Understanding cough and its management in lung cancer

Patient's experiences of coughing after lung cancer surgery: A multicenter qualitative study

PURPOSE

Cough is one of the most common symptoms after lung cancer surgery, which seriously affects the quality of life. Little research has been conducted on patient's experiences of cough following lung surgery. This study aimed to elucidate the experience of coughing after lung cancer surgery from the patient's perspective regarding symptoms and their impacts on daily life, as well as triggers and dealing strategies.

METHODS

Between June 2023 and July 2023, we conducted semi-structured interviews with patients from outpatient clinics of two hospitals who were pathologically diagnosed with lung cancer and experienced cough after surgery through convenience sampling. The interview recordings were transcribed and analyzed by two researchers. The traditional content analysis and thematic analysis were used to identify the common codes, subthemes, and themes.

RESULTS

A total of 28 participants were interviewed. The mean age of the participants was 55.21 years (range: 36-75 years), and 21 participants were female. Most patients (75%) were interviewed within 6 months of surgery. We identified five themes (accompanying symptoms, incentives, effects, solution, and information sources) and 12 subthemes (local symptoms, systemic symptoms, personal factors, external factors, emotion, relationship with others, reduced quality of life, medical measures, nonmedical measures, no measures, relatives and friends, and the Internet). Patients with lung cancer may experience various cough symptoms after surgery, which a variety of internal and external factors can trigger. The coughing imposes a double burden on the physical and psychological due to the negative emotions it provokes.

CONCLUSION

We generated a concept framework of cough after lung cancer surgery, providing a basis for further development of measurement tools from the patients' perspective. The lack of knowledge related to coughing highlights the need for adequate and timely health education and professional medical care.

Patient's experiences of coughing after lung cancer surgery: A multicenter qualitative study

Purpose

Cough is one of the most common symptoms after lung cancer surgery, which seriously affects the quality of life. Little research has been conducted on patient's experiences of cough following lung surgery. This study aimed to elucidate the experience of coughing after lung cancer surgery from the patient's perspective regarding symptoms and their impacts on daily life, as well as triggers and dealing strategies.

Methods

Between June 2023 and July 2023, we conducted semi‐structured interviews with patients from outpatient clinics of two hospitals who were pathologically diagnosed with lung cancer and experienced cough after surgery through convenience sampling. The interview recordings were transcribed and analyzed by two researchers. The traditional content analysis and thematic analysis were used to identify the common codes, subthemes, and themes.

Results

A total of 28 participants were interviewed. The mean age of the participants was 55.21 years (range: 36–75 years), and 21 participants were female. Most patients (75%) were interviewed within 6 months of surgery. We identified five themes (accompanying symptoms, incentives, effects, solution, and information sources) and 12 subthemes (local symptoms, systemic symptoms, personal factors, external factors, emotion, relationship with others, reduced quality of life, medical measures, nonmedical measures, no measures, relatives and friends, and the Internet). Patients with lung cancer may experience various cough symptoms after surgery, which a variety of internal and external factors can trigger. The coughing imposes a double burden on the physical and psychological due to the negative emotions it provokes.

Conclusion

We generated a concept framework of cough after lung cancer surgery, providing a basis for further development of measurement tools from the patients' perspective. The lack of knowledge related to coughing highlights the need for adequate and timely health education and professional medical care.

Cough hypersensitivity and chronic cough

Chronic cough is globally prevalent across all age groups. This disorder is challenging to treat because many pulmonary and extrapulmonary conditions can present with chronic cough, and cough can also be present without any identifiable underlying cause or be refractory to therapies that improve associated conditions. Most patients with chronic cough have cough hypersensitivity, which is characterized by increased neural responsivity to a range of stimuli that affect the airways and lungs, and other tissues innervated by common nerve supplies. Cough hypersensitivity presents as excessive coughing often in response to relatively innocuous stimuli, causing significant psychophysical morbidity and affecting patients' quality of life. Understanding of the mechanisms that contribute to cough hypersensitivity and excessive coughing in different patient populations and across the lifespan is advancing and has contributed to the development of new therapies for chronic cough in adults. Owing to differences in the pathology, the organs involved and individual patient factors, treatment of chronic cough is progressing towards a personalized approach, and, in the future, novel ways to endotype patients with cough may prove valuable in management.

