Management of Dyspnea in Advanced Cancer: ASCO Guideline

Abstract

PURPOSE To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer. METHODS ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020. RESULTS The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea. RECOMMENDATIONS A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .

Implementing the battery-operated hand-held fan as an evidence-based, non-pharmacological intervention for chronic breathlessness in patients with chronic obstructive pulmonary disease (COPD): a qualitative study of the views of specialist respiratory clinicians

“…Most clinicians in our focus groups were unfamiliar with published evidence for the fan’s effectiveness from RCTs or related guideline recommendations. Most guidelines recommending the fan for chronic breathlessness either focus specifically on cancer [ 17 , 18 ] or are for palliative care more generally [ 40 – 42 ], with only the New Zealand COPD Guidelines [ 43 ] and a ‘workshop report’ from the American Thoracic Society (ATS) targeted at specialist respiratory clinicians [ 9 ]. The fan could be recommended across a wide range of respiratory guidelines and clinical pathways, including those for pulmonary rehabilitation and inpatient or outpatient management of breathlessness.…”

“…The fan’s potential for benefit, few disadvantages and low cost combine with its portability to warrant its implementation as a ‘first-line’ intervention for amelioration of chronic breathlessness that should be recommended to all affected patients alongside disease-directed treatments [ 9 , 17 , 18 ]. However-as for many evidence-based interventions-specific efforts may be needed to drive implementation.…”

Timely Palliative Care: Personalizing the Process of Referral

“…Palliative care teams can provide a variety of non-pharmacologic and pharmacologic measures to alleviate symptoms such as pain, dyspnea and nausea when they first present. Subsequent visits can allow the palliative care team to optimize symptom control by providing therapeutic trials, active titration, proper education, longitudinal monitoring, and reinforcement of treatment adherence [ 32 , 33 ]. Successful symptom management not only improves quality of life, but also prevents escalation of symptoms leading to avoidable emergency room visits and hospitalizations [ 34 , 35 ].…”

Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines

“…For dyspnoea, the initial focus should be on optimising treatment of a patient’s underlying disease. 63 , 64 Treating potentially reversible causes should be considered. Non-pharmacological treatment could provide short-term benefit but at EoL this may not be tolerated.…”