Palliative Care and Pain Management

Palliative Care and Pain Management

Robert M. Taylor

Amit Agrawal

Palliative care (PC) is a holistic approach to medical care for patients with serious illness that focuses on optimizing comfort and quality of life (QOL) for patients and their families. The Report of the National Consensus Project (NCP) Clinical Practice Guidelines for Quality Palliative Care states: “The goal of PC is to prevent and relieve suffering and to support the best possible QOL for patients and their families, regardless of the stage of the disease or the need for other therapies. PC is both a philosophy of care and an organized, highly structured system for delivering care. PC expands traditional disease-model medical treatments to include the goals of enhancing QOL for patient and family, optimizing function, helping with decision making, and providing opportunities for personal growth. As such, it can be delivered concurrently with life-prolonging care or as the main focus of care” (1). As such, PC is appropriate for many patients with head and neck cancer (HNC), even those who may be cured of their cancer, but suffer significant symptoms and/or functional impairments, as well as the risk of recurrence.

Indeed, patients with HNC represent an important and challenging population for modern medicine. Although new therapies have significantly improved life expectancy and survival for patients with HNC, many patients who benefit from these treatments are left with significant problems as a result of their cancer and therapy, including pain, dysphagia, dysarthria, disfigurement, and psychological sequelae. Family and social problems may be significant. Because addiction to alcohol is a risk factor for HNC, and because many alcoholics abuse other substances, addiction and substance abuse may further complicate the patient’s struggles and the medical system’s ability to provide care.

Ideally, treatment of patients with HNC should include a collaboration of surgery, medical oncology, radiation oncology, speech therapy, nutrition, and a PC team. PC teams often include professionals from medicine, nursing, social work, chaplaincy, pharmacy, and other professional disciplines. Among the other disciplines that may provide additional important support for HNC patients are psychology and addictionology.

One of the priorities of those working in the field of PC is to encourage incorporation of PC into the earlier phases of cancer treatment, often referred to as moving PC “upstream.” This priority is based on the reality that PC is much more than end-of-life (EOL) care and provides important benefits for patients with cancer during the earlier phases of their illness. PC must be distinguished from hospice care, which is appropriate for, and limited to, patients who are estimated to have 6 months or less to live (assuming their disease runs its expected course). Although hospice is an important component of PC, PC is a much broader enterprise that is appropriate for patients at any stage in a serious illness, such as cancer. Furthermore, although comprehensive PC is best provided by an interdisciplinary PC team, the principles of PC can often be integrated into the care of cancer patients by non-PC clinicians.


While presenting symptoms and level of dysfunction caused by early stages of HNC are typically less severe, it is extremely common in patients presenting with advancedstage primary or recurrent disease to experience significant and often debilitating symptoms caused either directly or indirectly by their tumor. Although variable according to tumor type and location, progressive pain is an extremely common symptom particularly in patients presenting with advanced and/or recurrent disease (2,3,4). Pain in patients with advanced disease may be due to one or multiple factors (5,6) including extensive soft tissue and/or bony
infiltration, direct perineural involvement by tumor, and/or disease affecting substantial portions of exposed mucosal surfaces resulting in local ulceration/irritation. As such, pain caused by cancer or its treatment is felt to be mediated by neuropathic and/or local inflammatory mechanisms (7) and may be associated with systemic inflammation as well (8). Pain causes not only physical distress and dysfunction, but significant psychological effects with negative impact upon overall QOL (3). Unfortunately, underassessment of severity of pain as well as factors involving physician discomfort, lack of understanding pain mechanisms and thus strategies necessary to achieve sufficient symptom relief, lack of recognition of important coexisting psychological factors such as depression, as well as concerns regarding potential for addiction or substance abuse often lead to undertreatment of pain in patients affected by this disease. It is thus important for physicians and healthcare providers to both become knowledgeable in basic tenets involved in oncology pain management as well as to regularly involve healthcare providers with specific expertise in pain and PC in order to maximally benefit patients and minimize suffering due to such symptoms.

