Once referred to as a silent killer but more recently as "the disease that whispers,"
ovarian cancer’s early-stage symptoms are often vague and mimic other gastrointestinal
or genitourinary illnesses. Although the median age at time of diagnosis is 63 years
old, most women attribute the nonspecific nature of symptoms to menopause or stress
(National Cancer Institute [NCI], 2014). Over time, tumor growth produces the hallmark
clinical findings of pelvic ascites, abdominal distension, and pain, leading the patient
to seek out evaluation and eventual diagnosis and treatment. The majority of women
(61%) who present for evaluation will already be in the advanced stages of the disease
(NCI, 2014).
According to the NCI, there will be an estimated 22,240 new cases of ovarian cancer
in the United States this year, as well as a resultant 14,030 deaths (NCI, 2014).
It is the deadliest of all gynecologic cancers. Though this disease accounts for only
3% of all cancer cases in women, it is the fifth leading cause of cancer-related death
(Martin, 2011; NCI, 2014). There has been no improvement in the mortality rate in
the past 40 years. Advanced ovarian cancer runs a chronic course, often with variable
phases of latency. In three quarters of patients, tumor recurrence will occur. Long-term
survival of greater than 5 years for those with advanced disease will only be achieved
in approximately 25% of patients (NCI, 2014; Ozols, 2005).
Treatment
The primary intervention for patients with ovarian cancer is complete/optimal surgical
cryoreduction. In the case of advanced disease, a debulking surgery will be performed
involving a total hysterectomy; salpingo-oophorectomy; omentectomy; lymph node sampling;
and the removal of as much tumor as possible, which may include resection of the peritoneum,
diaphragm, and areas of the bowel (Martin, 2011).
Surgery is frequently followed by the administration of combination chemotherapy using
paclitaxel plus carboplatin. For some patients, intraperitoneal chemotherapy with
cisplatin will be used to improve progression-free and overall survival (Martin, 2011).
Most women will eventually become resistant to first-line therapies and will require
treatment with second-, third-,
and possibly fourth-line chemotherapy regimens.
Symptom Burden
Symptom management of patients with ovarian cancer is done along a continuum: It begins
at diagnosis and continues to the end of life. Symptoms can be both disease- and treatment-related.
The most common symptom experienced from diagnosis through completion of treatment
is fatigue (Donovan, Hartenbach, & Method, 2005; Ferrell, Smith, Cullinane, & Melancon,
2003; Price et al., 2013). Abdominal and pelvic pain is associated with both treatment
and the disease itself. Disease- and treatment-related gastrointestinal symptoms are
frequent. Symptoms include bloating, nausea and vomiting, constipation, anorexia,
and diarrhea (Ferrell et al., 2003; Herrinton et al., 2007). In advanced disease,
bowel obstructions can occur due to compression of the tumor on the intestine or decreased
peristalsis. In addition, when patients become resistant to chemotherapy, ascites
can return. Chemotherapy can result in hair loss, neutropenia, and thrombocytopenia,
as well as peripheral neuropathy and memory problems.
Early Palliative Care: Symptom Management Through the Trajectory of Disease
Optimal symptom management in advanced ovarian cancer can be achieved by integrating
early palliative care with early cancer care. According to the World Health Organization
(WHO), palliative care "is applicable early in the course of illness, in conjunction
with other therapies that are intended to prolong life, such as chemotherapy or radiation
therapy, and includes those investigations needed to better understand and manage
distressing clinical complications" (WHO, 2014). Comprehensive treatment that includes
surgical, radiation, and medical oncologists in collaboration with palliative care
allows the oncologist to focus on the management of cancer while the palliative care
team addresses a large number of physical and psychosocial concerns (Bruera & Hui,
2010). Co-management of ovarian cancer patients allows enhancements to quality of
life by relieving symptoms associated with cancer and its treatment effects (Meier
& Brawley, 2011).
Role of Palliative Care
The scope of palliative care varies across sites and locations and ranges from only
end-of-life care to the management of symptoms and other distressing issues involved
throughout the trajectory of disease. Recent definitions of palliative care (see Figure)
describe a comprehensive interdisciplinary approach focused not only on symptom management
but also on the physical, psychosocial, and spiritual needs of patients and their
families during a serious illness (Center to Advance Palliative Care, 2011; Levy et
al., 2012; Smith et al., 2012; WHO, 2014). Palliative care specialists/teams seek
to provide an additional layer of support and education beyond that of the primary
team. They work with both patients and their caregivers. Care is often delivered as
a holistic, empathetic resource for communication regarding disease, prognosis, and
disease-related treatment choices in addition to management of intolerable symptoms
and psychosocial issues.
