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The Royal Marsden 

Palliative care perspective 

of advanced gynaecological 

cancer management 

Dr Jayne Wood 

Consultant Palliative Medicine 

The Royal Marsden and Royal Brompton 

Palliative Care Service 

1

2 


Objectives 

– Bowel obstruction 

– Nausea and Vomiting 

– Ascites

3 


Bowel Obstruction

4 


Malignant Bowel Obstruction 

– 3% all cancers 

– Autopsy studies of patients with ovarian cancer: 

– Large and small bowel involvement in 49% and 42% 

cases resp. (Rose et al,1978) 

– Large and small bowel involvement in 78% and 70% 

cases, with bowel obstruction in 51% cases (Dvoretsky 

et al,1988)

5 


Pathophysiology 

Accumulation of secretions 

Distension 

Secretion of fluid 

Raised intraluminal pressure 

Obstruction of venous drainage 

Reduced oxygen consumption 

Intestinal gangrene 

Perforation

6 


Therapeutic approaches 

– Surgery 

– Stents 

– Decompressive techniques 

– Chemotherapy 

– Pharmacological treatments 

– Pain 

– Nausea/vomiting 

– Constipation 

– Feeding

7 


Surgery 

– Published data 1989-1997 (OTPM, 2004) 

– Operative mortality 9-40% 

– Complication rate 9-90% 

– Survival influenced by post-operative 

chemotherapy 

– Urch et al (2002) 

– Prospective study 

– No statistical difference in median survival for 

patients receiving surgery or medical treatments

8 


Decompressive techniques 

– Nasogastric tube 

– 12-29% resolution symptoms but 32-45% 

symptoms recur (Butler 1991) 

– Complications 

– Gastrostomy tube 

– Consider if symptoms failing to settle with medical 

management and surgery inappropriate 

(Campagnutta et al 1996) 

– Caecostomy tube

9 


Pharmacological treatments 

– Pain 

– Opioids 

– Anti-spasmodic drugs 

– Nausea and vomiting 

– Antiemetics 

– Anticholinergics 

– Steroids 

– Somatostatin analogues 

– Constipation

10 


Steroids 

– Feuer DJ, Broadley KE (2000) 

– Trend for evidence that steroids may bring about 

resolution (NNT=6) 

– Low incidence of side effects 

– No effect on survival 

– May palliate symptoms well 

– Length of trial period unknown (suggest 5d)

11 


Octreotide vs Hyoscine Butylbromide 

– Mystakidou et al (2002) 

– 68 patients with inoperable bowel obstruction 

– Randomised to receive hyoscine butylbromide or 

octreotide 

– Significant improvement in octreotide arm with 

respect to: 

– Nausea 

– Vomiting 

– Fatigue 

– Anorexia 

– No difference in relation to pain 

– BUT low doses of hyoscine butylbromide used

12 


Feeding 

– Parenteral nutrition 

– Should not be routine (Ripamonti et al, 2002) 

– Most will absorb sufficient fluid from gut to prevent 

thirst 

– Consider alternative management to iv fluids if 

thirst present 

– Indicated if: 

– Surgery being considered 

– Starvation likely to be cause of death

13 


Impact of Malignant Bowel Obstruction 

– Gwilliam et al (2001) 

– Inability to eat: 

– Social and emotional loss 

– Inadequacy and displacement 

– Social disengagement 

– Disruption of identity 

– Alteration in activity 

– Deterioration of mental ability

14 


Nausea & Vomiting

15 


Incidence 

– Advanced Cancer 

– 60% report nausea 

– 30% report vomiting 


– Impairs QOL 

– Distressing 

– Aggravates cancer-related symptoms

16 


Definitions 

– Nausea 

– “feeling of need to vomit, often accompanied 

by autonomic symptoms 

– Retching 

– “rhythmic, laboured, spasmodic movement of 

diaphragm and abdominal muscles” 

– Vomiting 

– “forceful expulsion of gastric contents 

through mouth”