Progressive disease bulk due to disease location in the upper aerodigestive tract and/or neck can also result in severe functional compromise by interfering with vital functions including eating, swallowing, and respiration which may require more urgent intervention independent of disease status. Assessment by the head and neck surgeon and/or oncologist is necessary to determine both oncologic course as well as to guide management of existing or potential tumor and/or treatment-related complications (airway compromise, dysphagia, bleeding, infection) including consideration of whether patients may benefit from adjunctive interventions such as tracheostomy or feeding tube placement. Such interventions must be discussed with patients as to their impact which although may extend longevity are not likely to be temporary measures in patients with recurrent and often incurable disease.

Not uncommonly, particularly in cases of advanced disease, troublesome bleeding occurs due to friability and vascularity of exposed tumor surfaces which can be a source of significant distress to both patients and caregivers. In mild cases, it is reasonable to employ local measures such as application of direct pressure, use of topical hemostatic agents, coagulation, and wound care (e.g., measures to maintain moisture and reduce bacterial load). In recalcitrant cases, interventional radiologic procedures such as endovascular tumor embolization can be considered to control recurrent bleeding (9,10). In the dire situation of threatened, impending, or actual severe sudden bleeding resulting from exposure, erosion, or compromise of major vascular structures (e.g., carotid blowout), depending upon the acuity and stability of the patient, consideration can be given to intervention such as endovascular carotid stenting, occlusion, or open carotid artery ligation which often achieves immediate stabilization and control of bleeding (11,12). It must be realized, however, that such measures are considered extreme and although potentially lifesaving in the short term are associated with high morbidity (e.g., stroke) with dubious impact upon QOL and overall survival. As such, in patients recognized to be at risk of such events (previously treated patient with recurrent neck disease in setting of open neck and/or pharyngeal wound), this potential event should be discussed with patients and families and the patient’s wishes ascertained including the use of aggressive resuscitation measures, which may not be desired particularly when the goals of care remain primarily palliative.

Due to the significant and variable presentation of advanced head and neck malignancy, whether primary or recurrent, patients require assessment often in multidisciplinary fashion in order to address the oncologic as well as functional, and symptomatic aspects of their disease. Although there may be some overlap, involvement of caregivers in the areas of oncology, pain and PC, speech/swallowing, nutrition, mental health, and nursing play crucial roles in the management of patients with HNC.


In the setting of advanced head and neck malignancy in which standard curative intent therapy is not felt feasible, it is still not unreasonable to consider antineoplastic strategies in an effort to achieve reduction in tumor burden as this has been shown to achieve meaningful palliation of debilitating symptoms such as pain, swelling, and dysphagia (13,14). Although more difficult to measure, additional factors potentially improved by such efforts also include reduction in tumor-related complications such as bleeding or impingement upon local vital functions such as airway. Such strategies include palliative use of chemotherapy/systemic therapy, radiotherapy, and surgery. The use and selection of such modalities alone or in combination often depend upon factors such as patient functional status, prior therapy, as well as practical feasibility and expected functional morbidity associated with such measures.


It has been shown that systemic therapy can be expected to achieve meaningful response and thus reduction in tumor burden ranging from 10% to 30% of cases of advanced recurrent disease when patients have undergone significant prior therapy although the effect of therapy is temporary (median time to progression 6 months, survival <12 months) (15,16,17). Higher rates of disease response can be achieved with combination of more than one systemic agent compared to monotherapy, although such response typically occurs at the expense of higher toxicity and morbidity either without substantial improvement or only modest improvement in overall survival (15,16).
Such impact may not be desirable when the intent of therapy is symptom palliation particularly in situations where declining patient functional status may preclude aggressive measures. As such, it is not unreasonable to utilize systemic monotherapy in such situations, although multiagent therapy should be considered particularly when patients possess good performance status as there is some evidence that multiagent therapy can achieve improvement in specific parameters such as pain and swallowing without negatively impacting overall global QOL measures (14). Commonly utilized systemic agents used either as monotherapy or in combination include methotrexate, platinum compounds (cisplatinum, carboplatinum), 5-fluorouracil, taxanes (paclitaxel, docetaxel), as well as in recent years targeted therapy strategies using agents such as cetuximab which target the epidermal growth factor receptor pathway. Although symptomatic benefit is more likely in patients who achieve measurable disease response to therapy, interestingly, symptomatic improvement can also be observed despite absence of overt response to treatment albeit in a smaller proportion of patients (13).

