workers from 165 countries share knowledge and experience to make it possible to achieve a level of health for all people on earth that will enable them to lead socially and economically fulfilling lives.
The number of cancer patients is growing all over the world. Of the 9 million new cases that WHO estimates occur annually, more than half are in developing countries. At the time of diagnosis, most cases are incurable - cancer deaths are expected to rise in most parts of the world, largely due to aging populations.
Combating pain and other cancer symptoms is a priority for the WHO cancer control program.
Due to the lack of both sufficiently effective preventive measures, early detection and radical therapy of cancer, as well as a satisfactory medical base and trained personnel in the coming years active supportive therapy will be the only real help and manifestation of humanism towards many cancer patients. In this regard, the dissemination and application of already existing knowledge regarding the management of pain and other symptoms of this disease will be able to make life easier for patients to the greatest extent.
Among those suffering from malignant neoplasms there is a contingent of patients who, due to the prevalence of the tumor process or due to the presence of severe concomitant diseases, are not subject to surgical, radiation, and chemotherapeutic methods of treatment. Meanwhile, the progression of the disease leads to the development of a number of painful symptoms that require palliative care.
It should also be noted that in some patients who have undergone radical surgery for cancer, as well as previously received radiation or chemoradiation therapy, at a certain stage of the disease, relapses, tumor metastases to various organs and tissues, accompanied by severe clinical manifestations, occur. They also need symptomatic treatment to relieve the most painful symptoms of the disease.
There has been some progress in alleviating the suffering of these patients in recent years. This is due not so much to the emergence of new methods of pain relief as to the improvement in the quality characteristics of the existing ones.
The ethical aspects of the problem of helping these patients are aimed at improving the quality of life. Difficulties in conducting symptomatic therapy arise when the patient needs help at home.
Symptomatic treatment - this is an active general assistance to an oncological patient at that stage of the disease when anticancer therapy is ineffective. In this situation, the fight against pain and other somatic manifestations, as well as the solution of the patient's psychological, social or spiritual problems become of paramount importance.
The goal of symptomatic treatment is to provide the most satisfactory living conditions with a minimum favorable prognosis.
Palliative care has its origins in the hospice movement. In recent years, palliative care has received official recognition in many countries, including Russia. It has now become a medical specialty in the UK.
And while palliative care is the only real help for most cancer patients, only a small fraction of cancer-fighting drugs are used for palliative care. In addition, little or no funding is allocated for training health workers to provide this type of care. The last period of the life of patients doomed to death can be qualitatively improved through the application of modern knowledge in the field of palliative treatment, which is often ignored or considered when choosing a treatment method as an unremarkable alternative.
The palliative care development program includes: home help, counseling service, day care, inpatient care, post-death support.
The basis of out-of-hospital care is constant professional supervision. Palliative care requires the involvement of different categories of healthcare professionals who are able to assess the needs and capabilities of patients, who are able to provide advice to both the patient and his family members, who know the basic principles of using drugs for pain relief and symptomatic treatment, and who are able to provide psychological support to both patients and and their families.
Ideal home care requires a continuous continuity of care between hospital and home. The entire burden of caring for patients with progressive illness at home rests with the family. Family members should therefore be trained in food selection and preparation, administration of analgesics and other necessary medications, and some specific medical problems.
Ignorance or fear in the patient's home can be the main reason why even a fairly well-organized palliative care system will fail.
Palliative therapy aims to improve the patient's quality of life, but its effectiveness can be assessed only by "criteria" rather conditional.
It is no coincidence that the subjectivity of most assessments of the quality of life is often viewed as a factor limiting their application. As a rule, physical symptoms, the safety of body functions, as well as the psychological status of the patient and social well-being are components of the assessment of his condition. Any tests that assess the quality of life should ideally be based on universal human values.
The duration of "survival" is often used as the only criterion for assessing the success of the treatment. A review of studies in the field of chemotherapy in incurable cancer patients did not reveal any evidence of an improvement in the general condition of patients. And yet, how can you estimate those few extra months of life resulting from costly treatment and serious side effects, suffering from pain and despair? Nevertheless, doctors do not dare to abandon the use of anticancer treatment, which turns out to be unsuccessful.
According to other authors, today oncologists have vast knowledge and technological capabilities. For half a century, cancer has ceased to be a fatal diagnosis. Life time - 5 years increased from 40% in the 60s to 50% in the 90s, and in children it even reached 67% instead of 28%, including all tumors and all stages. The cure rate for a number of tumors in adults and children has reached 80% .
For patients who were previously considered incurable, there is now a specific treatment that has become routine, such as reduction of tumor volume followed by radiation or chemoradiation therapy, surgical interventions for tumor breakdown - necrectomy, nephrectomy despite metastases of kidney cancer, chemoembolization in case of liver metastases ... With solitary metastases of sarcomas in the lungs, liver, melanoma dropouts, when severe symptoms of obstruction develop (lung compression, liver pain, threat of bone fracture), surgery is also indicated to ensure the most asymptomatic survival.
