This section describes the major problems that can happen with advanced cancer. You may have some of these problems and symptoms or none of them. The section "Problems grouped by location of cancer," describes problems that are related to specific types of cancer.

Broken bones (fractures)

When cancer moves into bones, it can make them weak, so that they are more likely to break (fracture). Fractures occur most often in the leg bones near the hip because these bones support most of your weight. Cancer in the bone may cause severe pain for a while before the bone actually breaks. If an x-ray is taken at that time, it may show that the bone is likely to break.

Treatment: The best approach is to prevent the fracture. This is done with surgery to put a metal rod through the weak part of the bone. They do this while you are in a deep sleep (under general anesthesia).

If the bone has already broken, then something else will be done to support the bone. Usually surgeons put a steel support over the fractured area of the bone.

Radiation treatments may also be given to prevent any more damage. Usually about 10 to 15 treatments are needed, although some doctors give the total dose of radiation in only 1 or 2 treatments. The radiation therapy will not make the bone stronger, but it may stop further damage. After radiation surgery may still be needed to prevent a fracture.

If bones of the spine (the vertebrae) are fractured, vertebroplasty may be used to support them. In this procedure an acrylic cement is injected into the damaged bones of the spine. The area is numbed first and an imaging scan, like a CT scan, is used to guide the needle to the right place. Vertebroplasty often reduces pain right away and can be done in an outpatient setting.

Medicines you take or the cancer itself may make you confused, dizzy, or weak. This can lead to falls and accidents. Falls can cause fractures, especially in bones made weak by the cancer. Talk with your cancer care team about safety equipment you can use at home. Some things that you might find helpful are shower chairs, walkers, and handrails.

Blocked bowel (bowel obstruction)

When cancer blocks either the small intestine or large intestine (colon), digested food or stool cannot move through. This is called bowel obstruction. The symptoms include severe cramping, belly (abdomen) pain, and vomiting. The vomit may contain digested food, bile, and sometimes stool. Bowel obstruction occurs most often with abdominal or pelvic cancers.

Treatment: It is very hard to solve this problem with surgery, and many patients are too sick to go through surgery. Others have such a poor outlook that surgery may not help much. Most studies have shown that patients with advanced cancer who develop this problem live only a short time. The decision to have surgery should be weighed against the chances of returning to a comfortable life.

An operation called a colostomy may help if only the colon is blocked. In this operation the surgeon cuts the colon above the blockage. The cut end is then brought to the outside of the abdomen. Your stool can empty into a bag that is put around the opening.

If the bowel is blocked in only one area, a small, stiff tube called a stent may be able to be placed through the blocked area to keep it open. This can be an option for blockages of the colon and the small intestine.

Treating only the symptoms is often the best choice for many patients. This is called supportive care. For example, the stomach’s contents can be removed through a tube placed through your nose (called a nasogastric or NG tube) which is attached to a suction device. This often relieves nausea and vomiting. If this helps, the NG tube can be replaced by a tube that goes directly into the stomach through the skin. You would also need to stop eating and to drink only small amounts to relieve thirst. If needed, you can take medicines for pain and nausea as a shot (injection) or as a patch.

Confusion

People with cancer that is getting worse often become restless, anxious, depressed, irritable, or angry. The person may look sleepy and not respond to questions one minute, but be wide awake and alert the next. Or they may be loud and agitated but unable to tell you why. They may see and hear things that are not really there, and say things that don't make sense to others. These symptoms should be reported to the doctor, since this kind of confusion can often be treated.

Many different things can cause confusion:

• liver disease
• bowel blockage (obstruction)
• bladder blockage
• medicines
• medicine withdrawal
• low blood sugar
• cancer that has spread to the brain
• infection
• pain
• blood chemistry changes, such as too much calcium

Treatment: There are many ways to treat confusion, but the best approach is to find the cause and treat it. A physical exam will be done and x-rays may be taken. Blood tests may be done to look at how well the organs are working and check the blood chemistry. Medicines, especially pain medicines, may be looked at closely and adjusted to see if the confusion changes.

Constipation

Constipation is when stool gets hard, dry, and you have trouble passing it out of your body. It can be caused by many of the changes that go along with advanced cancer, such as:

• medicines (especially opioid pain medicines, such as morphine)
• diet changes, including eating and drinking less
• decreased activity
• blood chemistry changes, such as too much calcium or too little potassium

Treatment: Preventive measures are the best way to deal with constipation. Prevention includes

• talking to your health care team about the problem before it becomes severe
• taking laxatives before the problem starts
• drinking enough fluids
• getting plenty of fiber
• mild exercise, like short walks or even chair exercises

If possible, the cause of the constipation should be found and, treatment should be aimed at it. A physical exam, blood tests, or even x-rays may be done, depending on what your doctor suspects may be causing the constipation.