Figure 1
Several partial definitions of palliative care. Information from Center to Advance
Palliative Care (2011), Levy et al. (2012), Smith et al. (2012), WHO (2014).
Evidence for the Early Integration of Palliative Care
One of the most widely received studies on the early integration of palliative care
was performed on a population of patients newly diagnosed with metastatic non–small
cell lung cancer. Patients with metastatic non–small cell lung cancer, like those
with ovarian cancer, have a substantial symptom burden and may receive aggressive
care at the end of life. Their prognosis is often grim.
In a randomized controlled trial, Temel and colleagues investigated the impact of
early palliative care on quality of life and survival (Temel et al., 2010). They found
that patients who received early palliative care experienced significant improvement
in quality of life compared with patients who received standard care. Patients who
participated in the intervention also reported lower rates of depression and were
more likely to have their resuscitation preferences documented in the medical record
(Temel et al., 2010). In addition, after the study had concluded, analysis demonstrated
that those who received early integrated palliative care had a longer median survival
than those in the standard-care group.
Bakitas and colleagues (2009) carried out Project ENABLE (Educate, Nurture, Advise,
Before Life Ends). This randomized controlled trial assigned individuals who were
newly diagnosed with advanced gastrointestinal, lung, genitourinary, and breast cancers
to receive a multicomponent nursing-led intervention in collaboration with standard
care vs. standard care alone. For those receiving the intervention, advanced practice
nurses with palliative care training conducted formal education sessions with patients,
followed by monthly telephone contacts for ongoing case management that included assessments
for additional referrals or resources, until the time of the patient’s death (Bakitas
et al., 2009). Results demonstrated that patients assigned to the intervention group
reported significantly better quality of life and mood, as well as positive effects
on symptom intensity. Post-study analysis demonstrated that patients who received
the intervention had a greater median survival time, but this difference was not statistically
significant.
More recently, a pilot randomized trial sought to evaluate the benefits of a nurse
practitioner–directed palliative care intervention for patients with metastatic cancer
(Dyar, Lesperance, Shannon, Sloan, & Colon-Otero, 2012). Patients who received the
intervention had an initial consultation (and a 1-month follow-up) with an oncology
nurse practitioner who taught them about hospice; helped them to fill out living will
forms; and also assessed their psychological, physical, cognitive, social, and spiritual
needs. The intervention group showed statistically significant improvement in emotional
and mental well-being, as well as statistically improved quality of life, compared
with the control group. This study was limited in that it had a small cohort of only
26 patients. The results demonstrated by the outcome improvements related to the nurse-driven
intervention, as well as patient feedback, encouraged widespread adoption of the intervention
(Dyar et al., 2012). For ethical reasons, researchers decided to forego accruing greater
participation into the control population.
Barriers to Care
Confusion regarding the term "palliative care" often leads to underutilization or
delayed referrals until late in the disease trajectory. Physicians often equate palliative
care with end-of-life care or hospice and have feelings that referral to palliative
care will destroy hope (Hui et al., 2012). Some see palliative care as simply "the
pain team." Both physicians and patients must come to understand that the inclusion
of palliative care into treatment should not be considered giving up on the patient,
but rather sharing expertise between both teams to continue disease-modifying therapy
while optimizing patient and caregiver quality of life and outcomes.
Conclusion
In the context of advanced disease, quality of life is most affected by the symptoms
patients experience. Ovarian cancer, which most often presents in the later stages
of disease, carries a heavy symptom burden related to both the disease process and
its treatment interventions. Recent studies have exhibited the positive impact of
early palliative care on non–small cell lung cancer patients who, like those with
ovarian cancer, carry a high burden of disease and poor prognostic outcome. Early
integration of palliative care into the collaborative management of ovarian cancer
patients may lead to improved patient outcomes and greater quality of life throughout
the disease trajectory. Palliative care is not restricted to those who are at the
end of life but rather is aimed at allowing patients and their caregivers to experience
quality of life without the burden of distressing symptoms and anxieties related to
illness.