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Supportive care in oncology Learning Zone
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Supportive care in cancer

Declaration of sponsorship Sandoz
Read time: 60 mins
Last updated:22nd May 2023
Published:25th Aug 2022
In this section

Why is supportive care critical to cancer management?

Join Dr Aapro and Dr Lyman for a discussion on the definition and importance of supportive care in cancer management.

Many high-efficacy cancer treatments have been developed over the past decade, bringing with them new benefits as well as challenges for modern cancer therapy – despite the advances, many patients still experience high rates of morbidity and adverse effects resulting from treatment1. The burden of adverse effects caused by cancer treatments plays a critical part in determining a patient’s clinical outcomes.

There is a growing body of evidence showing that providing supportive care to address the adverse effects of cancer treatment can lead to improvements in quality of life and survival2,3. However, worldwide variations in the definition of supportive care, a lack of clarity on who should provide these services, and lack of a universal clinical model, have created barriers to implementation4, creating a significant need for ‘supportive oncology care’ to become a specialty in its own right. With the rising incidence of cancer worldwide5, and many patients living longer with improved treatments6, this need is becoming critical7.

What is supportive care in cancer?

Watch Dr Aapro discuss the origins and definitions of supportive care in oncology.


The Multinational Association of Supportive Care in Cancer (MASCC) defines supportive care as:

The prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side effects across the continuum of the cancer experience from diagnosis through treatment to post-treatment care8

Supportive care manages the toxicities and side effects of cancer treatment, is evidence-based and utilises a patient-centred approach. With optimal supportive care models implemented into practice, there are numerous benefits for patients, families and health care practitioners (HCPs), including8:

  • Reduced symptoms and complications of cancer
  • Prevention and/or reduction of treatment toxicities and side effects
  • Increased adherence to treatment due to better management of side effects
  • Increased tolerance, and thus benefits, of cancer treatment
  • Improved communication between patients, caregivers, and health practitioners
  • Easing of the emotional burden for patients and caregivers
  • Psychosocial support for cancer survivors

Role of the multidisciplinary team in supportive care

Watch Dr Aapro discuss the structure and function of a proposed multidisciplinary team that could be involved throughout the cancer patient’s journey.

Supportive care covers the physical, emotional, social, spiritual and informational needs of the patient, and cannot be provided by a single clinical specialty alone9. As with other multidisciplinary teams (MDTs), a ‘core team’ is required to address everyday problems and concerns of the patient, whilst an ‘extended team’ will be involved as the need arises1. The ‘core team’ usually consists of oncologists, surgeons, pathologists, radiotherapists, nurses and other specialists according to the type of cancer10. The core team will require regular ongoing and specific training in the principles of supportive care, to ensure the model is being implemented correctly, as well as appropriately engaging members of the extended team in a timely manner1,10. The structure of a supportive care team is illustrated in Figure 1.

SupportiveCareInOncology_Tab1_Figure1.png

Figure 1. Structure of the supportive care team (Adapted10).

Is supportive care synonymous with palliative care? What is the difference?

Watch Dr Aapro discuss the difference between these terms, as well as highlight how supportive care changes for the geriatric patient with cancer.

What is the difference between supportive care, palliative care and patient-centred care?
What is the difference between supportive care, palliative care and patient-centred care?
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How is supportive care different in the geriatric patient?
How is supportive care different in the geriatric patient?
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Supportive care emerged as a response to specifically address the toxicities and side effects of cancer treatment throughout the entire cancer continuum11. Palliative care has historical roots in end-of-life and hospice care and, although it encompasses the same principles of supportive care, confusion among HCPs and patients between the use of the terms has created barriers to implementation12. Studies have shown that patients and HCPs are more responsive to the term ‘supportive care’ than ‘palliative care’, with many patients and HCPs hesitant to engage palliative care services because of the association with end-of-life and discontinuing treatment12.

It is a common misconception that supportive care and palliative care are separate, with the latter focused more on end-of-life care. It is important for HCPs to understand that whilst these terms originated to address different concerns, they have evolved to encompass the same principles of supportive care and patient-centred care13. The European Society for Medical Oncology (ESMO) has suggested that the term ‘patient-centred care’ be used to cover both supportive and palliative care approaches during the continuum of cancer illness, while the World Health Organization (WHO) and the American Society of Clinical Oncology (ASCO) include the principles of supportive care in their definition of palliative care14. ASCO asserts that the two terms and types of care, though having different origins, are one and the same15. The HCP should therefore take time to dispel the negative connotations surrounding palliative care, whilst remaining conscious of its potential effect on the patient and family12. Supportive care could therefore be considered an overarching principle, with palliative care an integral part of that care.