Validation of the Japanese version of the Manchester Cough in Lung Cancer Scale

BACKGROUND

Cough is one of the most common distressing symptoms in lung cancer. However, there is no specific measure of cough in lung cancer in Japanese. The present study aimed to determine the validity of the Japanese version of the Manchester Cough in Lung Cancer Scale (MCLCS).

METHODS

The MCLCS is a cough-specific quality of life (QOL) questionnaire for lung cancer, consisting of 10 items on cough frequency, distress, impact, and severity. Items are evaluated on a scale of 1 to 5 (1: never, 2: some of the time, 3: often, 4: most of the time, and 5: all of the time). Total scores can range from 1 to 50, and higher scores indicate worse cough-related QOL. The Japanese version of the MCLCS was created by forward and backward translation. Patients completed the Japanese version of MCLCS, the Leicester Cough Questionnaire (LCQ), and the cough visual analog scale (VAS). To confirm the reliability of the MCLCS, Cronbach's α coefficient was calculated, and for validity, the Spearman's rank correlation coefficient was used to assess the correlations between MCLCS and LCQ or cough VAS.

RESULTS

Of the total 192 lung cancer patients enrolled in this study, 73 had a cough in the past week. The median MCLCS score was 28 and demonstrated an excellent internal consistency (Cronbach's α coefficient = 0.83). MCLCS was strongly and significantly correlated with LCQ and cough VAS.

CONCLUSIONS

The Japanese version of MCLCS is a valid measure for assessing cough in lung cancer patients.

Validation of the Japanese version of the Manchester Cough in Lung Cancer Scale

BACKGROUND

Cough is one of the most common distressing symptoms of lung cancer. However, there is no specific measure of cough in lung cancer in Japanese. The present study aimed to determine the validity of the Japanese version of the Manchester Cough in Lung Cancer Scale (MCLCS).

METHODS

The MCLCS is a cough-specific quality of life (QOL) questionnaire for lung cancer that consists of 10 items on cough frequency, distress, impact, and severity. Items are evaluated on a scale of 1-5 (1: never, 2: some of the time, 3: often, 4: most of the time, and 5: all of the time). Total scores can range from 1 to 50, with higher scores indicating worse cough-related QOL. The Japanese version of the MCLCS was created through forward and backward translation. Patients completed the Japanese version of the MCLCS, the Leicester Cough Questionnaire (LCQ), and the cough visual analog scale (VAS). To confirm the reliability of the MCLCS, Cronbach's α coefficient was calculated, and for validity, the Spearman's rank correlation coefficient was used to assess the correlations between MCLCS and LCQ or cough VAS.

RESULTS

Of the total 192 lung cancer patients enrolled in this study, 73 had a cough in the preceding week. The median MCLCS score was 28, demonstrating an excellent internal consistency (Cronbach's α coefficient = 0.83). MCLCS was strongly and significantly correlated with LCQ and cough VAS.

CONCLUSIONS

The Japanese version of MCLCS is a valid tool for assessing cough in lung cancer patients.

Symptom trajectories during chemotherapy in patients with non-small cell lung cancer (NSCLC) and the function of prolonging low dose dexamethasone in promoting enhanced recovery after chemotherapy

Background

Lung cancer, mainly non‐small cell lung cancer (NSCLC), is one of the leading causes of death worldwide. Currently, chemotherapy is still the most significant treatment strategy for NSCLC. However, scant attention has been paid in previous studies to those patients who often experience various symptoms and discomfort during chemotherapy treatment cycles.

