Palliative Care: Managing Stage 4 Lung Cancer Symptoms

In the last phase of lung cancer, the cancer can lead to an unpredictable situation. It is important to understand the palliative care available to manage the chronic symptoms of stage 4 lung cancer. This can help alleviate the discomfort, stress and other adverse effects that accompany those symptoms. The information below is applicable to all subtypes of lung cancer that share the following similar symptoms:

• Pain
• Chronic cough
• Stridor (tightening of the airway)
• Hemoptysis (blood coughing)
• Pleural effusion

Palliative pain management is an important care component for many advanced-stage lung cancer patients. Effective pain management enhances their quality of life, allowing them to spend time with loved ones and engage in daily activities.

Referrals to pain specialists experienced in palliative care are crucial when the pain becomes difficult to manage. This is common among late-stage patients whose cancer has spread to other parts of their body.

Non-steroidal anti-inflammatory agents (NSAIDs) are initially used for mild cancer pain. It can be combined with adjuvant analgesics for specific pain types or cancer treatment side effects. However, it is important to note that the use of NSAIDs has certain contraindications. Therefore, it is crucial to discuss it with your cancer care team before taking them. They will provide you with all the relevant information to ensure you get the best possible treatment.

For moderate to severe pain, opioids are standard, but they have adverse effects that require close monitoring. Opioids are also used to manage chronic cough in advanced-stage lung cancer patients.

Adjuvant analgesics are employed alongside opioids to address other clinical conditions along with cancer pain, such as depression and nausea.

For metastatic sites like bone and brain, external beam radiation therapy (EBRT) may be used to relieve pain. Integrative therapies, like acupuncture and music therapy, are recognized as complementary pharmacological methods for reducing cancer pain.

Related: Palliative Care in Lung Cancer: Management of Chronic Pain

As lung cancer progresses to the later stage, coughing may intensify and become more painful for some patients. Opioids are used to manage severe cough, besides being the standard management of cancer pain.

Stridor refers to the tightening of the airway that obstructs normal breathing. Although it is rare, when it happens, it can escalate into a critical situation that requires immediate emergency care. If you experience difficulty breathing, please contact emergency medical services (EMS) or go to the nearest emergency room.

Hemoptysis (blood coughing) in lung cancer can be life-threatening. The definition of life-threatening bleeding is characterized by the expectoration of a large amount of blood and/or a rapid rate of bleeding.

While it is common for lung cancer patients to have small amounts of blood in sputum, any instances of

• Blood-tinged sputum (enough to fill a paper cup) or
• Blood-soaked materials (e.g., paper towels)

must be reported to the cancer care team.

In cases of overwhelming hemoptysis, urgent sedation may be required to manage the situation. The primary goal is to secure the patient's airway and stop the bleeding. Bronchoscopic techniques are often employed to

• visualize the airway
• identify the source of the bleeding
• insert endobronchial management devices

In some cases, stereotactic body radiation therapy (SBRT) may be considered for tumors located further away from the central airway. This approach can help alleviate symptoms and control bleeding.

Pulmonary hemorrhage is a known complication associated with the use of an antiangiogenic agent. Therefore, it is contraindicated in these patients and those who have experienced hemoptysis.

Pleural effusion is a condition in which fluid builds up in the area between the lungs and chest. The fluid buildup presses against the lungs and makes it difficult to breathe.

There are several palliative options to manage pleural effusion:

• Thoracentesis - This procedure is often the first-line treatment for malignant pleural effusions. It involves the removal of excess pleural fluid using a needle, guided by ultrasound for precise localization. The goal is to remove as much fluid as the patient can tolerate, typically up to a limit of 1.5 liters. Even the removal of smaller volume removal can provide immediate relief. However, pleural effusions in lung cancer patients often recur, with up to two-thirds of these recurrences happening within one month.
• Chest tube or catheter drainage - For patients with recurrent pleural effusions, chest tube or catheter drainage may be considered. This method allows for the gradual removal of fluid over hours or days into a special bottle. The PleurX drainage catheter is one example that allows patients to manage pleural effusion conveniently at home. It involves catheter placement as an outpatient procedure and drainage into a vacuum bottle that can be accessed easily by the patient. Read here for more information on PleurX.

As lung cancer progresses to its final stage, patients may experience a range of symptoms that can be both physically and emotionally challenging. Coping with these symptoms can be difficult and it is essential to have a good understanding of what to expect during this time. This understanding can help patients better prepare to manage these symptoms and improve their quality of life. It is recommended to talk to your cancer care team to learn ways to relieve the discomforts you may be experiencing. By using this information and the resources available, you can make the most of your time and focus on what matters most to you.

Read next: Approaching the End of Life With Lung Cancer: What to Expect and What to Do