home Analyzes Symptomatic remedies. Symptomatic therapy Symptomatic treatment of cancer patients

Symptomatic remedies. Symptomatic therapy Symptomatic treatment of cancer patients

What is symptomatic therapy? Symptomatic therapy is: Treatment of manifestations of the disease (symptoms) without a targeted impact on the underlying cause and mechanisms of its development (in the latter cases they speak of etiotropic or pathogenetic treatment, respectively). It is aimed at eliminating individual symptoms of diseases (for example, the use of analgesics for pain).

Chemical and biological methods. These include the main conservative methods of influencing a sick body. Physical conservative methods. These include physiotherapy, hydrotherapy, massage and exercise therapy. Basically, these methods are considered auxiliary.

Target? alleviation of the patient's suffering, for example, elimination of pain due to neuralgia, injuries, debilitating cough due to damage to the pleura, vomiting due to myocardial infarction, etc. S. t. is often used in cases of emergency treatment - until an accurate diagnosis is established (for example, infusion of blood or blood substitutes in acute anemia, artificial respiration and cardiac massage in a state of clinical death.Sometimes eliminating the symptom is impractical (for example, the administration of painkillers in an acute abdomen makes subsequent diagnosis difficult).

Basic principles of symptomatic therapy 1. Identification of the main causes of deterioration in the patient’s well-being and condition (pain, nutritional and metabolic disorders, disorders in the neuropsychic sphere, compression of vital organs, cachexia, dyspeptic syndrome and other syndromes). 2. Determination of the leading link causing the occurrence of the syndrome (manifestation of the tumor process itself, its nonspecific complications, paraneoplastic disorders, consequences of previously administered antitumor or symptomatic treatment, exacerbation of concomitant diseases, neuropsychic reactions). 3. Timely diagnosis of acute reversible conditions, including those requiring surgical intervention, hospitalization if necessary for intensive care or surgical symptomatic treatment. 4. Organization of a system of care, general regime, nutrition of the patient, measures to create a favorable psychological climate. 5. Correction of psycho-emotional disorders in the patient. 6. Prescribing medications according to indications, using a stepwise scheme - from mild to strong drugs with timely change of drugs in order to prevent addiction and the development of dependence. 7. Selection of rational and convenient routes of drug administration for use at home, taking into account the nature of functional disorders that prevent the manifestation of usual pharmacological effects.

Conventionally, all therapy can be divided into the following sections: 1. Chemotherapy - treatment with drugs obtained chemically. Drugs can be in the form of injections, tablets, tinctures, ointments, etc. Drugs in this group are prescribed at all stages of patient management. 2. Biotherapy - treatment with drugs obtained from human and animal tissues. Preparations can be in the form of injections, extracts, ointments, emulsions, tablets, etc. - they often have a combined effect and are least harmful to the body

3. Herbal medicine - treatment with drugs obtained from herbal medicinal raw materials. Preparations can be in the form of tinctures, infusions, extracts, decoctions, ointments, emulsions, tablets, etc. - they often have a combined effect and are least harmful to the body. It is advisable to prescribe herbal medicines at all stages of patient management. 4. Physiotherapy is the treatment of infectious patients using therapeutic devices. Physiotherapy in the treatment of patients is used quite often, mainly during the recovery period, but can also be used at all stages of patient therapy. 5. Balneotherapy and hydrotherapy is the treatment of protracted and chronic forms of diseases using natural sources. More often, balneotherapy and hydrotherapy are carried out in sanatorium-resort conditions. In large medical outpatient institutions, balneotherapy and hydrotherapy departments are being created, where treatment is carried out in artificially created conditions with imported mud and mineral waters.

Symptoms for which symptomatic therapy is prescribed For pain. The peculiarity of pain due to tumors is their persistence, progression and irreversibility. Pain can occur due to direct damage to the nerve due to tumor or paracancrosis inflammatory infiltration, compression due to peritumoral edema, necrosis, impaired blood flow, obstruction of internal organs, paraneoplastic manifestations in the form of arthritis and periostosis. When prescribing pain treatment, certain rules should be followed. It is necessary to assess the situation from the point of view of the extent to which the possibilities of symptomatic, surgical, radiation or chemotherapy treatment have been exhausted, and obtain a formal opinion from an oncologist on the implementation of symptomatic treatment at the place of residence and, possibly, some recommendations for its use. For pain of moderate and mild intensity, therapy should begin with the use of non-narcotic analgesics. Medicines should be taken “by the hour”, in advance and, if necessary, more often than prescribed, at the first sign of discomfort. Developed pain is more difficult to control and requires large doses of medications.

FOR NAUSEA AND VOMITING. The causes of nausea and vomiting are varied: brain metastases, hypercalcemia, gastrointestinal obstruction; they may also be associated with treatment, primarily chemotherapy, radiation therapy, and the use of narcotic analgesics. The purpose of taking antiemetic drugs is to prevent nausea and vomiting. Combinations of drugs that enhance the effect of each other are usually used. TREATMENT FOR FEVER. The diagnosis of tumor fever is established by excluding infectious complications of cancer. Most often it is observed in patients with lymphogranulomatosis, with malignant lymphomas, with leukemia, with colon cancer, hepatocellular cancer, kidney cancer, pancreatic cancer, bone sarcomas, cancer metastases in the liver. The goal of therapy is to avoid sudden changes in temperature, since an increase in temperature is usually accompanied by chills, and a decrease is usually accompanied by sweating and weakness, which leads to rapid exhaustion of the patient. It is necessary to establish the nature of the temperature curve; antipyretics must be applied in advance and “clockwise” in order to “cover” the entire period of the expected temperature increase. Therapy begins with the maximum single doses and then “works out” the optimal doses.

Often chemotherapy and other types of treatment greatly worsen the general physical condition of the patient, causing severe intoxication (nausea, vomiting, lack of appetite, weakness, pressure surges). Here we can offer a course of maintenance therapy at home to relieve the above syndromes, which in turn do not allow further methods of treating the disease.

Conclusion It is hardly advisable to consider the entire possible range of therapeutic measures for symptomatic therapy, since an individual approach to the treatment of each patient is necessary. It is important to note that there are no contraindications for the implementation of the goals of symptomatic therapy, and it should be carried out to the fullest extent possible in order to stop or reduce the severity of complications of the tumor process, special treatment received or concomitant diseases.

The goal of palliative treatment is to make life easier for the patient and his loved ones.”

Most solid tumors with metastases in adults are incurable, so the goal of treatment in such cases is to eliminate the painful symptoms of the disease and, if possible, make the patient’s life easier. Upon learning of their diagnosis, many patients experience fear of suffering and what they will endure. To optimize treatment, it is necessary that from the moment of diagnosis it be carried out comprehensively, with the participation of specialists from different fields. The degree of involvement of these specialists during treatment varies.

However, the following goals of palliative treatment can be distinguished:

ensure maximum benefit for the patient from the participation of all specialists by providing him with medical, psychological, social and spiritual assistance at all stages of cancer;
to reduce, if possible, the negative psychological impact and experiences of the patient during the transition from “active” treatment to palliative;
to help patients “come to terms with their illness” and be able to live as actively as possible for the rest of their lives;
support the patient and their caregivers during treatment, and after death, help the family cope with the loss.

"System"

Specialists providing assistance to the patient are united in a group that has a complex organization and ensures the entire process of diagnosis, clarification of the stage of the disease and treatment. However, it is precisely this circumstance that often confuses the patient and his relatives, especially if the hospital is based in several buildings or there is a need to transfer the patient to a specialized center or the diagnosis has not been definitively established. Disadvantages associated with the relative autonomy of departments, the need to make extensive notes in the medical history, etc., have decreased with the advent of multidisciplinary teams and their composition includes doctors of a new specialty - patient care. Thanks to this organization of work, continuity in the work of different specialists improves, patients have less to repeat when they are interviewed, they better understand the purpose of each doctor’s visit and know who to turn to if they feel “lost in this system.”

Difficulties associated with the need to communicate sad news

The message of sad news always causes negative emotions and dissatisfaction in the patient and his family members. Many patients leave the doctor without wanting to listen in more detail to their diagnosis and prognosis, without knowing what advances exist in the treatment of their disease, or, conversely, they want to receive more information than they were told. There are few free people who prefer to know less, completely trusting their doctor (perhaps less than 5%). Patients who are dissatisfied with the amount of information provided to them have a more difficult time getting used to their diagnosis, more often experience anxiety and become depressed. It is important to know how much information a patient needs at one or another stage of his illness. Information is dosed taking into account the characteristics of the patient and his disease.

Good news strengthens the patient's trust in the doctor, reduces uncertainty, and allows the patient and his family to be better prepared practically, psychologically, and emotionally for treatment. In the event of sad news, the matter is not limited to its communication. This is a process in which the news is often repeated, the diagnosis is explained, the patient and their loved ones are informed about the state of affairs in this area, and perhaps prepare them for the death of a person close to them.

Delivering sad news - ten steps

This approach can be used as a general framework and adapted to specific situations. Remember that the patient has the right, but not the obligation, to listen to sad news.

Preparation. Check out the facts. Make an appointment. Find out from the patient who he allows to be present. Make sure you are not disturbed (turn off your cell phone).
Find out what the patient already knows. Both the doctor and the patient’s relatives usually underestimate the degree of his awareness.
Find out if the patient needs additional information.
Do not prevent the patient from denying your news. Denial is a way of coping. Let the patient control the amount of information.
Warn the patient that you are about to deliver unpleasant news. This will give him time to collect his thoughts and see if he can listen to your information.
Explain the situation to the patient if he asks for it. Speak more simply and clearly. Avoid harsh statements and medical jargon. Check whether the patient understood you correctly. Be as optimistic as possible.
Listen to the concerned patient. Avoid premature encouragement.
Do not interfere with the outpouring of the patient's feelings.
Summarize what has been said and make a plan, this will avoid confusion and uncertainty.
Express your willingness to help the patient. Communicating sad news is a process. Give the patient time to ask you questions; It is advisable to give him written information indicating the care specialist to whom the patient can contact in the future. Specify the time, place and purpose of the next meeting with the patient or the next study.

Uncertainty

Uncertainty is one of the psychological states that is especially difficult for a person to experience. This is the condition in which most patients with oncological pathology remain from the moment they develop dangerous symptoms and the start of the examination until the end of treatment. The doctor also faces a dilemma when trying to reassure an anxious patient and inform him about his illness with an uncertain prognosis. This is especially difficult when it is necessary to obtain informed consent from the patient for clinical trials or treatment methods, the effectiveness of which is problematic.

In such cases, there are always fears of discomfort, disfigurement, disability, addiction, and death.

Most patients who are told that they have a malignant tumor have already encountered a similar disease in the past among relatives or friends. It is advisable for the doctor to know how such an experience affected the patient. You can cheer him up. Misconceptions must be corrected. If concerns are justified, they should be acknowledged and the associated anxiety should be addressed.

