Connections Are Clearly More Complex

CME articles on palliative medicine are to be welcomed, since they are very important. In the article of Bausewein and Simon (1), the sections regarding drug treatment of palliative symptoms are appropriate and reflect the current state of knowledge.

Unfortunately, the authors did not stringently adhere to their stated objective of restricting the recommendations to patients with refractory dyspnea (for example, in the title, in the defined learning objectives on page 564, and in the algorithm on page 567). It is not stated clearly enough that the cited evidence is from studies that explicitly included only patients in whom tumor specific treatments (chemotherapy, radiotherapy, or surgery) was no longer indicated or not sufficiently effective.

From an oncological perspective, this limitation likely leads to considerable deficits, particularly regarding the care for patients in a palliative setting. The systematic evaluation of possible causes of dyspnea and cough is a crucial step towards the best possible treatment in the palliative setting. tThis is, for example, stated in the current US guidelines on palliative medicine published by the National Comprehensive Cancer Network (2). A plain chest x-ray (as suggested by Bausewein and Simon) will, for example, not be sufficient to detect pulmonary embolism, which is quite common in cancer patients, or malignant pericardial effusion.

Another important issue not covered by this article is the administration of local treatments such as radiotherapy. Radiotherapy is well recognized as a very effective local treatment generally associated with only minor adverse effects in the treatment of tumor or metastasis related dyspnea, cough, or hemoptysis. Furthermore, the aspect of communication with the patients was not appropriately mentioned. As described in the Canadian guidelines on the relief of dyspnea, preventive treatment of dyspnea should be initiated before a patient displays symptoms, This can be achieved by using structured education programs for patients and by discussing effective, symptom oriented treatment measures that can be applied when the malignant disease is progressing (3).

The process of multidisciplinary treatment decision making is mandatory in order to provide the most appropriate treatment approach for each individual cancer patient being in a palliative situation .Such a process requires a great expertise (4), which has been emphasized by the authors of this CME article. However, the authors have not mentioned important disciplines that can contribute very effectively to the relief of dyspnea in palliative cancer patients. The S3 guideline on palliative medicine that is currently under development will likely provide a more comprehensive perspective.