Oncology Nurses Address Knowledge Gap in Palliative Care for Advanced Lung Cancer

Although standards of care exist for the curative management of cancer, they are not as well defined for patients whose disease needs to be managed with palliative intent. The American Society for Radiation Oncology (ASTRO) released an updated guideline which states that some patients with incurable non-small cell lung cancer (NSCLC) should receive concurrent chemotherapy along with palliative thoracic radiation therapy.

This is an update to a guideline published in 2011 that said there was no benefit to adding concurrent chemotherapy for patients with lung cancer undergoing palliative thoracic radiation therapy. Based on updated reviews of studies published from March 2010 through July 2016, ASTRO amended the guideline for patients who meet certain eligibility criteria, including being diagnosed with stage III NSCLC that is deemed incurable by their treating physicians, are candidates for chemotherapy, have an ECOG performance status between 0 and 2, and have a life expectancy of at least 3 months.

Patients with incurable NSCLC may experience symptoms such as chest pain, cough, labored or obstructed breathing, coughing up blood, and acute esophagitis.

In an interview with Oncology Nursing News, Benjamin Moeller, MD, PhD, chair of the guideline task force and a radiation oncologist at the Levine Cancer Institute in Charlotte, North Carolina, discussed what the updated guideline means for oncology nurses and how it can help in the effort to mitigate symptom burden for patients.

How is the updated guideline useful to oncology nurses?

It outlines the rationale for why a patient’s care team may have elected to administer concurrent chemoradiotherapy to a patient with incurable stage III NSCLC, in spite of the known added risks of side effects, in hopes of a modestly improved survival and/or increased durability of symptom palliation versus what could be achieved with chemotherapy alone or radiation alone.

When should a physician or nurse bring this discussion up with a patient or their caregiver?

This is an appropriate option to discuss at the time of initial diagnosis, in the context of all first-line treatment options for that patient.

Are there adverse effects that can be experienced by patients who receive concurrent chemotherapy with radiation therapy?

Adding palliative thoracic radiation to chemotherapy significantly increases the rate of radiation esophagitis, which the patient experiences as 1 to 2 weeks of mild-to-moderately painful swallowing. Adding chemotherapy to palliative thoracic radiation significantly increases the rate of low blood counts. Both treatments also commonly cause fatigue.

How can a nurse help a patient in understanding palliative care?

Studies show that healthcare teams generally do a poor job of communicating goals of care to patients with cancer treated in the palliative setting. Nurses are well positioned to address this knowledge gap by giving patients additional opportunities to clarify goals of care beyond their conversations with physicians.

Are there other ways in which a nurse can help a patient improve quality of life?

Nurses play a very important role in educating patients about side effects from treatment. Arming patients with knowledge about anticipated toxicities can help to make sure they recognize the associated side effects early and alert the treatment team so that they can be managed, thereby minimizing the impact on their quality of life.