Advanced Cancer

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Managing general symptoms of advanced cancer

The previous section talked about dealing with problems that are caused by cancer spread to certain areas. This section describes some of the other major problems that can be seen in people with advanced cancer. Often these are not caused directly by the cancer or can have more than one cause. You may have some of these problems and symptoms or none of them. (This list is in alphabetical order.)

Anemia

This topic is covered in more detail in the document Anemia in People With Cancer.

Anemia (low red blood cell counts) is common among patients with cancer. It can be caused by the cancer itself, cancer treatments, or deficiencies in iron or certain vitamins.

Cancers, especially when they are advanced, make something that turns off red blood cell production in the body. Some cancers (like lymphoma and multiple myeloma) also sometimes cause the body to destroy red blood cells (called hemolytic anemia). Cancers in the stomach and intestine can bleed, leading to anemia. Cancer can also cause anemia if it spreads to the bone marrow (this is different from spread to bones). Bone marrow is found inside certain hollow bones and contains the cells that make new blood cells. When cancer cells spread to the bone marrow, they can crowd out the cells that make new blood cells, leading to lower blood cell counts. This is most common in lymphoma, but other types of cancer can spread to the bone marrow, too.

Diagnosis

Symptoms of anemia include:

  • Feeling tired and weak
  • Shortness of breath with little activity
  • Being pale
  • Rapid heart beat

Anemia is diagnosed with a simple blood test (the complete blood count or CBC). Other blood tests can be used to see if the body is destroying the red blood cells or if the patient has low levels of iron or certain vitamins. Results of blood tests can lead the doctor to suspect that the cancer has spread to the bone marrow, but in order to know for certain, samples of bone marrow need to be removed for testing. This is called a bone marrow aspiration and biopsy, and was discussed in the section about diagnosing advanced cancer.

Treatment

  • If the anemia is causing symptoms, often the first treatment is to give blood (a transfusion). This might not be as helpful if the body is destroying the red blood cells. (More information about transfusions can be found in our document Blood Transfusion and Donation.)
  • If the patient has low levels of iron or certain vitamins, the patient will be given supplements. If anemia is caused by cancer spread to the bone marrow, treating it (with chemotherapy, for example) can help. There are also drugs that tell the body to make more red blood cells.

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 say why. They may see and hear things that are not really there, lose track of their surroundings, or say things that don’t make sense to others. These symptoms should be reported to the doctor, since 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

Many of these were discussed in the previous section.

Treatment

The best approach to treatment is to find the cause and treat it, when possible. This means a physical exam, often with lab tests to look for signs of infection and blood chemistry problems. Imaging tests may also be needed. Any medicines being taken, especially pain medicines, may be looked at closely and adjusted to see if the confusion changes. If the patient is agitated, sometimes medicines can be given to calm them down.

Constipation

When you are constipated, your stool gets hard, dry, and you have trouble having bowel movements. It can be caused by many of the changes that go along with advanced cancer, such as:

  • Medicines (especially opioid pain medicines, like morphine and oxycodone)
  • Diet changes, including eating and drinking less
  • Decreased activity
  • Changes in blood chemistry, such as too much calcium or too little potassium

Constipation can lead to abdominal (belly) pain and nausea. If severe constipation goes untreated, patients can develop a blockage in their bowel (obstruction). In extreme cases, surgery may be needed to unblock the bowel.

Treatment

Prevention is the best way to deal with constipation when possible. Ways to help prevent or relieve constipation include:

  • Talking to your health care team about the problem before it becomes severe
  • Taking laxatives before the problem starts or gets bad
  • Drinking plenty of fluids
  • Getting plenty of fiber
  • Getting mild exercise, like short walks or even chair exercises

If possible, the cause of the constipation should be found and treated. A physical exam, blood tests, or even imaging tests may be done, depending on what your doctor suspects may be causing it.

Opioid pain medicines (like morphine, oxycodone, and fentanyl) commonly cause constipation. This side effect does not get better over time, and will get worse as the dose of the medicine is increased. Anyone taking an opioid regularly should also be taking something to prevent and treat constipation.

A number of drugs and laxatives are used to help treat constipation. Talk to your cancer care team about what might work best for you. If drug treatments don’t work, your cancer care team may need to look for other more serious possible causes of constipation, such as pressure on the spinal cord or bowel blockage (obstruction).

