MARCH is Colorectal Cancer Awareness Month, a time to highlight the importance of early detection and comprehensive care for colorectal cancer patients.
While early treatment improves survival rates, many patients are diagnosed at an advanced stage, requiring not only medical interventions but also symptom management and quality-of-life care.
This is where palliative care plays a crucial role.
Roles of palliative care in colorectal cancers
Palliative care aims to improve the quality of life for patients and their families living with life-threatening illnesses. It does so by preventing and relieving suffering from physical issues, as well as by offering psychological and social support.
Palliative care involves a multidisciplinary team comprising palliative care specialists, specially trained doctors, nurses, pharmacists, social workers, and physiotherapists who collaborate to provide relief, support, and comfort throughout the disease journey.
Patients diagnosed with chronic conditions such as colorectal cancer benefit greatly from palliative care services. This approach can be initiated at any stage of the illness, including at the time of diagnosis, and can be provided alongside curative treatments.
For patients with advanced colorectal cancer, palliative care will provide crucial support in managing symptoms such as severe abdominal pain, bowel obstruction, and nausea.
Apart from colorectal cancer, those with end-stage cardiac or renal disease, progressive neurodegenerative disorders, and severe chronic airway limitations are also among the key groups eligible for palliative care.
Commonly used medicines in palliative care for colorectal cancer patients
Medicines are the cornerstone of palliative care for colorectal cancer patients, ensuring comfort by managing distressing symptoms such as pain, shortness of breath, nausea, and anxiety.
The treatment goals are dynamic and may change depending on disease progression and whether the patient is stable, deteriorating, or experiencing complications like bowel obstruction or metastatic spread. Therefore, dosing strategies, formulations, and routes of administration are tailored to meet patient evolving needs.
Recognising the importance of palliative care in cancer management, the World Health Organisation (WHO) has released a list of essential medicines based on common symptoms in these patients.
Similarly, the Malaysian Palliative Care Services Operational Policy has proposed a list of essential medicines to ensure seamless accessibility, particularly for those with colorectal cancer requiring symptom management and supportive care.
A variety of medicines are commonly used in palliative care for colorectal cancer patients, each targeting specific symptoms to improve comfort and quality of life. They are:
Medicines for pain management
Pain is one of the most debilitating symptoms affecting cancer patients. A recent study has shown a decline in the prevalence of pain, attributed to advances in pain management guidelines, a multidisciplinary approach, and pharmacist involvement, all contributing to better patient outcomes.
Simple analgesia such as paracetamol, celecoxib (a non-steroidal anti-inflammatory drug), and morphine (an opioid) can be used to treat nociceptive pain (tissue-related pain). In contrast, nerve-related pain (neuropathic pain) arising from damage or compression responds better to specialized medicines such as gabapentin and amitriptyline.
Generally, opioids like morphine or oxycodone are used for moderate to severe cancer pain, typically administered orally in controlled-release formulations for chronic pain management or in immediate-release solutions and injectables for breakthrough pain episodes.
Additionally, transdermal opioid formulations such as fentanyl patches are available for chronic pain when oral administration is not feasible due to symptoms like vomiting or disease progression. Common side effects of opioids include drowsiness, nausea, vomiting, and constipation.
Medicines for breathing difficulty (dyspnoea)
Dyspnoea or shortness of breath is a distressing and often frightening symptom affecting a significant proportion of patients with advanced cancer.
Pharmacological intervention is always necessary, with strong evidence supporting the use of opioids such as morphine at lower doses than those required for pain relief.
Additionally, benzodiazepines like lorazepam can help manage shortness of breath when it triggers panic and anxiety, preventing a cycle of worsening symptoms.
While medicines play a crucial role, non-pharmacological approaches such as relaxation exercises, breathing techniques, and using a handheld fan directed at the face can provide additional relief for some patients.
Medicines for nausea and vomiting
Nausea and vomiting are common symptoms among cancer patients, often resulting from opioid use, chemotherapy, or complications such as bowel obstruction.
First-line treatment typically includes metoclopramide, though it may cause drowsiness. Alternatively, antipsychotic medicine, such as haloperidol, is frequently used, with potential side effects such as drowsiness, dry mouth, and involuntary movements in some patients.
For chemotherapy-induced vomiting, granisetron is an option. However, it may lead to headaches, constipation, or drowsiness.
Medicines for confusion
Confusion or delirium is a common neuropsychiatric condition among palliative care patients. The initial approach involves identifying and addressing potential reversible causes such as medicines, infections, dehydration, or electrolyte imbalances.
If symptoms persist, non-pharmacological measures like maintaining a calm environment and providing emotional support are prioritized before considering medicinal interventions.
For agitated or psychotic patients, haloperidol is commonly used, followed by newer antipsychotics such as olanzapine or risperidone.
In cases where anxiety or restlessness is predominant, midazolam or lorazepam may be administered.
However, caution is required as these medicines can cause drowsiness and increase the risk of falls.
In conclusion, the use of medicines in palliative care for colorectal cancer patients is multifaceted. Therefore, individualised treatment plans should be tailored to each patient's needs and preferences.
Patients and caregivers must understand the purpose of each medicine, its proper administration, and potential side effects. They should also seek guidance from healthcare providers for necessary adjustments or concerns.
With effective palliative care and support, colorectal cancer patients can maintain comfort and dignity throughout their journey, even in the face of challenging circumstances.
If there are any inquiries regarding medicines, please call the National Pharmacy Call Centre (NPCC) at the toll-free number 1-800-88-6722 during weekdays from 8am to 5pm, except on public holidays.
Chevena Arunasalam is a UF14 Pharmacist Officer at Hospital Shah Alam, Selangor.