Orthopedic surgery is associated with both removal of the tumor and therapeutic osteosynthesis followed by radiation (compression of the vertebrae, instability of the pelvic bones, the risk of fracture of long or flat bones).
Radiotherapy External beam therapy Local irradiation is an effective way to relieve bone pain in 85% of patients, with complete disappearance of pain noted in 50% of cases. The pain, as a rule, disappears quickly, in 50% or more, the effect is observed within 1-2 weeks. If there is no improvement 6 weeks after treatment, the likelihood of an analgesic effect is low.
So far, experts have not come to a consensus regarding the most effective doses and modes of fractionated irradiation. The effectiveness of various modes of irradiation depends on the technical equipment of the institution, as well as on the shape, location, size of the tumor and the stage of the disease. Some authors are inclined to conduct a single irradiation in a severe group of patients with severe pain syndrome, noting that it is no less effective than fractionated courses and does not exclude the possibility of repeated irradiation of the same area in case of relapse of pain.
In cases of multiple localization of pain, radiation therapy with an expanded radiation field or irradiation of half of the body is used.
The analgesic effect was observed in 75% of patients, however, 10% showed toxicity with suppression of bone marrow function, complications from the gastrointestinal tract, pneumonia.
Targeted radioisotope therapy
Provides accurate dose delivery to the tumor to achieve maximum therapeutic effect and reduce toxicity.
Radioisotope strontium-89 , emitting b-rays, is usually used for multiple mts in the bone. The analgesic effect can be achieved in 80% of patients, of which 10-20% note the complete disappearance of pain.
Samarium-153 emits b - and g - rays and is used for diagnostic and therapeutic purposes. The isotope is labeled with EDTMR (ethylenediaminetetra - methylene phosphonate) and thus a pharmacological drug is obtained that selectively accumulates in bone metastases. There are separate reports that the drug in a single dose of 1.9 mCl / kg provided rapid pain relief in almost 60% of patients. The analgesic effect persisted for about 16 weeks.
For pain resulting from damage to the membranes of the brain, cranial nerves and spinal cord, radiation is the therapy of choice, both in primary lesions and in the case of metastases.
Chemotherapy is recognized in most countries as an independent discipline. The effectiveness of treatment with chemotherapy drugs is high, but the development of adverse reactions sharply worsens the quality of life of patients. The undesirable effects of specific treatment can be acute (immediate reactions), early (polyneuritis, mucytes) and delayed (secondary tumors, neuropathies, mental disorders).
Bisphosphonates Despite the fact that the mechanism of action of bisphosphonates is not precisely established, these drugs have been successfully used in oncology and are the drugs of choice for relieving pain intensity. No convincing evidence has yet been presented to support the use of oral bisphosphonates to reduce bone pain.
Repeated courses of intravenous administration of pamidronate provided pain relief in 50% of patients at a dose of 120 mg. The use of pamidronate in higher doses (up to 600 mg per day) had a more pronounced effect, however, the gastrointestinal toxicity of the drug prevents its widespread use.
According to preliminary data, the most suitable contingent for receiving bisphosphonates are patients with metastases in the bone of the skeleton of breast cancer. The median survival in this group of patients is 2 years.
The quality of life and the duration of specific treatment have been little studied, however, as well as the effect of stopping palliative therapy on the quality of the rest of life. The leading symptom in patients with stages III-IV is moderate to severe pain.
The patient suffers not so much because he knows his diagnosis and poor prognosis for life, but from the consciousness of what hellish pains he will experience. Although suffering is a broader concept than pain, this term must be understood as a threat to the mental, physical and social integrity of each patient.
Pain is one of the dire consequences for a cancer patient. For clinicians, this is one of the most difficult diagnostic and treatment problems in oncology.
Pain rarely occurs at the onset of the disease (10-20%). Published data indicate that about 4 million people are currently suffering from pain of varying intensity every day, of which about 40% of patients with intermediate stages of the process and 60-87% - with generalization of the disease.
With severe pain syndrome, pain loses its physiological protective function and becomes a meaningless, life-aggravating factor, thus developing into a complex medical and social problem. Patients in the stage of generalization of the tumor process spend the last weeks and months of life in a state of extreme discomfort. Therefore, pain management becomes extremely important, even if it is a palliative measure in relation to the underlying disease.
At the beginning of the third millennium, cancer treatment is becoming more and more complex, which will make it possible to heal or prolong the life of an increasing number of patients while maintaining acceptable living conditions.
Many oncological clinics in our country have trained specialists in symptomatic therapy who are qualified in the diagnosis and treatment of pain. Together with oncologists, they coordinate specialized pain management with other treatments.
Pain in some cases is directly related to the tumor or is a consequence of its treatment. The pain can be constant or intensify, disappear or appear over time, change localization.
Given the multifaceted manifestations of chronic pain and the variety of diagnostic methods for assessing the effectiveness of treatment measures, it is necessary to use an integrated approach, which can be considered in three main directions: assessment of the nature of pain, therapeutic tactics and continuous care. In the structure of chronic pain syndrome, various types of pain may be present or dominate: somatic, visceral, deafferentation. Each type of pain is caused by a different degree of damage to tissues and organs of pain, both by the tumor itself and by its metastases.
