Nicola Holtom
Case history
A 65-year-old man presented as an emergency with bowel obstruction and hydronephrosis having experienced 3 months of rectal pain and altered bowel habit. A rectal tumour was inoperable, and defunctioning ileostomy and ureteric stent insertion was performed.
He was referred for neoadjuvant chemoradiotherapy. He was informed that pre-operative treatment was likely to reduce risk of local recurrence by up to two-thirds. He was undecided whether to proceed with the treatment due to concerns about long-term toxicities. His medications included ibuprofen and paracetamol.
He was referred to specialist palliative care for symptom control and psychological support. He had been feeling overwhelmed since diagnosis, and felt that he was losing control over his life.
His main complaints were:
♦ Profuse mucous discharge causing disruption to his life. He was evacuating his bowels of mucus hourly, day and night
♦ Exhaustion. Sleep was disrupted by anxiety about rectal leakage. On one occasion he had taken a sleeping tablet and was incontinent of mucous rectal discharge.
♦ Rectal tenesmus pain: a constant feeling of needing to evacuate his bowels associated with intermittent shooting pains in the rectum every few hours.
♦ Psychologically low in mood. He was struggling to adjust to his diagnosis and the effects on his life. The stoma and pads affected his body image. He felt embarrassed by malodour and had withdrawn socially from friends and family. He was mourning his loss of health and role, and felt useless. His general practitioner had prescribed citalopram but he had not taken it.
Question
1. How would you manage his physical symptoms?
Answer
1. How would you manage his physical symptoms?
For management of mucous discharge the options include reduction of peritumour inflammation using prednisolone suppositories (5mg twice a day) or prednisolone retention enema (20mg every 2–3 days). Non-steroidal anti-inflammatory agents (NSAIDs) and octreotide also reduce the volume of discharge. It is important to keep the area dry, protect the skin with barrier ointment, and monitor for fungal infection. Due to the severity of symptoms, octreotide 200μg/24h via a syringe driver was commenced. Within 48h mucous discharge was controlled and he was sleeping through the night. He was subsequently commenced on Sandostatin LAR 20mg subcutaneously every 4 weeks.
With regard to pain management, tenesmus pain has a significant neuropathic component and can be difficult to treat. Tenesmus is likely to increase during chemoradiotherapy and it is important to establish an effective analgesic regime prior to commencing treatment. In accordance with NICE guidelines for the management of malignant neuropathic pain the first-line treatment is to start an opioid and add an antineuropathic agent if the patient develops adverse effects or pain is not controlled. Strong opioids are generally best administered with a non-opioid, and if there is a neuropathic component (as in tenesmus pain) specific antineuropathic agents may be required.
Oral morphine 2.5mg as needed 4-hourly was effective in controlling pain and transdermal fentanyl (12μg/72h) was commenced as this is relatively less constipating than other strong opioids. Tolerance to strong opioids is not a practical problem and physical dependence does not prevent a reduction in the dose of morphine if the pain ameliorates as a result of treatment.
Laxatives should be prescribed routinely for constipation unless there is a reason for not doing so, for example the patient has an ileostomy.
At mid treatment review, he complained of low-grade discomfort in the rectum and was using oral morphine 10mg three to four times a day with good effect.
Question
2. How would you adjust his analgesic medication?
Answer
2. How would you adjust his analgesic medication?
As his pain was opiate-responsive (oral morphine gave total relief of symptoms for 4 h), the fentanyl patch was increased to 25μg/72h.
On completion of treatment he complained of increasing rectal pain, which was only partially relieved with morphine.
Question
3. How would you optimize analgesic control?
Answer
3. How would you optimize analgesic control?
Patients sometimes experience a flare in pain due to treatment. If the pain is responding to opiates the dose should be titrated until symptoms settle. If the pain is not completely relieved with opiates, steroids or NSAIDs can be effective. However, if the psychosocial dimension of suffering is ignored, success will be limited.