Psychological support in the long term

Paradoxically, patients often feel a greater need for support after completion of treatment, when they need to reassess their lives and overcome the upcoming difficulties associated with survival. They often receive psychological support through observation programs and may feel helpless when regular contact with specialists ceases. This problem is compounded by the fact that there are only a few curable cancers in adults, so patients must live with the fear of relapse.

Symptomatic treatment

Physicians and other health care professionals involved in the day-to-day care of cancer patients have a significant clinical responsibility for assessing symptoms and managing them.

Symptoms may vary:

directly related to a malignant tumor;
manifestation of side or toxic effects of palliative therapy;
affecting the physical, psychosocial, emotional and spiritual sphere of the patient;
caused by another reason not related to the underlying disease.

Therefore, the symptoms detected in the patient require careful assessment in order to create the optimal plan to eliminate them.

Eliminating pain

Pain management is an important part of both palliative and radical treatment of a cancer patient. In approximately 80-90% of cases, pain can be eliminated by prescribing conventional painkillers orally in combination with drugs from other groups in accordance with WHO recommendations. Ineffective pain relief can worsen other symptoms, including fatigue, anorexia and nausea, constipation, depression and feelings of hopelessness. Pain can also become an obstacle to regularly taking chemotherapy drugs and visiting a doctor on time. Relieving pain at the cost of increasing side effects is unacceptable in most cases, so there is a need to develop effective interventions.

The most common causes of intractable pain in cancer patients may be the following.

A simplified approach to examination, which does not allow establishing the true cause of pain and its type, or identifying and assessing the general unfavorable background. lowering the pain threshold. If this background is not taken into account, the prescription of analgesics alone will not be able to eliminate pain. Correction of the psychological background is necessary.
Lack of a systematic approach to pain management, including a lack of understanding of the WHO three-step regimen for pain management in cancer patients, the role of adjuvant analgesics, and opioid dose titration. “Panic prescription” of analgesics often leads to the development of side effects.

The ideal treatment for pain involves addressing its cause. Therefore, correctly selected palliative chemotherapy, radiation or hormonal therapy comes first. In palliative treatment, the use of analgesics is a generally accepted criterion for assessing response to therapy. However, even if the patient is prescribed a course of antitumor therapy, the use of analgesics does not lose its meaning, since the analgesic effect of therapy does not occur immediately and, moreover, can be incomplete and short-lived.

Categories of pain in cancer

The role of a carefully collected anamnesis in the treatment of pain can hardly be overestimated, since it allows doctors to clarify its mechanism and, therefore, select the optimal pain therapy.

Is the pain acute or chronic?

A malignant tumor does not always cause pain in a patient. Sudden pain can be a consequence of an acute complication of both the tumor itself and antitumor therapy, and sometimes it is completely associated with other causes. Examples of such causes include a pathological bone fracture leading to the need for orthopedic treatment, acute pathology of the abdominal organs requiring urgent surgical examination, or mucositis that develops during or after radiation therapy.

On the other hand, chronic increasing pain may indicate tumor progression and infiltration of soft tissues and nerve roots.

What type of pain?

Somatic pain, for example with metastases in the bones, phlegmon, is localized and constant.

Visceral pain is usually vaguely localized, variable in nature, and often accompanied by nausea and other symptoms (for example, with metastases to the liver or abdominal lymph nodes).

Neuropathic pain, classically described as “shooting pain,” is usually localized to the distribution of the affected nerve (eg, nerve root compression pain).

How does the patient interpret pain?

Pain has a strong emotional component and is significantly influenced by mood and morale. Understanding how a patient interprets their pain can help create a more realistic plan to manage it. For example, does the appearance of “new” pain cause anxiety in the patient, does it reduce his general activity, does the patient consider it a harbinger of the terminal stage of his disease. Eliminating anger, fear or irritation helps achieve more effective pain relief.

Drug treatment of pain

The principles of the three-step pain treatment regimen are as follows.

The analgesic is selected depending on the intensity of the pain, and not on the stage of the tumor process.
Analgesics for long-term use are prescribed to prevent pain. It is also necessary to have analgesics ready to quickly relieve pain when it intensifies.
Prescribing one pain medication is rarely sufficient.
Treatment should begin with a fast-acting analgesic, and then switch to long-acting drugs and maintain a stable dose.
Spioids are usually used in combination with non-narcotic analgesics.
Adjuvant analgesics are usually prescribed based on the cause and type of pain.

First stage. Analgesia with non-narcotic drugs

Paracetamol is a non-narcotic analgesic. It also serves as an antipyretic, but does not have an anti-inflammatory effect. Side effects when prescribed at a therapeutic dose are rare. As an alternative, you can prescribe drugs from the NSAID group, for example, ibuprofen at a dose of 400 mg 3 times a day, although this leads to the need for simultaneous administration of gastroprotectors and control of renal excretory function. Paracetamol can be used in combination with NSAIDs without fear of serious complications.

Second stage. Analgesia with weak opioids

Patients should continue treatment with non-narcotic analgesics. If the analgesic effect is insufficient, a weak opioid drug is prescribed. Subtherapeutic doses of codeine, which are often found in over-the-counter medications, should be avoided.

Third stage. Analgesia with potent opioids

If the pain does not stop, basic analgesic therapy with non-narcotic analgesics should be continued, but weak opioids should be replaced with strong ones. Treatment begins with a fast-acting drug given every 4 hours, with a double dose at night. The analgesic effect occurs after approximately 30 minutes, reaches a maximum at 60 minutes and lasts 4 hours if the dose is selected correctly. The dose prescribed “on demand” when pain intensifies should be one-sixth of the daily dose of the drug. Laxatives should be prescribed at the same time and antiemetics should be available.

Morphine solution or tablets (fast-acting drug):

10 mg every 4 hours (eg, at 6 a.m., 10 a.m., 2 p.m., 6 p.m., and 20 mg at 10 p.m.);
dose “on demand” - 10 mg;
oral administration is more preferable, although the drug can also be administered subcutaneously and intravenously;
treatment with morphine is carried out while taking laxatives; if necessary, the patient is given antiemetic drugs;
basic therapy also includes taking paracetamol in combination with or without NSAIDs.

Opioid dose selection

The morphine dose is adjusted every 24 hours until the optimal dose is found. The on-demand dose received during the previous 24 hours should be included in the adjusted dose. For example, if over the past day the patient received 30 mg of morphine “on demand”, in addition to the 60 mg prescribed as basic therapy, the following correction is carried out:

the single dose is increased to 15 mg;
the dose taken at night is adjusted to 30 mg;
The on-demand dose is set to 15 mg.

After dose stabilization (i.e., when the patient receives the drug “on demand” no more than once a day), morphine is prescribed, for example, at a dose of 10 mg every 4 hours and at a dose of 20 mg at 22 hours.

The total daily dose is 60 mg.
Extended-release morphine at a dose of 30 mg 2 times a day.
Rapid-release morphine is prescribed “on demand” at a dose of 10 mg. The bioavailability of morphine when taken orally is approximately 30%.

A significant part of it is metabolized (first pass effect) and excreted along with metabolites by the kidneys. The dose of morphine is subject to significant individual variations. Over time it has to be increased somewhat. Morphine has an important feature - a proportional relationship between the total daily dose and the dose taken “on demand”. Clinical experience and clinical trial results indicate that there is no pain that cannot be controlled with opioids, the only question is the dose of the drug. However, for some types of pain, this dose is too high and therefore unacceptable due to side effects, such as sedation. In such cases, such as neuropathic pain, adjuvant analgesics play a particularly important role.

Opioid toxicity.

Nausea and vomiting: metoclopramide 10-20 mg 4 times a day or haloperidol 1.5-3 mg at night.
Constipation: regular use of co-dantramer or co-dantrusate.
Drowsiness: usually the severity of this effect decreases by the 3rd day after the next dose increase.
Dry mouth: unlimited fluid intake, oral care.
Hallucinations: haloperidol in a dose of 1.5-3 mg orally or subcutaneously in an acute situation.
Respiratory depression occurs only in cases where the dose of the drug exceeds the dose required to achieve analgesia, or when the drug accumulates, for example due to impaired renal excretory function.
Dependence (physical and mental) and addiction.

Alternatives to potent opioids for chronic pain.

Diamorphine: Used when parenteral analgesic administration is necessary.
Fentanyl: Patients with chronic persistent pain are prescribed a transdermal form of the drug (fentanyl patch), and if the pain increases, morphine is administered. The sedative effect and the ability to cause constipation are less pronounced. When the first patch is applied, an alternative opioid is administered simultaneously.
Methadone: can be used instead of morphine, administered orally, the toxic effects are the same, although the analgesic is less predictable. In cases of liver dysfunction, methadone treatment is safer.

Adjuvant analgesics

The need for adjuvant analgesics may arise at any stage of pain management. To make the best choice of medications, it is important to understand the mechanism of pain, but once you prescribe a drug, you must also be prepared to stop it if it is not effective enough. Otherwise, the patient will accumulate a lot of drugs, the prescription of which will be difficult to regulate, and the effectiveness of treatment will be low. Adjuvant analgesics include the following drugs.

Other treatments

Pain relief methods

For some malignant tumors, such as pancreatic cancer, which grows into neighboring tissues, they resort to blockade of the celiac plexus. In case of tumor infiltration of the nerve trunks in the armpit, a brachial plexus block is performed to eliminate pain.

For pathological fractures, when surgical fixation of the fragments is impossible, epidural anesthesia is indicated.

For severe pain that does not respond to conventional treatments, pain management specialists should be consulted.

Palliative radiotherapy

External beam radiation therapy can help treat pain associated with local tumor infiltration, such as metastatic lesions in the bone. However, it should be remembered that the maximum analgesic effect of radiation therapy is achieved within several weeks. Additionally, radiation may make the pain worse initially. Pain management during and after radiation therapy should be given due attention.

The use of radioisotopes that accumulate in bones, such as strontium, is justified for diffuse pain associated with osteoblastic metastases, for which conventional painkillers are ineffective. Radioisotopes are especially actively absorbed in areas with intense bone turnover. There is a risk of severe myelosuppression with this treatment method.

Maintenance therapy

There are also a number of other treatments available to complement pain management.

These include the following:

transcutaneous electrical nerve stimulation;
occupational therapy;
physiotherapy;
acupuncture, aromatherapy and other reflexology methods;
relaxation therapy, including massage and hypnosis;
psychotherapy and patient education.

Elimination of nausea and vomiting

Nausea and vomiting occur in approximately 70% of patients with advanced cancer. As with treating pain, eliminating these symptoms also requires understanding their mechanisms.

