As in advanced cancer of any site it is important to help the patients to understand where they are in their illness with regard to stage of advancement and what may or may not be realistically achieved.

11.1 Referral to palliative care

There are many reports suggesting unmet needs, both physical and emotional, in patients with advanced colorectal cancer leading to the view that patients may benefit from access to palliative care services before the “terminal” phase.²⁴⁷

Patients with advanced colorectal cancer whose physical or emotional symptoms are difficult to control should be referred to a specialist in palliative care without delay.

11.2 Symptom management

Patients with advanced disease frequently have multiple symptoms. Pain, fatigue and emotional distress are those most commonly reported, and the number and severity of symptoms increases as the cancer advances.²⁴⁸

11.2.1 PAIN

Pain is still common in severely ill patients with cancer and its severity underestimated.²⁴⁹ In a recent national audit, 58% of cancer patients in the acute hospital setting recorded their pain as either moderate or severe.²⁵⁰ Evidence level 3

Abdominal pain is common, and may be caused by the tumour itself or bowel obstruction. It may also be due to liver metastases or coeliac plexus involvement.

Involvement of the coeliac plexus, lumbosacral root, spinal cord or cauda equina can cause pain in a nerve root distribution which is difficult to describe and may be burning, numbing, tingling, shooting, or like toothache. Treatment of the pain requires a multidisciplinary approach, and although the pain may respond to opioids, additional drugs such as gabapentin, amitriptyline or ketamine may be used. Perineal pain and tenesmus may respond to opioids and to agents such as gabapentin.

For a more detailed discussion of pain assessment and management see the SIGN guideline on control of pain in patients with cancer.²⁵¹

11.2.2 MALIGNANT BOWEL OBSTRUCTION

Patients who develop small or large bowel obstruction, and in whom surgery is inappropriate, can be managed in most cases without intravenous fluids or a nasogastric tube. Pain (visceral and colic), nausea and vomiting, can often be controlled for weeks using analgesics, anti-emetics and antisecretory drugs parenterally - most often given by syringe driver. Patients may then be able to eat and drink. Parenteral hydration is sometimes indicated to control nausea, whereas regular mouth care is the treatment of choice for dry mouth.²⁵² A Cochrane review concluded that there was weak evidence that corticosteroids (dexamethasone 6-16 mg IV) may help the resolution of inoperable obstruction in some patients²⁵³ with few side effects. Evidence level 1+,4

Medical measures such as analgesics, antiemetics and antisecretory drugs should be used alone or in combination to relieve the symptoms of bowel obstruction.

11.2.3 FATIGUE

Fatigue has been identified as a common problem for patients.²⁵⁴ In the absence of any correctable cause corticosteroids may be of some benefit.²⁵⁵

11.2.4 NUTRITION AND WEIGHT LOSS

Patients and families understandably focus on what patients are able to eat. Although there is no evidence that nutritional supplements, parenteral or enteral feeding are of benefit in preventing cancer cachexia when the disease is advanced, evidence is emerging that it may be of value at an earlier stage.²⁵⁶ Referral to a specialist state registered dietitian or advice from a nutrition support team should be sought where appropriate.

As anorexia and weight loss are so distressing for the patient and their family, the issue of nutrition must be addressed.