A number of drugs and laxatives can be used to treat constipation. Talk to your cancer care team about what might work best in your situation. If you don't respond to treatment, your cancer care team may need to look for other more serious possible causes of constipation, such as pressure on the spinal cord and bowel blockage (obstruction).

Fatigue (tiredness)

Fatigue is one of the most common symptoms reported by cancer patients. It is a physical, mental, and emotional tiredness that does not get better with rest. It can make it hard for you to find the energy to do the things you normally can or want to do. Fatigue can be caused by:

• the cancer itself
• the cancer treatment
• not eating well
• pain
• feeling stressed or depressed
• sleep problems
• not enough red blood cells (anemia)

Treatment: There is no one cure for fatigue. In each case, treatment is aimed at the cause of the fatigue.

Blood transfusions can help some patients who have low red blood cell counts (anemia). Other patients can take medicines that help the body make more red blood cells. Talk with your doctor about treatment choices for very bad anemia.

Light or medium exercise with a lot of rest breaks in between can often help with fatigue. You can also save energy by doing what needs to be done first and letting other things wait. Try to think of energy as gold. You want to invest only in what’s most important to you. It may also help to spread your activities all through the day rather than trying to get things done all at once.

Sometimes stimulant drugs can help to overcome the feelings of fatigue. Talk to your doctor about whether this is something you could try.

For more information, please see our documents, Anemia in People With Cancer and Fatigue in People With Cancer.

Hypercalcemia: Too much calcium in the blood

Cancer patients may have too much calcium in their blood for many reasons. Most often, it is related to cancer that has spread to the bones. This causes calcium to be released from the bones into the bloodstream. Other times the cancer cells make a substance that causes high calcium levels. Blood levels of calcium can get so high that it is dangerous.

Early symptoms of too much calcium include:

• constipation
• passing urine very often
• feeling sluggish
• feeling thirsty all the time and drinking large amounts of fluid

Late signs and symptoms are muscle weakness, muscle and joint aches, confusion, coma, and kidney failure.

Treatment: Giving fluids and drugs like pamidronate (Aredia^®) or zoledronic acid (Zometa^®) can quickly bring blood calcium down. These are usually given into the veins by IV (intravenous) infusion.

If the cancer can’t be treated, the calcium level will go back up again and again need to be treated. Sometimes a high blood calcium level can be the first sign of cancer. In this case, treating the cancer will also treat the calcium problem.

Nausea and vomiting

Advanced cancer can cause nausea and vomiting, either from treatment or from the cancer itself. Nausea and vomiting are most often caused by cancer treatment and get better over time after treatment is finished. Nausea can also be caused by some pain medicines. This usually gets better as your body gets used to the drug, but can also be helped with medicines to treat nausea. Constipation can also lead to problems with nausea, so preventing and treating constipation is very important. Nausea and vomiting can be problems for many cancer patients, but there is effective treatment for them.

Too much vomiting can be dangerous. It can cause you to lose too much water (dehydration) or to breathe in food or liquids (aspiration).

Treatment for nausea

• Try bland foods, such as dry toast and crackers.
• Drink as much as you can. Try Popsicles, gelatin, broth, or cold clear liquids.
• Eat several small meals and snacks at bedtime if you get sick only between meals.
• Eat things that smell pleasant, like lemon drops or mints.
• Eat food cold or at room temperature to make the smell and taste weaker.
• Ask the doctor about medicines to help with nausea and use them as directed. Do not wait until the nausea is severe before taking a drug to fight it.
• Try to rest quietly with your head elevated for at least an hour after each meal.
• Learn meditation and relaxation techniques.
• Distract yourself with soft music, a favorite TV program, or company.

Treatment for vomiting

• If you are in bed, lie on your side so that you won’t breathe in or swallow your vomit.
• Sometimes taking a medicine by mouth (orally) can bring on nausea or vomiting. Your doctor may be able to prescribe your medicines in a different form instead. Some medicines are available as suppositories, skin patches, or gels that are applied to the skin. (Suppositories are drugs that you can take through your rectum. The medicine in the suppository is absorbed into the blood stream and then travels to the brain to stop the nausea.)
• Learn meditation, self-hypnosis, and relaxation techniques.
• Eat ice chips or frozen juice chips that you can munch on slowly.