In cancer patients, especially in the later stages of the disease, pain of several types can be observed simultaneously, which complicates their differential diagnosis. So, the principles of complex and adequate treatment of pain syndrome in cancer patients are based, first of all, on taking into account the causes and mechanisms of the onset and development of pain in each specific case.
Pain treatment The goal of pain treatment is to relieve the pain of a cancer patient so that he does not experience undue distress during the last months and days of his life. The simplest and most accessible method for patients and doctors of all specialties is the method of pharmacotherapy. Knowledge of the pharmacology of analgesics can make cancer pain therapy effective. Treatment should be carried out taking into account the individual characteristics of the patient, and the use of drug therapy, analgesics, neurosurgical, psychological and behavioral methods - in full accordance with his needs. It is proved that drugs are effective in 80% of patients when used correctly:
each patient receives the drug he needs in an adequate dose at correctly selected intervals.
Currently, non-narcotic and narcotic analgesics are used in pain therapy according to the WHO three-stage scheme, consisting of the sequential use of analgesics with increasing potency in combination with adjuvant therapy as the intensity of pain increases. Simultaneously with the appointment of anesthesia, it is necessary to begin therapy for the tumor process.
Achieving adequate pain relief is governed by 3 basic rules:
1. Choose a drug that eliminates or significantly reduces pain in 2-3 days.
2. Prescribe analgesics strictly on a clockwise basis, ie. the patient should receive the next dose of the drug until the previous dose is terminated.
3. Acceptance of painkillers should be "ascending" - from the maximum weak-acting dose to the minimum potent. When choosing an analgesic and an initial dose for a patient, one should take into account: general condition, age, degree of exhaustion, intensity of pain, previously used painkillers and their effectiveness, state of liver and kidney function, degree of absorption of the drug, especially with the oral route of administration.
The assessment of the patient's possible life expectancy should not influence the choice of analgesic. Regardless of the stage of the disease and prognosis patients with severe pain should receive strong pain relievers ... The use of narcotic analgesics remains the most common, simple and effective treatment for severe pain. The correct dose is the dose that has a good effect. The use of opioid analgesics is associated with the development of physical dependence and tolerance to them. These are normal pharmacological reactions to continued administration of these drugs. Patients with persistent pain syndrome can take the same effective dose for many weeks or even months. To be sure, over-concern with the problem of mental dependence leads to the fact that doctors and patients are not using opioids in high enough doses, which, unfortunately, does not lead to pain relief. It is necessary to evaluate the effectiveness of treatment every 24 hours and adapt the dose in accordance with the patient's condition, the effectiveness of analgesia and the severity of side effects.
Between fixed injections of morphine preparations, if necessary ("shooting" of pain), a short-acting analgesic is used, for example, prosidol, which is used to prevent planned pain (painful procedure, endoscopic examination), and other painful short-term manipulations, as well as to control any new pain.
The conversion factor for opioids is difficult to determine, so it is rational to prescribe narcotic analgesics on the "ascending ladder" - promedol, omnopon, morphine.
The risk of drug overdose is low if the patient is under constant medical supervision.
According to our many years of experience, patients who receive adequate doses of narcotic analgesics for a long time do not develop mental dependence. Opioid use can be discontinued if the pain problem has been successfully resolved with radiation or chemoradiation therapy, and the dose should be gradually reduced until withdrawal is complete to prevent withdrawal symptoms.
Scientific research on the fight against pain in cancer has provided new information on the causes and characteristics of pain, and most importantly - to study the mechanism of action of opioids on pain in cancer. It has been proven that patients who have been taking narcotic drugs for a long time rarely develop tolerance, physical and mental dependence.
Consequently, the risk of developing such dependence should not be a factor taken into account when deciding on the use of opioids in patients with severe pain syndrome.
Morphine formulations can be safely administered in increasing amounts until adequate pain relief is obtained. The "correct dose" is that dose of morphine that effectively relieves pain as long as the adverse reactions it causes are tolerated by the patient. There is no standard dose of morphine (WHO, 1996)
Overall, the results of studies on the use of opioids in cancer patients indicate that both the public and health care professionals should place much more hope than now on the possibilities of available cancer pain relief methods. However, today there are many reasons why a full-fledged treatment of pain in cancer patients is not carried out:
1. Lack of a unified, targeted policy in the field of pain relief and palliative care.
2. Poor awareness of healthcare organizers about the possibilities of pain relief methods.
3. The use of opioids for pain in cancer patients leads to the development of mental dependence and to their abuse.
4. Legal restrictions on the use and supply of opioid analgesics.
At each stage of treatment, before increasing the dose of an analgesic, it is necessary to use co-analgesics (a group of drugs that have, in addition to the main action, the effects due to which they relieve pain): tricyclinic antidepressants, corticosteroids, hypnotics, antipsychotics.
