Palliative and hospice care in gynecologic cancer: A review

Despite the increasing availability of palliative care, oncology providers often misunderstand and underutilize these resources. The goals of palliative care are relief of suffering and provision of the best possible quality of life for both the patient and her family, regardless of where she is in the natural history of her disease. Lack of understanding and awareness of the services provided by palliative care physicians underlie barriers to referral. Oncologic providers spend a significant amount of time palliating the symptoms of cancer and its treatment; involvement of specialty palliative care providers can assist in managing the complex patient. Patients with gynecologic malignancies remain an ideal population for palliative care intervention. This review of the literature explores the current state of palliative care in the treatment of gynecologic cancers and its implications for the quality and cost of this treatment.     

Palliative care in gynaecological oncology

Women with a gynaecological malignancy often suffer significant symptom burden, both physically and psychologically, throughout the course of their disease. Despite advances in treatment, up to 25% of women diagnosed with a gynaecological malignancy will die from recurrent disease. Early palliative care involvement can provide a holistic approach to care with the benefit of improving symptom control and quality of life for both the patient and carer as well as lowering resource utilisation at the end of life. Palliative care can be offered alongside curative or life prolonging treatment as well as at end of life. This article reviews the management of common physical symptoms and complications experienced by patients with advanced gynaecological malignancy.     

Palliative care in gynaecological oncology

Gynaecological malignancy accounts for significant patient morbidity and mortality. Clinical aims focus upon palliative management and supportive care when potentially curative treatment options are exhausted. Patients with recurrent, advancing or terminal disease may suffer severe and distressing physical and psychological effects associated with both cancer diagnosis and treatments. It is of paramount importance that patients, families and carers are provided with the assistance they need to have as high a quality of life as possible.This review focuses upon the provision of relief from pain and other distressing symptoms commonly associated with gynaecological malignancy. In addition, we highlight some of the important aspects of psychosocial care.     

Palliative care in gynaecological oncology

Gynaecological malignancy accounts for significant patient morbidity and mortality. Clinical aims focus upon palliative management and supportive care when potentially curative treatment options are exhausted. Patients with recurrent, advancing or terminal disease may suffer severe and distressing physical and psychological effects associated with both cancer diagnosis and treatments. It is of paramount importance that patients, families and carers are provided with the assistance they need to have as high a quality of life as possible.This review focuses upon the provision of relief from pain and other distressing symptoms commonly associated with gynaecological malignancy. In addition, we highlight some of the important aspects of psychosocial care.     

Acute and chronic pain management in palliative care

Every palliative care patient should have the expectation that acute and chronic pain management will be an integral part of their overall care. However, in all too many instances, the pain of cancer is often grossly under-treated. This issue is of concern because more than 80% of patients with cancer pain can find adequate relief through the use of simple pharmacological methods. It is even more troubling to note that women and minority groups have their cancer pain under-treated more frequently. Physicians with the basic skills of assessment and treatment will be able to control the symptoms in the majority of cancer pain patients. However, there are still some patients who may require other modalities to control their moderate to severe pain. A thorough understanding of all pain management options will help the gynaecological oncologist to maintain an acceptable quality of life for their patients throughout the therapeutic and palliative phases of care.     

Palliative care in gynaecological oncology

Women with a gynaecological malignancy often suffer significant symptom burden, both physically and psychologically, throughout the course of their disease. Despite advances in treatment, up to 25% of women diagnosed with a gynaecological malignancy will die from recurrent disease. Early palliative care involvement provides a holistic approach to care with the benefit of improving symptom control and quality of life for the patient and their carers, as well as lowering resource utilisation at the end of life. Palliative care can be offered alongside curative or life prolonging treatment as well as at end of life. This article reviews the management of common physical symptoms and complications experienced by patients with advanced gynaecological malignancy.     

Hormone replacement therapy in women with a history of breast cancer.