Depression

You can get more information about this in our document called Anxiety, Fear, and Depression.

Feeling sad and down at times is normal with cancer and the side effects of treatment. But you don’t have to feel down all the time. Depression can be a very serious problem, but it can be treated. Talk to your doctor if you feel down or depressed. A trained mental health professional may be able to help you feel better – no matter what’s making you feel depressed.

About 1 in 4 people with cancer will become clinically depressed. And these numbers are higher in those with advanced cancer. Clinical depression is more than being sad. It can cause great distress and require medical care. Patients, family, and friends should watch for the following symptoms of depression.

  • Ongoing sad or “empty” mood
  • Feeling hopeless and helpless
  • No interest or pleasure in everyday things
  • Less energy, feeling tired, being “slowed down”
  • Trouble sleeping, early waking, or oversleeping
  • Loss of appetite or overeating
  • Trouble focusing, remembering, or making decisions
  • Feeling guilty or worthless
  • Feeling grouchy
  • Crying a lot
  • Thoughts of suicide; trying to kill yourself

Please talk to your doctor or see a mental health professional if you have 5 or more of these symptoms for 2 weeks or longer. Family members and friends should also encourage a patient with these symptoms to get help.

Treatment

Several types of treatment may be helpful, including:

  • Medicine
  • Counseling
  • Social activities
  • Learning new problem-solving skills

People treated for depression are often surprised at how much better they feel. Depression and feelings of sadness can become a way of life, but it doesn’t have to be that way.

Fatigue (tiredness)

For more details than shared here, please see our document Fatigue in People With Cancer.

Fatigue is one of the most common symptoms among cancer patients. It’s a physical, mental, and emotional tiredness that doesn’t 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:

  • Cancer itself
  • Cancer treatment
  • Not eating well or getting enough fluids
  • Pain
  • Feeling stressed or depressed
  • Sleep problems
  • Not having enough red blood cells (anemia)

Treatment

There’s no single cure for fatigue. In each case, treatment is aimed at the cause of the fatigue.

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 money. You want to invest only in what’s most important to you. It may also help to spread out your activities through the day rather than trying to get things done all at once.

Sometimes stimulant drugs can help overcome the feelings of fatigue. Ask your doctor if this is something you could try.

Pain, depression, and sleeping problems can and should be treated. Talk with your doctor if you have any of these problems.

Treatment of anemia was discussed earlier in this section

High calcium levels

High calcium levels (hypercalcemia) are most often caused by cancer that has spread to bones, and so are discussed under the heading “If cancer has spread to bones” in the previous section.

Nausea and vomiting

You can get more information on nausea and vomiting in our document called 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. Some pain medicines can cause nausea. This usually gets better as your body gets used to the drug, but medicines to treat nausea can also help. 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 they can be treated.

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

Treatment to help prevent or relieve nausea

  • Try bland foods, such as dry toast and crackers.
  • Drink plenty of liquids. Try ice pops, gelatin, broth, or cold clear liquids.
  • Eat several small meals and snacks if you get sick only between meals.
  • Eat things that smell pleasant to you, like lemon drops or mints.
  • Eat food cold or at room temperature to make the smell and taste weaker.
  • Ask your doctor about medicines to help with nausea and use them as directed. Do not wait until the nausea is bad 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 in case you vomit. You don’t want to breathe it in or swallow it.
  • Ask your doctor about medicines to help with vomiting and use them as directed.
  • 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 tablets that dissolve under the tongue, suppositories (drugs that you take through your rectum), skin patches, or gels that are put on the skin.
  • 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. Then, try small amounts of 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 a part of cancer treatment that they can’t avoid. This is not true. A number of drugs work very well to prevent and treat nausea and vomiting. Work with your doctor to find the right drugs for you.

Pain

We have more detailed information on how to manage pain in our document called Guide to Controlling Cancer Pain.

Many patients with advanced cancer have pain. For these people, controlling pain is an important goal 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 with pain medicines

Medicine taken by mouth is the most common way to treat cancer pain. 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 you with milder pain relievers like acetaminophen (Tylenol®) or nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin®). These drugs can be very helpful in treating some kinds of 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 often the best drugs to control cancer pain. Unless you have a history of drug or alcohol abuse, it’s very unlikely you will become addicted to opioids if you use them as directed for pain. Talk to your doctor or nurse about any concerns you might have about using pain medicines.