The critical role of supportive care in cancer management

Watch Dr Aapro highlight the impact of cancer treatment and the related toxicities on patient quality of life and treatment outcome.

Numerous studies have demonstrated that implementing a supportive care model as part of cancer management improves the outcome in many different aspects of a patient’s life2,3,16-18

Systemic treatments have rapidly evolved from being predominantly cytotoxic chemotherapy and radiotherapy, to immunotherapies and targeted therapies19. Despite the advances in cancer therapy, tolerance to treatment remains a key issue. The emergence of novel treatments has seen an increase in new toxicities and side effects, necessitating alternative management approaches19. MASCC has created guidelines for supportive care strategies addressing many of these toxicities, to ensure optimal outcomes for patients that HCPs can familiarise themselves with.

Patients undergoing cancer treatments often experience a high burden from the side effects of treatment (Figure 2). Unmanaged side effects can lead to patient discomfort, treatment non-adherence and suboptimal cancer management. This can subsequently increase the cancer burden through dose delays, dose reductions and treatment withdrawal. Management of side effects is therefore a critical component of providing supportive care that has a direct impact on treatment outcomes20.

SupportiveCareInOncology_Tab1_figure2.png

Figure 2. Impact of cancer treatment and side effects on the patient (Adapted20).

There is evidence to show that a lack of supportive care is associated with profoundly detrimental outcomes. Evidence gathered from populations with limited access to supportive care for reasons of socioeconomic, geographical, and racial barriers have shown that survival, secondary complications arising from treatment, and health-related quality of life are all negatively impacted21-24.

In the UK, a national initiative to implement supportive care into existing cancer management plans has been trialled with great success3. Studies have returned positive results including3:

  • Improved symptom control and quality of life
  • Reduced 30-day mortality
  • Improved overall survival
  • Reduced healthcare costs

Similarly, initiatives to implement early supportive care in US clinics showed improved overall survival and quality of life25.

Advance care planning

Advance care planning (ACP) is a process that "supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care"26. ACP informs treatment decisions that can be documented in an advance directive (AD). Palliative care specialists are skilled in providing ACP support for patients but are a limited resource. To address this limitation, the CONNECT study was undertaken to investigate the impact of a nurse-led intervention on ACP uptake among patients with advanced cancer. Given that oncology nurses often have special relationships with their patients, they may be well suited to providing ACP support26.

The CONNECT study involved a secondary analysis of a cluster randomised controlled trial examining the impact of nurse-based primary palliative care. Patients with advanced cancer were randomly assigned to receive either monthly primary palliative care visits with trained nurses within their cancer centre or standard care. Nurses in the intervention arm received special training in ACP27.

ACP uptake was assessed at enrolment and 3 months later, evaluating whether an end-of-life conversation (EOLC) occurred with the oncologist, and whether an AD was completed. Multivariable logistic regression tested differences in ACP uptake by treatment arm adjusted for various factors.

Of the 672 patients enrolled, 54% (182/336) patients in the intervention arm and 58% (196/336) in the standard care arm lacked an EOLC at baseline and completed the 3-month assessment. In the intervention arm, 45.1% (82/182) of patients had an EOLC after 3 months, compared with 14.8% (29/196) in the standard care arm. Regarding ADs, 33% (111/336) of patients in the intervention arm and 31% (105/336) in the standard care arm did not have ADs initially but completed the 3-month assessment. Among these, 43.2% (48/111) in the intervention arm and 18.1% (19/105) in the standard care arm completed an AD during the study27.

The study concluded that nurse-led primary palliative care increased ACP uptake among patients with advanced cancer. Training oncology nurses within community cancer centres to provide primary palliative care may help improve ACP access. These findings highlight the potential of specialist healthcare professionals, including oncology nurses, to provide primary palliative care and contribute to improving the quality of care for patients with advanced cancer27.

Side effects associated with cancer treatments

In this video, Dr Aapro discusses how novel cancer treatments are resulting in new side effects, and the management challenges this presents for HCPs.