Health care professionals in modern Western societies will meet an increasing number of women surviving breast cancer. How the menopause of these women should be treated is still an open question. Use of hormone replacement therapy (HRT) may, at least in theory, increase the risk for recurrence of cancer, but its categoric refusal is a double-edged sword because it also denies these women all the undisputable health benefits HRT provides. This refusal is not, however, supported by the observational data available so far on this question, because HRT has not increased the risk for breast cancer recurrence. In fact, it is well established that HRT abolishes hot flushes and improves significantly these patients' quality of life. At present, we have no effective nonhormonal alternatives for the control of vasomotor symptoms, and the efficacy of phytoestrogens in the treatment of menopausal symptoms is unproven. Selective estrogen receptor modulators (SERMs) which protect against osteoporosis and perhaps also against breast cancer, and which may have beneficial effects on the cardiovascular system, aggravate hot flushes and are therefore not useful, at least in the first postmenopausal years. In some countries, progestins are often prescribed for the control of such patients' vasomotor symptoms, but their safety has never been assessed in clinical trials, and in theory they can be harmful. Randomized clinical trials (RCT) on the use of HRT in breast cancer survivors are underway, but their completion will take years, and even these may be open to criticism. Tibolone may appear to be an appealing alternative for HRT, but it should also be studied with RCTs in this indication. At present, a patient with a history of breast cancer must be given balanced information as to the possible benefits and risks of HRT, and she herself must make the decision whether or not to start HRT.     

Counseling the perimenopausal woman

The PMP time is a time of hormonal fluctuations. As such, a woman may have many symptoms or none. It may also be a time of many life changes both positive and negative. The clinician has an opportunity to educate patients to prepare them for this time and to help them maintain health through the menopause. Because this time in a woman's life is largely unstudied, treatment options (if any) can be uncertain. For many women, the choice to use an OC to control cycles and treat other symptoms is an option. Finally, it is a time when excellent communication and counseling are imperative. The counseling must be effective and in a manner in which the patient learns well. The communication between the clinician and patient must be open and the patient must have realistic expectations about any therapy that may be chosen. The clinician must recognize that each woman is unique and has unique needs. A goal for both should be relief of symptoms, health maintenance, and enhancement of her overall quality of life.     

Hospizbewegung

Although dying, death and mourning in our society have been faded out of the daily routine and become taboo themes, a civic movement for “hospice” has also arisen and more and more forms and facilities for supportive care of terminally ill patients are now available. This includes voluntary helpers, nursing and social workers with additional qualifications, palliative medical consulting services, out-patient palliative medical services and finally in-patient hospices for people who can no longer be (temporarily) accompanied at home. These aspects will be dealt with in detail using the example of the Christophorus Hospice Association in Munich. In addition to pain therapy, the main aims of the palliative care are the wishes, targets and satisfaction as well as the quality of life of patients and their relatives. Comprehensive nursing care by a multidisciplinary team can allow patients to fulfil the desire to die in familiar surroundings. The achievements of palliative medicine give terminally ill patients the freedom to make their own decisions and lighten the individual spiritual approach to the last transition in their life which they have to bridge and endure.     

Current surgical management in ovarian cancer recurrences

Ovarian cancer is a tumor with a high trend of recurrence and this occurrence consistently increases the difficulty of the patient cure and reduces the efficacy of current treatments. The role of surgery in persistent or recurrent ovarian cancer is controversial and the type of surgery can be different according to the different stages and invasion of tumor; it can be a debulking surgery followed by chemotherapy (to eradicate the most part of ovarian cancer, leaving a minimal tumoral residue), an interval surgery (for advanced ovarian cancer stage in previously operated patients, followed by 2 or 3 inductive chemotherapy cycles and subsequently a cytoreductive redo surgery) and a cytoreductive secondary surgery, after optimal primary surgical treatment and minimal tumoral recurrence. In some cases it is possible either to perform a debulking surgery during a primary (after the conclusion of primary treatment) or a salvage or palliative surgery (to improve, after an acceptable time period, clinical symptoms in patients with progressive cancer or resistant to treatments). The aims of surgical therapy, to be performed in a patient with ovarian cancer relapse, are to reduce, as much as possible, the tumour size, to increase the quality of life and to increase the survival time; in this review different surgical techniques to be carried out in each case, selected for disease staging, for tumour cells kinetic and for surgical goals, are discussed.     