For persistent pain of a painful nature, the so-called neuropathic, opioids are not very effective. In the treatment of pain in this group of patients, Tramal - an initial dose of 50 mg every 6 hours, increasing the dose to 100-150 mg and reducing the intervals of administration every 4 hours, the maximum daily dose is 900-1200 mg. At the same time, amitriptyline was used at an initial dose of 10-25 mg in the morning, with good tolerance, the dose was increased to 150-200 mg. Carbamazepine 10 mg x 2 r per day, the dose was also gradually increased until an analgesic effect was obtained. Pain relief usually occurs after 7-10 days. Adverse reactions are correlated with the dose of each drug used.
Tramadol hydrochloride (Tramal) is the most widely used for the conservative treatment of pain syndromes. , which, according to WHO recommendations, belongs to the second stage of pain therapy, occupying an intermediate place between therapy with non-steroidal anti-inflammatory drugs and narcotic analgesics. The drug has a unique dual mechanism of action, which is realized through binding to m-opioid receptors and simultaneous inhibition of the reuptake of serotonin and norepinephrine. It is the synergism of both mechanisms of action that determines the high analgesic efficacy of Tramal in the treatment of pain syndromes. In addition, clinically important is the fact that there is no synergism of side effects, which explains the greater safety of the drug in comparison with classical opioid analgesics. Unlike morphine, Tramal does not lead to respiratory and circulatory disorders, gastrointestinal and urinary tract motility, and with prolonged use does not lead to the development of drug dependence. The use of Tramal is indicated in the absence of efficacy from previous therapy with non-opioid drugs for oncological pain of moderate intensity.
The analgesic potential of Tramal, according to different authors, ranges from 0.1 to 0.2 of the potential of morphine, it is equal to or slightly exceeds the potential of codeine; in terms of effectiveness, 50 mg of Tramal is equivalent to 1000 mg of metamizole. Tramal is especially indicated for the relief of pain in somatic and visceral tumor formations. The drug is used in various injectable forms: solutions for injections (ampoules 1 and 2 ml), 50 mg in 1 ml, capsules 50 mg, rectal suppositories 100 mg and tablet forms 100 and 150 mg, which is optimal when choosing a method of administration for various localizations of tumors ... The maximum daily dose is 400 mg per day. If the maximum dose is ineffective, a transition to opioid analgesics (morphine hydrochloride, promedol, etc.) is indicated with the preservation of non-opioid therapy or the additional appointment of another non-opioid analgesic.
Treatment with Tramal is well tolerated by patients: the quality of life improves (sleep, appetite is normalized), which favorably distinguishes the drug from narcotic analgesics, which inhibit the physical and mental activity of patients. In addition, one cannot ignore the psychosocial aspect of prescribing the drug in severe cancer patients, which improves their quality of life, facilitates the work of medical personnel in terms of communicating with the patient.
In cases where the possibility of drug therapy has been exhausted, special, so-called invasive methods of anesthesia (epidural, subarachnoid blockade) should be used.
Somatic symptoms The most common common symptom in cancer patients with advanced cancer is asthenia (weakening), usually accompanied by loss of appetite and malnutrition. However, the underlying mechanism of some symptoms, such as cachexia - anorexia - asthenia, is currently not clear enough. Such patients should be in the hospital for parenteral nutrition (fat emulsions, amino acids, carbohydrates, vitamins, etc.) under medical supervision.
There is an urgent need to support research in this area in order to develop rational therapy.
Therapeutic efforts should take into account the interactions of symptoms, the role of the causative factor in reducing the manifestations of these symptom complexes. This task is best accomplished when palliative care is carried out by physicians specializing in this area.
In other areas of cancer care, the emphasis should be on the prevention and early diagnosis of unwanted symptoms through regular examination of the patient.
When a patient with persistent symptoms is being treated, medications should be taken regularly to prevent nausea, vomiting, and constipation. Taking medication on an “as needed” basis instead of taking it regularly is often the cause of much untreatable suffering.
Simultaneous treatment with several drugs, although the need for this often arises, can create additional difficulties for the patient, because his weakened state disrupted the normal excretion metabolism.
In addition to copper stone therapy, a variety of physical and mental treatments can contribute to patient comfort. Skillful use of non-drug therapy can supplement the effect of pharmaceuticals, which sometimes allows you to reduce the dosage of the drug and the risk of adverse reactions.
Mental manifestations: reactive anxiety (fitness disorder) is observed in 20-32% of cases. Depression - from 50 to 65%, is observed in patients who have learned about the diagnosis when they first find themselves face to face with inevitability and death. Often this is accompanied by a state of numbness, complete detachment, and then a mental disorder. It is during this period, more than ever, that the patient needs support (emotional, social, spiritual).
No disease can be cured without eliminating the root cause of the pathological condition. It should be looked for in the symptomatology - a complex of external signs of the disease. Symptomatic therapy involves the impact on these manifestations. The most striking examples of such treatment are the use of pain relievers, antipyretic, mucolytic drugs. In addition, symptomatic therapy, as a rule, is included in the treatment course when working with more complex clinical cases - for example, when it comes to oncological pathologies. It can be aimed at eliminating undesirable manifestations of the disease before or after surgery, as well as at the stage of palliative treatment.