Side effects of cancer treatment may be short-term, long-term or even life-long and present a significant barrier to receiving adequate treatment as the dose may need to be reduced, delayed or discontinued due to the toxicities8. This is a phenomenon labelled ‘dose-limiting toxicity’ and is a major issue faced when administering anti-cancer therapy8.

Adherence to various treatments is influenced by numerous factors including access and cost; however, the biggest influence is the tolerability of side effects28. Tolerability and adherence vary across treatment modalities29,30(Figure 3). Being aware of the side effects and educating the patient on what to expect is a critical component of improving adherence, tolerance, and treatment outcomes.

SupportiveCareInOncology_Tab1_Figure3.png

Figure 3. Adherence according to anti-cancer treatment modality (Adapted29,30).

General side effects

Fatigue

Cancer-related fatigue (CRF) is one of the most common and distressing symptoms experienced by patients during their treatment31,32 and is reported to be more distressing than pain, nausea or vomiting33. CRF can be dose-limiting and have a negative impact on treatment adherence, efficacy, and survival32,34. Despite its frequency, CRF remains underreported, underdiagnosed, and undertreated31. Prevalence rates vary from 50% to 100% depending on the type of treatment, dose, and type and stage of cancer35-37. Fatigue in cancer is strongly associated with depression, anxiety, and physical disability, with severe fatigue being a predictor of shorter survival38,39. Many common adverse effects of cancer treatment contribute to and worsen CRF including32,33,35:

  • anaemia
  • pain
  • muscle deconditioning
  • sleep-wake disturbance
  • vomiting
  • diarrhoea
  • malnutrition

Haematological side effects

In this video, Dr Lyman discusses some common haematological side effects of cancer treatment and the guideline recommended management approaches.

Thrombosis

Chemotherapy and tumour surgery resulting in patient immobilisation frequently cause cancer-associated thrombosis, with the most common complication being venous thromboembolism (VTE)40. Severe complications of VTE constitute a major cause of mortality among people with cancer41. Treating VTE in the cancer patient can become complex, as typical management with anticoagulants is associated with an increased risk of bleeding and unfavourable drug interactions, which therefore limits the therapeutic options available for cancer treatment41,42.

Thrombocytopenia

Systemic chemotherapy is the most frequent cause of thrombocytopenia; however, any myelosuppressive cancer treatment can induce this condition43,44. Thrombocytopenia significantly increases the risk of internal haemorrhage and is associated with worse clinical outcomes45.

Thrombocytopenia frequently occurs with thrombosis, making treatment difficult because of the competing risks of recurrent thrombosis and increased bleeding46,47

HCPs should exercise caution and vigilance when using myelosuppressive cancer treatments by regularly monitoring platelet levels.

Anaemia

Up to 39% of cancer patients present with anaemia at the time of diagnosis and up to 40% have iron deficiency. If not identified early this can be further exacerbated by cancer treatment48. Anaemia causes fatigue, dyspnoea, functional deterioration, and a reduction in the quality of life; it has also been associated with a poorer response to cancer treatment and lower survival49. Anaemia can result from myelosuppression due to chemotherapy and radiotherapy and has been linked to immunotherapy, specifically checkpoint inhibitors48,50.

Neutropenia

Neutropenia (including febrile neutropenia and neutropenic colitis) is a life-threatening complication associated with increased morbidity and mortality, and is a leading cause of dose reduction and delay51.

Neutropenia most often results from chemotherapy and radiotherapy, but with the emergence of new targeted and immunotherapies, its prevalence in cancer patients is rising51,52

Other causes of neutropenia include tumour malignancies and lymphoproliferative malignancies, such as natural killer cell lymphomas, hairy cell leukaemia, and chronic lymphocytic leukaemia53.

Lymphoedema

Lymphoedema is the accumulation of lymph fluid that obstructs the flow of the lymphatic system, causing persistent swelling in an affected body part54. Lymphoedema is most commonly seen after radiation therapy or lymph node dissection. It occurs in 10–40% of patients with breast cancer and 80% of patients with lymph node dissection in the groin54. Secondary lymphoedema is caused through fibrotic tissue changes that occur post-treatment, causing structural and functional changes that block the flow of circulating lymph55.

Learn more about the management strategies for haematological side effects

Gastrointestinal side effects

Watch Dr Lyman highlight the most common and distressing gastrointestinal side effects of cancer treatment experienced by people with cancer.