Iatrogenic. Prescribing opioids may cause nausea. Chemotherapy may cause nausea and vomiting at the beginning or during treatment. Radiation therapy, especially if the brain or small intestine is exposed to radiation, can cause nausea.
Metabolic. Elevated serum calcium may be accompanied by dehydration, constipation, abdominal pain, and confusion. Some patients experience nausea and vomiting without accompanying symptoms. Uremia also causes nausea, often without any other symptoms. If a metabolic mechanism for the occurrence of nausea and vomiting is suspected, it is necessary to perform a biochemical blood test to determine the calcium content in the serum and kidney function.
Increased intracranial pressure associated with metastatic lesions of the brain and its membranes. Anamnesis plays a role in diagnosis (changes in the nature of the headache). It is necessary to examine the fundus to exclude papilledema.
Subacute or acute intestinal obstruction, especially if the patient is diagnosed with a malignant tumor of the abdominal organs. The presumptive level of obstruction can be established on the basis of anamnesis [time of onset of nausea and vomiting, contents of vomit (unchanged food, fecal vomit), presence of stool and passage of gas, abdominal pain]. To clarify the diagnosis and the possibility of eliminating intestinal obstruction, CT scan of the abdomen and intubation enterography are performed.
Pseudo-obstruction of the intestine. If this pathology is suspected, along with other studies, a digital rectal examination should also be performed. If a patient notices the appearance of watery stools against the background of symptoms of intestinal obstruction, then it is most likely due to the fact that the fluid in the dilated intestine flows around the feces in the area of the obstruction.
Pain. Insufficiently effective pain relief can cause nausea.

Many neurotransmitter receptors are involved in the development of nausea and vomiting. Most of them are located in various areas of the central nervous system. However, peripheral receptors and neural pathways also play a significant role. Optimal selection of an antiemetic drug requires an understanding of the mechanisms of nausea and knowledge of the point of application of the drug.

The antiemetic drug is selected taking into account the most likely cause and taken by the most appropriate route.
If vomiting makes it impossible to take the drug orally, it is prescribed sublingually, buccally, rectally, intravenously, intramuscularly or subcutaneously. Long-term subcutaneous administration of the drug using a perfusion pump is especially effective.
Patients should take antiemetic drugs regularly.
If nausea and vomiting do not disappear within 24 hours, a second-line drug is prescribed.
Elimination of nausea and vomiting includes measures aimed at correcting each of the causes of these symptoms (hypercalcemia, renal excretory function, treatment with drugs that can cause vomiting, intestinal obstruction).
Metoclopramide is classified as prokinetic. It can be prescribed with caution in cases of impaired gastric emptying or subacute intestinal obstruction, but if vomiting or colicky abdominal pain worsens, the drug should be discontinued. In case of complete intestinal obstruction, metoclopramide cannot be prescribed. Cyclizine neutralizes the effect of metoclopramide, so both drugs should not be prescribed at once.
It should be remembered that there may be several reasons that cause nausea and vomiting in a cancer patient. If they are unknown or first-line therapy is ineffective, it is advisable to prescribe levomeprazine, which acts on several types of receptors at once. Due to its wide spectrum of pharmacological activity, this drug is often effective even in cases where combination therapy with selective antiemetic drugs does not help. The anxiolytic properties of levomeprazine make it preferable for this category of patients, although when prescribed at a dose of more than 6.25 mg/day, it often has a pronounced sedative effect.

Eliminate constipation

Causes of constipation

There are many causes of constipation in cancer patients.

Drugs, especially opioid analgesics and some antiemetics, such as 5-HT3 receptor blockers.
Dehydration associated with insufficient fluid intake, frequent vomiting or diuretic therapy.
Anorexia: insufficient food intake and changes in its quality composition.
Reduced motor activity and general weakness.
Hypercalcemia, especially if it is combined with dehydration, nausea, abdominal pain, confusion, although these associated symptoms may be absent.
Spinal cord compression: Constipation is usually a late manifestation.
Intestinal obstruction associated with adhesions due to tumor infiltration, surgery or radiation therapy, as well as obstruction of the intestine by a tumor or compression of the pelvic organs by a tumor.

Clinical manifestations

Retention of stool or absence of stool.
Nausea and vomiting.
Abdominal pain, usually colicky.
“Paradoxical diarrhea” (the appearance of watery stools against the background of constipation).
Urinary retention.
Acute psychosis.

Diagnostics

History: Questioning the patient is especially important to identify contributing factors and preventable causes of constipation, such as those related to difficulties caring for the patient at home.

Digital rectal examination.

X-ray of the abdomen is indicated only in cases where it is necessary to differentiate intestinal obstruction from pseudo-obstruction.

Blood test: serum calcium level.

Treatment

Non-medicinal.

Drink more fluids and foods rich in fiber.
Increased physical activity.
Possibility of privacy. Respect for the patient's self-esteem.

Medication.

Treatment of cachexia and anorexia

Cachexia

Cachexia is understood as an increase in energy consumption independent of will, leading to a sharp decrease in the mass of both muscle and fat tissue.

Occurs in more than 85% of patients with advanced stage cancer.
Often associated with anorexia, cachexia is different from fasting because weight loss cannot be prevented by increasing nutrient intake alone.
Cachexia most often develops in patients with advanced solid tumors, especially lung and gastrointestinal cancer.
The mechanisms of development of cachexia are unclear, although the role of cytokines circulating in the blood is obvious, such as tumor necrosis factor, which causes metabolic disorders, in particular protein breakdown, lipolysis, and enhancing gluconeogenesis.
Cachexia is the main cause of symptoms that appear at the end of the disease and lead to physical impotence, psychological and social maladjustment. It is painful both for the patient and for his family.

Anorexia

Decreased or lack of appetite.

It can be combined with increased fatigue and cachexia in advanced tumor processes and have no other specific cause.

However, when examining you should be aware of possible preventable causes of anorexia:

nausea;
constipation;
depression;
metabolic disorders, such as increased calcium levels in the blood, uremia;
infection, such as oral candidiasis;
intestinal obstruction, ascites.

Treatment

The cause should be eliminated if possible. The measures taken usually do not affect cachexia.

General measures

Nutrition optimization. It is recommended to eat often, in small portions, and eat when you feel hungry. Food should be high in calories and have a relatively small volume. To stimulate appetite, you can drink a small amount of alcohol.

It is necessary to ensure that food brings pleasure to the patient and does not cause negative emotions. Caregivers should not be overly persistent.

It is necessary to stimulate the patient's activity whenever possible.

Drug treatment

Nutritional supplements. High-calorie protein mixtures (for example, Ensure). Glucocorticoids (eg, prednisolone 25 mg once daily) can improve appetite and general condition and reduce nausea, but do not increase muscle mass.

Progesterone improves appetite, although there is no convincing evidence that it causes weight gain.

Sometimes, against the background of active antitumor therapy, enteral and parenteral nutrition is advisable, but with tumor progression it is not justified.

Elimination of symptoms of respiratory damage

Causes of shortness of breath in cancer patients

There are many reasons for shortness of breath in patients with a malignant tumor with metastases. They may be treatable, so patients should be carefully examined.

Pulmonary causes.

Lung tumor.
Pneumonia.
Effusion in the pleural cavity (if fluid accumulates again, the advisability of pleurodesis should be discussed).
Carcinomatous lymphangitis.
Obstruction of a large airway with collapse of the lung distal to the obstruction.
Concomitant chronic obstructive pulmonary disease.

Cardiovascular causes.

Effusion into the pericardial cavity.
Congestive heart failure.
Pulmonary embolism.
Obstruction of the superior vena cava.
Anemia.
Heart rhythm disturbances. Neuromuscular disorders.
Muscle weakness and rapid fatigue.
Armored breast cancer (cancer en cuirasse) manifested by tumor infiltration of the chest wall.
Respiratory depression, such as that associated with opioids.
Damage to peripheral nerves, such as the phrenic nerve.
Tumor infiltration of the vagus nerve: hoarse voice, sometimes “bull” cough. An examination by an ENT specialist is indicated: palliative injection of a soft tissue filler into the vocal fold may help eliminate this symptom.

Psychological state of the patient.

Fear, anxiety.

Treatment

If possible, eliminate the cause of shortness of breath

An integrated approach is required using non-drug treatment methods, such as breathing exercises, physiotherapy, relaxation therapy, and massage. We need to help patients so that their expectations are realistic.

A number of medications can be tried as a palliative measure to reduce shortness of breath.

Opioids. Morphine at a dose of 2.5 mg 4 times a day orally reduces respiratory drive and weakens the response to hypoxia and hypercapnia. It reduces the discomfort associated with shortness of breath and also suppresses cough.
Benzodiazepines reduce anxiety, cause sedation, and may also relax muscles. Concerns regarding the possibility of respiratory depression are usually unfounded, particularly when treated with lorazepam 1-2 mg orally on demand.

Oxygen therapy can eliminate or reduce hypoxia. It may also reduce shortness of breath, which appears to be due to a facial refreshing effect or a placebo effect. Caution should be exercised in patients with chronic obstructive pulmonary disease.

Treatment of lymphedema

Impaired lymphatic drainage leads to excessive accumulation of interstitial fluid called lymphedema. Lymphedema most often occurs on the extremities. It is a dense swelling, in which, after pressing with a finger, a hole does not form on the tissue, limits the patient’s activity and is difficult to treat. The causes of lymphedema are:

tumor infiltration of lymphatic vessels;
violation of the integrity of the lymphatic system associated with excision of lymph nodes, and changes in it caused by radiation therapy.

Lymphedema of the limb should be differentiated from edema associated with thrombotic or tumor occlusion of the deep veins. It is very important to distinguish between these conditions, since their treatment is different.

Prevention of lymphedema

Prevention of lymphedema is more rational and effective than treatment. It is important to give the patient a correct understanding of this complication. If necessary, you can contact a lymphedema specialist. Massage and exercise.

It is important to avoid injury and infection of the affected limb by wearing protective gloves when working in the garden, protecting from sunlight and performing venipuncture on a healthy limb). Vigorous treatment for skin infections.

Treatment

Daily skin care. Self-massage and exercise. Wearing elastic stockings.

For refractory edema, elastic bandaging of the limb may be necessary before fitting elastic stockings. There are no drugs to treat lymphedema.

Psychological support and correction of mental disorders

Assessing the mental state, providing psychological support and correcting mental disorders should be an integral part of the treatment of a cancer patient. Psychological problems may be associated with such emotions and conditions as:

denial and confusion;
anger;
anxiety;
sadness and depression;
feeling of loss;
alienation;
insufficient management of one's condition.

Clinicians should be aware that a patient's psychological problems are often unaddressed and take the time to examine mental status. It is always necessary to be attentive to the problems of the patient and those caring for him. The patient's mental state can be assessed using various rating scales and systems.

Hospital Anxiety and Depression Scale.
Functional assessment of the effectiveness of cancer treatment.
Functional vital indicator in cancer patients.
European Quality of Life Questionnaire.

Treatment

Self-help. Patients should be involved in monitoring treatment, helping them set realistic goals and formulate coping strategies.

Formal support. Patients have the opportunity to seek help from an experienced consultant at a clinic or hospital information center. Specialists providing palliative treatment have the opportunity, if necessary, to seek help from a psychologist and psychiatrist.

Psychotherapy. If the patient has severe anxiety and depression, it is advisable to conduct behavioral and short-term psychotherapy.

