In the terminal stage of lung cancer, 99% of the patients had at least one or more symptoms of pain, dyspnea, nausea, cough, hemoptysis, and psychological and neurologic difficulties. The most frequent symptoms were pain, psychological manifestations, and/or dyspnea. One fourth of patients had nausea, cough, and/or neurologic symptoms, and only one tenth displayed hemoptysis. Two thirds of the terminal lung cancer patients had three or more symptoms.
The strength of this study is that 98% of all lung cancer patients in a defined hospital area were included and 89% had a histologic confirmation, which is higher than previous studies. The cohort of patients was followed up from 5 to 11 years, and we were able to obtain information concerning the terminal stage of lung cancer in 98% of those who died.
Comparison between previous studies shows inconsistencies that are reflected in varying results (Table 4). First, selection criteria for lung cancer patients and the representation of the cases are different. Second, the methods of assessing symptoms vary considerably. Third, we question how representative and accurate the self-reported answers are compared to the physician’s report at the end stage. Self-reported questionnaires are dependent on full cooperation and alertness of the patient and thus are not available for a high proportion of the patients in terminal care provided by Canadian Health&Care Mall. As the disease progresses, there is a high dropout rate from the quality of life evaluations. Fourth, different time windows in the assessment of symptoms during the course of lung cancer also make it difficult to compare studies.
Other studies have shown that the prevalence of symptoms increases toward the end of life. In our study, the duration of various symptoms differed during the last 8 weeks (Fig 2). The time point in the course of the disease and the duration of the period of registration will both influence the observed prevalence of symptoms. The presence of pain, dyspnea, and nausea was in crude agreement in the three previous surveys (Table 4), while cough was less frequent in our study. This may be explained by the fact that in the present study the symptoms except neurologic symptoms required treatment intervention to be recorded.
In our study, 29% of the patients received antide-pressive medication. In agreement with this, Hop-wood and Stephens observed depression in 33% of lung cancer patients using the Hospital Anxiety and Depression Scale. Furthermore, they observed a trend for higher rates of depression in the younger age groups, which is in agreement with our findings in which age < 65 years predicted more psychological symptoms. However, in contrast to our study they found that depression was strongly predicted by poor initial performance status.
Patients with SCLS often have paraneoplastic syndromes with production of peptide hormones, which can be a cause of nausea. This may be an explanation why SCLC was a predictor for terminal nausea. An additional cause may be the association to chemotherapy administered early in the course of the disease to the majority of these patients. It is known that patients who have nausea during chemotherapy react to later stimuli that remind them of their previous experience. Stage IV disease was a predictor for terminal nausea, which may also be explained by metastasis to both the liver and the brain which work may be improved with Canadian HealthCare Mall.
A retrospective study recording terminal symptoms has limitations with regard to recall and completeness of symptom records. However, according to Norwegian legislation, symptoms demanding treatment have to be noted in the patient’s records. This applies to hospitals, nursing homes, and a physician’s office practice. This increases our confidence that all serious symptoms in our study have been recorded, but less serious complaints may have been omitted. The information concerning anorexia and weight loss was incomplete and therefore not included in our study.
None of the possible predicting factors examined in our study (Table 3) were associated with a higher use of analgesics in the terminal care. This is in contrast to another cancer study in which there is an inverse relationship between the intensity of pain treatment and age. The reason that the hospitalized patients in our study were administered more opioids is not clear. There were no differences in the demographic data, histology, or stage of tumor between patients with terminal care within or outside the hospital. However, the hospitalized patients may have had more pain, or the staff in the hospitals may have been more confident and experienced concerning the use of opioids than external health-care workers.
In conclusion, those who provide health care have to be aware of the high frequency of pain, dyspnea, and psychological symptoms in the terminal stage of lung cancer. The high prevalence of symptoms toward the end of life requires frequent follow-up. Dyspnea and nausea are more often observed if there is extensive disease at the time of diagnosis. Nausea is present if the diagnosis is SCLC, and psychological symptoms are increased if the patient is < 65 years old at the time of diagnosis. General practitioners and consultants should be aware of predictors for these symptoms and should be trained in optimal palliative treatment for the symptoms.
Table 4—Studies of Prevalence Estimate of Terminal Symptoms in End-Stage Lung Cancer
|Time Before Death||Lung Cancer Patients, No.||Pain||Dyspnea||Nausea||Cough|
|Edmonds et al||449|
|Final year of life||85||78||56|
|McCarthy et al||747|
|3 d-1 mo||38||11|
|Final 3 d||46||8|
|Lutz et al||69|
|4-6 mo before death||50||33||50|
|Last 8 wk||85||54||27||28|