VOL: 98, ISSUE: 45, PAGE NO: 28
David Maher, BA, PG Dip, RGN, is Macmillan senior lecturer, department of postregistration nursing, University of Hertfordshire, HatfieldThe Publication of The NHS Cancer Plan (Department of Health, 2000) placed onerous responsibilities on cancer and palliative care services to establish effective ways of coordinating the work of the various public, private and voluntary sector care providers. As a result, cancer and palliative care networks were created, with the aim of offering cancer patients an integrated pathway of care from diagnosis through to death.
The Publication of The NHS Cancer Plan (Department of Health, 2000) placed onerous responsibilities on cancer and palliative care services to establish effective ways of coordinating the work of the various public, private and voluntary sector care providers. As a result, cancer and palliative care networks were created, with the aim of offering cancer patients an integrated pathway of care from diagnosis through to death.
Prevalence of lung cancer
Lung cancer is the third most common cause of death in men, and accounts for about 25 per cent of all cancer deaths (NHS Executive, 1998). Cigarette smoking accounts for around 90 per cent of cases. Survival depends on the type of cancer, the person's age and their general level of health, but only 5.5 per cent of patients survive for five years.
Lung cancer can be broadly divided into two types: small cell (SCLC) and non-small cell (NSCLC). Correct staging of the disease is imperative if the patient is to receive appropriate treatment.
SCLC is associated with a poor prognosis and is often advanced at the point of diagnosis. In this instance, palliative care is appropriate and should focus on improving quality of life, relieving symptoms and providing psychosocial support. NSCLC has better survival rates, but for most patients a cure remains elusive. Surgery is appropriate for around 10-15 per cent of patients with NSCLC and a further 10 per cent benefit from radical radiotherapy.
Most patients with early-stage NSCLC are offered surgery or radiotherapy rather than chemotherapy, which is thought to have little therapeutic benefit (Bailey, 2001). Most patients with either type of lung cancer are treated palliatively, which often improves survival and quality of life (Hoyal et al, 2002). Surgery is primarily reserved for patients with early-stage NSCLC (stage I or IIa), though it carries an inherent risk to life (5 per cent), and those planning treatment must be certain that the disease is localised and that the staging is accurate. This is crucial if 'open and shut' cases are to be reduced to European and North American levels (NHS Executive, 1998).
The patient and his or her family should be able to discuss the risks and benefits of surgery with the multiprofessional team, who should offer realistic information based on individual circumstances. This may involve acknowledging the uncertainty associated with the outcome and survival after surgery. Life-threatening complications occur in 10 per cent of cases and side-effects such as pain may be present for several years postoperatively (NHS Executive, 1998).
Radiotherapy in NSCLC may be appropriate when the patient declines, or is not fit for, surgery. Radical treatment is normally indicated for localised disease. Most patients are given continuous hyperfractionated accelerated radiation therapy (CHART), which involves receiving treatment three times a day for 12 days. The toll on physical and psychological well-being must be explained to patients - it can include excessive tiredness, soreness and haemoptysis. CHART is expensive, as patients need to stay in hostel-type accommodation and receive treatments outside of working hours, but the improvement in outcome is significant. Preoperative radiotherapy is not associated with increased survival and postoperative radiotherapy is harmful.
Palliative treatment involves pharmacological and non-pharmacological approaches to alleviate the symptoms. Supportive radiotherapy is used to ease obstruction caused by tumour growth. Other interventions might include treatment of anaemia, infection or reversible symptoms caused by pleural effusion. Involving the patient and relatives is important when the treatment goals shift from curative to palliative care. This is when the patient may experience feelings of abandonment and hopelessness. The multiprofessional team must be familiar with referral criteria and the availability of specialist services locally. Staff should endeavour to discuss sensitive issues openly and maintain a commitment to the patient and family. Palliative care is provided in the community, hospitals and nursing homes, with only a small minority of patients requiring care in a hospice. This places general nurses in the forefront of care, supported by specialist palliative care professionals who offer advice either directly or indirectly.
Assessment of advanced lung cancer
In many cases, assessment is a slow and complex process of careful and active listening. Irrespective of the care setting, the striking feature of the symptoms, including anxiety, fatigue and agitation, is the difficulty in distinguishing one from another.
