COPD

Ask the right questions for lung cancer symptom control: Prof David Currow


By asking the right questions, clinicians can do much more to help lung cancer patients avoid debilitating symptoms such as breathlessness, fatigue and cough, according to oncologist Professor David Currow.

Patients often have a huge burden of avoidable symptoms that go unreported because they aren’t given the opportunity to volunteer all of them to their treating doctor, according to Professor Currow, CEO of the Cancer Institute NSW.

While clinicians have been trained to ask ‘open’ questions when taking a history, this does not lend itself to revealing the wide range of symptoms that patients experience and which they often cover up, Professor Currow said.

“If you ask patients questions such as ‘what’s troubling you?’ you only get one or two responses, but if you ask patients to rank their problems from a list, you’ll get ten,” he said.

Breathlessness was a problem for almost all patients, but seldom volunteered on open questioning because people went to great lengths to minimise it.

“If you ask patients if they have breathlessness they say ‘no’,  but if you ask ‘what have you given up to avoid being breathless?’, they will tell you they have stopped gardening or given up sex or no longer dress themselves,” said Professor Currow.

There may also be an unconscious bias among clinicians to focus on the symptoms such as pain that could be most readily controlled.

“We go to the things we can fix, but let’s be sure we’re addressing the problems that patients identify as priorities,” he said.

For dyspnoea it was worthwhile looking at reversible causes, given that 40% of patients have hypoxaemia, 20% have anaemia and up to half have bronchospasm, Professor Currow noted.

And a hand-held battery-operated fan was a simple and inexpensive solution that could make a huge difference to symptom control for patients with dyspnoea, he added.

There was little evidence of benefit for benzodiazepines in dyspnoea, whereas there was now good evidence from COPD patients to support the use of regular, low dose, extended release morphine.

Cough was another troublesome and undertreated symptom but Newcastle, NSW, researchers had shown pregabalin could produce improvements in cough severity and frequency.

Fatigue was an overwhelming problem for many patients, which should be acknowledged and warranted discussion with physiotherapsists, occupational therapist and exercise physiologists, Professor Currow suggested.

The key message was that symptom control was an important part of  enabling patients to do what they wanted with their remaining time, he said.

“The patient’s perspective is very different from the physician’s perspective. And the take home message is: how do we find out what is happening?” he concluded.

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