Symptomatic therapy in oncology
In oncological practice, symptomatic therapy is usually understood as a set of measures aimed at eliminating the most serious and dangerous consequences of tumor processes and correcting postoperative complications. In addition, in some cases, symptomatic therapy can be palliative in nature, that is, it is designed to alleviate the patient's condition and improve his quality of life when full recovery is not possible.
The need for symptomatic therapy in cancer hospitals arises regardless of the stage of the disease. So, when a tumor is just discovered and does not manifest itself in any way, the patient may experience panic attacks and even depression. Of course, this condition (symptom) requires medical correction. Radical removal of malignant tumors is also accompanied by symptomatic therapy, since the body always "responds" to any outside intervention. And finally, symptomatic therapy is necessarily included in the medical protocol at the stage of rehabilitation of cancer patients. After radical treatment, the immune system is weakened, it is required to restore the basic vital functions of the body. And modern drugs to eliminate unwanted symptoms have the necessary corrective effect.
1. Interruption of pain pathways: a) conservative methods (local anesthetic and neurolytic blockade of peripheral nerves, para-vertebral sympathetic, peri- and epidural, caudal and intrathecal blocks); b) neurosurgical methods (somatic, visceral and cranial neurotomy and neuroectomy, sympathectomy, chordotomy and tractotomy).
2. Modification of pain perception: a) neurosurgical methods (prefrontal leukotomy, etc.); b) pharmacotherapy with narcotic and non-narcotic analgesics, sedative neuroleptics and various other means (additional prescription of tranquilizers, psychotropic drugs); c) acupuncture and electroacupuncture.
Following the presented working scheme, when trying to eliminate the cause of pain, it is necessary first of all to assess the possibilities and feasibility of performing palliative or symptomatic surgery - removal of one of the largest tumor foci, partial tumor resection, unloading operations that can relieve the patient from severe discomfort for a long time.
Persistent and intense pain caused by a large, localized primary neoplasm (sarcoma) with ulceration may be an indication for palliative limb amputation (even if there is dissemination). The modern level of surgery and anesthesiology makes it possible to perform palliative operations up to interscapular-thoracic and inlet-iliac amputations for lesions of the bones of the girdle of the upper and lower extremities, which are quite justified even as a measure to eliminate pain. Another example is mastectomy for inoperable ulcerated breast cancer, eliminating the source of pain, inflammation, bleeding, and infection.
Sometimes removal of the primary tumor focus in order to eliminate pain leads to a decrease in distant metastases. Oncological practice has reliably established this, at least for clear cell kidney cancer and neuroblastoma in children. The mechanism of regression of metastases is not clear, but it is assumed that it is most likely associated with immunological rearrangements in the body.
Causal therapy of pain syndrome often encounters the need to surgically eliminate tumor obstruction of the gastrointestinal tract, urinary tract, bile ducts, arterial and venous vessels. Palliative gastrostomy, gastroenteroanastomosis, cholecystostomy, enterostomy, the imposition of an unnatural anus, colostomy, in some cases, ureteral transplantation and other unloading interventions are performed on a daily basis not only in oncology, but also in the general surgical clinic.
It is far from often technically feasible and operations are performed for occlusion of blood vessels. Perhaps, only when the carotid artery is occluded by a rapidly growing chemodectoma (paraganglioma) or its metastases, resection of a portion of the vessel with replacement with a Teflon prosthesis is used.
There are practically no operative possibilities to reduce pain syndrome due to compression lymphostasis. Patients with a widespread tumor process usually do not live up to the realization of the effect of multi-stage and complex reconstructive operations in conditions of reduced reparative functions.
Emergency laminectomy for compression of the spinal cord by epidural growths of a tumor (mainly malignant lymphomas) is performed to prevent paraplegia rather than because of pain.
Conservative decompression measures for obstructive pain syndrome are not specific. They can involve suction of gastric contents through a tube (pyloric stenosis), insertion of a long rubber tube for a specified period (obstruction of the small intestine), evacuation of pyometra (cancer of the cervix and cervical canal), and similar procedures.
Reduces pain in limb lymphostasis (condition after mastectomy and radiation therapy for breast cancer, parametric relapses and metastases of cervical cancer, various metastatic and lymphoma lesions of the retroperitoneal, mainly inguinal-iliac lymph nodes) elevated position and bandaging with elastic (knitted ) bandage, light massage from the fingertips to the proximal sections, occasionally the use of diuretics and special exercises (hand swings, rotation of raised arms, legs, etc.), the meaning of which is to externally forcing the lymph outflow due to muscle efforts.
There is no serious objection to the opinion that, where the nature and localization of the neoplasm allows it, pain-relieving radiation treatment (including as a stage of palliative radiotherapy). The decision to conduct pain-relieving radiation therapy should not be dominated by the very fact of a widespread tumor process. The final assessment of indications and the development of a plan for such treatment, of course, is the prerogative of the radiologist, but the possibilities of using radiotherapy to control pain should be well known to the surgeon and therapist who supervises the patient in this phase of the disease. Discussion of the issue of analgesic (palliative) radiation therapy is always legitimate in case of primary inoperable cancer, metastases of a malignant tumor to the lymph nodes, bones and soft tissues, relapses after surgery and, in some cases, at the site of the former irradiation. The radiation sensitivity of the tumor can be considered the determining factor of the effect of pain-relieving radiation treatment.
