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Sickle cell syndromes

1 What is sickle cell disease? Sickle cell disease is an autosomal recessive inherited blood disorder caused by mutation in the ß-globin gene resulting in production of an abnormal hemoglobin (Hb), hemoglobin S (HbS), which polymerizes under deoxygenated conditions leading to formation of distorted “sickle-shaped” erythrocytes from which the disease derived its name. It is prevalent in individuals of African, Middle Eastern, Southern European, and Indian…

Developmental erythropoiesis

1 Define fetal erythropoiesis. In the fetus, erythropoiesis begins at approximately the fourth gestational week and is primarily formed in the extravascular yolk sac. By the fifth gestational week, erythropoiesis begins within the liver. Only in the last gestational trimester does erythropoiesis (and myelopoiesis) take place in the bone marrow. Simultaneously, major changes occur in the structure of hemoglobin (Hb). Initially, embryonic Hbs are expressed. Subsequently…

Psychosocial and spiritual distress

Introduction Palliative care is dedicated to treating the whole person, which extends beyond the physiological condition to include the biological, psychological, social, and spiritual arenas—known as the biopsychosocial-spiritual model of care. With attention to all of these domains of care, palliative care clinicians strive to attend to the “total pain” of their patients, including psychosocial and spiritual distress. The provision of palliative care is an inherently…

Late toxicities management

Late toxicity management Patients who receive palliative radiation therapy (RT) generally have limited life expectancy. Historically, late toxicity has been uncommon in this population given the typically lower total radiation doses used in palliative RT and the relatively long latency to manifest. However, patients with incurable cancer generally live longer with modern treatments, and palliation is now characterized by more aggressive dose regimens. Practitioners of palliative…

Abdomen and pelvis: Symptoms and toxicities

Abdomen and pelvis radiation-related symptoms and toxicities Overview The severity of radiation-related toxicity is related to the total dose received, fraction size, and overall treatment time, in addition to other patient-related factors such as concurrent receipt of systemic therapy, prior treatments, and predisposition to radiation side effects. Palliative radiotherapy is typically delivered in a shorter time frame with a larger dose per fraction (though notable exceptions…

Chest and thorax: Symptoms and toxicities

Overview In the last several decades, cancer-related treatment has significantly advanced, including increased utilization of immunotherapy, improvements in surgical precision and radiation techniques, advances in palliative medicine, and greater emphasis on patient quality of life. Focal treatment of metastatic disease—in particular oligometastases—is increasingly emphasized and accepted. Many of the world’s most prevalent cancers commonly metastasize to the lung parenchyma, including breast, lung, colorectal, uterine leiomyosarcoma, and…

Management of symptoms and treatment-related toxicities of head and neck cancers

Introduction Malignancies of the head and neck can be challenging to manage due to the frequent involvement of the mucosal surfaces of the aerodigestive surfaces causing bleeding, airway obstruction, pain, malnutrition, and impaired communication abilities. Toxicity and impairment caused by invasive neoplasms can result in severe morbidity and can significantly affect a patient’s quality and length of life. Radiation therapy (RT) is an essential component in…

Central nervous system: Symptoms and toxicities

Background Palliative radiotherapy (RT) is frequently recommended for the treatment of cancer progression within the central nervous system (CNS). The most common indications for palliative RT to this region include brain metastases, spinal metastases, spinal cord compression, leptomeningeal carcinomatosis, and palliative-intent treatment of primary brain neoplasms in the elderly or poor-performance-status patients. Radiation treatment modalities in this setting generally consist of external beam radiation and stereotactic…

Management of skin toxicity

Introduction Radiation-induced skin reaction (RISR), or radiation dermatitis, is one of the most common side effects of radiation therapy (RT). RISR can vary in severity, impact the quality of life (QoL), and limit the extent of treatment tolerance by patients. Acute skin toxicity, occurring during or soon after treatment, is common and typically temporary. In contrast, late skin toxicity occurs in relatively fewer patients, can take…

Management of fatigue

Introduction Symptom control increasingly is recognized as an important component in the multidisciplinary management of cancer patients, as it allows for the successful completion of treatment and improves the quality of life (QoL) throughout the course of the disease. Fatigue is one of the most common symptoms of cancer and cancer treatments. In one large study of cancer patients, those with advanced cancer had a high…

