OncologyTier 2Topic

Palliative care in oncology

Focus

Palliative care in oncology focuses on symptom control and quality of life for patients with advanced/incurable cancer, delivered alongside, not only after, disease-directed treatment
Early palliative care integration in advanced cancer improves quality of life and symptom burden, and in some trials has shown a survival benefit comparable to some active anticancer therapies

Cancer pain arises through multiple overlapping mechanisms (nociceptive - tissue/bone/visceral; neuropathic - nerve infiltration/compression) which often require different analgesic approaches used together, not a single agent alone

Pain assessment should characterise the mechanism (nociceptive vs neuropathic) since this directs specific therapy choice, not just severity

WHO analgesic ladder - stepwise progression from non-opioid (paracetamol/NSAID) to weak opioid to strong opioid, adding adjuvants at any step (neuropathic agents - gabapentinoids, TCAs; corticosteroids for pain from mass effect/bone metastases; bisphosphonates/denosumab for bone pain from skeletal metastases)
Breakthrough pain requires an as-needed immediate-release opioid dose alongside regular background analgesia, not simply increasing the background dose alone
Other common symptoms requiring specific management: nausea (mechanism-directed antiemetic choice), breathlessness (opioids, fan therapy), delirium (identify and treat reversible precipitants first, environmental measures, antipsychotics for severe distress)

Bone metastases (pain, pathological fracture risk), malignant bowel obstruction, cancer-related fatigue, delirium at end of life

Effective symptom control is achievable in the great majority of patients with a systematic, mechanism-based approach - undertreatment of cancer pain remains common and is often driven by clinician under-dosing or opioid-related anxiety rather than a lack of effective options

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