Psychiatric treatment. The attending physician of a cancer patient must promptly recognize mental disorders that require consultation with a psychiatrist and medication correction (for example, antidepressants or anxiolytics). Psychotropic medications help approximately 25% of cancer patients with anxiety and depression.

Help with terminal excitation

Assessment of the patient's condition

Even with approaching death, due attention should be paid to the mental state of the patient, since in some cases it is possible to alleviate suffering and reduce pre-death excitement.

The following factors may cause additional suffering to the patient:

However, the scope of examination of a dying patient should be limited so as not to cause him additional suffering. It is important to achieve an optimal state of physical and psychological comfort to ensure a dignified and peaceful end to life.

Treatment for terminal cancer

All drugs that are not essential for the patient are discontinued. In practice, this means that only analgesics, anxiolytics and antiemetics are left. If the dying patient is unconscious, glucocorticoids are usually discontinued.

Oral administration of drugs should be avoided. Subcutaneous administration using an infusion pump is often preferred. This does not require hospitalization, although significant efforts may be required from health care workers and relatives caring for the patient.

Intravenous administration of drugs is also undesirable (sometimes it is simply impossible). Cannulating a vein is painful and may cause additional suffering.

Drugs should be administered as required. Subcutaneous infusion is optimal, allowing relief of painful symptoms without the need for additional doses. It is important that caregivers have ready access to the drug to administer it as needed.

Opioids. Treatment with these drugs, if previously administered, should be continued, but the dose of the drug should be reconsidered for subcutaneous administration. The dose on demand is 1/6 of the daily dose. If the patient has not been given opioids before, but intense pain needs to be eliminated, a small dose of diamorphine is administered, for example, 5-10 mg subcutaneously for 24 hours, and if the pain intensifies, an additional 2.5 mg subcutaneously. Observe the effect and increase the dose if necessary.

Anxiolytics, such as midazolam, are administered at a dose of 10 mg/day subcutaneously and 2.5-5 mg on demand. The effect of the drug should be carefully monitored, as there is often a need to significantly increase the dose. The drug also has antiemetic properties. Sometimes, despite increasing the dose of midazolam, agitation increases. In such cases, levomeprazine is additionally prescribed, which has a sedative property. First, 25 mg is administered subcutaneously, then an additional 50 mg over 24 hours. Depending on the effect, the dose can be increased. Haloperidol is also effective, prescribed in a dose of 5 mg subcutaneously on demand.

Antiemetics are added to treatment at the same time as opioids.

Increased bronchial secretion is often more burdensome for the patient’s relatives than for him. A conscious patient is more concerned about dry mouth - an inevitable side effect of drug suppression of bronchial secretion. If the patient is unconscious, then it is usually sufficient to change the position of his body or carefully evacuate the mucus using suction. Usually, hyoscine hydrobromide is administered subcutaneously at a dose of 400 mcg or the drug is added to the syringe of the perfusion pump. Instead of hyoscine hydrobromide, glycopyrronium can also be prescribed. The side effects of these drugs are the same as those of M-anticholinergic drugs.

Explanatory work. It is necessary that the patient’s relatives (and the patient himself, if he is conscious) know what purpose this or that doctor’s prescription serves. It should be explained how important it is to achieve adequate pain relief while avoiding significant sedation. Caregivers should know what drugs are contained in the subcutaneous infusion solution, monitor their effect and adjust the dose if necessary. Time spent at the bedside of a dying patient will allow relatives to experience the loss with greater understanding and without anger or suspicion and will leave them with fewer questions regarding the last hours of his life.

Referring to an outpatient or inpatient palliative care service for advice or assistance for refractory symptoms or other care before or after death.

Complex symptomatic treatment

Care for a dying patient in a hospital is increasingly becoming formalized with the participation of teams of different specialists. This is in line with NICE guidelines covering the physical, social, psychological and spiritual aspects of such care.

In oncological practice, there are three types of treatment: radical, palliative and symptomatic. By radical we mean treatment that is accompanied by the greatest percentage success in curing a particular type of tumor with the maximum period of observation. Typically, follow-up is five years or more. Palliative treatment is designed for a temporary effect. The name comes from the root of the languages of the Romano-Germanic group palliare - to cover. It is used to mean a half measure or a remedy that temporarily alleviates the manifestation of a disease, but does not cure it. Symptomatic treatment is a set of therapeutic measures aimed at eliminating the most painful manifestations of the tumor process, or at treating complications or correcting consequences associated with antitumor treatment.

For each primary patient, a council (consisting of a surgeon, radiation therapist and chemotherapy) must determine the direction of the upcoming course of treatment, which is very important for assessing the subsequent effect and corresponding clinical and scientific conclusions. If radical treatment is not possible, the leading guideline in the choice of both palliative and symptomatic treatment is “quality of life.”

The need for symptomatic treatment arises in almost all cancer patients. For example, a patient of stage I of the disease, after he learned about the presence of a tumor, experiences such pronounced depressive states that this requires not only repeated, detailed conversations with the doctor, but also appropriate medication prescriptions. Symptomatic treatment, often medicinal, carried out in parallel with radical or palliative treatment, as a rule, does not cause serious problems, since the main attention is paid to the actual antitumor measures. It should be noted that symptomatic treatment may be required both in the absence of signs of the underlying disease and in the presence of such.

Thus, symptomatic treatment is carried out:

When carrying out radical treatment;

When carrying out palliative treatment;

If special antitumor treatment is not possible;

To eliminate the consequences of special treatment, i.e. as a complex of restorative treatment in the absence of signs of tumor. In the form of prolonged or repeated courses of treatment, ensuring a satisfactory quality of life for the patient (see Chapter 29 “Rehabilitation treatment”).

Symptomatic treatment requires special attention in patients of clinical group IV, when this type of therapy becomes the main one. The main difference between palliative and symptomatic treatment is that such treatment does not affect survival. It should be noted that sometimes the line between palliative and symptomatic treatment is quite difficult to draw. For example, it is known that radical removal of the primary tumor for the purpose of decompression, elimination of the source of infection, stopping bleeding with suturing of blood vessels, etc. lead to a reduction in metastases, although in this case the goal is not to influence the tumor tissue in order to reduce its volume. For this effect, the prescription of symptomatic therapy is calculated as a side effect, since the tumor mass provokes the occurrence of a certain symptom and the effect of treatment is expected to be purely symptomatic, associated with a decrease in tumor volume. Any other special antitumor treatment - chemotherapy or radiation - can be used with the same calculation.

28.1. TYPES OF SYMPTOMATIC TREATMENT

Symptomatic treatment is of the following types. *Non-specific(not accompanied by an effect on tumor tissue):

- surgical interventions - usually carried out outside the area of the tumor, for example, with stenosis of hollow organs, various parts of the gastrointestinal tract, as well as with stenosis of the respiratory and urinary tracts, with compression of blood vessels and nerves, bleeding, etc.;

- medications - painkillers, antiemetics, anti-inflammatory, psychotropic, vitamins, anabolic hormones, corticosteroids, etc. Almost the entire arsenal of drugs mentioned in the domestic Pharmacopoeia is at the disposal of oncologists.

Specific(accompanied by an effect on tumor tissue):

- "sanitizing" operation - clearly not radical removal of the tumor;

- radiation treatment - carried out on the area of bone metastasis for analgesic and anti-inflammatory purposes or irradiation of the mediastinum in order to eliminate the syndrome of the superior genital vein;

- cytostatic agents (chemotherapy) - are used exclusively for the purpose of eliminating any symptom.

The importance of introducing rational methods of symptomatic therapy into clinical practice is due to the large number of patients assigned to clinical group IV of dispensary registration.

In foreign specialized literature, the terms “palliative” and “symptomatic treatment” are not distinguished. In domestic practice, this division is quite clearly defined. Symptomatic treatment is aimed at eliminating complications associated with the growth of malignant tumors, while the impact on tumor tissue or metastases is not expected or is minimized. Symptomatic surgery includes operations such as bypass, external drainage of the biliary tract, bleeding control, tracheotomy, gastrostomy, colostomy, etc.

While “palliative treatment” is a series of measures aimed at improving the quality of life and its duration, including the use of radiation and chemotherapy. This type of treatment assumes that special methods will slow down the development of the tumor for some time, and, perhaps, conditions will be created for the use of more radical methods. The term “palliative care” is used in foreign literature and assumes that as the disease progresses, all special methods of palliative treatment have been exhausted and the patient is indicated

only the care and attention of relatives and friends. In this situation, at a certain stage, if necessary, symptomatic treatment is included.

Oncological diseases are often accompanied infectious complications, which sharply worsen the quality of life, force repeated courses of treatment in a hospital setting, and are the most common direct cause of death in cancer patients. The prerequisites for the development of infectious complications are both internal (sharp decrease in immunity, exhaustion, anemia) and external causes (major surgical trauma with massive blood loss, chemotherapy and/or radiation treatment). The use of glucocorticoids at almost all stages of patient management also reduces immunity. The range of infectious complications is very diverse. Wound infections, pneumonia, genitourinary infections, even sepsis often develop. A “nosocomial” infection that causes inflammatory processes is often of a mixed bacterial-fungal nature and, as a rule, is very resistant to therapy with the most modern means.

The second most common cause of death in cancer patients is thromboembolic complications. The tendency to increased thrombus formation in oncological pathology was noticed by clinicians of the 19th century. Armand Throusseau introduced this syndrome in 1861 in his famous lecture on the combination phlegmasia alba dolens and tumor cachexia. Paradoxically, the lecturer himself later diagnosed himself with disseminated stomach cancer based on the development of migratory thrombosis of the deep veins of the leg. Since then, the combination of migratory vein thrombosis in a patient and the presence of tumor pathology is known in medicine under the name “Trousseau syndrome”, and the appearance of thrombotic complications preceding the manifestation of the tumor is known as “thrombotic mask” (cited from “Practical Oncology”: selected lectures / Edited by S. A. Tyulandina and V. M. Moiseenko) Thus, a wide variety of tumor localizations and latent forms of cancer often manifest themselves with the development of migrating thrombotic complications. As with any type of thrombosis, the trigger is a combination of pathological factors known as Virchow's triad: stasis, damage to the endothelial lining of blood vessels, blood hypercoagulation. The problem of pathogenesis and prevention of thrombotic

complications remains relevant. Deep vein thrombosis of the lower extremities and pelvis remains the main source of pulmonary embolism, which develops in 40-66% of patients after surgery.

In cases of oncological pathology, the main factor is the state of hypercoagulation, caused by the development of the tumor itself and associated hemostasis disorders. The mechanism of disruption of the hemostatic system is quite complex and includes many interrelated factors at different levels of hemocoagulation. Triggering factors can be both the body’s own reaction to the development of neoplasia and more specific factors: the release of highly active tissue thromboplastin, fibrinolysis activators into the bloodstream, as well as the entry of specific procoagulants into the bloodstream. Moreover, an increase in the level of tumor-dependent tissue thromboplastin is a marker of tumor growth and is characteristic of almost all solid tumors. The second most important factor is stasis, due to several reasons. First of all, this is long-term immobilization of patients, due either to the volume and nature of the surgical intervention, or to the extent of the process.