17 


Physiology 

Central stimulation: 

CTZ 

Cerebral cortex 

Vestibular apparatus 

Visual cortex 

Peripheral stimulation: 

Gut 

Pharynx 

Vomiting Centre 

Gastric atony 

Retroperistalsis 

Abdominal contraction

18 


Causes 

Brain metastasis 

Raised ICP 

Anticipatory 

Emotional/psychological/ 

spiritual 

Metabolic disturbance: 

Uraemia 

Electrolyte disturbance 

Hormone imbalance 

Oral thrush 

Cough 

Treatment related: 

Chemotherapy 

Radiotherapy 

Opioids 

Antibiotics 

Gastric stasis 

Constipation 

Bowel 

obstruction

19 


Management 

– Identify underlying cause 

– Note contents 

– Timing 

– Discontinue drugs with emetic side effects 

– Examine patient 

– Mouth 

– Pharynx 

– Abdomen 

– Neurological systems 

– Blood tests 

– Imaging

20 


Management 

– Treat 

– Non-drug 

– Acupuncture 

– Calm atmosphere 

– Small snacks 

– Bland foods 

– Drugs 

– Most potent 

– Regular administration 

– Appropriate route 

– Titrate adequately

21 


Anti-emetics 

– Glare et al (2004) 

– Nausea in patients with advanced cancer 

– Good evidence for use of: 

– Metoclopramide and cancer related dypepsia 

– Steroids and bowel obstruction 

– LITTLE ELSE…..

22 


Antiemetics 

Prokinetics 

– Dopamine antagonists 

– Indications 

– Gastric stasis 

– Gastritis 

– Examples 

– Metoclopramide 

– Domperidone 

– Side effects 

– Extrapyramidal side effects 

– Neuroleptic malignant 

syndrome 

– Drowsiness 

– Restlessness 

Haloperidol 

– Paucity of evidence 

– Trend of evidence that 

effective in nausea secondary 

to: 

– Variety of cancers 


– Epidural morphine 

– Unknown causes

23 


Antiemetics [2] 

Antihistamines/anticholinergics 


– Mechanical bowel obstruction 

– Raised intracranial pressure 

– Motion sickness 

– Example 

– Cyclizine 

– Hyoscine hydrobromide 

Phenothiazines 


– Unknown cause 

– Chemo- and 

radiotherapy induced 

nausea and vomiting 

– Example 

– Levomepromazine 

– Side effects: 

– Sedation, 

lowering of 

seizure threshold 

– Subcut route = twice 

as potent as oral 

route

24 


Antiemetics [3] 

5HT3 antagonists 



– Radiotherapy 

– Bowel distension 

– Renal failure 

– Examples 

– Granisetron 

– Ondansetron 

– Side effect of 

constipation 

Steroids 

– Mode of action 

– Reduce permeability of 

BBB 

– Deplete GABA in 

antiemetic neurones 

– Anti-inflammatory 


– Raised intracranial 

pressure 



– Example 

– Dexamethasone

25 


Ascites

26 


Ascites 

Obstruction 

of lymphatic 

drainage 

Cytokine release 

eg. VEGF, VPF, 

IL-6, TNF 

Accumulation of fluid 

Activation of reninangiotensinaldosterone 

system

27 


Diuretic Therapy 

– 1 RCT (n=68), 3 cohort studies (n=43) and 1 case 

report (n=2) 

– Diuretic use inconsistent 

– Weak evidence assessing efficacy 

– Overall success ~ 43% cases (based on 5 studies) 

– Interval between initiation and response poorly 

defined 

– Phase II data: response may depend upon plasma 

renin/aldosterone concentration

28 


Paracentesis 

– Temporary relief for 90% patients (Smith et al, 2003) 

– Complications: 

– Hypovolaemia 

– Hypoproteinaemia 

– Bowel perforation 

– Infection 

– Formation of drainage nodules 

– Peritoneocutaneous fistulae 

– Pain

29 


Cochrane Database Syst Rev. 2010 Jan 

20;(1):CD007794. 

