Symptoms in Advanced Hematologic Malignancies and Other Serious Hematologic Conditions

Abstract

This chapter will cover both common and uncommon non-pain symptoms associated with malignancies. Cancer-related fatigue (CRF) is described as a subjective sensation of tiredness out of proportion to any change in activity and severe enough to affect function. Cancer related may be a disorder of a sense of effort and central in origin. Exercise, corticosteroids, American ginseng, and psychostimulants may improve fatigue. Cachexia complex metabolic syndrome is characterized primarily by weight loss (5% weight loss over 6 months) which is most often accompanied by of muscle, adipose tissue, anorexia, anemia, and reduced physical function. The best treatment for cancer cachexia is cancer remission. There are no approved medications for the management of cachexia, and nutritional support alone is inadequate. Combinations of exercise, nutritional support, medications to stimulate appetite (e.g., megestrol acetate, olanzapine), and anti-inflammatories (e.g., celecoxib, omega-3 fatty acids) in small randomized trials have been found to improve outcomes. Mucositis from chemotherapy or radiation therapy is painful, interferes with nutritional intake, is associated with systemic infections and other complications, and increases the length of hospital stay and treatment costs. The evidence for treating mucositis is sparse. Pruritus is a sensation that provokes the desire to scratch. The behavior associated with pruritus extends to the desire to rub or pinch damaged skin with devices. Basic skin care is essential. Treatment of the underlying condition may also ameliorate pruritis. Treatment of the underlying condition may also ameliorate pruritis Lymphoma treatment quickly relieves pruritus related to Hodgkin’s disease and non-Hodgkin’s lymphoma. The classification of hiccups is based on duration. Hiccups are caused by coordinated contractions of intercostal muscle and diaphragm followed by a few milliseconds with involuntary closure of the glottis. Hiccups occur anywhere between 4 and 60 times a minute and can interfere with breathing, eating, and sleep, and can worsen pain, fatigue, weight loss, and dyspnea, dramatically reducing QOL. Pharmacologic management has centered on dopamine, GABA, and serotonin receptors. Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that include inability to catch one’s breath, ineffective breathing, increased work of breathing, and chest tightness. The correlation of chest radiographic findings and spirometry to dyspnea is quite poor. Treating the underlying cause is the first line of therapy. Low doses of opioids, particularly morphine, and corticosteroid may reduce dyspnea in patients who are imminently dying. The core criteria for delirium comes from the DSM-IV and consists of disturbance of consciousness with loss of the ability to focus and shift attention. Half of patients undergoing hematopoietic stem cell transplants experience delirium during therapy, and the pretransplant risk factors are low cognitive functioning, lower physical functioning, higher creatinine, total body irradiation, older age, and prior alcohol or drug abuse. Prevention of delirium is more successful than treatment of delirium. Anxiety and depression are common symptoms which not only impair quality of life but also makes it difficult managing other symptoms such as pain and fatigue. When considering treatment for depression, both pharmacotherapy and psychotherapy are effective, especially in combination. Psychotherapy is recommended at all stages of depression or anxiety. When pharmacotherapy is considered, prognosis should be evaluated as many medications may take about 4 weeks to reach an effect. The multiplicity of symptoms that occur in advanced hematologic malignancies and other advanced blood disorders is a challenge to hematologists/oncologists. Consideration of palliative care consultation should be considered in patients with high symptom burden.