Methods

This study included 127 NSCLC patients who completed an EORTC QLQ‐C30 questionnaire and specifically designed symptom diary. Chi‐square test, factor analysis, Pearson correlation coefficient and hierarchical cluster analysis were used to perform multivariate analysis.

Results

We identified the top five most‐frequent symptoms within the chemotherapy cycle which included fatigue, insomnia, cough and sputum, appetite loss and hypodipsia. These symptoms were at a moderate level on chemotherapy treatment days 3–7, and were then reduced to a stable and lower level in the following two weeks. A statistically significant difference in adverse events (AEs) was found between 54 patients who received dexamethasone (treatment group) and the control group: fatigue (risk ratio [RR]: 1.48; 95% confidence interval [CI]: 1.120–1.961; p = 0.006), insomnia (RR: 1.34; 95% CI: 1.016–1.778; p = 0.038), cough and sputum (RR: 2.00; 95% CI: 1.484–2.695; p < 0.001), appetite loss (RR: 1.28; 95% CI: 0.959–1.696; p = 0.095). In total, 62 patients completed the EORTC QLQ‐C30 scale. The functioning scales of the treatment group were higher than the control population within positive effect sizes (ES: 0.1–0.8). Apart from diarrhea scales, most symptom scales were lower than the control group within negative effect sizes (ES: 0.1–0.9).

Conclusions

In this study we identified the top five most frequent post‐chemotherapy AEs in a chemotherapy treatment cycle and found that dexamethasone was well tolerated by NSCLC patients who received platinum‐based chemotherapy and substantially alleviated the symptom burden and improved the health‐related quality of life (HRQOL) of patients.

Assessment and management of cough among patients with lung cancer in a radiotherapy department in China: a best practice implementation project

OBJECTIVES

This project aimed to implement an evidence-based practice to assess and manage lung cancer-associated cough, thereby relieving patients' physical pain and psychological challenges and improving their quality of life.

INTRODUCTION

Cough is one of the most common symptoms experienced by patients with lung cancer. If a cough is not proactively managed, patients may develop decreased compliance with treatments and experience a reduced quality of life. Cough assessment and management are essential components of nursing practice that should include evidence-based interventions.

METHODS

Seven evidence-based audit criteria were developed from current evidence. The JBI Practical Application of Clinical Evidence System (PACES) was used to perform a baseline audit on 30 patients and 20 nurses in the Department of Radiotherapy of Nanfang Hospital. The Getting Research into Practice (GRiP) component of PACES was used to identify barriers, strategies, resources and outcomes. Following implementation of strategies to improve compliance, a post-audit was conducted using the same sample size and audit criteria.

RESULTS

The seven evidence-based audit criteria were as follows: 1) Clinicians have received training on the assessment and management of lung cancer-associated cough; 2) In patients with lung cancer-associated cough, a comprehensive assessment was conducted to identify any co-existing causes linked to cough; 3) Any reversible causes of cough were treated according to evidence-based guidelines; 4) A validated scale was used to assess the frequency and severity of cough and distress experienced by the patients; 5) Patients (and their caregivers) have received education regarding management of cough; 6) Patients (and their caregivers) have received training on cough suppression exercises; 7) For symptomatic therapy, a stepwise approach was followed according to evidence-based guidelines. The baseline results showed that compliance rates were 0% for criteria 1, 4 and 5; 70% for criterion 6; 80% for criterion 7; 90% for criterion 3 and 93% for criterion 2. The implementation of strategies to increase compliance with best practice, including establishing training and education programs for nursing staff and patients, utilizing some validated scales to assess the frequency and severity of cough and the distress caused to the patients, and establishing a quality control team to supervise implementation of the assessment and management of cough, achieved ≥ 93% compliance rate for all seven audit criteria.