Management of drainage for malignant ascites in gynaecological cancer. Keen, A. et al 

– Benefit and harms of different practices in the management of 

drains for malignant ascites in advanced or recurrent 

gynaecological cancer. 

– Evidence re: 

– How long should the drain stay in place 

– Should the volume of fluid drained be replaced intravenously 

– Should the drain be clamped to regulate the drainage of fluid 

– Should any particular vital observations be regularly recorded 

– No relevant studies were identifed 

– Unable to make recommendations 

– Large, multi-centre RCTs are required to evaluate the efficacy and 

safety of the management of ascitic drains when in situ and their 

impact on QOL.

30 


Paracentesis [2] 

– Stephenson et al (2002) 

– Variation in practice between local hospice and hospital, in 

relation to: 

– Prior USS 

– Use of IV fluids 

– Length of time drains left in (hospital>hospice) 

– Length of inpatient stay (hospital hospice 

– Clinical guidelines drawn up: 

– Prior USS only if ascites not easily clinically identified or 

signs of bowel obstruction present 

– IV fluids only if patient at risk of hypovolaemia 

– Free drainage of 5L or for 5 hours – whichever is sooner

31 


Paracentesis [3] 

– Findings: 

– Procedure repeated more frequently in post-guidelines 

group, BUT 

– No significant difference in mean volumes drained 

– No cases of symptomatic hypotension in postguidelines 

group 

– Significant reduction in: 

– number of prior USS 

– Mean time drain left in 

– Mean duration of patient stay 

– BUT are hospital patients more at risk of complications…

32 


Indwelling peritoneal catheters

33 


PleurX peritoneal catheters 

Hospital Guidelines now on intranet ....

34 


Audit of use of PleurX peritoneal catheters: 

Results 

– N = 15 

– 100% technical success rate 

– Complications: 

– Leakage (14%): 

– amended with additional suture 

– The average: 

– Number of previous paracentesis was 3.6 (range 0 

– 7; median of 3). 

– Time between insertion and death was 23.9 days 

(range 8 - 46 days; median of 21 days). 

– No drains were removed between insertion and 

death.

35 


PleurX drain in management of malignant ascites: safety, complications, longterm 

patency, factors predictive of success. 

Br J Radiol. 2012 May;85(1013):623-8. Epub 2011 Mar 22. Tapping, CR et al. 

– Over a 4y period 

– 28 consecutive patients (32 drain insertions) 

– 7 males and 21 females (mean age, 61 years) 

– 4 inserted with combination of fluoroscopic and ultrasound 

guidance and 28 under ultrasound guidance alone. 

– 100% technical success rate for the insertion of the drain 

– No procedure-related deaths and no major complications 

– Minor complications were reported 

– Three (10%) immediate; three (10%) early; and two (7%) late. 

– Factors significantly associated with complications: 

– chemo, low Hb, low albumin, high WBC and high c-reactive 

protein 

– Length of time the drains in situ: 5 to 365 days (mean, 113 days) 

– 24 (86%) in situ and functioning until the patients' death. 

– 4 (14%) drains dislodged but drains remained patent until the 

patient's death.

36 


Multiple Choice Question 1 

A Cochrane review (2000) on the use of steroids in 

bowel obstruction showed that there was: 

1. No trend for evidence that steroids may bring 

about resolution 

2. Low incidence of side effects 

3. Negative effect on survival 

4. Unlikely to palliate symptoms well 

5. Clear evidence to suggest a length of trial period

37 



Which of the following antiemetics does not act at the 

D2 receptor 

1. Metoclopramide 

2. Haloperidol 

3. Aprepitant 

4. Cyclizine 

5. Levomepromazine

38 



Which of the following complications might be 

associated with paracentesis: 

1. Bowel perforation 

2. Formation of drainage nodules 

3. Leakage at drain site 

4. Peritoneocutaneous fistula 

5. All of above

39 


Conclusion 



– Ascites

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