**3. Symptoms of advanced disease**

Initial symptoms vary from mild anemia to bowel obstruction. In extremis, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases [9].

For a significantly part of symptoms or complications, the main treatment approach is surgery, by resection of the primitive tumor or stoma, eventually resection of liver metastasis, combined with radiotherapy (for rectal cancer) and chemotherapy (adjuvant or for metastatic disease).

Beyond surgery, the management of metastatic disease has significantly changed over the last three decades with the incorporation of antiangiogenics (bevacizumab and panitumumab) and anti EGFR1 agent (cetuximab), and more recently, immunomodulation with anti-PD1 and Anti PD-L1 agents. Nowadays the multidisciplinary approach is essential [19].

Emergency management of colorectal cancer patients still represents a major issue and is associated to high morbidity/mortality, and where there was often no time for patient directives to be established. The two major situations are obstruction and massive bleeding. Perforation is a rare presentation [20]. For these situations, palliative surgery may be the most appropriate approach.

Obstruction is traditionally approached surgically by colonic resection, stoma, or internal by-pass or a stenting [21].

Bleeding may be managed by surgery or less invasive approaches, including radiotherapy, laser therapy and other transanal procedures [12].

Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma [11].

In cases of more advanced disease, patients may present with jaundice (due to liver metastasis or biliary tract obstruction) or malignant ascites. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation [22].

### *Colorectal Cancer*

Biliary obstruction was most common cause of jaundice, and standard techniques of biliary cannulation by endoscopic retrograde cholangio-pancreatography are the main treatment option. When it fails, endoscopic ultrasound-guided biliary drainage is a better option compared to percutaneous drainage [23].

Biliary obstruction can be the presentation of an advanced stage of disease. Median overall survival after onset of jaundice was 1.5 months but may improved to 9.6 months in patients submitted to a biliary decompression who were able to receive further chemotherapy. Jaundice due to metastatic colorectal cancer is often an ominous finding, representing aggressive tumor biology or exhaustion of therapies [14].

Jaundice represents a major concern for patients, from the unpleasant feeling of itching and to the limitations of social interaction because the change in color of the skin.

Malignant ascites accompanies a variety of abdominal and extra-abdominal metastasis and mainly peritoneal dissemination of disease. It is a cause of high morbidity, major discomfort, and several other symptoms, leading to a significant reduction in the patient's quality of life. This situation raises several treatment challenges where treatment options include a multitude of different procedures but with limited efficacy, new clinical problems as loss of proteins and electrolyte disorders that may cause diffuse edema, and some degree of risk [24].

Patients with anasarca usually present with great discomfort, with cold, thin skin and with skin transudate. These are situations that may require palliative sedation and suspension of parenteral hydration since excess of fluids worsens symptoms [25].

The treatment of malignant ascites primarily includes paracentesis and diuretics, as first-line treatments. Diuretic therapy is effective at the very beginning of the disease but efficacy declines with tumor progression and was associated with dry mouth and orthostatic hypotension [15].

Paracentesis is widely adopted but it is associated with significant patient discomfort, risks of bleeding or bowel perforation, and loss of significant amount of albumin, with worsening of peripheral edema.

Intraperitoneal chemotherapy, targeted therapy, immunotherapy, and radioisotopes are rarely an option in this situation [13].

Some symptoms of advanced disease may be less specific for colorectal carcinoma and represent a systemic impairment by neoplastic disease, like cachexia/ sarcopenia.

Cachexia is a multifactorial syndrome characterized by loss of appetite, weight, and skeletal muscle (sarcopenia) [26], leading to a cluster of symptoms like fatigue, functional impairment, increased treatment-related toxicity, poor quality of life, and reduced survival. Across malignancies, cachexia becomes more prevalent as the disease progresses, impacting approximately half of patients with advanced cancer [27].

Cachexia is a situation where preventive treatment is the most efficient. Once severe sarcopenia is established, the condition is rarely reversible. The nutritional approach should start with the development of anorexia, before weight loss begins [28].

Dietary counseling and physical activities must be offered with the goals of providing patients some advice for the preemptive management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely due to the discomfort, increment of costs and social life limitations.

