ASCO has issued a new guideline on the clinical management of dyspnea in adult patients with advanced cancer.1 Dyspnea—or breathlessness—is a common and distressing symptom affecting upward of 70% of patients with advanced cancer.2
“Dyspnea is a highly prevalent symptom, particularly when people with advanced cancer approach the end of life,” said Margaret L. Campbell, PhD, RN, FPCN, of Wayne State University, Detroit, and Co-Chair of the ASCO Expert Panel. “The major challenge with dyspnea is that we don’t have a large toolkit to manage it, compared with what is available to manage other cancer symptoms, like pain.”
Dr. Campbell, together with fellow Co-Chair David Hui, MD, of The University of Texas MD Anderson Cancer Center, and several other experts, reviewed the available evidence supported by the Agency for Healthcare Research and Quality systematic review of nonpharmacologic and pharmacologic interventions to alleviate dyspnea. An additional systematic review was conducted to guide recommendations on dyspnea assessment, management of underlying conditions, and palliative care referrals.
Hierarchical Approach
Based on the available evidence, the guideline recommends a hierarchical approach to dyspnea management starting with assessment. “One theme is definitely assessment,” Dr. Hui said. “We have to ask our patients about dyspnea; our patients may not be telling us.”
Specifically, clinicians should perform systematic assessment of dyspnea during every inpatient and outpatient encounter with patients who have advanced cancer using validated patient-reported outcomes. In cases where a patient may be unable to self-report, clinicians should use a validated observation measure. Comprehensive evaluation will include assessment of the severity, chronicity, potential causes, triggers, and associated symptoms.
Some of the causes of dyspnea are potentially reversible. They include pleural effusion, pneumonia, airway obstruction, anemia, asthma, chronic obstructive pulmonary disease, pulmonary embolism, or treatment-induced pneumonitis. Patients should be given goal-concordant treatment consistent with their health and wishes.
“Patients with advanced cancer and dyspnea are often quite sick,” Dr. Hui said. “Dyspnea assessment is often a good opportunity to serve as a trigger for an interdisciplinary palliative care referral. A referral is actually the strongest recommendation from the guideline panel.”
Available Interventions
To help resolve dyspnea, the guideline recommends first attempting available nonpharmacologic interventions including the following:
- Airflow interventions, such as directing a handheld or table-top fan at the cheek
- Standard supplemental oxygen for patients with hypoxemia who have dyspnea
- Supplemental oxygen is not recommended if SpO2 (oxygen saturation) is greater than 90%.
- A time-limited therapeutic trial of high-flow nasal cannula oxygen therapy may be offered if patients have significant dyspnea and hypoxemia despite standard supplemental oxygen.
- A time-limited therapeutic trial of noninvasive ventilation may be offered to patients who have dyspnea despite the use of standard measures.
- Other interventions, such as breathing techniques, posture, relaxation, distraction, meditation, or acupressure/reflexology, may be offered.
“If the patient has severe dyspnea, and we can’t achieve a satisfactory level of comfort with nonpharmacologic interventions, then we need to address pharmacologic interventions,” Dr. Campbell said. “However, this is where our toolkit gets pretty small.”
Systemic opioids should be offered when nonpharmacologic interventions are insufficient. Short-acting benzodiazepines can be offered to patients experiencing dyspnea-related anxiety and continue to experience dyspnea despite opioids. Systemic corticosteroids can be offered in cases with airway obstruction or when inflammation is likely a factor in dyspnea.
Bronchodilators should be used for palliation of dyspnea when patients have established obstructive pulmonary disorders or evidence of bronchospasm. Continuous palliative sedation can be offered in cases of dyspnea that is refractory to all standard treatment options and all applicable palliative options, as well as in patients who have an expected life expectancy of days.
Call for Research
“Certainly, there is much more room for improvement in these guidelines,” Dr. Hui said.
According to Dr. Campbell, when she started doing research on dyspnea in the late 1990s, she could count the worldwide dyspnea researchers on one hand. “Now, there is quite a cadre of people doing dyspnea research,” Dr. Campbell said.
Dr. Hui agreed that this area is growing and that there are several active clinical trials being conducted on dyspnea. “If there is one take-home message here though,” Dr. Hui said, “it is that more research is needed.”
DISCLOSURE: Dr. Campbell reported no conflicts of interest. Dr. Hui has received research funding from Helsinn Healthcare. For disclosure information on other panel members, visit ascopubs.org.
REFERENCES
1. Hui D, Bohlke K, Bao T, et al: Management of dyspnea in advanced cancer: ASCO guideline. J Clin Oncol 39:1389-1411, 2021.
2. Henson LA, Maddocks M, Evans C, et al: Palliative care and the management of common distressing symptoms in advanced cancer: Pain, breathlessness, nausea and vomiting, and fatigue. J Clin Oncol 38:905-914, 2020.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, February 25, 2021. All rights reserved.