Radiation Therapy

In the setting of advanced recurrent locoregional disease, the use of radiotherapy in palliative format can be considered, although in most cases of advanced recurrent disease, prior radiotherapy in affected regions may preclude its use. The use of reirradiation has been utilized in situations in an effort to reduce tumor burden and achieve disease response with variable success using varying methodology involving standard fractionated, altered fractionated, stereotactic/conformal delivery, or brachytherapy delivery methods (18,19,20,21,22). It must be understood that even with altered delivery methods reirradiation alone is associated with low overall response rates and disease control in previously treated regions. Furthermore, despite demonstrated feasibility, the rate of severe treatment-related toxicity (i.e., grade 3 or greater) of reirradiation is significant (21,22). As such, in light of the low rate of observed disease response and significant treatment toxicity, the role of palliative reirradiation in achieving meaningful symptom relief in patients with otherwise incurable recurrent HNC remains unclear (21).

The use of reirradiation in combination with systemic chemotherapy (with or without surgery) has also been utilized in patients with advanced locoregional recurrence with sustained disease response documented in a small but significant proportion of patients (23,24,25). It must be understood, however, that long-term survival in this patient group remains low, and the morbidity and mortality associated with such measures are not small (23,24,25). Furthermore, the intent of such treatment should be considered definitive in nature, and as such, it would be difficult to categorize such treatment as palliative in intent. In situations of distant disease such as bony or central nervous system (CNS) metastases, it is reasonable to consider palliative radiotherapy to these sites in situations of severe symptoms or high potential for debility from disease (e.g., bone pain, impingement upon spinal cord/CNS) (26).


The use of surgery to reduce tumor burden in palliative fashion when meaningful chance of cure does not exist is controversial. In the situation of advanced recurrent head and neck malignancy, surgery is often not feasible or practical due to disease extent (i.e., unresectable) or patient factors (medical debility, poor nutritional/performance status). Even if feasible, surgery often carries substantial morbidity with high risk of postsurgical wound complications and substantial potential for negative impact upon functions including speech, swallowing, and respiration and as such is frequently associated with need for adjunctive devices such as tracheostomy and/or feeding tube which may be either at least temporary or may be long term or permanent in a significant proportion of patients (27). Furthermore, in patients previously treated for advanced disease, surgery for recurrent disease is associated with low chance of long-term disease control (27,28). As such, the benefit of surgical measures must always be carefully weighed against the potential substantial negative impact upon function and QOL particularly when odds of meaningful disease control are low and treatment intent is palliative. It is not unreasonable however to consider surgical efforts—even aggressive efforts—in situations where symptoms, QOL, and longevity are primarily impacted by locoregional disease provided that disease is felt to be reasonably addressed using surgery (with or without further adjuvant measures) and potential for recovery of function is substantial (i.e., via reconstruction and/or rehabilitative methods). It is also reasonable to consider palliative surgical measures in situations where distant disease may exist yet have indolent behavior provided that locoregional disease can be controlled where other methods such as chemotherapy and/or radiotherapy carry poor odds of reducing locoregional disease burden (e.g., adenoid cystic carcinoma, well-differentiated thyroid cancer). Such considerations must be taken in concert with careful surgeon assessment of the feasibility and functional impact of surgical treatment and honest discussion with patients and families regarding realistic expectations of any such proposed measures particularly with regard to symptom control and QOL.


The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (30). Pain is always subjective, and consists of a physiologic and a psychological component, both of which can alter the perceived severity and the level of distress resulting from pain.

Acute pain in HNC is often associated with therapeutic interventions, for example acute postoperative pain. Such pain is typically managed with short-term intravenous opioid therapy in the acute-care setting. Although management of acute pain can certainly be challenging and problematic, the predominant challenge in managing cancer-related pain relates to the management of chronic pain. Therefore, the focus of this discussion is on chronic pain in HNC.

In cancer pain, the etiology and mechanism of the physiologic component of the pain is often apparent, or can be inferred, based on the history, exam, and imaging studies. However, the distress caused by pain may be greatly influenced by a multitude of other factors, including psychological, social, and spiritual factors. Furthermore, cancer pain is often perceived as indicating persistent, progressive, or recurrent disease; whether it turns out to be correct or incorrect, this perception frequently further increases distress. Indeed, reassurance that the pain does not reflect active cancer may be very therapeutic (31).

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

May 24, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Palliative Care and Pain Management

Full access? Get Clinical Tree

Get Clinical Tree app for offline access