If you have pain that does not go away, 2 or more drugs are often used together. Your doctor may prescribe a long-acting pain reliever for you to take regularly, along with another shorter-acting medicine to take if you have “breakthrough” pain. It’s very important that you take the pain medicine regularly. This allows you to keep a steady level of it in your body without extreme highs and lows. It helps 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’ll have to take much more just to get the pain under control.

Opioids can make you sleepy. 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.

These drugs can also cause nausea and constipation. Constipation will not go away or get better on its own over time. If you are on opioids, you will need to take laxatives regularly, usually every day. Constipation can also be helped by using stool softeners regularly, eating a high-fiber diet, drinking plenty of liquids, and being as active as possible.

The best treatment for you depends on the type of pain you are having and how bad it is. Be sure to 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.

Some people need much higher doses of opioids than others. Don’t 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 addicted. Sometimes the dose goes up because the cancer is growing and causing more pain. Another reason 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 serious side effects. If this happens, it often helps to switch to a different opioid drug.

Other ways doctors can treat pain

Intrathecal pain pump

For patients whose pain isn’t well controlled with pain medicines given by mouth or a patch, other methods may be used. One choice is to give the pain medicine into the spinal canal. A catheter (a thin tube) is put into the space around the spinal cord and hooking it up to a pump that gives a continuous flow of pain medicine. When pain medicines are given this way, much smaller doses are needed than if the drugs are given by mouth or even by vein. This often means better pain control with fewer side effects. The downside is that you have to have a catheter placed which is then left in for some time and could get infected.

Nerve blocks

If cancer is causing pain by growing into a nerve, it may help to deaden the nerve for a time by injecting a numbing medicine (local anesthetic). If that helps, the doctor can inject something to kill the nerve.

Other ways of coping with cancer pain

There are other things you can do that may help you cope with cancer pain and feel more in control of your situation.

Get information: Knowing why you have a problem and what you can do about it can relieve stress. Don’t be afraid to ask why something is happening.

Take action: Doing something, sometimes anything, about a problem can help you feel more in control. For example, if the new drug you are taking for your pain isn’t helping, ask to try something else.

Distract yourself: Getting your mind off the pain is always a good idea. When you are focused on your pain it usually hurts more. If you are watching an interesting movie while in pain and waiting for the pain medicine to work, you might even forget about it for a while. Visits from friends and family can serve the same purpose.

Take it one step at a time: It’s easy to get overwhelmed if you focus on all the discomforts at once. Tackling one problem at a time makes it seem more possible that all the problems can be helped.

Talk with others: Sometimes, it’s a relief just to talk about how discouraged and frustrated you feel about your symptoms. Many people are good listeners and can listen without passing judgment or giving advice.

Express yourself in other ways: Talking isn’t easy for some. Writing in a journal, painting, or meditating may be other ways for you to express your feelings. For many people, humor is a good coping skill for rough times. Even when life seems bleak, there’s usually something that can lighten the mood and relieve stress.

Practice meditation: By focusing your mind on pleasant scenes you can direct your attention away from unpleasant feelings and thoughts. These mini-vacations may allow you to get a needed rest, both physically and emotionally.

Skin problems

People with long-term illnesses often get skin problems from sitting or lying too long in one position. These can become serious if they lead to infections. 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 plan to meet your 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.

Weight loss and not eating well

As cancer gets worse, many people feel weak, don’t feel like eating, and lose a lot of weight. This is often caused by the cancer itself and is not within the patient’s control. 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 keep losing 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’s very hard to treat this problem. Getting nutrients through a feeding tube can be uncomfortable and isn’t always helpful. Feeding through an IV (intravenous) line into a vein is also often not helpful. And it can burden patients with needles, tubes, and other supplies.

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

One drug that has been helpful is megestrol (Megace®). 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. Sometimes, corticosteroid drugs like prednisone are helpful, too.

Nausea, constipation, and depression can also lead to poor appetite. Treating these problems can often help.


Last Medical Review: 02/07/2014
Last Revised: 03/06/2014