It is known that malignant neoplasms are divided into radiosensitive (seminoma, thymoma, lymphosarcoma and other malignant lymphomas, Ewing's sarcoma, myeloma, all basal cell cancers and some epitheliomas), moderately radiosensitive (squamous cell carcinomas), moderately resistant (adenocarcinomas), and radioreseptic sarcomas, fibrosarcomas, teratomas, melanomas, chondrosarcomas). The sensitivity of the tumor to ionizing radiation is also reflected in the degree of differentiation of tumor cells, the ratio of the stroma and parenchyma. Poorly differentiated cancer variants with a small stromal component, small size, good blood supply and exophytic type of growth are more radiosensitive [Pereslegin I. A., Sargsyan Yu. X., 1973].
The limited tasks of analgesic radiation treatment make it possible to count on a symptomatic effect even in cases of relatively radioresistant tumors with obvious compression syndrome and tumor infiltration with perkfocal aseptic inflammation of the nerve structures, although it must be taken into account that metastases, as a rule, are much less sensitive to ionizing radiation than primary tumors.
In particular, a symptomatic or palliative antitumor effect can be obtained from a focal dose of 10-30 Gy (i.e., 1 / 4-2 / 3 of the usual therapeutic dose) with inoperable ulcerative forms of breast cancer and metastases of neoplasms of this localization in bones, lymph nodes (compression of the brachial plexus), metastatic bone lesions in prostate cancer, primary and metastatic cancer of the esophagus, skin, papillary thyroid cancer, parametric recurrence and metastases of cervical cancer and even rectal cancer in cases of sacral plexus compression, not to mention about more radiosensitive neoplasms. The worst results are observed in metastases of clear cell kidney cancer, the above radioresistant sarcomas of bones and soft tissues. The possibilities of pain-relieving radiation treatment for primary and metastatic cancer of the stomach (cardiac), colon, and pancreas are extremely limited.
The presence of multiple tumor foci in itself should not be a psychological barrier to pain-relieving radiation treatment, aimed primarily at one or more foci causing severe pain syndrome.
For radiation exposure to pain, it is not at all necessary to use megavolt sources (remote gamma therapy). With metastases in the bone and peripheral lymph nodes, superficially located tumors, a satisfactory symptomatic effect can be obtained using deep X-ray therapy (at a voltage of 200-250 kV). The use of contact methods of irradiation in order to relieve pain (intracavitary, interstitial) is real only in exceptional cases and in specialized institutions [Pavlov A. S, 1967].
In cancer patients who are subject only to symptomatic treatment, almost as a rule, the possibilities of cytostatic therapy are exhausted at the previous stages. For neoplasms of many localizations, cytostatic treatment is generally impossible. In addition, distant metastases to the lymph nodes, liver, lungs, and bones of a number of primary tumors, which are relatively sensitive to known cytostatics, are clearly more resistant to the same chemotherapeutic agents. In the current situation, it is rather difficult to pin hopes on the effectiveness of chemotherapy, but nevertheless, attempts to use cytostatics or their combinations to obtain a subjective analgesic effect due to sometimes insignificant regression of the tumor cannot be ignored if the patient's general condition does not significantly hinder this (absence of severe cachexia, liver failure and kidneys, the threat of bleeding from the tumor with a decrease in the number of platelets, etc.).
Cytostatic and hormonal therapy with analgesic purposes, of course, can be carried out in a hospital or on an outpatient basis only with the constant consultation of a chemotherapist or oncologist, who are responsible for assessing the prospects of the procedure, the specific choice of cytostatics, regimens and treatment programs.
For general orientation of the doctor in this aspect, it is useful to keep in mind the information about the antitumor spectrum of individual hormonal drugs, cytostatics or their combinations, given in Chapter VII when describing the methods of palliative chemohormone therapy of some particular manifestations of the common tumor process. These methods for neoplasms of the corresponding localizations make it possible to count on obtaining an analgesic effect.
Interruption of pain is not an end in itself in the treatment of complications of the tumor process or specific anticancer therapy associated with bacterial, viral and fungal infections, inflammation and necrosis (infected tumor ulcers, stomatitis, toxic neuritis, phlebitis, steroid stomach ulcers, "chemical" cystitis, radiation ulcers skin and mucous membranes). Pain relief in these cases is achieved as a result of complex symptomatic therapy, which has an independent meaning, which allows it to be considered separately in special chapters (see chapters VII, VIII and IX).
The most common and affordable method of treating pain syndrome in patients with advanced tumor process, when further specific antitumor or "causal" symptomatic treatment is futile, is drug therapy. The arsenal of pain relievers is currently quite diverse and enables the optimal choice of analgesics, their combinations with each other and with some drugs that potentiate the analgesic effect.