Role of palliative surgery in ovarian cancer

The most common indication for palliative surgery in recurrent ovary cancer is malignant bowel obstruction. After careful diagnosis of bowel obstruction, conservative management should be employed. If resolution of obstruction does not occur, the decision to perform surgery must be made. Several authors have reported on outcomes in patients undergoing surgery. Operative morbidity and mortality is 7–64% and 4–32%, respectively, and median survival is 5–33 weeks in these reports. Surgery should be considered in select patients after a thorough discussion with the patient regarding the likely outcome following the procedure, including the potential for morbidity and mortality. The surgery should be aimed at relieving the symptoms and improving quality of life.     

The Evidence for Increasing Cytotoxic Dose Intensity in the Treatment of Advanced Ovarian Cancer

Summary: There is a body of conflicting evidence regarding the place of dose intense chemotherapy for advanced ovarian cancer. It remains unproven whether dose intensity is more important than total dose delivered, and measures of drug delivery to the tumour itself are absent or crude. There are various methods under evaluation for reducing the toxicity of chemotherapeutic drugs, thus enabling larger doses to be given. However, we must not lose sight of the fact that current treatment is palliative for the majority of women, making the quality of life an important issue. The place of dose intense cytotoxic chemotherapy, for the treatment of advanced ovarian cancer, must be evaluated in large, carefully designed, prospective trials which, if possible, should include a quality of life assessment.     

Palliative radiation therapy for gynaecological malignancies

Patients with advanced, recurrent, or metastatic gynaecological malignancies constitute a heterogenous population with diverse symptomatology. Progressive abdominopelvic disease can result in vaginal or diffuse pelvic bleeding, pain, and visceral or lymphovascular obstruction. Gynaecological cancer can also develop debilitating metastases, in particular to bone, central nervous system, or chest. Radiation therapy is a local-regional treatment modality, that, when applied judiciously, can lead to substantial symptomatic relief and tumour response. Individualized application is necessary, balancing efficacy and patient convenience versus treatment intensity, expected duration of palliation and potential toxicity. Important factors to consider are a patient's performance status, extent and sites of tumour, specific symptoms, and life expectancy. The optimal incorporation of radiotherapy is best achieved in the context of a multidisciplinary approach that addresses all facets of palliative care in patients with incurable gynaecological malignancies, to maximize their quality of life and functional level.     

Palliativmedizinische Maßnahmen bei gynäkologischen Malignomen und Mammakarzinomen gemäß S3-Leitlinie

Palliative care plays an important role in the care of patients with advanced gynecological tumors and breast cancer. In addition to an empathic and honest communication, adequate pain and symptom control of the patients is essential. Randomized studies have shown that early integration of palliative care into the oncological treatment of patients with advanced cancer not only improves the quality of life but can also improve survival. Overall, palliative care is helpful for most patients with advanced gynecological tumors and breast cancer and should be provided early and as a low threshold offer.     

Palliativmedizin – weit mehr als nur Schmerztherapie

The WHO definition of palliative care clearly states that it is more than just pain therapy with a “humanistic touch”. The widespread misunderstanding of palliative medicine as a “pain therapy for dying (cancer) patients” has been disproved by clinical reality. The principles of palliative medicine are increasingly being applied to non-oncological patient groups, especially neurological patients. It is now generally accepted that palliative care is care for, but not just at the end of life. Palliative psychosocial and spiritual support play at least as important a role within palliative care as medical symptom control (pain, internal medicine and neuropsychiatric symptoms). The goal of palliative care, as Cicely Saunders said, is “to provide space” in order to allow patients to live fully until they die.     

复发性上皮性卵巢癌临床治疗进展

上皮性卵巢癌(epithelial ovarian cancer,EOC)患者如初次就诊时已为晚期,虽然肿瘤细胞减灭术和术后辅以紫杉醇/铂类为基础的联合化疗可使大部分患者获得临床缓解,但最终仍有80%的患者复发。复发性EOC的治疗原则是姑息而不是治愈,生存质量是再次治疗时考虑的重要因素。可根据患者初次手术情况及术后化疗方案及途径、疗效、毒副反应、复发类型等制定个体化的治疗方案,以缓解、控制症状、提高患者的生存质量及延长无进展生存期。对于仅限于单个病灶复发或手术能达到有效减瘤程度的倾向于减瘤术联合化疗,对那些大块而广泛甚至伴有远处转移的更倾向于只进行化疗。在制定方案时,常把耐药型、顽固型和难治型患者归为一组,鼓励其进行新药临床试验或接受非铂类制剂化疗;对敏感型推荐以铂类或铂类加紫杉醇为基础的化疗方案。生物治疗作为肿瘤治疗的另一种治疗模式日益受到重视,成为传统手术治疗和化疗的有力补充。     

