Supportive Care in Colon Cancer

Supportive Care in Colon Cancer

Volume 3, Number 3 • April 2006 commentary Dorothy M. K. Keefe Department of Medical Oncology RAH Cancer Center University of Adelaide South Australi...

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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.

Table 1

Common Problems in the Supportive Care of Patients with Colon Cancer3,8-22 Problem Nausea/Vomiting10

Cancer- TreatmentRelated Related

Available Treatments

Yes

Yes

Antiemetics

No

Yes

Limited: mouthwashes, ice analgesics

Other GIT Mucositis11

No

Yes

Antidiarrheals, octreotide

Constipation12

Yes

Yes

Laxatives, increased fluid intake

GI Obstruction8,9

Yes

Yes

Bowel rest, gastrostomy, stenting, surgical bypass

Anorexia13

Yes

Yes

Limited: steroids

Fatigue14,15

Yes

Yes

Limited: erythropoietin

Oxaliplatin-Induced Neuropathy3,16,17

No

Yes

Limited: slower infusion, calcium and magnesium

No

Yes

Limited: moisturizer, loose clothing

No

Yes

Limited: sun reduction

Yes

No

Symptomatic drainage, diuretics

Oral

Mucositis11

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.

References 1. Sonis ST, Elting LS, Keefe D, et al. Perspectives on cancer therapy-induced mucosal injury:

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

pathogenesis, measurement, epidemiology, and consequences for patients. Cancer 2004; 100(9 suppl):1995-2025. Keefe DMK. Gastrointestinal mucositis: a new biological model. Support Care Cancer 2004; 23:6-9. Cersosimo RJ. Oxaliplatin-associated neuropathy: a review. Ann Pharmacother 2005; 39:127135. Andre T, Boni C, Mounedji-Boudiaf L, et al. Oxaliplatin, fluorouracil, and leucovorin as adjuvant treatment for colon cancer. Multicenter International Study of Oxaliplatin/5-Fluorouracil/Leucovorin in the Adjuvant Treatment of Colon Cancer (MOSAIC) Investigators. N Engl J Med 2004; 350:2343-2351. Cunningham D, Humblet Y, Siena S, et al. Cetuximab monotherapy and cetuximab plus irinotecan in irinotecan refractory metastatic colorectal cancer. N Engl J Med 2004; 351:337-345. Scheithauer W, Blum J. Coming to grips with hand-foot syndrome. Insights from clinical trials evaluating capecitabine. Oncology 2004; 18:1161-1168. Childress J, Lokich J. Cutaneous hand and foot toxicity associated with cancer chemotherapy. Am J Clin Oncol 2003; 26:435-436. Mercadante S. Assessment and management of mechanical bowel obstruction. In: Portenoy RK, Bruera E, eds. Topics in Palliative Care. Volume 1. New York, NY: Oxford University Press; 1997:113-130. Ripamonti C, Twycross R, Baines M, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer. Support Care Cancer 2001; 9:223-233. Kris MJ, Hesketh P, Herrstedt J, et al. Devoted to the MASCC antiemetic guidelines. Support Care Cancer 2005; (13):85-96. Rubenstein EB, Peterson DE, Schubert M, et al. Clinical practice guidelines for the prevention and treatment of cancer therapy-induced

172

12.

13.

14.

15.

16.

17.

18.

19.

20. 21.

22.

oral and gastrointestinal mucositis. Cancer 2004; 100(9 suppl):2026-2046. Woodruff R. Constipation in Palliative Medicine. 2nd ed. Melbourne, Australia: Asperula Pty, Ltd Publishers; 1993:176-183. Laviano A, Meguid M, Rossi-Fanelli P. Cancer anorexia: clinical implications, pathogenesis, and therapeutic strategies. Lancet Oncol 2003; 4:686-694. Cella D, Kallich J, McDermott A, et al. The longitudinal relationship of hemoglobin, fatigue and quality of life in anemic cancer patients: results from five randomized clinical trials. Ann Oncol 2004; 15:979-986. Boogaerts M, Coiffier B, Kainz C, et al. Impact of epoetin beta on quality of life in patients with malignant disease. Br J Cancer 2003; 88:988-995. Andre T, Figer A, Cervahtes A, et al. FOLFOX7 compared to FOLFOX4. Preliminary results of the optimox study. Proc Am Soc Clin Oncol 2003; 22:253 (Abstract #1016). Gamelin E, Gamelin L, Delve R, et al. Prevention of oxaliplatin peripheral sensory neuropathy by Ca2+ gluconate and Mg+ chloride infusions: a retrospective study. Proc Am Soc Clin Oncol 2002; 21:157a (Abstract #624). Denda M, Inoue K, Fuziwara S, et al. P2X purinergic receptor antagonist accelerates skin barrier repair and prevents epidermal hyperplasia induced by skin barrier disruption. J Invest Dermatol 2002; 119:1034-1040. Fabian CJ, Molina R, Slavik M, et al. Pyridoxine therapy for palmar-plantar erythrodysesthesia associated with continuous 5fluorouracil infusion. Invest New Drugs 1990; 8:57-63. Parsons SL, Watson SA, Steele RJ. Malignant ascites. Br J Surg 1996; 83:6-14. Lacy JH, Wieman TJ, Shively EH. Management of malignant ascites. Surg Gynecol Obstet 1984; 159:397-412. Roussel JG, Kroon BB, Hart GA. The Denver type for peritoneovenous shunting of malignant ascites. Surg Gynecol Obstet 1986; 162:235-240.