Palliation in lung cancer: breathlessness, pleural effusion, blocked airway, bone and brain

Breathlessness is the symptom patients fear most and it usually has several causes at once: tumour bulk, effusion, airway obstruction, lymphangitis, anaemia, pulmonary embolism, coexisting chronic obstructive pulmonary disease and anxiety. Each is treated on its own terms. A handheld fan directed at the face reduces the sensation through the trigeminal nerve and costs nothing; low-dose oral morphine is the best-evidenced drug; a benzodiazepine is added only when anxiety is prominent; oxygen helps only if the patient is hypoxic, and not otherwise. Breathlessness services that combine breathing control, pacing and psychological support improve distress without changing lung function.

A malignant pleural effusion is drained, and the choice between talc pleurodesis and an indwelling pleural catheter has been settled by two randomised trials. TIME2 found breathlessness relief identical over 42 days (mean visual analogue score 24.7 against 24.4 mm, difference 0.16 mm, p=0.96), and AMPLE found the catheter reduced total hospital days in the remaining lifespan (median 10.0 against 12.0 days, p=0.03). The catheter is the only option where the lung is trapped and cannot re-expand; pleurodesis needs an inpatient stay but no ongoing care at home.

An endobronchial tumour causing stridor, collapse or post-obstructive pneumonia is treated at rigid bronchoscopy: mechanical debulking, cryotherapy, argon plasma or laser to open the lumen immediately, then a silicone or metal airway stent to hold it open, and external beam or endobronchial brachytherapy for more durable control. Massive haemoptysis is an emergency treated with bronchial artery embolisation. Superior vena cava obstruction is relieved by an endovascular stent within a day, faster than radiotherapy, and steroids are given while it is arranged.

Painful bone metastases are treated with a single 8 Gy fraction of radiotherapy: the Dutch Bone Metastasis Study found the response to initial treatment identical to a multi-fraction course (71 against 73 percent, p=0.84), and retreatment, when needed, worked in 63 percent. A bisphosphonate or denosumab reduces skeletal events. Spinal cord compression is an emergency: dexamethasone immediately, MRI of the whole spine the same day, then surgery or radiotherapy within 24 hours.

Brain metastases from lung cancer are increasingly treated without whole-brain radiotherapy. JROSG 99-1 showed that adding whole-brain radiotherapy to stereotactic radiosurgery for one to four metastases did not lengthen life (median 7.5 against 8.0 months, p=0.42), though it halved twelve-month brain recurrence (46.8 against 76.4 percent), and QUARTZ showed whole-brain radiotherapy adds nothing at all to steroids and supportive care in patients unsuitable for surgery or radiosurgery. Several drugs now control brain disease themselves: osimertinib, lorlatinib, alectinib, selpercatinib and repotrectinib all cross into the central nervous system, and in CROWN five-year intracranial progression was close to abolished.

Early integrated palliative care alongside oncological treatment is recommended from diagnosis of incurable lung cancer; in the trial that established it, patients randomised to early palliative care reported better quality of life and mood, received less aggressive end-of-life care and lived longer. NICE NG122 covers the lung cancer pathway in England.