28.2. SYMPTOMS AND SYNDROMES REQUIRING SYMPTOMATIC TREATMENT IN ONCOLOGICAL PRACTICE. THEIR ORIGIN AND TREATMENT

The syndromes and symptoms listed below most often require adequate treatment. They are grouped into several groups based on the similarity of manifestations and consequences in the development of the disease. To the group of symptoms that define general nutrition patient, include cachexia, anorexia, constipation, diarrhea, vomiting. Symptoms compression, causing organ dysfunction; mechanical disturbances of absorption, which usually increase as the tumor develops. Hypercalcemia, renal and liver failure and, as a consequence of this, endogenous intoxication accompanies the development of a tumor disease and is observed, as a rule, during the generalization of the process. Exogenous intoxication usually develops

against the background of drug treatment, often chemotherapy. Pain syndrome, mental disorders usually associated with the development of the tumor process and the personal characteristics of the patient. The division of symptoms is artificial, since it should be taken into account that they all develop in one patient. Impact on one symptom entails aggravation or, which happens much less frequently, a decrease in manifestations or elimination of another symptom.

Please note that symptoms may be caused by the tumor itself- germination of bones, blood vessels, nerves, organs, soft tissues; compression, displacement, replacement, stretching, deposition of proteins secreted by the tumor in various vital organs: liver, kidneys, heart, stomach (amyloidosis and other paraproteins). TO complications of the tumor process, also requiring special treatment should include pathological fractures, muscle spasms with bone damage, tumor necrosis, inflammation and infection of organs, perforation, peritonitis, arterial and venous thrombosis due to compression, thrombophlebitis. Asthenization of the body the occurrence of symptoms such as constipation, bedsores, and trophic ulcers should be explained. The result of the toxic effects of the tumor are paraneoplasia; they usually manifest themselves in the form of polymyositis, osteoarthropathy, neuroendocrine disorders, and various skin manifestations with associated symptoms. Both the tumor and treatment measures can be caused by violations functions of natural detoxification systems.

Symptomatic treatment is aimed at improving the quality and increasing life expectancy by preventing and treating these phenomena that accompany the “natural” development of the tumor process. Elimination of disease complications, as a rule, is achieved without direct impact on the primary lesion or metastases. The principle of symptomatic treatment - there are no “incurable” patients, there are only incurable stages of the tumor.

Symptomatic treatment as an independent and important stage comes to the fore in the development of some emergency conditions and is carried out according to generally accepted canons of resuscitation. In case of oncological diseases, emergency conditions can arise in the following situations:

1) before the moment of detection, the patient was diagnosed with a tumor. For example, the development of superior vena cava syndrome in lung cancer or lymphoma. Then the necessary emergency treatment measures are carried out so as not to affect the potential for subsequent specific treatment;

2) life-threatening conditions may occur in a patient receiving special treatment. In this situation, it is important to avoid changing the treatment plan;

3) in a patient with clinically obvious signs of the terminal stage of cancer. The decision to apply the full scope of modern therapeutic interventions in order for the patient to continue to live should be based not only on the data of a thorough diagnostic examination, but also on an analysis of the prognosis of the further course of the disease.

In foreign literature, it is recommended to deploy the entire possible arsenal of “rescue” measures only if there is a likelihood of cure or achieving a relatively long-term remission (at least two weeks). In domestic practice, in clinical settings, such decisions are usually made collectively. Euthanasia generally contradicts the point of view of modern domestic medicine.

Symptom of cachexia, its mechanism and treatment

Cachexia is known as one of the most common and characteristic consequences of a common tumor process. It is not a mandatory symptom complex in the clinic of malignant neoplasms and at the same time can occur in a number of other diseases (tuberculosis, gastric ulcer, pancreatitis, etc.). Cachexia in cancer patients does not have any specific features. There are two possible explanations for the mechanism of its genesis in malignant neoplasms:

1) replacement and destruction of a vital organ are associated with the mechanical factor;

2) toxic, systemic, hormone-like effect due to the release of toxins by the tumor.

Mechanically disrupt the nutritional process of tumors in any part of the intestinal tube, starting from the oral cavity and pharynx. These tumors, due to pain and impaired swallowing, prevent adequate nutrition. Stenosing tumors of different parts of the pharynx

and esophagus disrupt the passage of the food bolus. Compression of the esophagus from the outside by metastases to the lymph nodes of the mediastinum leads to the same consequences. Inflammation accompanying tumors of the mouth, pharynx, stomach, esophagus and intestines, caused by a variety of (often fungal) flora, causes pain that disrupts the nutritional process (refusal to eat, impaired absorption). Mechanical obstacles during the passage of food can arise due to cicatricial stenosis of the anastomotic zones after operations in various areas of the gastrointestinal tract, as well as due to radiation and toxic stomatitis and esophagitis.

Disturbances in the process of food passage require anti-inflammatory treatment, the prescription of antispastic and wound-healing agents (for ulcers of the oral cavity, pharynx, esophagus). To ensure access of food to the stomach and intestines, a gastrostomy and gastrointestinal (bypass) anastomoses can be applied to ensure the passage of food humus bypassing the tumor. For example, in case of tumors that prevent the passage of food at the level of the gastric outlet, a gastroenteroanastomosis may be applied in some patients. Or, given the slow growth rate of esophageal tumors and their relatively low tendency to generalize, a “symptomatic operation” - gastrostomy - is acceptable. These interventions can prolong the patient's life by several months or even years.

In case of damage to the mucous membrane of the mouth and esophagus by cytostatics, with irradiation and concomitant inflammation, in addition to anti-inflammatory therapy with antibiotics, in accordance with the detected flora and sensitivity studies, astringents and enveloping agents are used, such as a decoction of chamomile, oak bark, tannin, and egg white applications . In case of severe ulceration of the oral mucosa, it is recommended to treat the ulcers with vitamin B 12, 5% methyluracil solution. It should be remembered that stomatitis is usually accompanied by agranulocytosis and requires urgent blood testing and appropriate therapy. If food absorption is impaired in the initial stages of development of gastrointestinal organ replacement, the administration of gastric juice, enzyme preparations (panzinorm, pancreatin), and choleretic agents can be effective. Food may be poorly absorbed as a result of tumor damage to the stomach and intestines, multiple metastases to the liver, and impaired liver function

due to intoxication, due to amyloidosis of the small intestine, as a consequence of agastric syndrome (dumping syndrome) or after resection of the small intestine.

It is known that the presence of a tumor even outside the digestive tract without detectable metastases quite often causes progressive weight loss in the patient, which indicates a metabolic disorder towards catabolism. Tumor intoxication is recognized and acquires a biochemical “face”. Thus, some tumors produce so-called ectopic hormones, which are not characteristic of normal parent tissues. The systemic effects of this process include a wide range of metabolic disorders in cancer patients. The production of corticotropin by neoplasms is known: oat cell lung cancer, pancreatic cancer, thymomas and carcinoids, pheochromocytoma, gangliomas and paragangliomas; less commonly, malignant tumors of the thyroid gland, adrenal cortex, liver, prostate gland, ovary, mammary gland, and esophagus. Ectopic gonadotropin is produced by hepatoma, mediastinal teratomas, and lung carcinoma; antidiuretic hormone - tumors of the lung and pancreas.

The production of antidiuretic hormone by tumors is accompanied by water retention and hyponatremia (decreased concentration due to plasma dilution). When the sodium level decreases below 135 mmol/l, a neurological syndrome develops (weakness, confusion, nausea, vomiting, loss of coordination). To eliminate these phenomena, 10% sodium chloride solution is administered slowly intravenously and water consumption is limited.

With an excess of parathyroid hormone, the leading pathology is hypercalcemia, accompanied by weakness, vomiting, and ECG changes. Hypercalcemia should be kept in mind in breast cancer with osteolytic bone metastases, and in diffuse myeloma with extensive bone lesions. Small changes can be relatively easily stopped with water loads (drink up to three liters of liquid per day) and a diet excluding milk, butter and cheese. In general, the prevalence of the second mechanism of cachexia is an indication for detoxification therapy. Cancer cells intensively consume nitrogen from tissues, resulting in a decrease in nitrogen content in muscles, myocardium, and skin. Moreover, the tumor uses the disintegration products of these tissues for its growth.

Clinically, the growth of the tumor mass always leads to increased glucose consumption, which is accompanied by a decrease in blood sugar levels. In patients with diabetes mellitus and cancer, blood glucose levels are normalized, and in patients with normal blood sugar levels, there may be attacks of hypoglycemia, accompanied by weakness, dizziness, palpitations, and mental disorders. To a large extent, this is a consequence of the metabolic characteristics of tumor cells. A growing tumor inhibits the normal processes of oxidative phosphorylation and activates anaerobic glycolysis. This process is characterized by less economical use of carbohydrate energy with the release of only part of the energy contained in them. The tumor therefore needs an increased constant supply of glucose. Cancer patients should be administered large amounts of glucose. In the experiment, moderate hyperglycemia not only did not stimulate tumor growth, but significantly restrained it and inhibited the process of dissemination of tumor cells. This effect is used to conduct “courses” of symptomatic treatment in incurable patients in the form of intravenous injections of glucose solution. This is often used when supervising patients at home.

Therapeutic tactics for cachexia, where possible, should include eliminating the causes of disturbances, for example, the passage of food, and eliminating purulent infections. Enteral nutrition is optimal, compensating for the deficiency of plastic and mineral substances, energy balance and vitamins. Sometimes parenteral nutrition is required, which is carried out only if it is impossible to provide adequate nutrition by the enteral route. To improve the absorption of plastic substances from food, anabolic hormones are widely used - retabolil (5 mg once a week), nerobol. Objective indicators of the effectiveness of therapeutic measures to normalize nutrition are normalization of albumin levels in the blood serum, positive nitrogen balance, improvement of immune status, general well-being of patients, and weight gain.

Vitamins and biogenic stimulants were not used for a long time in the treatment of cancer patients; it was believed that they stimulate tumor growth. Currently, the autonomous process of regulation of tumor growth has been proven and such stimulation does not occur with an adequate supply of plastic substances from the outside.

Anorexia, vomiting and diarrhea are common causes of cachexia in cancer patients. Their treatment is usually approached with mandatory consideration of the development mechanism, and treatment can be classified as measures to eliminate the causes of nutritional decline.

Symptom of anorexia, hypercalcemia

The causes of anorexia - loss of appetite - are different. It occurs as a result of tumor intoxication, impaired sense of smell and taste, accumulation in the body of under-oxidized products such as lactic acid, ketones, due to the direct effect on the appetite center of tumor toxins - products of tumor decay or its metabolism, as well as due to psychological factors - refusal to eat, up to the development of depressive states. Anorexia occurs with tumor damage to the gastric mucosa or neoplasms of the central nervous system. Endogenous intoxication can be a consequence of infection, uremia, liver dysfunction, febrile reactions, constipation. Exogenous causes of appetite disturbance are the use of cytostatics, narcotic analgesics, barbiturates.

