19. Palliative medical care – Cervical Carcinoma
Major changes in the chapter on palliative medical care
This chapter has been altered. It has been revised and shortened with reference to the cross-sectional guideline (Level 3 guideline on “Palliative Care for Patients with Incurable Cancer,” AWMF register no. 128/001OL, version 2.1, January 2020). The topics “Management of colostomy/stoma” and “ Pain” have been added.
C. Stromberger, M. Kloke, A. Letsch
More detailed discussions on this topic are available in the Level 3 guideline “Palliative Care for Patients with Incurable Cancer” (AWMF register no. 128/001OL, version 2.1, January 2020). The following recommendations and statements are borrowed from that guideline.
Evidence-based recommendation from S3 guideline Palliative Medicine
(AWMF Reg. No. 128/001OL, Version 2.1 - January 2020)
Following a diagnosis of incurable cancer, all patients shall be offered palliative care, regardless of whether tumor-specific therapy is being provided.
Consensus-based recommendation from S3 guideline Palliative Medicine
(AWMF Reg. No. 128/001OL, Version 2.1 - January 2020)
In the case of incurable cancer, the physical, psychological, social, and spiritual needs, as well as burdens and information requirements, of patients and their relatives shall be assessed repeatedly and reassessed again if the clinical situation changes.
- Consensus
- Strong consensus
Evidence-based recommendation from S3 guideline Palliative Medicine
(AWMF Reg. No. 128/001OL, Version 2.1 - January 2020)
Patients with incurable cancer and a highly complex situation shall receive specialized palliative care.
Palliative medicine (synonymous with palliative care) is defined as an approach aimed at improving the quality of life of patients and their families who are facing the problems associated with a life-threatening disease [739], [740], [741], [742], [743], [744], [745], [746], [483], [747], [748], [747], [481], [484], [484]. This is achieved by preventing and alleviating suffering, through early recognition and careful assessment and treatment of pain and of other problems of a physical, psychosocial and spiritual nature [739], [740], [741], [742], [743], [744], [745], [746], [483], [747], [748], [747], [481], [484], [484].
The WHO definition of palliative care implies a holistic approach, taking into account all four dimensions of the human being. This also justifies the inclusion of the family in treatment efforts, which do not end with the patient’s death but include the mourning phase. Palliative care requires a multiprofessional and interdisciplinary team approach. Early integration (based on the principle of involving palliative care specialists as systematically as possible in parallel with tumor-modifying treatment) has proven to be relevant for quality of life and, in individual cases, survival time, and it is now considered the standard of care. Palliative care affirms life and recognizes dying as a normal process, so that its goal is neither to delay nor to accelerate death.
Patients with advanced cervical carcinoma in whom curative treatment is not possible (with surgery, radiochemotherapy, or surgery with adjuvant radiochemotherapy) or with distant metastases (M1) can usually be assumed to have progressive disease leading to death.
19.1 Patients’ needs
The foremost goal in palliative medical treatment — individual quality of life — can only be evaluated and defined by the patient herself [749], [750]. Burdens for the patient may be of a physical, psychosocial, spiritual, and existential nature [741], [742], [743], [744], [745], [746], [483], [747], [481], [747], [748], [484], [484]. The need for support should be regularly assessed together with the patient using suitable validated and multidimensional instruments (see also the Level 3 guideline on palliative medicine).
A high regard for the patient’s autonomy and involvement is a prerequisite for the treatment of these patients and is one of the essential components of palliative medicine. In addition to the routine recording of the patient’s own assessment of her quality of life and symptomatic burden, this also includes supportive monitoring of treatment decisions in compliance with the medical ethical principles of beneficence, nonmaleficence and appropriateness (justice). Information about palliative medical options should be provided in the context of promoting and supportively monitoring treatment decisions. Relatives or other persons whom the patient trusts should be included in the discussions. To enable the patient to have her person of trust express her presumed will to the best extent possible even if disturbances of consciousness occur during the course of the disease, counseling and support are offered for establishing treatment wishes and goals, and if appropriate for drawing up an advance health-care directive (“living will”) and precautionary power of attorney. These should be expressed as specifically as possible and should include plans for probable or possible emergency situations during the course of the disease.
With regard to other palliative medicine considerations, independent of the underlying diagnosis, reference may be made to the Level 3 guideline on “Palliative Medicine” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020) [751]. This provides a detailed discussion covering multiple organs regarding symptomatic control, palliative care, psychosocial support, and available care structures.
19.2 Relatives’ needs
The inclusion of the patient’s relatives is a central aspect of palliative care. The patient has the option to have relatives or other persons of trust included in discussions in accordance with her own wishes. However, the wishes and anxieties of the relatives themselves, as well as their needs for information, for example, also play an important role. With regard to other aspects of palliative medicine involving looking after relatives, reference may be made to the Level 3 guideline on “Palliative Medicine” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020) [751].