Things to avoid

• Don’t force yourself to eat or drink when you have an upset stomach or are vomiting.
• Don’t lie flat on your back.
• Stay away from foods that have strong smells.
• Don’t eat foods that are sweet, fatty, salty, or spicy.
• Stop eating for 4 to 8 hours if you are vomiting a lot. After that time, try clear liquids.

Call the doctor if you

• breathe in or swallow vomit
• throw up more than 3 times an hour for 3 hours or longer
• see blood or something that looks like coffee grounds in your vomit
• can’t keep down more than 4 cups of liquid or ice chips in a day
• can’t eat for more than 2 days
• can’t take your medicines
• feel weak or dizzy

Many people think that nausea and vomiting are just a part of cancer treatment that they can't avoid. This is not true. There are a number of drugs that work very well to prevent and treat nausea and vomiting. Work with your doctor to find the right drugs for you. For more information on how to manage nausea and vomiting see our document, Nausea and Vomiting.

Pain

Many patients with advanced cancer have pain. For these people, controlling pain and managing symptoms are important goals of treatment. There are many ways to ease pain caused by cancer. Sometimes pain is relieved by treatments that kill cancer cells (like chemo or radiation therapy) or slow their growth (like hormone therapy or bisphosphonates). Don’t be afraid to use medicines or other treatments, including complementary therapies, to help with your pain. Getting effective pain relief will help you feel better. It will make it easier for you to focus on the things that make you happy and are important in your life. Some studies show that cancer patients who get effective pain treatment may live longer than those who do not. The first and most important step is letting your cancer care team know about your pain. Do not accept it as normal.

Treatment: Medicine taken by mouth is the most common way to treat pain. Often 2 or more drugs are used together. If you become unable to take medicines by mouth, there are many other ways you can get them, such as through the skin in a patch, in shots, or in a vein. Other ways to help with pain include massage, heat and cold, and changing your body position.

Your doctor may start with drugs such as acetaminophen (Tylenol^®) or nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin^®). These drugs can be very helpful in treating bone pain. If these aren’t helping, you will likely be given an opioid such as codeine, hydrocodone, morphine, or oxycodone. Codeine and hydrocodone are considered "mild" opioids, while morphine and oxycodone are stronger. Opioids are considered the best drugs for helping cancer patients control their pain. Unless you have a history of drug or alcohol abuse, you can take these drugs without worrying about getting addicted. It is rare for cancer patients to develop addiction to opioids. Talk to your doctor or nurse about any concerns you may have about using pain medicines.

With all pain medicines, it is very important that you take the medicine regularly. Here's why:

• taking a medicine regularly allows you to keep a steady level of it in your bloodstream without extreme highs and lows. This helps to keep your pain under control while lowering many of the side effects (like nausea and feeling sleepy).

• if you wait until the pain is bad to take the medicine, you will have to take much more just to get the pain under control

Opioids can make you sleepy. They can also cause nausea and constipation. Most of the sleepiness goes away after a few days. But it may not go away if you are taking high doses. You may have to choose between having less pain and being drowsy or having more pain and being more alert. The constipation does not go away or get better with time. It can be helped by regular use of stool softeners, a diet high in fiber, drinking plenty of liquids, and being as active as possible. Still, if you are on opioids, you will need to take laxatives regularly. Most people need to take one or more laxatives every day.

The best treatment for you depends on the type of pain you are having and how bad it is. Tell your cancer care team if the methods that you are using are not working. You may need to add a new medicine, try a different medicine, try a different schedule, or adjust the dose.

Also, some people require much higher doses of opioids than others. Do not be concerned about needing to take large amounts of drugs. It has nothing to do with your being intolerant of pain or a “complainer.” It just means that your body needs more medicine than average. Often the dose of opioid needed goes up over time. This does not mean that you have become an "addict." Sometimes the dose goes up because the cancer is growing and causing more pain. Another reason that you may need a higher dose is that your body has become tolerant of the drug. This is only really a problem if the dose you need causes severe side effects. If this happens, it often helps to switch to different opioid drug

We have more detailed information on how to manage pain in our document, Pain Control: A Guide for Those with Cancer and Their Loved Ones.

Paralysis because of pressure on the spinal cord

Cancer sometimes spreads to the bones in the spine. As the tumor grows, it can put pressure on the nerves in the spinal cord. This is called spinal cord compression. Symptoms can range from pain to weakness and paralysis (not being able to move). This also can affect the nerves to your bladder so you will have trouble urinating. Early treatment can help reduce permanent nerve damage.

