- Advanced Cancer
- What is advanced cancer?
- What is metastatic cancer?
- Can advanced or metastatic cancer be prevented?
- How is advanced cancer found?
- How is advanced cancer treated?
- Surgery for advanced cancer
- Ablative techniques for advanced cancer
- Radiation therapy for advanced cancer
- Drug treatment for advanced cancer
- Clinical trials
- Complementary and alternative therapies for advanced cancer
- Managing symptoms of advanced cancer, by location
- Managing general symptoms of advanced cancer
- What should you ask your doctor about advanced cancer?
- Coping with advanced cancer
- Sources of support
- Choices for palliative care
- Advance directives
- Additional resources for advanced cancer
- References: Advanced cancer
Managing symptoms of advanced cancer, by location
This section will cover the symptoms you might have when advanced cancer is in different places in your body. Not everyone will get all the symptoms, and some of the information here may not apply to you. Your doctor can tell you the most about where the cancer is and what symptoms it might cause.
If the cancer is in the abdomen (belly)
Fluid in the abdomen (ascites)
Some cancers can cause fluid to build up in the abdomen (called ascites [ah-site-eez]). This can make your belly swollen and feel uncomfortable. The fluid can also push on your lungs and make it hard to breathe.
The doctor can remove the fluid with a long, hollow needle (called paracentesis). This relieves the problem for a while, but it often comes back unless the cancer is treated and gets better. If the fluid keeps coming back, sometimes a thin, flexible tube called a catheter can be put through the skin and left in place to let the fluid drain out without having to use a needle over and over.
Cancer in the abdomen can sometimes block the intestines. This is called bowel obstruction. The blockage keeps digested food or stool from moving through. This leads to severe cramping, belly pain, and vomiting. If the blockage isn’t relieved, the pressure that builds up can cause a hole to form in the intestine (a perforation) that lets the contents of the intestine spill into the abdominal cavity. This spreads the bacteria from the intestine into the abdominal cavity, leading to a severe infection. This leads to even worse pain with nausea and vomiting. This is very serious and can be fatal.
If your doctor suspects a bowel obstruction (or perforation), he or she will order x-rays or a CT scan of the abdomen.
It’s often very hard to solve this problem with surgery, because many patients are too sick to have an operation. Others may have cancers that are so advanced that even if they can have surgery, it may not help for long. The decision to have surgery should be weighed against the chances of returning to a comfortable life.
An operation called a colostomy (kuh-lahs-tuh-me) may help if only the colon (large intestine) is blocked. In this operation the surgeon cuts the colon above the blockage. The cut end is then connected to an opening (stoma) on skin of the abdomen (belly). Stool then comes out into a bag that’s put around the opening.
If the bowel is blocked in only one area, a small, stiff tube called a stent may be put into the blocked area to help keep it open. This can be an option for some blockages of the colon and the small intestine, as it does not require surgery.
If surgery or stents to relieve the blockage aren’t practical, treatment of the symptoms is often a good 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 and may help keep pressure from building up and causing a perforation.
If an NG tube is helping, it sometimes it can be replaced by a tube that goes right into the stomach through the skin (called a G tube). You would also need to stop eating and would drink only tiny amounts to relieve thirst.
If needed, you can get a shot (injection) or a patch for pain and nausea. A drug called octreotide (Sandostatin®) can also stop the production of digestive juices and improve some of the symptoms that go along with a blocked bowel.
Cancer in the abdomen can also sometimes block the thin tubes that carry urine from the kidneys to the bladder. (These tubes are called the ureters [your-uh-ters].) If this happens, you may stop urinating. The urine then backs up in the kidneys, and they stop working. This often makes you feel very tired and sick to your stomach.
The doctor may suspect kidney blockage based on symptoms and order lab tests of kidney function. If these are abnormal, an ultrasound or a CT scan of the kidneys may be done to look for signs of blockage.
In many cases, a small tube called a stent can be threaded up from the bladder and through the ureters to keep them open and allow urine to flow again. Another option is to put a tube through the skin and right into the kidney to allow the urine to drain into a bag outside the body. This is called a nephrostomy (neh-frahs-tuh-me).
If cancer has spread to bones
This topic is covered in more detail in our document, Bone Metastasis.
Cancer spread to bone is sometimes found with x-rays or other imaging tests before the person has symptoms. It’s often treated with drugs such as a bisphosphonate or denosumab to help prevent (or delay) problems.
The main symptom from cancer spread to the bones is pain. Even though the cancer may have spread to many places in the bone, it usually only hurts in a few of them.