19.3 Palliative and hospice care
Palliative medical care covers medical control of symptoms, palliative nursing, and psychosocial support form the onset of incurable cancer up to death [741], [742], [743], [744], [745], [746], [752], [747], [481], [747], [481], [484], [484], [753]. In the palliative situation, all of the steps required are oriented towards the patient’s individual treatment and life goals [741], [484]. The availability of palliative treatment services in accordance with need is the result of a consent process lasting many years [741]. Staged palliative care is the necessary prerequisite for varying the intensity of treatment according to the symptomatic burden, while at the same time ensuring the continuity of palliative support [754], [755].
Symptomatic control, palliative nursing, and psychosocial and spiritual support represent four dimensions of palliative treatment here, which must be included in every high-quality palliative care service, independently of the level of specialization at which the service is located [742]. To ensure timely integration of support services, palliative care is also provided simultaneously with tumor-specific therapies — ideally at the same time as (i) disease-modifying treatments with the primary therapeutic goal of prolonging life or achieving sustained symptomatic relief (palliative therapy); (ii), for prophylaxis against or treatment of side effects of the disease or therapies for it (supportive therapy) [739], [740], [744], [484], [756], [757], [758], [759]; and (iii) for psychosocial and psycho-oncological care tailored to need.
In patients who continue to have a severe physical, psychosocial, or spiritual burden despite palliative medicine measures, specialized palliative medical care is useful. This is provided by a specialist palliative care team (Spezialisierte ambulante Palliativversorgung, SAPV) in the outpatient field and for inpatients by the hospital’s palliative care service, supplemented by the outpatient hospice service (Level 3 guideline on “Palliative Medicine in Incurable Cancer,” AWMF register no. 128/001OL, version 2.1, January 2020) [741], [484].
19.4 Treatment for specific symptoms
Patients with cervical carcinoma often have a severe symptomatic burden even in the locally advanced stage. Complex pain syndromes, malignant lymphedema, gastrointestinal symptoms (from constipation to malignant intestinal obstruction), malignant wounds, depression, and fatigue are common. The general and specific principles of treatment for these symptoms are presented in detail in the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020) [751].
In the following, malignant lymphedema is discussed specifically in patients with cervical carcinoma and, for frequently occurring symptoms or symptom complexes, reference may be made to the relevant chapters in the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020) [751].
19.4.1 Symptomatic treatment for malignant lymphedema
Secondary lymphedema in the context of cancer is mostly of multifactorial origin: surgical interventions, particularly lymphadenectomy, status post radiotherapy/radiochemotherapy, obstruction of the lymphatic drainage pathways by tumor, and post/infectious [760]. No data are available on the prevalence of lymphedema in the lower extremities.
Malignant lymphedema significantly limits the quality of life for the affected patients. It leads to immobility, causes pain, and prevents the wearing of clothing. It can lead to significant volume shifts with electrolyte imbalance and protein loss, as well as erysipelas. In extreme cases, it causes compartment syndrome, with a risk of losing the limb.
19.4.1.1 Detection and evaluation
The pillars of basic diagnosis are taking a medical history, inspection, and palpation, and they should be performed in this order. In the presence of comorbidities relevant for differential diagnosis, such as previous cardiac diseases, leg vein thrombosis, post-thrombotic syndrome, or hypo-/dysproteinemia, and/or inconclusive results of the clinical examination, appropriate additional procedures should be performed in order to confirm the diagnosis, depending on the patient’s general condition and her resilience.
19.4.1.2 Treatment
Malignant lymphedema (MLE) is a chronic clinical picture that requires treatment. Treatment for MLE differs from therapy for primary and secondary lymphedema of nonmalignant origin in several respects [760]. The basic treatment consists of skin care and if necessary skin cleansing. In reversible MLE, manual lymphatic drainage followed by compression therapy may be used. Complex decongestive therapy is always contraindicated if the return flow of the mobilized fluid will lead to new problems, such as an increase in the volume of the interstitial space (ascites, pleural effusion, pericardial effusion), deterioration of organ function (cardiac insufficiency), reduction in arterial blood flow (e.g., peripheral arterial occlusive disease, PAOD), risk of thrombus spread, and hematoma formation in the presence of cellular or humoral coagulation disorders. Particularly in the palliative situation, the patient’s burden of therapy should be in acceptable proportion to the potential gain. This issue must be considered together with the patient. It has been shown that patients’ self-answered questions on quality-of-life impairment correlate with objective functional impairment and assessments of extent [761].
Surgical intervention in the lymphatic drainage system is not indicated in MLE.