Nausea and vomiting

Chemotherapy-induced nausea and vomiting (CINV) is common and distressing for patients, and is the number one cause of dose delays and discontinuation56. CINV occurs in up to 80% of patients and can have a significant impact on quality of life. Prolonged CINV can also result in the following57:

  • Serious electrolyte and metabolic imbalances
  • Malnutrition and anorexia
  • Cognitive impairments
  • Oesophageal tears
  • Delayed wound healing and dehiscence
  • Withdrawal from potentially useful and curative antineoplastic treatment
  • Loss of independence and functional ability

Mucositis (oral and gastrointestinal)

Mucositis refers to inflammatory, erosive, and ulcerative lesions of any part of the gastrointestinal (GI) tract, including the mouth and oesophagus, that occurs secondary to cancer therapy58. Mucositis can be classified according to the type of cancer therapy involved as chemotherapy-induced mucositis, radiation-induced mucositis, or a combination of the two59. More recently, mucositis following targeted anticancer therapies has been described60-62. Oral mucositis occurs in approximately 20–40% of patients receiving conventional chemotherapy for solid tumours, over 80% of patients receiving head and neck radiotherapy, and about 80% of patients undergoing high-dose chemotherapy prior to haematopoietic stem cell transplantation63. GI mucositis is also prevalent, with an incidence of 50–89% in patients receiving various chemotherapy regimens64.

Diarrhoea and constipation

Diarrhoea and constipation present a constant challenge in the treatment of cancer and are primary contributors to dose reductions, delays and cessation of treatment65. Constipation is believed to occur in 16% of cancer patients66, whilst incidence of diarrhoea can be as high as 80%67.

Diarrhoea and constipation can persist for many years after the discontinuation of treatment, presenting a significant clinical problem68

Diarrhoea and constipation are usually attributed to conventional cytotoxic drugs such as chemotherapy, but many molecularly targeted agents, including tyrosine kinase inhibitors and monoclonal antibodies, are also associated with the conditions65,69.

Cachexia and anorexia

Cachexia is a major cause of morbidity and mortality in late-stage cancer and can occur following prolonged chemotherapy70,71.

Cachexia is a devastating condition characterised by muscle wasting, malnutrition and weakness, with a significant impact on quality of life and treatment success70,72

Two major symptoms of cancer cachexia are anorexia and weight loss that is not improved with increased food intake73,74. Wasting mostly occurs in skeletal muscle and adipose tissue, but other organs, such as the brain, liver, pancreas, heart, and gut, are also involved in cachexia, making it a multiorgan syndrome75.

Learn more about management strategies for gastrointestinal side effects

Cardiovascular side effects

Dr Lyman discusses the common cardiovascular and respiratory side effects of cancer treatment below.

 

Targeted therapies such as monoclonal antibodies and small molecule inhibitors of protein kinases, are associated with cardiovascular and metabolic sequelae76. These include heart failure or a decline in ejection fraction, peripheral and cardiac ischaemic events, pulmonary hypertension, arrhythmias, and QT-prolongation76,77.

Development of cardiac dysfunction secondary to treatment is associated with significantly lower chances of survival78

The effect of antineoplastic drugs on cardiomyocytes can be categorised as either type I or type II cardiotoxicity78. Type I cardiotoxicity is dose-dependent and irreversible, and is characterised by structural changes to cardiomyocytes, leading to apoptosis78. Conversely, in type II cardiotoxicity, cardiomyocytes lose contractility, leading to cardiac dysfunction and reduced cardiac output, but this is not associated with any significant changes to cardiac structure78. 

Respiratory side effects

Pulmonary toxicity is a well-documented complication of several anti-cancer treatments, with breathlessness and dyspnoea among the most common pulmonary side effects79. A study of 923 mixed cancer patients found that breathlessness was reported by over 50% of patients with primary cancers of the breast, lung, genitourinary organs, head and neck, and those with lymphoma80.

All modalities of cancer treatment, including chemotherapy, radiation therapy, targeted therapy and immunotherapy can cause significant and potentially fatal pulmonary complications81-84

The presentation of pulmonary toxicity ranges from dry cough and shortness of breath to sudden respiratory failure and may mimic other conditions such as infection or pulmonary oedema79. Clinicians should therefore maintain heightened awareness and focus on early detection.