The following example shows how nurse and patient perception of a given situation can differ - the patient is 73 years old and has advanced cancer of the bronchus. His respiratory rate is 30 breaths per minute and he is 'mouth-breathing' using his shoulders and upper chest muscles. He is holding his oxygen mask tightly round his face and looks anxious. The nurse asks if he requires medication for his breathlessness. The patient declines and says he feels 'champion' and is pleased he managed to get out of bed for the first time in a week. He asks if she could help him have a bath later in the day when the ward is quieter.
Mismatches between what the nurse observes and how the patient feels, as described above, are common. For example, oxygen saturation levels may be quantitatively poor and at odds with the patient's self-report of relative well-being. In this respect, nurses need to be careful not to assume they know what the patient needs based solely on what they see.
This example reflects the findings of Krishnasamy et al (2001), suggesting quality of life is often reasonably high in lung cancer patients even when the burden of illness is extensive. It echoes the findings of Sutcliffe and Holmes (1996), who suggest professionals and families often interpret symptom distress very differently, leading to an inadequate assessment and a lack of relief for the patient.
A comprehensive and holistic approach to assessment will enable nurses and other professionals to develop strategies for care that maximise an individual's capabilities and coping mechanisms when experiencing symptoms such as breathlessness, one of the most distressing aspects of lung cancer (Hoyal et al, 2002).
This symptom presents differently in each patient. Patients may feel as if they are choking or suffocating, or they may worry that if they slow their breathing down, they will receive less air. It is crucial to instil a feeling of confidence in patients' ability to control breathlessness, rather than allow it to control them. The manifestations of breathlessness can be ameliorated through coping techniques. This involves recognising that breathlessness is determined by a mixture of psychological, physical and emotional elements, and may cause patients to limit their mobility, breathe rapidly (using ancillary muscles) and become anxious. In time, without supportive interventions, feelings of helplessness and a sense of being a burden may affect a patient's quality of life.
Nurses can assist a lung cancer patient who is experiencing breathlessness in a number of ways (Bailey, 2001). These include:
- Assessing the causes of breathlessness - such as triggers - and interventions that help;
- Finding out what the patient and family make of the breathlessness and the meaning attached to the illness (nursing therapeutically involves the conscious use of self within this relationship);
- Providing information on breathing techniques such as distraction therapies, auditory and visual aids and abdominal breathing;
- Employing task management techniques: planning activities based on the patient's priorities;
- Setting goals in terms of social and functional abilities (the first goal in the example cited above was for the patient to get out of bed and the second was to have a bath, which helped him cope with his breathlessness);
- Teaching patients how and when to use pharmacological interventions (such as the use of bronchodilators and analgesia).
This approach will enhance a patient's perception of well-being, and assist in maximising the efficacy of other interventions.
Treating breathlessness with drugs (Hoyal et al 2002; Bailey, 2001) is difficult because the symptoms may be caused by a variety of factors related to the cancer (for instance the side-effects of treatment) or existing or new conditions such as heart disease. For some patients, the exact cause may not be known, so the use of drugs demands a logical and purposeful approach. There are common principles to assist in drug prescription and administration including:
- Balancing side-effects and drug interactions with potential benefit;
- Prescribing medications regularly for recurrent symptoms at the correct interval;
- Evaluating effectiveness continually with the patient, the family and the multiprofessional team;
- Discontinuing unnecessary medications;
- Seeking advice from specialist palliative care nurses and doctors if symptoms are not resolved quickly.
Prevention offers the best way of reducing the incidence of lung cancer because treatment options are limited. There is good news in terms of smoking rates, which have dropped significantly since 1976 (NHS Executive, 1998). However, the overall reduction masks increasing smoking trends, particularly in young girls and women.
There is a plethora of health-promoting activities, ranging from policy-led initiatives requiring nurses to empower local communities to reduce smoking, to TV campaigns offering direct advice to the public.
Patients with suspected lung cancer should be seen by a specialist within two weeks as part of the standard set out in The NHS Cancer Plan (Department of Health, 2000). Funding is now available for treatment planning, equipment and linear accelerators, which will help to reduce waiting times.
The management of lung cancer remains a major challenge. Individual responses to diagnosis and care, whether curative or palliative, make it difficult to predict outcomes. It is vital to understand that behind every outcome statistic is an individual person with unique perspectives and needs.
Health professionals need to use clinical, interpersonal and organisational skills to help patients express their fears and hopes. It requires courage to listen to patients and act on their wishes wisely, compassionately and in a manner that preserves the integrity and individuality of all concerned.