- Drugs that strengthen bones or slow bone destruction (bisphosphonates or denosumab)
- Radiopharmaceuticals, such as strontium-89, that are given into a vein (discussed in the section about radiation)
- Radiation therapy to especially painful bones
- Ablative techniques (discussed in the section “Ablative techniques for advanced cancer”)
When cancer moves into bones, it can make them weak and more likely to break (fracture). Fractures can occur in any bone, but they often occur 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.
To lower the risk of broken bones:
- Stay away from activities that are hard on your bones (examples: heavy lifting, jogging).
- Ask your doctor about drugs that strengthen bones (such as bisphosphonates or denosumab).
- Any very weak bones may need a protective rod put in by a bone surgeon.
It’s also important to do what you can to lower your risk of falling, which could lead to broken bones:
- Use a cane or walker as needed to keep you steady.
- If you need it, ask for help walking.
- Keep walkways clear.
- Do not change position quickly. This can cause dizziness or unsteadiness. Sit on the side of the bed for a minute or so before standing up.
- Wear rubber-soled slippers or shoes when walking or standing.
- Talk with your cancer care team about safety equipment you can use at home. Some things that you might find helpful are shower chairs and handrails.
When possible, the best approach is to prevent the fracture. This is usually done with surgery to put a metal rod through the weak part of the bone to support it. This is done while you are under general anesthesia (in a deep sleep and unable to feel pain).
If the bone has already broken, then something else will be done to support the bone. Usually surgery is done to put a steel support over the fractured area of the bone.
Radiation treatments may be given after surgery to try to prevent any more damage. Usually about 10 treatments are needed, but some doctors give the total dose of radiation in only 1 or 2 treatments. The radiation will not make the bone stronger, but it may help stop further damage.
If bones of the spine (the vertebrae) are fractured, vertebroplasty (ver-tee-bro-plas-tee) may be used to support them. In this procedure a type of bone cement is injected into the damaged bones. The area is numbed first and an imaging scan, such as 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.
High blood calcium levels
When cancer spreads to the bones, large amounts of calcium can be released in the blood, leading to high calcium blood levels. This is called hypercalcemia (hy-per-kal-see-mee-uh). High calcium levels can also occur in certain types of cancer because the cancer cells abnormally raise vitamin D levels or make a hormone that acts like parathyroid hormone.
Small increases in calcium levels may cause no problems or symptoms, but high levels can be dangerous.
Early symptoms of too much calcium include:
- Being constipated
- Urinating very often
- Feeling sluggish or sleepy
- Feeling thirsty all the time and drinking large amounts of fluid
Late signs and symptoms can include muscle weakness, muscle and joint aches, confusion, coma, and kidney failure.
High calcium levels affect the kidneys, leading to patients urinating too much and becoming dehydrated. The dehydration worsens the high calcium levels. That is why giving large amounts of intravenous (IV) fluids is a main part of the treatment. Bisphosphonate drugs like pamidronate (Aredia) or zoledronic acid (Zometa) are also used to bring blood calcium levels down quickly. These drugs are given into the vein and may be repeated monthly. Other drugs can be used if these don’t work. Treating the cancer itself can also sometimes help treat the calcium problem. If the cancer can’t be treated, the calcium level may go back up and need to be treated again.
Pressure on the spinal cord (spinal cord compression)
Cancer sometimes spreads to the bones in the spine. As the tumor grows, it can put pressure on the nerves in the spinal cord so that they become damaged. This can lead to numbness and weakness in the area of the body below the tumor. If it isn’t treated, it can progress to paralysis (inability to move) and complete loss of feeling. Most often this affects the legs, so that the patient can lose the ability to walk. If the tumor is pressing on the spinal cord in the neck, though, both the arms and the legs can be affected. Tumors pressing on the spinal cord can also affect the nerves to your bladder and rectum, which can lead to trouble passing urine and stool. Patients may feel constipated. Early treatment is important to help reduce permanent nerve damage and prevent paralysis.
Symptoms to watch for
- Severe back pain (this is usually the first symptom), especially if it’s in the middle of your lower back
- Numbness or weakness in your legs
- Trouble urinating or losing control of urine (often with new or worsening constipation)
Tell your doctor right away if you have these symptoms. An MRI is the most helpful test for seeing if cancer is pressing on the spinal cord. CT is used for patients who can’t have an MRI.
This is a medical emergency, and it needs to be treated right away.
- Drugs called corticosteroids (prednisone or dexamethasone) will be given to reduce spinal cord swelling. This will help with pain and help prevent further nerve damage.
- Surgery to remove all or part of the tumor and to make the spine more stable may be needed right away in some cases.
- Radiation therapy is often given to shrink the tumor.