No specific pharmacological intervention can be recommended as the standard of care, but progesterone analogs and short-term corticosteroids. It may be choose wisely because is associated with thromboembolic risk and gain of more fat gain than muscle mass [16].

**209**

*Palliative Care in Colorectal Cancer*

life [31].

chemotherapy.

difficult [34].

*DOI: http://dx.doi.org/10.5772/intechopen.93513*

of incidence arise from the forms and time of assessment.

effects of treatment, and/or comorbid conditions [30].

tendency to prolong antineoplastic treatment.

programs regardless of the physician.

support to afford this model of care [38].

**4. Time of palliative care in colorectal cancer**

nonsurgical modalities, is probably the best current option [31].

Among other nonspecific symptoms of colorectal carcinoma, but often associated with advanced neoplasia, 35–96% of patients experience pain, 32–90% experience fatigue, and 10–70% experience breathlessness [25]. The broad ranges

Symptom assessment in patients with advanced disease shows a progressive clustering of cascading events. Patients typically experience more than one symptom at any one time [29]. Grond et al. [16] found that 94% of those referred to a cancer pain clinic experienced additional symptoms, with 15% reporting at least five.

Symptoms may be a result of the interactions of conditions not only caused by the cancer itself, but as indirect consequences of the cancer, early or late adverse

Most patients with stage IV colorectal cancer have a poor prognosis, but numerous palliative modalities, as seem, are available today. When a cure is no longer possible, treatment is directed toward providing symptomatic relief, and a better quality of

It is difficult to draw the line between the usefulness of chemotherapy and therapeutic futility. As more drug options become available, the greater the

Functional activity indexes can correctly evaluate disability but need to be combined and integrated with other parameters to assess prognosis.15 Poor performance status values are the main point to assess the possibility of the usefulness of

Chemotherapy administration near death, showed that this approach did not improve quality of life for patients with poor performance status, and can be detrimental also for patients with good performance status [13]. Third line and beyond treatments prolonged overall survival versus palliative care, in high selected [32]. Aggressive care near the end of life as a sign of poor-quality cancer services [33] but, although numerous studies have measured these indicators, different criteria were used to define populations of interest make a comparison of results

Despite the frequency of symptoms and the limitations of antineoplastic therapy, oncologists did not systematically refer patients to a palliative care specialist, but only requested their intervention for pain and symptom management [35].

We need to change reality and dispel myths and prejudices in relation to palliative care to improve the quality of life between cancer diagnosis and death. It is necessary to change the role of the physician in navigating this course [36], or create referral

When a cure is no longer possible, treatment is directed toward providing symptomatic relief. The data available today leave little doubt that surgical resection, when feasible, may provide good palliation for some patients with metastatic disease. Although palliative surgery has been the mainstay of palliative care, an individualized multidisciplinary approach, which may involve both surgical and

In the last decade major changes in health-care delivery, changing demographics, and new treatment options have significantly changed the cancer patients' trajectory [37]. Now is the time to adapt the current models of palliative care to achieve the strongest dissemination to all cancer care settings. Implementation of palliative care can be achieved through recognition of emerging best practices and financial

### *Palliative Care in Colorectal Cancer DOI: http://dx.doi.org/10.5772/intechopen.93513*

*Colorectal Cancer*

therapies [14].

symptoms [25].

sarcopenia.

advanced cancer [27].

than muscle mass [16].

mouth and orthostatic hypotension [15].

are rarely an option in this situation [13].

of albumin, with worsening of peripheral edema.

the discomfort, increment of costs and social life limitations.

the skin.

Biliary obstruction was most common cause of jaundice, and standard techniques of biliary cannulation by endoscopic retrograde cholangio-pancreatography are the main treatment option. When it fails, endoscopic ultrasound-guided biliary

Biliary obstruction can be the presentation of an advanced stage of disease. Median overall survival after onset of jaundice was 1.5 months but may improved to 9.6 months in patients submitted to a biliary decompression who were able to receive further chemotherapy. Jaundice due to metastatic colorectal cancer is often an ominous finding, representing aggressive tumor biology or exhaustion of

Jaundice represents a major concern for patients, from the unpleasant feeling of itching and to the limitations of social interaction because the change in color of