Treatment of anorexia. In the initial stages of the manifestation of this symptom, bitterness is used that stimulates the appetite: tinctures of the herbs of wormwood, centaury and oregano, and trefoil leaf. Flavoring additives can stimulate appetite: cumin, mint, ginger, cinnamon, cloves, vanilla, nutmeg, pepper, mustard, grape wine, beer. Taking natural gastric juice, acidic drinks - kvass, syrups, fermented milk products, as well as sour and pickled vegetables may have a certain role in the treatment of anorexia. Glucocorticoids can increase appetite, but at the same time increase protein catabolism, so an indispensable condition when prescribing them is a sufficient content of proteins in the diet and a limitation of easily digestible carbohydrates. A febrile reaction that reduces the patient's appetite must be controlled by the use of antipyretics.

The significance of paraneoplastic syndromes in the development of anorexia is not always taken into account. The latter is often one of the early signs of hypercalcemia observed with multiple osteolytic bone metastases or the production of ectopic parathyroid hormone by malignant tumors - cancer of the lung, pancreas, liver, colon, adrenal

renal, ovary, vagina, uterus, bladder and kidney. Hypercalcemia affects the nerves and muscles, leading to weakness and dizziness. Common manifestations of hypercalcemia: anorexia, nausea, vomiting, constipation, polyuria, hypotension, muscle weakness, cardiac electrolyte disturbances, renal failure. The latter requires timely diagnosis and adequate treatment, otherwise a coma may develop. For hypercalcemia not higher than 2.75 mol/l, drinking plenty of fluids or infusion of an isotonic sodium chloride solution is sufficient. Avoid consumption of dairy products. Bisphosphonates are synthetic analogues of pyrophosphates that regulate the process of mineralization in the body. With their use, serum calcium levels normalize and the symptoms of hypercalcemia disappear (vomiting, drowsiness, constipation, bradycardia, polyuria).

Symptom of vomiting and its treatment

The most common cause of vomiting is stenosis of the distal esophagus, cardia, pylorus and underlying parts of the gastrointestinal tract. This symptom also occurs with metastases to the brain, endogenous intoxication with products of tumor breakdown and metabolism, with hypercalcemia and hyponatremia, intoxication from cytostatics and other medications.

The peripheral mechanism of vomiting in common forms of gastric cancer is associated with infiltrating tumor growth, inflammation of the mucous membrane, mechanical overstretching by food masses and secretions due to pyloric stenosis or scars in the area of the gastrointestinal or esophageal-intestinal anastomosis. One of the causes of vomiting may be drug-induced gastritis, which occurs with prolonged use of non-narcotic analgesics or as a consequence of treatment with cytostatics.

The central mechanism of vomiting is associated, as a rule, with exo- and endogenous intoxication, as well as with an increase in intracranial pressure due to the development of primary and metastatic intracranial tumors. Analysis of the causes of vomiting forces a differentiated approach to the prescription of symptomatic treatment. Thus, with a central mechanism of vomiting, dehydration is carried out: limiting fluid intake, prescribing glucocorticoids, intravenous mannitol solution and hyperosmolar solutions, etc. At

symptoms of severe dehydration due to vomiting of peripheral origin, transfusions of solutions of isotonic NaCL and 5% glucose with the addition of 4-6 ml of 5% ascorbic acid solution are indicated. Local anesthetics are used: novocaine, anesthesin, almagel, belladonna preparations, atropine alkaloids, antihistamines; tranquilizers that reduce the excitability of the cerebral cortex, including the vomiting center. Neuroleptics have the most powerful antiemetic effect, but they have an inhibitory effect on the respiratory center and have limited use in oncology. Metaclopramide preparations (cerucal, raglan) are currently widely used.

Symptoms of constipation and its treatment

A tendency to constipation is quite often observed in cancer patients, which is associated with a sedentary lifestyle, a gentle diet, represented mainly by easily digestible foods with a small amount of fiber. Constipation accompanies treatment with codeine-containing and morphine-containing drugs. In most cases, treatment begins with a diet with a lot of fiber, as well as petroleum jelly, olive oil, etc., since vegetable oils soften the contents of the intestines. Sea kale powder and saline laxatives, by increasing the volume of intestinal contents, stimulate peristalsis. Contact stimulants are also used: castor oil, purgen, isafenin, preparations of rhubarb, buckthorn, etc. In general, the prescription of laxatives should be approached with great caution. Only with full confidence that the gastrointestinal tract is intact can contact “stimulating” laxatives be used. It is necessary to take into account the danger of excessive blood supply to the pelvic organs when taking certain laxatives in patients with tumors of the female genital area, since taking laxatives can cause uterine or intestinal bleeding if the tumor is located appropriately. It is obvious that contraindications to the prescription of certain laxatives are almost more important than the indications. The dangers of impaired intestinal motility, water, electrolyte and vitamin balance due to local and systemic effects become really dangerous with long-term use. In the absence of contraindications, enemas are prescribed.

Diarrhea and its treatment

Diarrhea (diarrhea) is a rarer complication. It occurs in cases of damage to the small intestine due to lymphogranulomatosis, hematosarcomas, cancer of the ascending colon, pancreas, thyroid cancer (medullary form), amyloidosis of the small intestine.

More naturally, diarrhea occurs as a complication of special antitumor treatment; as a result of radiation damage to the small intestine, surgical interventions (gastrectomy, subtotal gastrectomy, colectomy), accompanied by impaired absorption of water from the intestine, enterocolitis, as well as due to specific treatment with cytostatics. Dysbacteriosis may occur as a side effect of antibiotic therapy with manifestation in the form of diarrhea.

The treatment uses the principles of dietary nutrition, as in chronic anacid gastritis and enterocolitis - high-calorie, mechanically and chemically gentle food with a sufficient amount of proteins and vitamins. For dysbacteriosis, the use of biological preparations from microbes, representatives of the normal intestinal microflora is indicated: colibacterin, bifidumbacterin, lactobacterin, bificol.

Symptomatic treatment of renal and liver failure

Acute and chronic renal and liver failure quite often accompany the development of cancer at different stages, especially in the terminal stage.

Renal failure leads to the accumulation of end products of nitrogen metabolism in the blood with the progressive development of nephrotic syndrome. Impaired renal function can be caused in oncological practice for a number of reasons.

1. Tumor invasion: replacement of renal parenchyma - kidney cancer, leukemia, lymphogranulomatosis, hematosarcoma; obstructive nephropathy - compression of the ureters by metastatically changed retroperitoneal lymph nodes or the development of obstructive uric acid nephropathy with rapid lysis of tumor cells (lysis syndrome).

2. Features of the metabolism of malignant tumors: accumulation of paraproteins and uric acid in the blood.

3. Complications of the treatment: cytostatic therapy - platinum derivatives, methotrexate, due to radiation nephritis; antibacterial therapy - aminoglycosides, cephalosporins.

Prevention and treatment. Hyperhydration with the introduction of 2.5-3 liters of liquid, alkalization of urine - the introduction of sodium bicarbonate, vitamins C, B 6, ATP, cocarboxylase, cardiac glycosides, diuretics, rheopolyglucin. In the presence of uric acid nephropathy, evidence of which is an increase in the content of uric acid in the blood serum and uric acid crystals in the urine sediment, use xanthine oxidase inhibitors - allopurinol, zyloric: 400-600 mg per day orally.

Nephrotic syndrome promotes the loss of protein in the urine. It can occur during paraneoplastic processes in a number of tumors and lymphomas, in particular in myeloma. It is based on glomerulonephritis and renal amyloidosis. This syndrome is also observed in advanced lung cancer, lymphogranulomatosis, breast tumors and other localizations. Regardless of the cause of nitrogen imbalance or protein loss, hypoproteinemia, hypoalbuminemia and anemia are almost always observed in cancer patients.

TO liver dysfunction are due to the following reasons.

Primary liver cancer or metastases to the liver, cytostatic therapy, development of acute or the presence of chronic infectious or serum hepatitis. Liver failure is based on metabolic disorders due to the effects of a tumor or the direct damaging effect of cytostatics. In the blood, a violation of indicators certifying normal liver function appears: the content of transaminases, LDH, and alkaline phosphatase increases. At the same time, due to inhibition of albumin synthesis in the liver, their concentration in the blood decreases.

Liver failure, which develops against the background of replacement of its specific tissue with tumor tissue, due to the development of either primary liver cancer or metastases to the liver, is practically not corrected by symptomatic therapy. In the case of drug-induced or infectious hepatitis, treatment includes the prescription of a diet (table? 5), enzymes, antispasmodics, choleretic agents, corticosteroids, vitamins C, group

py B, as well as the introduction of a 5-20% glucose solution with insulin. Undoubtedly, the use of interferon drugs (reaferon, realderon, welferon, intron-A) should be considered promising. If metabolic acidosis develops, administration of sodium bicarbonate is indicated. It should be remembered that sluggish infectious or serum hepatitis can worsen liver function for a long time, therefore, in each case, when signs of liver failure appear, it is necessary to exclude the presence of hepatitis of any origin. Detoxification methods.

1. Strengthening natural detoxification systems:

a) taking laxatives that cleanse the intestines and prevent the absorption of toxic products;

b) infusion of drugs that bind toxic substances (albumin solution, hemodez) and transport them to the organs of excretion and detoxification;

c) artificial hemodilution (blood dilution), which makes it possible to reduce the concentration of toxic products in the body by improving microcirculation and “washing” them out of tissues, which leads to improved functioning of the decontamination and elimination organs;

d) forcing diuresis by administering hypertonic glucose solutions, diuretics (Lasix, furosemide, mannitol solution);

e) stimulation of lymph formation and lymph circulation (iv administration of mannitol and other hyperosmolar solutions - 40% glucose, 10% sodium chloride solution);

f) auxiliary therapy - oxygen inhalation to combat hypoxia, administration of antihistamines, proteolytic enzyme inhibitors (contrical 20 thousand units IV, splenin 1 ml IM, 5% aminocaproic acid solution - 100 IV ), drugs that improve the functioning of the respiratory system, circulatory system, liver, kidneys, external respiration (sirepara 2-3 ml, vithepata 1-2 ml i.m., 5% ascorbic acid solution i.v., 2.4% r- ra aminophylline IV).

3. Removal of toxic substances through exchange transfusion, drainage of lymph through drainage of the thoracic duct, removal of exudate, or peritoneal dialysis.