Symptoms to watch for

• trouble passing urine
• numbness or weakness in your legs
• very bad pain in the middle of your lower back

Tell your doctor right away if you have these symptoms. An MRI can usually tell if the cancer is pressing on your spinal cord. This is considered a medical emergency and treatment needs to begin right away.

Treatment

• steroids (prednisone or dexamethasone) to bring down the spinal cord swelling (and treat pain)
• radiation therapy to shrink the tumor causing the problem
• surgery to remove all or part of the tumor

Skin problems

People with long-term illnesses often get skin problems from sitting or lying too long in one position. Cancer patients may also get skin problems from:

• not eating well
• not being able to move around
• swelling
• some cancer treatments

Treatment

Talk with your cancer care team. They can recommend a skin care program for your special needs. The most important things you can do are change positions often when you are sitting or lying down and keep your skin clean and dry.

Superior vena cava syndrome: Blocked blood flow to the heart

The main vein that returns blood to the heart from the upper body is called the superior vena cava. It runs through the upper middle chest. Tumors in the chest or lung can grow large and press on this vein, blocking the blood flow. This will cause blood to back up in the lungs, face, and arms.

Symptoms include:

• shortness of breath
• a feeling of fullness in the head
• swelling in the face and arms
• coughing
• chest pain
• facial redness
• swollen neck veins

Treatment

Radiation therapy and/or chemo are often used to shrink the tumor. If this is not possible, you may have a metal tube (stent) placed in the vein to keep it open. This tube is put in through a large vein in your arm or neck and then threaded through the obstruction.

Trouble breathing

Trouble breathing can be caused by a tumor blocking the airway or by a build-up of fluid around the lungs. Some patients with a very low red blood cell count (severe anemia) may also feel short of breath. A tumor blocking blood flow to the heart is another possible cause. (See the section," Superior vena cava syndrome: Blocked blood flow to the heart," above.) Chronic lung diseases, such as emphysema, and other diseases not related to cancer can also make it hard to breathe. All of these problems either prevent the lungs from breathing in enough air, or keep them from getting enough oxygen for the cells of the body.

Treatment: When it’s possible, treating the cause will help relieve shortness of breath. Sometimes external beam radiation or laser treatment (given through a flexible tube that is passed through your mouth into your lung) can shrink a tumor in the lung.

Patients with fluid around the lungs may feel better after having this fluid removed. After numbing the skin, the doctor places a needle into the chest and drains the fluid.

Oxygen can be very helpful. It is breathed in through a little tube that goes under your nose or through a mask that goes over your mouth and nose.

Opioids like morphine are the most helpful drugs to relieve the feeling of shortness of breath. Anti-anxiety medicines, like Valium^®, can also help to reduce cough and ease the distress caused by shortness of breath. Sometimes medicines that help dry up mucus in the lung can help, too.

Having trouble breathing can make you feel anxious, worried, and even like you are in a panic. Some patients find these complementary methods helpful to ease the anxiety that can come with breathing problems:

• relaxation methods
• biofeedback
• guided imagery
• therapeutic touch
• aromatherapy
• music and art therapy
• distraction (watching movies, television, reading, etc.)
• a fan blowing air on you

Talk to your cancer care team or call us if you would like to learn more about any of these.

Weight loss and not eating well

As cancer gets worse, many people feel weak, lose their appetite, and lose a lot of weight. This is often caused by the cancer itself and is not within the control of the patient. The patient understands the importance of eating and may want to eat to help themselves, but they cannot force themselves to eat. Even if they do eat, they may continue to lose weight.

The reason for this is not known, but it may be caused by:

• substances released by the cancer into the blood that lower appetite and cause the body to burn more calories

• no longer being able to absorb nutrients from food

Treatment: It is very hard to treat this problem. Feeding through an IV (intravenous) tube rarely helps. And it can burden patients with needles, tubes, and other supplies. Feeding through a stomach tube is also uncomfortable and rarely helpful.

Sometimes, the best thing you can do is to eat smaller amounts more often. Avoid low-calorie or low-fat foods. Eat whatever appeals to you. This is the time for high-calorie foods and vitamins.

One drug that has been helpful is Megace^® (megestrol acetate). In high doses, it can bring back appetite in some patients. Drugs that help the stomach empty, such as metoclopramide (Reglan^®), can also help improve your ability to eat. Nausea, constipation, and depression can also lead to poor appetite. Treating these problems can also be helpful.

Last Medical Review: 01/28/2009
Last Revised: 01/28/2009