CONCLUSION

An evidence-based and nurses-oriented best practice for cough assessment and management was successfully established among patients with lung cancer-associated cough.

Prioritizing symptom management in the treatment of chronic heart failure

Chronic heart failure (CHF) is a chronic, progressive disease that has detrimental consequences on a patient's quality of life (QoL). In part due to requirements for market access and licensing, the assessment of current and future treatments focuses on reducing mortality and hospitalizations. Few drugs are available principally for their symptomatic effect despite the fact that most patients' symptoms persist or worsen over time and an acceptance that the survival gains of modern therapies are mitigated by poorly controlled symptoms. Additional contributors to the failure to focus on symptoms could be the result of under‐reporting of symptoms by patients and carers and a reliance on insensitive symptomatic categories in which patients frequently remain despite additional therapies. Hence, formal symptom assessment tools, such as questionnaires, can be useful prompts to encourage more fidelity and reproducibility in the assessment of symptoms. This scoping review explores for the first time the assessment options and management of common symptoms in CHF with a focus on patient‐reported outcome tools. The integration of patient‐reported outcomes for symptom assessment into the routine of a CHF clinic could improve the monitoring of disease progression and QoL, especially following changes in treatment or intervention with a targeted symptom approach expected to improve QoL and patient outcomes.

Aprepitant for Cough Suppression in Advanced Lung Cancer: A Randomized Trial

BACKGROUND

Although cough is a common and distressing symptom in patients with lung cancer, there is almost no evidence to guide treatment. Aprepitant, a centrally acting neurokinin-1 inhibitor, significantly decreased cough frequency in a pilot study.

METHODS

Patients with advanced lung cancer and cough lasting over 2 weeks despite a cough suppressant were randomized 1:1 to aprepitant 125 mg orally on day 1 and then 80 mg orally on days 2 to 7 with physician's choice of antitussive; or to physician's choice of antitussive alone. Evaluation was at baseline and on days 3, 7, 9, and 12. The primary end point was subjective cough improvement on day 9, measured by the Visual Analog Scale and Manchester Cough in Lung Cancer Scale. Secondary end points included quality of life (QoL) as measured by the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire and the EORTC Lung Cancer-Specific Quality of Life Questionnaire and toxicity.

RESULTS

Between 2017 and 2018, 128 patients were randomized. Median baseline cough duration was 90 days. Mean Visual Analog Scale scores (in mm) at baseline and day 9 were 68 and 39 in the aprepitant arm and 62 and 49 in the control arm, respectively (P < .001); mean Manchester Cough in Lung Cancer Scale scores at baseline and day 9 were 33 and 23 in the aprepitant arm and 30 and 25 in the control arm, respectively (P < .001). Overall QoL was not significantly different between the two arms; however, aprepitant led to a significant improvement in the cough-specific QoL domain (P = .017). Aprepitant did not increase severe adverse events.

CONCLUSIONS

Aprepitant led to a significant improvement in cough in advanced lung cancer, without increasing severe side effects.

TRIAL REGISTRY

Clinical Trials Registry-India; No.: CTRI/2017/05/008691; URL: http://ctri.nic.in.

The relationship between chronic obstructive pulmonary disease and non-small cell lung cancer in the elderly

Objectives

Chronic obstructive pulmonary disease (COPD) and NSCLC often coexist and have poor prognoses, but studies investigating the impact of COPD on NSCLC have reported inconsistent findings. The objective of this study was to compare survival between NSCLC patients with and without COPD.

Methods

Medical records were retrospectively collected from 301 elderly patients pathologically diagnosed with NSCLC from the Chinese PLA General Hospital. Ultimately, a total of 200 patients were enrolled in the analysis. The survival rates between the COPD‐NSCLC and non‐COPD NSCLC were assessed using log‐rank and Cox proportional hazard regression analyses.