Endocrine and metabolic side effects

Hypercalcaemia, though not directly resulting from any specific treatment, is a common symptom of cancer with huge potential to negatively impact on cancer treatment regimens. Approximately 20–30% of people with cancer experience hypercalcaemia during their illness85. Hypercalcaemia produces distressing symptoms for the patient and is strongly associated with poor prognosis and higher rates or mortality85,86. Symptoms of hypercalcaemia can be mistaken for normal side effects of cancer treatment and include87:

  • anorexia
  • nausea
  • abdominal pain
  • muscle weakness
  • fatigue
  • bony tenderness

Severe complications of hypercalcaemia include dehydration, nephrolithiasis, acute pancreatitis, acute renal failure, and altered mental status including coma87. Because hypercalcaemia can significantly complicate cancer management, this condition should not be overlooked88.

Hyponatraemia

Hyponatraemia is a common electrolyte abnormality associated with substantial morbidity and mortality, and can result from haemorrhage, diarrhoea, vomiting, ascites, oedema, or salt-wasting nephropathy89,90. Platinum-based therapies are now among the most widely used anti-cancer therapies, but are associated with hyponatraemia, which can be due to renal salt wasting syndrome or syndrome of inappropriate ADH (SIADH)91.

Hyponatraemia often follows chemotherapy with platinum-based compounds, which can cause damage to the renal tubules, resulting in renal salt-wasting syndrome91

Other known nephrotoxic cancer treatments linked to hyponatraemia include amphotericin, methotrexate, cidofovir and foscarnet92. Malignancy itself can also cause electrolyte imbalances, including hyponatraemia89,90.

Neurological and muscular side effects

Watch Dr Lyman discuss the most common neurological side effects resulting from cancer treatments.

Headache and memory impairment

Chemotherapy agents, such as all-trans-retinoic acid, procarbazine and 5-fluorouracil, as well as many others, have been implicated in causing headaches and memory impairment93. Patients receiving radiotherapy may develop acute radiation toxicity, which typically manifests as severe headache, fever, nausea, vomiting, decreased level of consciousness and worsening neurological deficits94.

Peripheral neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect of cancer treatment with a prevalence of 19–85%95. CIPN is a sensory neuropathy accompanied by motor and autonomic changes varying in intensity and duration95,96. Treatment options for CIPN are limited and it is therefore a significant cause of dose reduction and discontinuation95,96.

Dermatological side effects

Dermatological toxicities are well documented for chemotherapy and radiation therapy, but have become more prominent with the evolution of newer targeted therapies and immunotherapies97. Dermatological complications occur in up to 78% of patients receiving chemotherapy98, 90% receiving radiation therapy99, 20% receiving immunotherapy100 and 30–50% receiving targeted therapies101. Known side effects include97,102,103:

  • Alopecia
  • Acneiform (papulopustular) rash
  • Xerosis
  • Extravasation
  • Maculopapular rash (morbilliform eruption)
  • Hand–foot skin reaction
  • Stevens–Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN)
  • Nail toxicity
  • Acute radiation dermatitis (ARD)

While some forms of toxicities do not pose an imminent risk to the patient, other side effects such as TEN can prove fatal97.

Acute radiation dermatitis (ARD) is a well-known and frequently observed side effect of external beam radiotherapy (RT) in cancer patients, affecting as many as 95% of individuals. The development of ARD involves a multifaceted process, characterised by radiation-induced harm to both the epidermis and dermis. This damage leads to changes in the growth and differentiation of basal and epidermal keratinocytes, disruptions in the skin's protective barrier, and activation of proinflammatory markers that contribute to the symptoms associated with ARD104,105.

ARD typically appears as redness, swelling and blistering in the area that received radiation, and can also cause itching, pain and skin peeling. ARD can have a negative impact on a person's quality of life, as it can cause physical discomfort and interfere with daily activities such as sleeping, dressing and bathing. It can also affect a person's emotional wellbeing, causing anxiety, depression, and stress related to their cancer diagnosis and treatment. In severe cases, ARD can lead to skin infections and delay or interrupt radiation therapy, which can have a negative impact on the effectiveness of the treatment104-106.

SupportiveCareInOncology_Figure4.png

Figure 4. Summary of the side effects of cancer treatment on body systems107.

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