4. Application of hemosorption and lymphosorption (Panchenkov R.T., 1982).

28.3. PARANEOPLASTIC SYNDROMES

Paraneoplastic syndromes are very diverse, often accompany neoplasms, and often precede the diagnosis of the tumors themselves that caused the development of the syndrome. Most paraneoplastic syndromes come down to the manifestation of the action of various biologically active proteins or polypeptides, growth factors, cytokines, hormone-like substances that appear in body fluids in connection with the vital activity of the tumor mass. Paraneoplasia is due to the ability of most tumors to form immune and autoimmune complexes in the presence of immune suppression. Tumors can synthesize a number of biologically active substances similar to some human hormones, the main ones of which are adrenocorticotropic hormone of the pituitary gland (ACTH), antidiuretic hormone (ADH), thyroid-stimulating hormone of the pituitary gland (TSH), parathyroid hormone (PTH), somatotropin, glucagon, prolactin. These biologically inactive hormones, pseudohormones, produced by the tumor, create a competitive blockade of the action of normal hormones. Most human tumors have the property of provoking paraneoplastic symptoms: cancer of the lung, liver, kidney, breast, stomach, intestines, etc.

The activity of production of hormone-like substances is inversely proportional to the degree of tumor differentiation. Paraneoplastic manifestations are usually associated with polymyositis, osteoarthropathy, neuroendocrine disorders, and various skin manifestations with associated symptoms. Multiple hemangiomas and skin papillomas, the development of multiple hyper- and parakeratoses should be alarming and give reason to exclude tumors of internal localizations (Fig. 28.1).

One of the paraneoplastic syndromes that manifests itself in the oral mucosa is paraneoplastic pemphigus. This is a rather rare pathological condition of the mucous membranes of the mouth and other mucous membranes. It is a symptom of malignant lymphomas of various localizations. Paraneoplastic pemphigus is difficult to diagnose due to the fact that clinical signs may correspond to acantholytic pemphigus (pemphigus), non-acantholytic pemphigus (pemphigoid). For quite a long time, these phenomena can develop only on mucous membranes.

Rice. 28.1.Paraneoplasia. Seborrheic keratosis in a patient with colon cancer

membranes of the mouth, eyes, and genitals. In some cases, paraneoplastic pemphigus occurs on the red border of the lips and skin, very similar to the clinical manifestations corresponding to erythema multiforme.

In patients with lung cancer, one can trace the presence of paraneoplastic syndromes associated with hyperproduction of hormones (syndrome of secretion of adrenocorticotropic antidiuretic parathyroid hormones, estrogens, serotonin). The most typical manifestation is severe hypokalemic alkalosis, sometimes leading to seizures and coma. Neuromuscular and cutaneous paraneoplastic symptoms are not uncommon in lung cancer, sometimes appearing before the onset of clinical manifestations and, therefore, before the diagnosis of the underlying disease. Acrokeratosis of Bazex is known, manifested by hyperkeratosis of the feet and palms, which is associated with pulmonary failure caused by a tumor process in the lungs.

There may be phenomena of thrombophlebitis, various types of neuro- and myopathy, disorders of fat and lipid metabolism. Hypertrophic osteoarthropathy is typical, characterized by periostitis of long bones (tibia, ulna and radius), as well as small bones (metacarpal, metatarsal, phalangeal). When palpated, pain and fever are noted. Rheumatoid-like conditions, swelling and tenderness of the wrists, ankles,

knee and knee joints often accompany lung cancer. Marie-Bromberg syndrome is well known, manifested in thickening of the terminal phalanges of the hands in the form of “drumsticks”; swelling of the joints not only of the hands, but also of small joints of the extremities, thickening and sclerosis of long tubular bones are also noted. With a radical cure of the underlying disease, “tympanic fingers” and hypertrophic arthropathy quite quickly undergo reverse development.

Paraneoplasia is often observed in liver cancer, especially in the terminal stage. Hypoglycemia is observed, which is associated with impaired inactivation of insulin in liver cells. Characterized by itchy skin without jaundice, dry skin and mucous membranes. It is possible to develop hyperparathyroidism, which has a typical manifestation in the form of hypercalcemia and osteoporosis. Hypercortisolism and hypokalemia are typical, manifested by electrolyte changes in cardiac activity and a detailed picture of Itsenko-Cushing syndrome. Itsenko-Cushing syndrome has a number of characteristic symptoms: obesity with a characteristic distribution of fat (a “moon-shaped face” is typical), thinning of the skin and atrophy of elastic fibers develop, resulting in a characteristic striatal pattern in the form of reddish stripes on the skin of the abdomen, thighs and buttocks . Muscles weaken, osteoporosis and sclerotic changes in blood vessels, and arterial hypertension appear. Steroid diabetes often develops, causing increased appetite and polyuria.

Kidney cancer is characterized by a wide variety of paraneoplastic syndromes, which are noted in more than half of patients. Normally, the renal parenchyma produces many biologically active substances - renin, prostaglandins, the active form of vitamin D or other biologically active compounds that act as extrarenal hormones. These substances have the properties of parathyroid hormone, glucagon, insulin, human chorionic gonadotropin, etc. The tumor usually produces them in increased quantities. The consequence of this is arterial hypertension, erythrocytosis, hypercalcemia, hyperthermia, etc. Sometimes these symptoms are the only manifestation of a kidney tumor, therefore, for example, in case of “unreasonable” hyperthermia, the examination should include measures to exclude a kidney tumor.

Metastases from osteogenic sarcoma often cause osteoarthropathy, which may disappear after removal of the primary tumor or metastasis and recur as the tumor progresses. Manifestations of osteoarthropathy include pain along the long tubular bones, pain and swelling of the joints with an accompanying hyperthermic reaction. The pain may not be constant or “volatile”, i.e. not long lasting character. Prescribing non-steroidal anti-inflammatory drugs, as well as detoxification therapy, is quite effective.

28.4. TREATMENT OF PAIN SYNDROME

It is no coincidence that when it comes to symptomatic therapy, in most cases it seems that it is usually limited to the treatment of pain. And, indeed, chronic pain syndrome is the leading one in most incurable conditions in oncology, but not necessarily. About 30% of cancer patients report no pain.

The definition of this condition, proposed by the International Association for the Study of Pain, is: “Pain is an unpleasant sensation or emotional feeling associated with actual or potential tissue damage or described in terms of such damage.” Pain is always subjective; it is always an unpleasant and therefore emotional experience.

As a rule, pain occurs as a result of exposure to extremely strong irritants that cause functional and organic changes in the body. Pain warns the body of impending danger and allows the body to survive in unfavorable environmental conditions. This is a protective mechanism; when pain occurs, the body mobilizes various functional systems, and various behavioral, somatic and autonomic reactions arise.

Treatment of chronic pain requires adherence to certain principles that differ significantly from the principles of treatment of acute pain. For example, additional sedation is often desirable for acute postoperative pain, whereas it should be avoided in cancer patients. The exception is unbearable pain in the terminal stage. The role of coanalgesics is very great; among domestic authors, the more accepted term is

min “adjuvant agents”, such as psychotherapeutic drugs or corticosteroids. Whereas these drugs are rarely used in the treatment of acute pain.

In a cancer patient, pain is not a protective signal; this sensation is very dependent on the emotional state. The psychological factor is very important in the formation of pain. Pain that persists for 3 months can be classified as chronic pain syndrome. It becomes an independent disease and can continue even after the cause that caused it is eliminated. Depression makes the experience of chronic pain extremely difficult.

The sensation of pain is always subjective and depends not only on the cause, but also on the individual pain reactivity and emotional state of the patient. Insomnia, anxiety, depression, introversion, social dependence, isolation and prolonged inactivity of the patient contribute to increased pain. Chronic pain syndrome is usually accompanied by fear of the future, a state of hopelessness, helplessness and despair. Without eliminating or mitigating these factors, subsequent pain therapy, even with potent analgesics, may be ineffective. It has been noted that the subjective reaction to pain is most pronounced in comparison with the perception of other symptom complexes that develop in severe cancer patients.

Types of pain

Pain is divided by duration into acute and chronic, and by intensity into weak, moderate, strong and very strong. Subjective pain sensation must be characterized by the patient in order to prescribe adequate treatment. For differentiated pharmacotherapy, it is necessary to divide pain into the following types.

Nociceptive (physiological) pain, which is caused by the transmission of a painful stimulus from the peripheral nerves to the central nervous system. They are, in turn, divided into visceral and somatic. The latter is divided into soft tissue and bone. Visceral pain- a consequence of damage and overextension of hollow and parenchymal organs, carcinomatosis of serous membranes, ascites, hydrothorax, constipation, stretching of the organ capsule, obstruction or external compression of hollow organs, etc. Somatic WHO-

disappears when the skin, subcutaneous tissue, periosteum, joints are damaged, with muscle spasms, etc. Often described as dull, aching. These types of pain can usually be treated with traditional analgesics.

Neuropathic deafferentation pain - caused by dysfunction of the nervous system at the peripheral or central level. Appears in the absence of a painful stimulus and is caused by damage, compression or dysfunction of peripheral nerves, nerve trunks or any part of the central nervous system, therefore, associated with a violation of the mechanisms of nerve impulse transmission. It may be the result of a complete rupture or partial injury of a nerve, compression or sprouting of nerve fibers by the tumor itself or their displacement by enlarged lymph nodes, as well as due to infectious (for example, herpes zoster), inflammatory or ischemic processes. Such pain is assessed as burning, sharp, cutting, shooting, etc. To eliminate it, it is usually necessary to add anticonvulsants and antidepressants to complex drug therapy.

In the structure of chronic pain syndrome, various types of pain may be present or dominant: somatic, visceral, deafferentation. In incurable cancer patients, several types of pain can be observed simultaneously; their differential diagnosis is difficult. The causes of the pain syndrome are the same as those that cause the occurrence of other symptoms that require symptomatic treatment: compression and infiltration of nerve structures by the tumor, compression and obstruction of organs, stretching of the capsule, occlusion of blood vessels, inflammatory infiltration of the tumor and surrounding tissues, etc. It is necessary to distinguish pain caused by:

1) the tumor itself, i.e. compression and infiltration of surrounding tissues resulting from tumor growth;

2) due to tumor-reducing therapy;

3) associated with a tumor, i.e. resulting from phenomena accompanying cancer: inflammation, necrosis, paraneoplasia, etc.

It should be borne in mind that the patient may have pain that is not associated with the tumor and specific therapy for this disease. Thus, establishing the cause of pain must be preceded by certain diagnostic techniques.

Treatment of pain syndrome should be based on the organ in which it occurs and which mechanism of its formation prevails. If it is possible to use measures that eliminate the cause of pain, then pain treatment begins with them. Thus, swelling and infiltration of soft tissues, accompanied by pain, are more effectively eliminated by the use of diuretics and steroid therapy. With bone metastases, prostaglandins are produced, therefore, non-steroidal anti-inflammatory drugs (NSAIDs), which have pronounced anti-prostaglandin properties, will be most effective. Visceral pain is associated with an increase in tumor volume, usually accompanied by stretching of the organ capsule. In this case, the most effective is palliative surgical treatment, which reduces the stretching of the capsule. Pain resulting from necrosis and ulceration in the tumor area is most effectively treated by local treatment: wound treatment, surgical measures, etc. In this sense, any treatment aimed at eliminating any symptom, as a rule, helps reduce pain. Antispasmodics, sedatives, hypnotics, neuroleptics, major and minor tranquilizers, antihistamines, hormonal agents, especially glucocorticoids, have this effect.