If cancer has spread to the brain
The most common symptoms of cancer in the brain are headache or not being able to move part of your body, like an arm or leg. Other symptoms can include sleepiness or problems hearing, seeing, and even urinating. Seizures are another possible symptom of cancer in the brain. They aren’t common, but they can be very upsetting and scary for you and those around you.
MRI is generally the best test to find cancer in the brain. CT scans can also be helpful, especially if the patient has sudden symptoms which could also be caused by a stroke or if they can’t get an MRI.
Steroid drugs, such as dexamethasone, reduce the swelling around the tumors and often help with symptoms right away. If the patient had a seizure, medicine will be given to help prevent more of them. If there are only 1 or 2 areas of cancer spread in the brain, they may be removed with surgery or treated with stereotactic radiosurgery (a type of radiation therapy). Some patients, especially those with many tumors in the brain, are treated with regular external beam radiation to the whole brain.
If cancer has spread to the meninges
Some cancers can spread to the meninges (meh-nin-jeez) – the tissues that cover the brain and spinal cord. (This is called leptomeningeal spread, carcinomatous meningitis, or lymphomatous meningitis.) This can cause weakness in the arms and legs, slurred speech, trouble swallowing, vision problems, and weakness of the facial muscles.
Cancer spread to the meninges may be suspected based on symptoms, but it isn’t seen well on imaging tests like MRI. To diagnose this, the doctor must do a lumbar puncture (spinal tap) to remove some of the fluid that surrounds the brain and spinal cord (called cerebrospinal [suh-REE-bro-spy-nuhl] fluid or CSF). The fluid is looked at under a microscope to see if it contains cancer cells. (Lumbar punctures were discussed in the section “How is advanced cancer found?”)
Most chemotherapy (chemo) drugs given so they enter the blood can’t penetrate into the CSF, meninges, brain, or spinal cord. That’s why the most common treatment for leptomeningeal spread is to inject chemotherapy directly into the cerebrospinal fluid. (This is called intrathecal [in-truh-thee-kuhl] chemotherapy). This can be done during a lumbar puncture or through a device called an Ommaya reservoir.
An Ommaya reservoir is a dome-like device attached to a catheter. The dome part sits under the skin of the scalp, with the catheter going through a hole in the skull and into one of the cavities of the brain (a ventricle). Intrathecal chemo can be given by placing a needle through the skin and into the dome. The chemo goes through the catheter and into the CSF in the ventricle. The CSF in the ventricle circulates through the other ventricles and into the area around the brain and spinal cord. With an Ommaya reservoir, the patient can get intrathecal chemo without having to get repeated lumbar punctures.
Radiation to the brain and spinal cord can also be used to treat cancer that has spread to the meninges.
If cancer has spread to the liver
Cancer in the liver can make you lose your appetite and feel tired. Some patients feel pain in the upper right part of the abdomen (belly), where the liver is. Usually the pain isn’t bad and is less of a problem than the tiredness and appetite loss.
If there’s a lot of cancer in the liver, it can’t work well. The liver normally keeps levels of something called bilirubin low, but if it isn’t working well, this substance builds up. This build up, called jaundice, causes your eyes and skin to turn yellow. The liver also removes a number of toxic substances (including ammonia) from the blood. When the liver isn’t working well, these substances can build up and lead to the brain not working well, either. This is called hepatic encephalopathy (heh-PA-tik en-SEH-fuh-LAH-puh-thee), and can cause confusion, sleepiness, and even coma.
Cancer in the liver can also lead to fluid build-up in your belly, which is described in a section above. See “If cancer is in the abdomen (belly)”.
- If there are fewer than 5 tumors, they can sometimes be treated with surgery or ablative treatments (see “Ablative techniques for advanced cancer”).
- If there are more tumors, chemo may help. This may be given into a vein in your arm or right into a blood vessel leading to the liver.
- Sometimes a procedure can be done to block the blood supply to the cancer (this is called embolization [em-buh-li-ZAY-shun]).
- Hepatic encephalopathy is treated with a drug called lactulose or certain antibiotics. Patients are also put on a low-protein diet.
If the cancer has spread to the chest or lungs
Shortness of breath
Shortness of breath can have a number of causes. It can be caused by a tumor blocking the airway so that air has trouble getting in and out of the lungs. Cancer cells in the lungs can also make it hard for oxygen to get into the blood from the lungs. Fluid build-up around the lungs (a pleural effusion [plur-uhl eh-few-zhun]) can also cause shortness of breath (discussed below). A tumor blocking blood flow to the heart (called superior vena cava syndrome) or fluid around the heart (a pericardial effusion) are also possible causes (these are also discussed below)
Low red blood cell counts (anemia) can also make someone feel short of breath. Anemia is common in cancer patients. (Anemia is discussed in more detail in the section “Managing general symptoms of advanced cancer” and in our document Anemia in People With Cancer.)
