Volume 3, Number 3 • April 2006
commentary Dorothy M. K. Keefe Department of Medical Oncology RAH Cancer Center University of Adelaide South Australia
Supportive Care in Colon Cancer Introduction With the increasing subspecialization within oncology, it is becoming more and more common for practitioners to only see limited tumor types. And although many of the issues that relate to the supportive care of patients with different tumors do overlap, each tumor type probably does have special issues that can be examined for that tumor. Colorectal cancer is a very good example of this, with the tumor and its treatment having the potential to cause bowel problems (diarrhea, constipation, nausea, vomiting, and obstruction), nutritional problems (anorexia, weight loss, and taste disturbance), and fatigue. Occasionally, it can be difficult to determine whether it is the disease or the treatment that is the problem, and often it can be a combination. This idea of concentrating on the specific supportive care needs of a single tumor type could be usefully repeated in other diseases, such as lung cancer with its prevalence of breathing problems and breast cancer with its potential for disfigurement. It would be a useful tool for young doctors learning to care for patients with cancer, although, like most things in medicine, it would need regular evidencebased updates because of the rapid changes in management.
Mucositis In his article, Morse concentrates largely on mucositis, oral and gastrointestinal, and that is probably reasonable because of the current state of understanding of the different problems. Mucositis is often thought to be a problem confined to patients undergoing bone marrow transplantation, but in fact, the bulk of severe mucositis actually occurs in patients with solid tumors receiving standard-dose, multicycle che-
motherapy.1 Although mucositis has a lower frequency of occurence with standard-dose chemotherapy, the total number of patients receiving this form of treatment is very high. The mechanism of mucosal damage along the entire alimentary canal also has similarities, which puts patients at risk of mucositis at different points.2 Indeed, epigastric pain is a manifestation of esophageal mucositis, and chemotherapy-induced diarrhea is a manifestation of small intestinal or colonic mucositis.1
Toxicities Oxaliplatin Oxaliplatin-induced neuropathy is a relatively new problem for patients with colon cancer but an increasing problem with the use of this agent in the adjuvant setting.3,4 Further studies are obviously needed because, again, the large num-
ber of patients receiving this drug will produce a large number of patients who experience this problem. Newer Therapies Many of the newer, targeted, monoclonal antibody therapies produce rash and diarrhea, and once again, with the increasing use of these agents, more work is needed to define preventions or treatments.5 It could be that some people are genetically predisposed to develop multiple drug toxicities, and studies are under way into risk-prediction and symptom clusters. Even though hand-foot syndrome is very common with the use of capecitabine, it also occurs with taxanes and other agents.6,7 Specifically, looking at colon cancer drug toxicities should not stop us from investigating the toxicities shared by drugs used to treat other malignancies.
Common Problems in the Supportive Care of Patients with Colon Cancer3,8-22 Problem Nausea/Vomiting10
Cancer- TreatmentRelated Related
Limited: mouthwashes, ice analgesics
Other GIT Mucositis11
Laxatives, increased fluid intake
Bowel rest, gastrostomy, stenting, surgical bypass
Limited: slower infusion, calcium and magnesium
Limited: moisturizer, loose clothing
Limited: sun reduction
Symptomatic drainage, diuretics
Hand-Foot Syndrome6,18,19 Rash Ascites20,21,22
All chemotherapy-induced problems usually respond to dose-reductions and/or dose delays. Abbreviations: GI = gastrointestinal; GIT = gastrointestinal tract
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Supportive Cancer Therapy
Bowel Obstruction Bowel obstruction in colon cancer can be caused by the underlying malignancy, as discussed by Morse. However, the differential diagnosis includes chemotherapy toxicity or analgesic toxicity, and it is important to distinguish between them for treatment reasons. Opioid analgesics are a major cause of constipation, and it is very important to manage this predictable toxicity well to prevent the onset of bowel obstruction.8,9 It is interesting to note, however, that there are few studies about the management of malignant bowel obstruction. Such studies would be difficult to do, but it would not be so difficult for more units to publish their own series using local protocols. This might lead to progress in the management of bowel obstruction.
Conclusion To make this review fulfill the role of being a resource for those looking after colon patients with cancer, I think a table summarizing the particular problems and how they relate to colon cancer and/or its treatment would be useful (Table 1).3,8-22 In conclusion, there is merit in focusing on the supportive care needs of patients with colon cancer and expanding this idea to other malignancies.
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