Question
4. What psychological support could you offer this man?
Answer
4. What psychological support could you offer this man?
Following holistic assessment, full psychological assessment is needed if symptoms are identified. Symptoms are exacerbated by insomnia, exhaustion, anxiety, and depression. The severity of a symptom is measured by determining the impact that symptom is having on a patient’s life.
An explanation of the reasons for the symptoms does much to alleviate the psychological impact. This patient believed that his symptoms would continue indefinitely and was feeling despondent.
Nearly 50% of patients with cancer have a psychiatric disorder as judged by DSM criteria. However, in two-thirds of these patients it is a transient adjustment disorder with depressed or anxious mood.
The first step in helping patients who are feeling overwhelmed by their situation is to enable them to sleep. He was struggling to make decisions because of fatigue but he also wanted to retain autonomy. He described himself as being introspective and prone to worrying but did not feel that he was depressed. Once his symptoms were controlled his mood improved and he completed chemoradiotherapy treatment.
Three weeks later he complained of a 2-week history of increasing rectal pain and offensive rectal discharge. He had become preoccupied and introspective about his situation to the extent that he was unable to engage in family activities. He described anhedonia (loss of pleasure in life), insomnia, anorexia, and weight loss. He was gagging on medication. He was referred to dietetics. He believed his quality of life was so poor that at times he did not want to continue living, although there was no active suicidal behaviour.
Question
5. How would you manage this situation?
Answer
5. How would you manage this situation?
Depression, a sense of hopelessness, and exhaustion, greatly increase the risk of suicide. He felt in despair about his situation and agreed that it was important to optimize physical and emotional well-being prior to surgery. Fentanyl was increased to 50μg/72h and orodispersible mirtazapine 15mg at night was commenced.
Three weeks later he was feeling much more optimistic and was engaged with family life. He was sleeping well with no pain, his appetite had improved, and he had gained a stone in weight.
A re-staging CT scan after neoadjuvant chemoradiotherapy showed response within the primary tumour. A Dukes B adenocarcinoma was completely resected. Post-operatively pain was well controlled and fentanyl was reduced to 37μg/72h.
Three weeks after surgery he was admitted with increasing rectal pain and discharge. CT confirmed a large pelvic abscess, which was aspirated.
His mood was depressed with persistent anxiety and insomnia, being unable to stop thinking about his illness and suffering. He was preoccupied by his symptoms and worries about prognosis. He was losing hope of getting better. Mirtazapine was increased to 30mg and he commenced diazepam 5mg at night. Nasogastric (NG) feeding was commenced due to weight loss.
One month later he was coping well psychologically but experiencing recurrence of tenesmus pain and was using oramorph regularly with only partial pain relief.
Question
6. What are the options for managing his pain?
Answer
6. What are the options for managing his pain?
If pain is only partially relieved with opiates an antineuropathic agent should be added. He was commenced on gabapentin 100mg three times a day. Dose was titrated to 300mg three times a day until pain was controlled.
Two months later he was well. Nasogastric feeding stopped as his target weight was achieved. Diazepam was discontinued and analgesia reduced.
Discussion
Patients completing radical treatment often experience considerable symptom burden (physical and psychological). Thorough holistic assessment will identify their needs.
Patients should be reassured that symptoms can usually be controlled or significantly improved. Instead of expecting immediate, complete relief, symptoms can be improved a bit at a time and much can be achieved with determination and persistence. Never say, ‘There’s nothing more that I can do’.
Patients will benefit from shared care with specialist palliative care colleagues in seemingly intractable situations.
Progress and follow-up
Eleven months following initial referral he was pain free, psychologically well, and planning a return to work.
Further reading
Harvey M, Dunlop R. Octreotide and the secretory effects of advanced cancer. Palliative Medicine 1996; 10: 346–347.
NICE Supportive and Palliative Care Guidance, 2004 <http://www.nice.org.uk/CSGSP> NICE.
NICE Clinical Guideline 96. Neuropathic pain, 2010 http://www.nice.org.uk/nicemedia/pdf/CG96QuickRefGuide.pdf
The National Council for Palliative Care <http://www.ncpc.org.uk>