Experience, meanwhile, convinces that for practical purposes it is much more profitable to use a relatively limited set of drugs, the features of the action of which are well known to the doctor in detail and make it possible to differentiate pain therapy depending on the severity and causes of the latter.
To drugs with analgesic activity, often combined with other influences (anti-inflammatory, antipyretic, etc.) include the so-called small (non-narcotic) and large (narcotic) analgesics. Some combination (finished) drugs include several non-narcotic analgesics or drugs of the narcotic group.
Regardless of the characteristics of the means used, the fundamental, but, unfortunately, not always observed rules of analgesic therapy for malignant neoplasms, operate. The first of them consists in the choice of a drug that is adequate in effect to the leading cause of pain, the selection of its initial dose, the optimal route of administration and the mode of application, according to the degree of pain syndrome. This takes into account the characteristics of age-related reactions, individual sensitivity to an analgesic, its tolerance and known side effects.
Frequently practiced so-called conditional prescriptions of analgesics "for pain" are completely unjustified from ethical and most importantly pathophysiological positions. Expectation of pain is, first of all, a moral depressing and stressful factor for the patient, does not cause addiction to them, but, on the contrary, lowers the threshold for the perception of pain and, as a result, necessitates a premature increase in the dose of the analgesic.
Anesthetic therapy is much more effective if it is carried out solely on the basis of a firm order of prescribing drugs "by the hour" (usually for moderate pain every 3-6 hours, since most drugs do not work longer than this period). Without this, it is impossible to "erase memory and fear of pain", regulation - a decrease or a reasoned increase in the dose and a rational escalation of the method of analgesia. The rule of “prevention” of pain is so important that it is even suggested to wake up the patient for the next admission or injection of an analgesic, despite the fact that at the moment there may be no pain.
Another rule is the phased use of analgesics from less potent (and, accordingly, low-toxic, non-addictive) to potent and from drugs for oral administration to rectal and injectable dosage forms with a gradual increase in a single, daily dose of the drug, parallel to the intensity of the pain syndrome, and an increase in its rhythm. introduction.
In order to escalate the intensity of painful pharmacotherapy, sedatives and neurotropics, small doses of narcotic analgesics such as codeine and promedol orally, mixtures of those and other drugs, finally, opiates and mixtures consisting mainly of drugs and central anticholinergics (scopolamine orally or rectally) are added to individual non-narcotic analgesics ) and only with the resumption of pain are injectable forms of drugs used.
The correct choice of dose when switching to injections is facilitated by pharmacological data on the equivalent effect for the oral, rectal and parenteral routes of administration of analgesics. In particular, for non-narcotic drugs, the ratios for the mentioned methods of administration are usually equal to 1: 1: 1. The exception is reopirin and indomethacin, which are injected intramuscularly (reopirin), whether they are prescribed in suppositories (indomethacin) in a higher dose than inside: the content of butadione in the tablet of the first drug is 0.125 g, and in the dosage form for injection (ampoule with 5 ml of solution) 0.75 g, respectively, for indomethacin - 0.025 g in a capsule or dragee and 50 mg in one suppository. For the most common narcotic analgesics in practice - codeine, ethylmorphine (dionin), promedol, omnopon (pantopon) and morphine, single doses administered orally and rectally are approximately the same, while the equal effect in the case of switching from oral administration to parenteral administration of promedol ( subcutaneously, intramuscularly) is achieved with a dose reduction of 20%, omnopon (subcutaneously) - by 1/3, morphine by 1 / 2-2 / 3 (intramuscularly) or even 4-5 times (intravenously).
When prescribing any of the glucocorticoids for the purpose of analgesia (however, as for other indications) in suppositories, the single and daily doses increase approximately 4 times compared to oral administration, since only about 25% of the drug is absorbed from the rectum. Equivalent is the subcutaneous, intramuscular or intravenous administration of an oral dose of glucocorticoids increased by 1.5-2 times due to the peculiarities of the activity of their dosage forms. The doses of individual glucocorticoids - prednisolone, triamcinolone, methylprednisolone, dexamethasone, etc., contained in dosage forms for oral administration, sometimes differ by a factor of 10, but are balanced in such a way that tablets of different drugs are generally similar in effectiveness. With the exception of glucocorticoids, none of the drugs of drug analgesia for malignant neoplasms does not lead to the same or more pronounced analgesic effect when given orally as compared to parenteral administration.
The tactics of symptomatic pain therapy at each stage, ensuring the correct and systematic escalation of the intensity of analgesia, follows from the above rules and consists in the initial appointment of that dose (or doses of combined drugs), the analgesic effect of which can be completely count. In the future, attempts are made to establish a minimum level of doses that have the same effect. Against the background of relief of pain for the reasons mentioned above, this can be done much easier than with a gradual increase in the dose to the minimum effective. This tactic is applicable to everyone, but requires an exception for cases of prescribing opiates in old and senile age, as well as in patients with severe cachexia. In view of unpredictable adverse reactions in this category of patients, the minimum single doses of narcotic analgesics - promedol, omnopon and especially morphine (no more than 5 mg) are first prescribed and then, in the absence of significant complications, are increased every 24 hours by 50-100% to the required level. The intensification of opiate pain relief when high doses are reached (20-30 mg of morphine) is carried out carefully, by increasing them each time by 10-50%.