Assessing the intensity of chronic pain syndrome carried out by the patient himself. For this purpose, two methods have been proposed for hourly recording of pain in connection with taking a certain drug in a certain dose. The easiest and most convenient way to assess pain is on a 4-point scale verbal rating scale(SHVO):

0 - no pain;

1 - weak;

2 - moderate;

3 - strong;

Often used visual analogue scale(YOUR)

pain intensity from 0 to 10, which is offered to the patient, and he himself notes on it the degree of his pain. These scales make it possible to quantify the dynamics of chronic pain syndrome during treatment. Such a diary is necessary for the supervising physician to select adequate treatment. The basic principles of medicinal treatment of pain are as follows:

taking medications by the hour rather than on demand; treatment from a weaker analgesic to a stronger one (i.e., from non-narcotic analgesics, then to weak narcotic ones, and after their effect is exhausted, strong opiates are used); strict adherence to the dosage regimen; convenient route of reception, i.e. use the technique for as long as possible "per os".

Chronic pain syndrome requires complex treatment. Depending on the intensity of chronic pain, various treatment methods are used.

1. SPECIFIC methods of antitumor therapy - radiation, chemotherapy and hormonal therapy can be used for purely symptomatic purposes. Examples of such use of specific therapy: radiation is used for metastases in the bones, liver, retroperitoneal lymph nodes and in the area of affected nerve trunks and plexuses to eliminate pain. In this case, treatment is exclusively symptomatic. One of the most gentle and effective methods of pain relief in patients with a generalized tumor process is massive, targeted irradiation of the pituitary gland with high-energy protons. It is possible to eliminate pain through radiation therapy directed to the primary lesion or individual metastases. Chemohormone therapy is used as a systemic antitumor effect for severe inflammation with accompanying pain syndrome. Often, in inflammatory processes, therapy with specific antibiotics is used. This treatment is most effective for lymphomas and hormone-dependent tumors. Corticosteroids increase the pain threshold and are almost always used as adjuvant agents.

2. REGIONAL ANESTHESIA AND CHEMICAL DENERVATION at various levels of the nervous system. Regional anesthesia includes spinal, epidural and local, intravenous, intraosseous and conduction anesthesia. The latter is divided into stem, plexus and ganglion. The main mechanism of action of regional anesthesia is the suppression of afferent nociceptive impulses from the lesion at the level of the nerve trunks and spinal cord.

Epidural-sacral, sacral blockade, anesthesia of individual nerves and plexuses with drugs for local anesthesia (novocaine, lidocaine, trimecaine) are also used. So, in oncology

In clinical practice, epidural anesthesia with local anesthetics and narcotic analgesics in small doses has become widespread, thanks to the use of catheterization of the epidural space. The level of puncture in incurable patients depends on the location of the pain. Long-term epidural anesthesia provides a persistent analgesic effect for 12-36 hours. Pain relief with chemical denervation occurs in 80-83% of patients and lasts from 2 to 6 months. The level of puncture during epidural and intrathecal administration of neurolytic drugs depends on the localization of pain and segmental innervation of organs. Possible complications with this type of anesthesia: aseptic inflammation, irritation of the dura mater, sclerosis of nerve fibers. The entry of neuroleptics into the subarachnoid space can cause dysfunction of the pelvic organs: paralysis of the sphincters of the rectum, bladder, as well as decreased tone of the lower extremities.

Alcoholization of the pituitary gland through transnasal and transsphenoidal access provides partial or complete anesthesia in 95% of patients. The mechanism of anesthesia that occurs during chemical hypophysectomy is not clear enough. Overproduction of endorphins is considered as a factor contributing to the development of analgesia.

3. REFLEXOTHERAPY (acupuncture, electropuncture, transcutaneous electrical stimulation of certain brain structures). Electrical stimulation analgesia is effective in 50-60% of patients with mild or moderate pain syndrome. The effectiveness of this method progressively decreases after 2-3 weeks. If the patient's condition is satisfactory and pain is not expressed, acupuncture can be used. The mechanism of the pain-relieving effect of acupuncture is far from clear. It is believed that acupuncture also releases endorphins from the pituitary gland and midbrain. Electrical stimulation of acupuncture points is also used, mainly after surgery or as an additional method of pain relief in patients with advanced forms of malignant tumors.

4. SURGICAL method (tumor removal, decompression measures, immobilization, traction). Operations of “desperation” are various surgical interventions undertaken when the above methods of treating pain syndrome in incurable patients are ineffective, including

including neurosurgical ones. For hormone-dependent tumors, breast and prostate cancer, adrenal and hypophysectomy are performed. To relieve pain in the chest and upper abdomen, a posterior rhizotomy is performed.

5. DRUG therapy with analgesics, neuroleptics, sedatives, antidepressants and anticonvulsants. It should be distinguished depending on the intensity of the pain syndrome:

Mild pain- non-narcotic analgesics, non-steroidal anti-inflammatory drugs (acetylsalicylic acid, diclofenac, ibuprofen, indomethacin, ketorolac, analgin, paracetamol; combination drugs: baralgin, pentalgin, sedalgin, tempalgin).

Moderate pain- weak opiate (codeine, dihydrocodeine), synthetic opioid (tramadol).

Strong pain- a potent opiate (morphine hydrochloride, extended-release morphine sulfate). Synthetic opioid drug: buprenorphine.

To avoid the uncontrolled cumulative effect of drugs when using analgesics, the following basic rules must be taken into account: sequence of use, in increasing dosages, gradually increasing the strength of the drugs, administration according to a strict schedule in accordance with the duration of action of the prescribed drugs, timely treatment and prevention of side effects, sequential use coanalgesics, prescribing additional medications if necessary and regular contact with the patient to monitor effectiveness and side effects.

Side effects of drug therapy

Narcotic analgesics are most often characterized by nausea and vomiting, drowsiness, weakness and adynamia, decreased appetite, constipation, dizziness, and dry mouth. Dysphoria, disorientation, hallucinations, itching, and difficulty urinating are less common. In case of overdose, deep general central depression is observed: sleep, bradycardia, bradypnea, up to apnea. Pupils

against the background of chronic use of opiates, they are narrowed to pinpoint. Non-narcotic analgesics and various non-steroidal anti-inflammatory drugs can lead to irritation and erosions in the gastric mucosa, granulocytopenia, and hemorrhagic complications. Allergic reactions of the skin and mucous membranes are possible. When assessing the side effects of pain treatment, it must be borne in mind that many symptoms of the disease are similar to the side effects of drugs (anorexia, nausea, vomiting, constipation), this must be taken into account before and during treatment. The manifestation of side effects of drugs usually appears with the start of appropriate treatment or is accompanied by an increase in some symptom. Often, individual symptoms do not increase during pain therapy, but even decrease.

The use of corticosteroids for symptomatic purposes has a multifaceted rationale. Glucocorticoids have a strong anti-inflammatory and antiallergic effect. They also have antishock and antitoxic properties. Glucocorticoids cause hyperglycemia, which, given the tendency to anaerobic glycolysis in cancer patients, increases the need for glucose in connection with this, maintains satisfactory blood sugar levels. When using glucocorticoids, capillary permeability decreases, blood clotting increases with possible thrombus formation, which is useful in the presence of a disintegrating tumor with the threat of bleeding. Glucocorticoids promote calcium excretion, which is used for hypercalcemia. Apparently, an anabolic effect is associated with the accelerated breakdown of proteins and a delay in their synthesis. Hormones of the adrenal cortex cause some excitement, euphoria, the patient becomes more active, and the mood rises. Corticoids are most effective for brain tumors (accompanied by increased intracranial pressure), compression of peripheral nerve trunks, and tumors of the head and neck. Prescribed in a dose not exceeding 1 mg/kg body weight, in combination with Ca preparations (panangin, asparkam). For exudation, glucocorticoids are prescribed orally or by injection. It is possible to administer hydrocortisone (100-120 mg intrapleurally). Glucocorticoids are not administered into the abdominal cavity. Undesirable side effects of glucocorticoids: ulceration in the gastrointestinal tract, decreased resistance to infections, arterial hypertension.

Pain relief methods vary for different types of pain. For nociceptive pain:

SOMATIC (bone and soft tissue) - pharmacotherapy, electrical stimulation analgesia, detoxification.

VISCERAL - the same + palliative surgery (laparocentesis, gastrostomy, enterostomy, epicystostomy, tumor excision).

For NEUROPATHIC pain - the same + regional blockades, if ineffective - chemical denervation (alcohol, phenol), cordotomy.

Difficulties that are often encountered in the treatment of pain are that drugs are prescribed “as needed”, standard dosage, too weak analgesic, underestimation of pain intensity, fear of developing drug addiction, insufficient knowledge about coanalgesics. On the part of the patient and his relatives, problems often arise associated with the following misconceptions: tumor pain cannot be treated, analgesics can be taken only when “absolutely” necessary, fear of drug dependence (drug addiction), fear of developing tolerance to the drug, etc. . In this regard, it is necessary to carry out appropriate educational work with the patient and his relatives.

No disease can be cured without eliminating the root cause of the pathological condition. It should be looked for in symptoms - a complex of external signs of the disease. Symptomatic therapy involves influencing precisely these manifestations. The most striking examples of such treatment are the use of painkillers, antipyretics, and mucolytic drugs. In addition, symptomatic therapy, as a rule, is included in the treatment course when working with more complex clinical cases - for example, when it comes to oncological pathologies. It can be aimed at eliminating undesirable manifestations of the disease before or after surgery, as well as at the stage of palliative treatment.

Symptomatic therapy in oncology

In oncological practice, symptomatic therapy is usually understood as a set of measures aimed at eliminating the most serious and dangerous consequences of tumor processes and correcting postoperative complications. In addition, in some cases, symptomatic therapy can also be palliative in nature, that is, it is intended to alleviate the patient’s condition and improve his quality of life when complete recovery is not possible.

The need for symptomatic therapy in oncology hospitals arises regardless of the stage of the disease. So, when a tumor has just been discovered and does not manifest itself in any way, the patient may experience panic attacks and even depression. Of course, this condition (symptom) requires drug correction. Radical removal of malignant tumors is also accompanied by symptomatic therapy, since the body always “responds” to any external intervention. And finally, symptomatic therapy is necessarily included in the medical protocol at the stage of rehabilitation of cancer patients. After radical treatment, the immune system is weakened, it is necessary to restore the basic vital functions of the body. And modern drugs to eliminate unwanted symptoms have the necessary corrective effect.

SYMPTOMATIC TREATMENT SYMPTOMATIC TREATMENT - is aimed at eliminating individual manifestations (symptoms) of the disease (for example, prescribing painkillers).

Big Encyclopedic Dictionary. 2000 .

See what "SYMPTOMATIC TREATMENT" is in other dictionaries:

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Books

Symptomatic treatment for malignant neoplasms, M.L. Gershanovich. The book describes a system of symptomatic treatment of patients with common forms of malignant neoplasms when it is impossible to carry out or the possibilities of special…