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 to the cells of the body.
Getting extra oxygen can often be very helpful. It’s breathed in through a little tube that goes under your nose or through a mask that goes over your mouth and nose.
When possible, treating the cause will help relieve shortness of breath. Treating the cancer with chemotherapy or targeted therapy may help. If there is a single tumor blocking off an airway, treatment with radiation (external beam radiation, stereotactic body radiation therapy, or brachytherapy) may help. Another option is using a flexible tube that is passed down your throat and into the lungs (a bronchoscope) to deliver laser treatment to shrink the tumor.
Treatment of pleural effusions, pericardial effusions, and superior vena cava syndrome is discussed further down.
Sometimes fluid builds up in the lungs (called pulmonary edema [pull-muh-nair-ee uh-deem-uh). This is more common in people with heart problems. The fluid build-up can be treated with diuretics (water pills) and heart medicines.
Anemia can be treated with blood transfusions to help you feel less short of breath.
Morphine-like drugs (opioids) can be used to help relieve the feeling of shortness of breath. Anti-anxiety medicines, like diazepam (Valium®), can also help to reduce cough and ease the distress caused by shortness of breath. Sometimes medicines that help dry up mucus 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
- Guided imagery
- Therapeutic touch
- Music and art therapy
- Distraction (watching 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.
Fluid around the lungs (pleural effusion)
Cancer in the chest or lungs may cause fluid to build up in the chest around the lungs. This is called a pleural effusion (plur-uhl eh-few-zhun). The fluid can keep the lungs from filling up with air and make you short of breath.
- Placing a hollow needle through the skin to remove the fluid that has built up around the lungs (this is called thoracentesis [THOR-uh-sen-TEE-sis] and was discussed in more detail in the section about diagnosis).
- If the fluid builds up again, a small, flexible tube (a catheter) can be put through the skin and left in place to let the fluid drain into a bag.
- To remove the fluid and keep it from coming back, doctors sometimes perform a procedure called pleurodesis (plur-o-DEE-sis). A small cut is made in the skin of the chest wall, and a hollow tube is placed into the chest to remove the fluid. Then there are a couple of ways to keep the fluid from coming back. One way is to blow talc into the chest cavity (through a small cut in the chest wall) during an operation. Another way is to use the tube to put either talc (mixed with water), the antibiotic drug doxycycline, or a chemotherapy drug into the chest cavity. This causes the outside lining of the lung and the lining of the chest wall to stick together, sealing the space and limiting further fluid buildup. The tube is often left in for a couple of days to drain any new fluid that might collect.
- Treating the cancer with drugs, such as chemotherapy, hormone therapy, targeted therapy, or radiation therapy will lower the amount of fluid being made so that it doesn’t build up
Fluid around the heart (pericardial effusion)
The heart is coated by tissue that makes a sac (called the pericardium [pair-uh-car-dee-um]) that contains the heart in the chest. Although it isn’t common, cancer can spread to the tissue and cause fluid build-up around the heart (called a pericardial effusion [pair-uh-car-dee-uhl eh-few-zhun]). The fluid can press on the heart, so that it can’t pump blood well. Symptoms can include shortness of breath, low blood pressure, body swelling, and feeling tired.
- Removing the fluid with a long, hollow needle. This procedure, called a pericardiocentesis, is usually done in the hospital because the heartbeat needs to be monitored.
- To keep the fluid from building up again, a piece of the pericardium may be removed to allow the fluid to drain into the chest or belly. This is called a pericardial window. .
Superior vena cava syndrome
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 sometimes grow large and press on this vein, blocking the blood flow to the heart. This will cause blood to back up in the lungs, face, and arms.
Symptoms can include:
- Shortness of breath
- A feeling of fullness or pressure in the head
- Swelling in the face, neck, and arms
- Chest pain
- Facial redness
- Swollen neck veins
If not treated, this can affect blood flow to the brain, which can cause confusion, changes in consciousness, or even coma.
Superior vena cava syndrome needs to be treated right away. Radiation therapy and/or chemo are often used to shrink the tumor. If this is not possible, you may have a small metal tube called a stent put 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 blockage.
If the cancer has spread to the skin
Advanced cancer that has spread to the skin can cause lumps or even sores on the skin. These can be painful and may smell bad if they get infected.
- Radiation treatment to lumps or sores on the skin can shrink them and dry them out.
- Certain chemo drugs can be put right on the tumors and may help dry them up.
- Antibiotics can help with infections. The antibiotics may either be pills or a cream or powder that is put right on the sores.
Last Medical Review: 02/07/2014
Last Revised: 03/06/2014