The addition of barbiturates and antihistamines with a pronounced sedative effect to analgesics enhances the analgesic effect, but leads the patient to a state of stunnedness, passivity, which is not always desirable.
Early prescribing of synthetic, semi-synthetic and natural opiates for pain that is clearly relieved by non-narcotic analgesics is a common mistake. For each patient in need of anesthesia, the doctor should develop an indicative plan of pharmacotherapy, taking into account the origin of the pain syndrome, its severity, response to ongoing therapy and the probable life expectancy of the patient. The effect of pain relief, as a rule, increases.
There is no single method of analgesia for numerous variants of the tumor process and for all cancer patients. Therefore, the differentiated drug therapy corresponding to the origin and severity of pain in malignant neoplasms is based, in addition to the general principles of the use of painkillers, on the comparative variety of existing analgesics, taking into account the peculiarities of their pharmacological action and mechanism of action.
Non-narcotic ("small") analgesics represent a significant chemical and heterogeneous in structure and action group of drugs - derivatives of salicylic acid (sodium salicylate, acetylsalicylic acid, salicylamide), pyrazolone (antipyrine, amidopyrine, analgin, butadione) (paracetaminacetinophenol ) and the so-called non-steroidal anti-inflammatory drugs: indomethacin (methindol), mefenamic acid, ibuprofen (brufen), naprosyn, probon, etc. In oncological practice, acetylsalicylic acid (aspirin), amidopyrine (pyramidone) , phenacetin, paracetamol, indomethacin, breakdown, or some drugs combined with antispasmodics (baralgin).
The mechanism of the analgesic effect of non-narcotic analgesics is not yet fully understood. It is assumed that they have a central and peripheral influence: in the central nervous system (hypothalamus) they inhibit pain impulses in synapses and at the same time, suppressing the formation of prostaglandins in the inflammatory focus, prevent the sensitization of pain receptors to mechanical or chemical (bradykinin) irritation. Apparently, mediation of the analgesic effect of the listed agents through the anti-inflammatory effect [Salyamon L. S, 1961] is of some importance. It is therefore clear that non-narcotic analgesics are especially effective when the tumor process is complicated by concomitant inflammation, which increases the severity of the pain syndrome, as well as with pain emanating from the pelvic organs or the type of neuralgia and arthralgia.
Unlike non-narcotic analgesics, narcotic (codeine, hydrocodone, tecodine, ethylmorphine or dionine, promedol, fentanyl, estocin, pentazocine or lexir, omnopon, morphine) are more effective for visceral pain in cancer patients. However, clinical experience shows that non-narcotic analgesics, when administered in adequate doses, can initially have a pronounced analgesic effect, relieving pain, including those emanating from internal organs. K. Batz et al. (1976) believe that for this, the daily dose of acetylsalicylic acid should be 4-6 g, analgin up to 3 g, phenacetin or paracetamol 1.5 g, indomethacin 100-150 mg. It seems that skepticism about the role of non-narcotic analgesics in the symptomatic treatment of patients with malignant neoplasms is directly related to the use of conventional doses of drugs sufficient to achieve the desired effect in many other cases (in particular, in the postoperative practice of general surgical clinics), but not in tumor diseases. ... The arguments in favor of this treatment are given in table. 7 data of N. Herbershagen (1979), showing the level of doses of various agents from the mentioned group, providing control of pain in cancer patients. It is important to pay attention to the rhythm of drug administration.
Table 8 shows a comparative characteristic of the therapeutic activity of some non-narcotic analgesics among themselves and with narcotic analgesics, according to S. Moertel et al. (1974), who used drugs inside to patients with inoperable tumors.
Table 7.
Effective doses and modes of use of non-narcotic analgesics for malignant neoplasms
As you can see from the table. 8, acetylsalicylic acid, even in a relatively small dose (0.3-0.6 g every 4 hours), is quite competitive in its analgesic effect in inoperable malignant tumors with other drugs from the same group and codeine in a sufficiently large dose. Nevertheless, acetylsalicylic acid is by no means a universal analgesic for common forms of malignant tumors. In the case of taking acetylsalicylic acid at a dose of 3 g per day, an analgesic effect can be observed at first for relapses and metastases of neoplasms of the female genitalia to the lymph nodes and other structures of the pelvis, metastases of breast cancer in bones and soft tissues (especially in the pleura).
Obviously, there are no significant quantitative differences in the analgesic activity of non-narcotic analgesics, and acetylsalicylic acid could be considered a standard drug in the treatment of pain in cancer patients. At the same time, one cannot fail to see the benefit of using the qualitative features of the therapeutic and side effects of certain other non-narcotic analgesics.
Table 8.
Comparative characteristics of the effectiveness of some analgesics
| Analgesic agent | Single dose, g | Analgesic effect,% | Note |
| Non-narcotic analgesics: | |||
| acetylsalicylic acid | 0,65 | 62 | Statistically significantly higher than placebo (P |
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