Malignant ascites accompanies a variety of abdominal and extra-abdominal metastasis and mainly peritoneal dissemination of disease. It is a cause of high morbidity, major discomfort, and several other symptoms, leading to a significant reduction in the patient's quality of life. This situation raises several treatment challenges where treatment options include a multitude of different procedures but with limited efficacy, new clinical problems as loss of proteins and electrolyte

Patients with anasarca usually present with great discomfort, with cold, thin skin and with skin transudate. These are situations that may require palliative sedation and suspension of parenteral hydration since excess of fluids worsens

The treatment of malignant ascites primarily includes paracentesis and diuretics,

Intraperitoneal chemotherapy, targeted therapy, immunotherapy, and radioisotopes

Cachexia is a situation where preventive treatment is the most efficient. Once severe sarcopenia is established, the condition is rarely reversible. The nutritional approach should start with the development of anorexia, before weight loss begins [28]. Dietary counseling and physical activities must be offered with the goals of providing patients some advice for the preemptive management of cachexia. Enteral feeding tubes and parenteral nutrition should not be used routinely due to

No specific pharmacological intervention can be recommended as the standard of care, but progesterone analogs and short-term corticosteroids. It may be choose wisely because is associated with thromboembolic risk and gain of more fat gain

Some symptoms of advanced disease may be less specific for colorectal carcinoma and represent a systemic impairment by neoplastic disease, like cachexia/

Cachexia is a multifactorial syndrome characterized by loss of appetite, weight, and skeletal muscle (sarcopenia) [26], leading to a cluster of symptoms like fatigue, functional impairment, increased treatment-related toxicity, poor quality of life, and reduced survival. Across malignancies, cachexia becomes more prevalent as the disease progresses, impacting approximately half of patients with

as first-line treatments. Diuretic therapy is effective at the very beginning of the disease but efficacy declines with tumor progression and was associated with dry

Paracentesis is widely adopted but it is associated with significant patient discomfort, risks of bleeding or bowel perforation, and loss of significant amount

disorders that may cause diffuse edema, and some degree of risk [24].

drainage is a better option compared to percutaneous drainage [23].

**208**

Among other nonspecific symptoms of colorectal carcinoma, but often associated with advanced neoplasia, 35–96% of patients experience pain, 32–90% experience fatigue, and 10–70% experience breathlessness [25]. The broad ranges of incidence arise from the forms and time of assessment.

Symptom assessment in patients with advanced disease shows a progressive clustering of cascading events. Patients typically experience more than one symptom at any one time [29]. Grond et al. [16] found that 94% of those referred to a cancer pain clinic experienced additional symptoms, with 15% reporting at least five.

Symptoms may be a result of the interactions of conditions not only caused by the cancer itself, but as indirect consequences of the cancer, early or late adverse effects of treatment, and/or comorbid conditions [30].

Most patients with stage IV colorectal cancer have a poor prognosis, but numerous palliative modalities, as seem, are available today. When a cure is no longer possible, treatment is directed toward providing symptomatic relief, and a better quality of life [31].

It is difficult to draw the line between the usefulness of chemotherapy and therapeutic futility. As more drug options become available, the greater the tendency to prolong antineoplastic treatment.

Functional activity indexes can correctly evaluate disability but need to be combined and integrated with other parameters to assess prognosis.15 Poor performance status values are the main point to assess the possibility of the usefulness of chemotherapy.

Chemotherapy administration near death, showed that this approach did not improve quality of life for patients with poor performance status, and can be detrimental also for patients with good performance status [13]. Third line and beyond treatments prolonged overall survival versus palliative care, in high selected [32].

Aggressive care near the end of life as a sign of poor-quality cancer services [33] but, although numerous studies have measured these indicators, different criteria were used to define populations of interest make a comparison of results difficult [34].

Despite the frequency of symptoms and the limitations of antineoplastic therapy, oncologists did not systematically refer patients to a palliative care specialist, but only requested their intervention for pain and symptom management [35].

We need to change reality and dispel myths and prejudices in relation to palliative care to improve the quality of life between cancer diagnosis and death. It is necessary to change the role of the physician in navigating this course [36], or create referral programs regardless of the physician.
