Stephanie M. Harman, MD, FACP

 Last month’s Supportive & Palliative Care column by Biren Saraiya, MD, highlighted a recent ASCO position paper that recommended palliative care be considered early in the course of illness for patients with metastatic cancer and/or high symptom burden.

When I hear the word “innovation,” too often it is associated only with a technological wonder, such as a new stent or catheter.

Patients and clinicians alike fear the overuse of opioid medications for cancer pain, but the underuse of opioids is much more common.

Have you ever had a patient who did not have capacity to make medical decisions? These are vulnerable patients who have impairments and disabilities caused by medical or psychiatric conditions. In patients with cancer, this can be particularly challenging because they may have impaired capacity caused by their cancer or adverse effects of treatment. Many treatments are longitudinal and require active participation from the patient, which becomes complicated if a patient’s decision-making capacity changes. It can also be challenging to enroll patients in research who cannot participate in the informed-consent process.

Malignant bowel obstruction is an unfortunate but common complication of cancer. Whereas some patients may initially present with their cancer as a bowel obstruction, most patients with malignant bowel obstruction have had prior therapy and often have advanced disease. The most common solid tumor to present with malignant bowel obstruction at any stage is ovarian carcinoma, at as high as 20% to 50%; colorectal cancer follows, with rates between 10% and 28%.

When I was a palliative care fellow, my co-fellows and I would periodically check in with each other to see how “crispy” we were feeling, or even more telling, just comment to each other on how crispy we were looking. We were, of course, referring to our levels of burnout.

“I know you don’t have a crystal ball, but … how much time do I have?”

When even the knowledge of a cancer diagnosis can disrupt sleep, it is no wonder that patients receiving treatment for cancer have a higher incidence of sleep disturbances, from 19% to 63% as compared with the general population of 15% to 20%.

Many misperceptions exist regarding what “advance directives” exactly are, as well as physician order documents for limiting treatment. Although advance directives have not historically had the expected impact of patients’ preferences being honored, they have served as triggers for discussions of patients’ wishes and advance care planning.

Neuropathic pain occurs in a significant portion of patients with cancer. Although as much as 9% of cancer patients have solely neuropathic pain, many patients have a mixed pain syndrome, which often can be challenging to treat. Neuropathic pain is caused by abnormal or injured peripheral nerves or by abnormal pain circuits in the central nervous system causing a pain response.