Schmerztherapie und Symptomkontrolle in der Palliativmedizin

Efficacious pain therapy and good symptom control are the main challenges in the management of patients with advanced cancer, especially in the terminal phase. Pain is a prevalent symptom in cancer patients, affecting up to 90% of patients with advanced disease. Although adequate relief can be achieved in the majority of tumor patients following the guidelines of the World Health Organization, pain is often treated inadequately. According to the WHO analgesic stepladder, treatment should optimally consist of oral application at regular intervals. During their final phase, cancer patients experience distressing symptoms, e.g., constipation, nausea, vomiting, panic/anxiety, or dyspnea. Effective prophylaxis and cause-based therapy of these symptoms is of great importance in improving the quality of life of patients and their family members. Besides an appropriate medical treatment of pain and distressing symptoms skilled empathic communication addressing the psychosocial and spiritual problems of the patient with a short life expectancy can make a calm and peaceful dying possible.     

Hormone replacement therapy in women with a history of breast cancer

Health care professionals in modern Western societies will meet an increasing number of women surviving breast cancer. How the menopause of these women should be treated is still an open question. Use of hormone replacement therapy (HRT) may, at least in theory, increase the risk for recurrence of cancer, but its categoric refusal is a double-edged sword because it also denies these women all the undisputable health benefits HRT provides. This refusal is not, however, supported by the observational data available so far on this question, because HRT has not increased the risk for breast cancer recurrence. In fact, it is well established that HRT abolishes hot flushes and improves significantly these patients' quality of life. At present, we have no effective nonhormonal alternatives for the control of vasomotor symptoms, and the efficacy of phytoestrogens in the treatment of menopausal symptoms is unproven. Selective estrogen receptor modulators (SERMs) which protect against osteoporosis and perhaps also against breast cancer, and which may have beneficial effects on the cardiovascular system, aggravate hot flushes and are therefore not useful, at least in the first postmenopausal years. In some countries, progestins are often prescribed for the control of such patients' vasomotor symptoms, but their safety has never been assessed in clinical trials, and in theory they can be harmful. Randomized clinical trials (RCT) on the use of HRT in breast cancer survivors are underway, but their completion will take years, and even these may be open to criticism. Tibolone may appear to be an appealing alternative for HRT, but it should also be studied with RCTs in this indication. At present, a patient with a history of breast cancer must be given balanced information as to the possible benefits and risks of HRT, and she herself must make the decision whether or not to start HRT.     

Palliative care in gynaecological oncology

More than 20,000 new gynaecological malignancies are diagnosed each year. Sadly in many cases the disease is too advanced to be cured and management focuses on prolonging life and palliation of symptoms. Palliative care is a holistic approach to caring for individuals with advanced disease. It is multidisciplinary and aims to improve the overall quality of life for patients and their families. Provision of palliative care is not universal and management of symptoms both physical and psychological has been found to be suboptimal in many settings in the UK and worldwide. The World Health Organisation has targeted palliative care as a clinical priority.This article reviews management of physical symptoms; including pain, psychological and social support, and discusses issues around end of life care.     

The effect of cancer on reproductive health

The incidence of cancer and survival rates are increasing, as is the consequent impact on reproductive health. Delay in childbearing years is also an important factor. It is well documented that a significant number of cancer treatments are gonadotoxic. This can lead to fertility concerns and long term effects for both men and women. Fertility preservation should only take place if the patient is well enough, where there is time and if it will not worsen their oncological condition. In men, fertility preservation is a straightforward procedure, whereas in women it is more invasive, carries more risk and can significantly delay cancer treatment. The long term effects of cancer treatment include early menopause, erectile dysfunction, loss of libido and psychosexual dysfunction. These factors can significantly affect quality of life. Hence, well organised referral pathways and counselling services are paramount and must include a multidisciplinary approach involving relevant specialists.