Managing symptoms of advanced cancer

This section describes (in alphabetical order) many of the major problems that can happen with advanced cancer. You may have some of these problems and symptoms or none of them. The next section, called "Problems grouped by where the cancer is," describes problems that are related to cancer spread to certain areas.

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 pain, and vomiting. Bowel obstruction occurs most often with abdominal or pelvic cancers.

Treatment

It is 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 may help if only the colon 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. Bowels can then 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 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 aimed at 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. If this helps, the NG tube 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 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. A drug called octreotide (Sandostatin^®) can also improve some of the symptoms that go along with a blocked bowel.

Broken bones (fractures)

When cancer moves into bones, it can make them weak and 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

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 stop further damage.

If bones of the spine (the vertebrae) are fractured, vertebroplasty 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.

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 weakened 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.

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

Treatment

There are many ways to treat confusion, but the best approach will depend on the cause. A physical exam will be done and imaging tests may be taken. Blood tests may be done to look at how well the organs are working and check the blood chemistry. Any medicines being taken, 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, like 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 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 enough 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.

A number of drugs and laxatives can be used to help treat constipation. Talk to your cancer care team about what might work best in your situation. 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

Feeling sad and down at times is normal with cancer and the side effects of treatment. But there is room for happiness even with advanced cancer. 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 is 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 out 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.

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

Fatigue (tiredness)

Fatigue is one of the most common symptoms among 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:

• 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 is no single 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 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 money. 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 overcome the feelings of fatigue. Talk to your doctor about whether 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.

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

People with advanced cancer 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. In other cases the cancer cells may 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 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.

Treatment

Giving fluids and bisphosphonate drugs, like pamidronate or zoledronic acid, can often bring blood calcium levels down quickly. These are usually given into the vein by IV (intravenous) infusion. 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.

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 it 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 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 so that you won't breathe in or swallow your vomit.
• 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 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 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 called Nausea and Vomiting.

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 non-steroidal 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 considered the best drugs for helping cancer patients control their pain. Unless you have a history of drug or alcohol abuse, it is very unlikely you will become addicted to opioids. 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 is 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 will 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 does 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 diet high in fiber, 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. 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 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 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 may 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: For some, talking is not easy. 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 is 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.

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

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 program to meet your needs. The most important things you can do are changing positions often when you are sitting or lying down and keeping your skin clean and dry.

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. This can lead to numbness and weakness, and may even cause paralysis. Most often this affects the legs, but if the tumor is pressing on the spinal cord in the neck, both the arms and the legs can be affected. Spinal cord compression can also affect the nerves to your bladder, which can lead to trouble passing urine. Early treatment is important to help reduce permanent nerve damage and prevent paralysis.

Symptoms to watch for

• Severe back pain, especially if it is in the middle of your lower back
• Numbness or weakness in your legs
• Trouble passing urine or loss of urine control

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 a medical emergency, and it needs to be treated right away.

Treatment

• Drugs called corticosteroids (prednisone or dexamethasone) will be given to reduce spinal cord swelling (and treat pain).
• Radiation therapy is often given to shrink the tumor.
• Surgery to remove all or part of the tumor is needed right away in some cases.

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
• Coughing
• 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.

Treatment

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 obstruction.

Trouble breathing

Trouble breathing can have a number of causes. It 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," 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 to the cells of the body.

Treatment

When possible, treating the cause will help relieve shortness of breath. For tumors in the airways or lungs, sometimes external beam radiation or laser treatment (given through a flexible tube that is passed down your throat) can shrink a tumor.

Patients with fluid around the lungs (called a pleural effusion) may breathe better after having this fluid removed. After numbing the skin, the doctor places a hollow needle into the chest and drains the fluid. If the fluid builds up again, a catheter (a thin hollow tube) can be placed through the skin and into the chest that allows the fluid to drain into a bag. Another option is to put a chemical or talc into the space around the lung to prevent further fluid build-up. This is called pleurodesis.

Sometimes fluid builds up in the lungs (called pulmonary edema). This is more common in people with heart problems. The fluid build-up can be treated with diuretics (water pills) and other medicines that help the heart.

Anemia can be treated with transfusions to help you feel less short of breath.

Getting extra oxygen can often 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 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
• Biofeedback
• Guided imagery
• Therapeutic touch
• Aromatherapy
• 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.

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 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 is very hard to treat this problem. Getting nutrients through a feeding tube can be uncomfortable and is not 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.

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