Symptoms caused by metastases in palliative care for cancer

It’s possible to just have a single bone metastasis; however, it’s more common for cancer that’s spread to the bones to develop several metastases. Sometimes bone metastases occur without any symptoms, but pain that gets worse when moving is a typical symptom, since the cancer locally weakens the bone. If left untreated, the pain often leads to reduced physical activity and thus to decreased physical performance. Once the pain eases, moving becomes easier, and so does taking part in everyday activities. That’s why pain management is important.

Effective pain management can be provided with pain medication and radiation therapy. Medicine used for pain management often includes strong morphine-like pain medications. It’s important for pain medication to include both medicine taken regularly and additional short-acting medicine taken as needed, especially when physical exertion makes the pain worse. Additional short-acting pain medicine may be taken either in the event of sudden unanticipated pain or as a precaution before pain is likely to occur, like before exertion (for example, before getting out of bed in the morning, or before going for a walk, if pain is expected to get worse).

Palliative radiation therapy is aimed at symptom relief, and in most cases, provides pain relief, but the effects take days or possibly weeks to appear. Radiation therapy is usually given as a course of 1 to 10 treatments (“fractions”). Bone metastases may also cause fractures or, if located in the spine, a condition called metastatic spinal cord compression; in these cases, seek acute medical attention.

Metastatic spinal cord compression

Metastases located in the spine may press on the spinal cord, causing weakness in the legs (or if located in the cervical vertebrae, weakness in the arms) or faecal or urinary incontinence. This may be accompanied by back pain that is either band-like or radiates down the legs, sides, or arms. This is a serious symptom that requires an immediate visit to a hospital emergency department. The pressure put on the spinal cord by the tumour can be removed with radiation therapy and treatment with corticosteroids, and sometimes with the help of surgery. The sooner the treatment can begin, the better the patient’s functional capacity can be restored.

Fractures caused by metastases

Metastases in the bones can also result in fractures without trauma. Symptoms include sudden worsening of pain and, in cases such as hip fractures, not being able to walk due to pain. If suspecting a fracture, contact the unit responsible for your care or visit a hospital emergency department. Fractures can be treated with surgery, radiation therapy, and/or pain medication.

When cancer has spread to the lungs or pleura, it may cause shortness of breath, coughing, or blood in the cough (haemoptysis). If the bronchi are obstructed by a tumour, palliative radiation therapy is effective in relieving shortness of breath. In addition, medication such as morphine may be used to relieve shortness of breath. Morphine-like medicines are also effective in reducing the cough reflex.

Metastases in the pleura produce pleural effusion, which can be removed either by performing a pleural tap or by inserting a drainage catheter that can be used to remove the fluid over the course of several days or on a more long-term basis. This provides immediate relief for shortness of breath.

Metastases in the liver may not cause any symptoms for a long time, and they are often painless. As the liver becomes enlarged, the capsule around the liver may stretch and cause pain in the right side. Corticosteroids and pain medicines are effective in relieving the pain.

In the later stages, as the cancer advances, liver function may be impaired, causing swelling (oedema) in the legs and feet, a build-up of fluid in the abdomen, or disruptions in bile flow (resulting in jaundice, or yellow skin), which then leads to fatigue and loss of appetite. If fluid in the abdomen is causing distressing symptoms such as a swollen belly, nausea, constipation, or shortness of breath, the fluid can be removed either by performing a one-time ascitic tap or by inserting a drainage catheter that can be used to remove the fluid over the course of several days. This usually provides immediate symptom relief. Fatigue and loss of appetite can be relieved with corticosteroids, while compression bandaging or socks can be used to relieve oedema.

Cancer can spread to the abdomen in a pattern resembling a spider web, disrupting bowel function and thus causing nausea and constipation. Both nausea and constipation can be relieved effectively with medications.

Sometimes a bowel obstruction may occur, which could require surgery. In the case of advanced cancer, if surgery is not an option, the symptoms can be relieved with medications. Symptoms of bowel obstruction include constipation, nausea, vomiting, and stomach pain. Bowel obstruction requires acute medical treatment – contact either the unit responsible for your care or the emergency department.

There may also be a build-up of fluid in the abdomen (ascites), causing the belly to grow large and swollen. If there is a large volume of fluid in the abdomen, the belly is swollen and may feel quite uncomfortable. A swollen abdomen may also press on the lungs, which causes shortness of breath, especially when lying down. If the symptoms are causing distress, contact the unit responsible for your care. As with the pleura, fluid in the abdomen can be removed by performing a puncture with a needle or by inserting a drainage catheter to let the fluid out, which provides rapid symptom relief.

In addition to being a potential cosmetic issue, metastases in the skin may result in small amounts of blood seeping through the skin, as well as infections, sores, and/or an unpleasant odour. Skin metastases can be treated with radiation therapy and sometimes with surgery. Larger areas of skin are treated with a variety of dressings and with local treatment methods.

When cancer spreads to a lymph node, the node becomes enlarged. Metastases in the lymph nodes may interfere with the lymphatic flow and, for example, cause swelling in the limbs. The swelling can be treated with compression products or with bandages. If an enlarged lymph node is painful, it can be treated with radiation therapy. Pain medication is also effective.

Lymph nodes can also be treated with radiation therapy if they cause an obstruction by pressing on the ureter, bronchus, or esophagus, for example. In the case of cancer originating from the lymphatic system (lymphoma), corticosteroid medicines are also effective in shrinking enlarged lymph nodes.

Metastases in the brain can cause headaches, nausea, and a variety of neurological symptoms, such as double vision or other vision problems, loss of balance, speech problems, confusion, decreased consciousness, paralysis, or seizures.

If these symptoms appear, contact the unit responsible for your care; if the symptoms are severe or begin suddenly, visit the emergency department. A course of corticosteroids serves as first aid; once the symptoms have settled, plans may be made for radiation therapy, and sometimes surgery, if needed.

In addition to local symptoms caused by metastases, advanced metastatic cancer causes fatigue and may result in loss of appetite. Ways to try and reduce fatigue include getting fresh air and appropriate physical activity. It’s also important to adhere to a regular sleep-wake cycle. When it comes to treatment for loss of appetite, small portions according to the patient’s preferences usually work best. Additionally, corticosteroid medication can be used to ease fatigue and improve appetite temporarily. At the end of life, fatigue intensifies, and the need for sleep and rest increases.