Chronic conditions and cancer at the end of life

The majority of people diagnosed with cancer are older and therefore are likely to have co-morbidities at the time it is diagnosed and if the cancer progresses to advanced disease. Guidance in the process of managing long-term co-morbidities at the end of life requires clarity about the goals of care for the person’s cancer, and for each of his/her co-morbidities. Why was a particular therapy started in the first place? What risk is the therapy mitigating, and does it need to be continued? Very few studies help to inform the process of ceasing medications. For example, with cachexia and its associated weight loss, frequently encountered in advanced cancer, the management of two of the most frequent conditions-hypertension and diabetes-will change. The need for anti-hypertensives will decrease or the person will risk postural symptoms and the need for lower doses of hypoglycaemic agents and liberalised diets will be hallmarks of managing diabetes in order to avoid hypoglycaemia. Mostly, this care is in the setting of multiple co-morbidities, making review a complex and continuing process. Changes in co-morbidities can also directly influence the anti-cancer therapies that are available to patients, because of characteristics of the drug itself or changes in metabolism or elimination. Adjusting chemotherapy in advanced disease also requires careful evaluation of the goals of palliative treatment-are there symptoms that can best be addressed by disease modifying treatments or are there other more direct, better tolerated symptom control therapies available? Not only will there be a need for active management of long-term co-morbidities, but people will need to adjust psychologically to these changes. Modifying the goals of treatment is often the most overt signal to people that their disease is progressing and therefore can be particularly confronting. Such changes will often precipitate, or are an opportunity for, much wider conversations about life, dying and death.