If lymphatic fluid leaks spontaneously, the patient’s quality of life is severely impaired and infection is highly probable. This condition can be prevented by targeted percutaneous lymphatic drainage. For this purpose, after local anesthesia (optional), small needle puncture incisions with a depth of 0.3–0.5 mm are usually made at four to eight sites on the extremity. These are then treated using a bag system such as that commonly used for neonatal stomas. In addition, a special form of manual lymphatic drainage can be used, in which the MLE is mobilized in the direction of the puncture channels. Mild compression therapy with anti-thrombosis stockings (with holes at points of the pouch tips for drainage) may be used as a supportive measure. This procedure, which is also highly effective in relation to patient mobility and pain relief, very rarely results in infections. Compartment syndromes can also almost always be prevented in this way. In extreme cases, several liters of fluid per day can be drained from the legs under high tissue pressure. This procedure was first described in 2009 and has undergone minor technical modifications by users over the years. Since then, it has undergone numerous modifications, although the principle of drainage of interstitial fluid via stab incisions in the skin has remained the same [762].
19.4.2 Constipation
For the definition, detection, assessment and therapeutic principles in constipation, reference may be made to Chapter 13 of the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020).
19.4.3 Malignant intestinal obstruction (MIO)
For the definition, cause, diagnosis and treatment options in MIO, reference may be made to chapter 14 of the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020).
19.4.4 Management of colostomy / stoma
Patients who receive an ostomy experience sometimes drastic changes, with a significant reduction in their quality of life. There appears to be a clear correlation between stoma-related complications and a deterioration in the patient’s quality of life [763]. Comprehensive stoma care has preoperative and postoperative roles. For example, the future site of the stoma can be marked preoperatively with a trial plate to allow good intraoperative positioning. Postoperative provision of the patient with the relevant information should be offered by stoma therapists as early as possible and should allow safe self-care. If this is still difficult to start with or is limited by other factors, the aim should be to achieve an individually adapted care approach in the outpatient setting.
Stoma-related complications are particularly distressing. These include secondary bleeding, hematoma formation, stoma edema, skin irritation, ulceration, and stoma necrosis. During the later course, stress may occur due to stoma prolapse, stoma retraction, stoma stenosis, and parastomal hernias. These complications may be due to patient factors such as obesity and increased intra-abdominal pressure, as well as surgical and technical reasons. In addition, the risk of electrolyte disturbances, dehydration, and renal failure must also be considered in the palliative situation.
19.4.5 Malignant wounds
For the definition, detection, assessment, and treatment principles in malignant wounds, reference may be made to Chapter 15 of the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020).
19.4.6 Tumor-related cloaca formation
In the advanced local or metastatic situation, tumor-related infiltration of the bladder or rectum may lead to fistula formation and subsequent cloaca formation. Depending on the overall situation, exenteration with palliative intent for symptomatic control may be useful in such situations. The usefulness and feasibility of such a measure should be carefully discussed and weighed up in consensus with the patient, especially in the palliative situation. In individual cases, such operations can even lead to a prolongation of life and provide a better initial situation for other palliative treatment options. During the discussion, the patient’s level of suffering is the decisive factor, and an individual assessment of the balance between the risk of surgical mortality and the massive burden of cloaca formation is necessary.
If surgical resection or exenteration does not appear possible or reasonable, an alternative urinary and fecal diversion via a suprapubic catheter or colostomy should be evaluated as an effective method of symptom control. Even in the presence of distant metastases, these measures are often capable of alleviating the distressing effects of cloaca formation and achieving significant short-term improvement in the patient’s quality of life.
19.4.7 Pain
For the definition, detection, assessment, and treatment principles in tumor pain, reference may be made to Chapter 9 of the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020).
Special mention should be made here of the special situation of tumor-related nerve infiltration in the lesser pelvis. Tumors in the pelvis can lead to damage to the sacral plexus, lumbar plexus, or entire leg plexus. In some cases, this can even be an initial symptom of advanced tumor disease.
As a rule, plexus lesions are caused by direct tumor spread, but they can also be caused by adjacent bone or lymph-node metastases. Symptoms are often intensifying and usually severe pain, along with progressive sensorimotor deficits in the supply area of the leg plexus. In addition, the affected leg may become dry and overheated if the sympathetic nerve trunk is affected. Incontinence may be an indication of bilateral involvement. The diagnostic work-up includes rectal, gynecological, and, if necessary, urological examinations, abdominal ultrasound, and CT/MRI of the pelvis.
Treatment, also with palliative intent, can include surgical measures, radiotherapy, and chemotherapy. Adequate pain therapy is obligatory in all cases. In view of the neuropathic pain component that is often present, this may be complex and should include a multimodal pain approach (see the chapter on tumor pain in the Level 3 guideline on palliative medicine; AWMF register no. 128/001OL, version 2.1, January 2020).
19.4.8 Depression
For the definition, detection, assessment, and treatment principles in depression, reference may be made to Chapter 17 of the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020).
19.4.9 Fatigue
For the definition, detection, assessment, and treatment principles in depression, reference may be made to Chapter 10 of the expanded Level 3 guideline on “Palliative Medicine in Incurable Cancer” in the oncology guideline program (AWMF register no. 128/001OL, version 2.1, January 2020).
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