Management of pain

Pain is highly prevalent in the oncology patient population, estimated to be more than 70% in advanced stages of disease. Pain is not necessarily associated with lower survival odds in patients with advanced cancer, but it does impact the overall quality of life. Different types of pain syndromes are present in all stages of cancer and are not adequately treated in 56% to 82.3% of patients.…

General symptom overview: Importance of side effect management, CINV, anorexia, and cachexia

Palliative care (PC) principles apply to many symptoms and situations. In many patients with a number of underlying conditions, symptoms can vary markedly and range from physical to psychological to spiritual. In this chapter, we will attempt to offer a framework for approaching patients with varied symptoms and will take a deeper dive into several common gastrointestinal symptoms: nausea and anorexia We will begin with a…

Palliative radiotherapy in the older adult

Introduction Many countries are in the early stages of a major demographic shift, stemming from the so-called “baby boomers” coming of age and thus an increasingly older population. This has clear implications for clinical practice, as age is the number one risk factor for the development of cancer, and therefore, we will see greater numbers of older adults with cancer in the coming years. In the…

Palliative radiotherapy in oligometastases

Introduction Halsted et al. theorized that there was an orderly, contiguous, and stepwise mechanism for the spread of cancer within the body, extending from the primary tumor to the lymphatic system, lymph nodes, and ultimately, distant sites. , This theory supported the idea that aggressive local treatment, including mastectomy or radiotherapy, can prevent disease spread and improve survival. However, Fisher et al. proposed an alternate theory,…

Palliative radiotherapy in the spine

An estimated 40% of cancer patients are diagnosed with spinal bone metastases (SBM), which can result in significant morbidity including pain, neurologic compromise, fracture, and spinal cord compression. Metastatic spinal cord compression (MSCC) develops in approximately 5% of cancer patients , ; however, the incidence varies with tumor histology and the most common primary histologies are lung cancer, prostate cancer, and multiple myeloma. For patients in…

Palliative radiotherapy in the brain

Indications for palliative radiation The most common indication for palliative radiation to the brain, brain metastases are a very common occurrence in the contemporary management of oncology patients, representing the most common brain tumor in adults and outnumbering primary brain tumors by an estimated factor of 10. Although far less common, primary brain tumors can also cause significant symptoms in patients and represent another indication for…

Palliative radiotherapy in bones

Introduction Non-spine bone metastases are a common source of pain and morbidity among patients with metastatic cancer. Although their true incidence is unknown, estimates ranging as high as 30% to 70% have been reported during the course of their malignancies among patients with the most common cancer histologies. Radiotherapy is widely recognized as an effective tool in the palliation of bone metastases, providing pain relief in…

Radiotherapeutic palliation of bone marrow diseases—leukemia and multiple myeloma

Introduction Hematologic malignancies arising from bone marrow cell populations classically include leukemias, either of lymphocytic or myelogenous origin, and multiple myeloma (MM), of plasma cell origin. The mainstay of definitive therapy for these malignancies is high-dose chemotherapy with local therapy, such as radiation therapy (RT) typically reserved for palliation. However, in the modern era of improved systemic agents and prolonged patient survival, the management of the…

Radiotherapeutic palliation of lymphoma

Introduction Radiotherapeutic palliation of lymphoma is unique among cancers for several reasons. First, unlike most cancers, even patients with disseminated “stage IV” disease can be routinely cured or put into a lasting remission with systemic therapies alone. Even in the relapsed or refractory setting, salvage systemic regimens and stem cell transplantation offer curative options for patients with lymphomas. In the recent era of immunotherapies and biologically…

Palliative radiotherapy in pediatrics

Background An estimated 11,060 new cases of pediatric cancer will be diagnosed in the United States in 2019. In children ages 0 to 14, the most common diagnoses are leukemia (28%), central nervous tumors (21%), and neuroblastoma (7%) ( Fig. 17.1 ). In adolescents ages 15 to 19 the most common malignancies are Hodgkin lymphoma (15%), thyroid carcinoma (11%), and central nervous system (CNS) tumors (10%).…