Results

A total of 117 COPD‐NSCLC and 93 non‐COPD NSCLC patients were enrolled in the analysis. The median overall survival times were 108.5 months in the non‐COPD group and 45.0 months in the COPD group (HR: 2.05; 95% CI, 1.36‐2.97, P = 0.0004). After 118 patients underwent propensity score matching, the median overall survival times were 100.6 months in the non‐COPD group and 51.9 months in the COPD group (HR: 1.59; 95% CI, 1.096‐2.64, P = 0.0459). The multivariate analysis showed that presence of COPD (HR 1.619, P = 0.030), old age (HR 1.007, P < 00001), an advanced disease stage (stage Ⅲ HR 5.513, P < 0.0001; stage Ⅳ HR 11.743, P < 0.0001), the squamous cell carcinoma histological subtype (HR 3.106, P < 0.0001), the presence of a cough (HR 2.463, P = 0.001) a higher serum carcinoembryonic antigen level (HR 1.001, P = 0.023) and higher NRL (HR 2.615, P = 0.007) were independent factors that were significantly associated with poorer survival.

Conclusion

A diagnosis of COPD had significant poorer survival outcomes in NSCLC than that of patients without COPD in this elderly population.

Cough in Patients With Lung Cancer: A Longitudinal Observational Study of Characterization and Clinical Associations

BACKGROUND

Cough is common in patients with lung cancer, and current antitussive treatments are suboptimal. There are little published data describing cough in patients with lung cancer or work assessing clinical associations. The aim of this study is to fill that gap.

METHODS

This was a longitudinal prospective observational single-cohort study over 60 days. Patients were assessed through self-reported validated scales and, in a subsample, ambulatory cough monitoring at study entry (day 0), day 30, and day 60.

RESULTS

At study entry, 177 patients were included and 153 provided data at day 60. The median duration of cough was 52 weeks (interquartile range, 8.5-260). Cough was described as severe enough to warrant treatment in 62% of the patients. Depending on the scale used, performance status was associated with both cough severity and cough impact (P < .001) at study entry, whereas higher cough severity at study entry was associated with female sex (P = .02), asthma (P = .035), and reflux disease (P < .001). Cough impact at study entry was additionally associated with experiencing nausea (P = .018). Cancer characteristics (ie, cancer stage, histology) were not associated with cough severity nor cough impact; neither was smoking or COPD.

CONCLUSIONS

This is the first study to describe characteristics of cough in patients with lung cancer and to identify clinical associations that may be relevant for its treatment. Our data suggest that cough is a frequent and distressing symptom and an unmet clinical need. Its association with gastrointestinal symptoms in this study may improve our understanding of pathophysiology and therapeutic options for cough occurring in patients with lung cancer.

Long-Term and Latent Side Effects of Specific Cancer Types

Although many cancer survivors diagnosed with early-stage disease will outlive their cancer, they may continue to experience long-term and/or latent side effects due to cancer treatment. Many of these side effects are common and contribute to worse quality of life, morbidity, and mortality for cancer survivors. This article summarizes the treatment side effects for several of the most prevalent cancers in the United States.

Symptomatic Treatment of Cough Among Adult Patients With Lung Cancer: CHEST Guideline and Expert Panel Report

BACKGROUND

Cough among patients with lung cancer is a common but often undertreated symptom. We used a 2015 Cochrane systematic review, among other sources of evidence, to update the recommendations and suggestions of the American College of Chest Physicians (CHEST) 2006 guideline on this topic.

METHODS

The CHEST methodologic guidelines and the Grading of Recommendations, Assessment, Development, and Evaluation framework were used. The Expert Cough Panel based their recommendations on data from the Cochrane systematic review on the topic, uncontrolled studies, case studies, and the clinical context. Final grading was reached by consensus according to the Delphi method.

RESULTS

The Cochrane systematic review identified 17 trials of primarily low-quality evidence. Such evidence was related to both nonpharmacologic (cough suppression) and pharmacologic (demulcents, opioids, peripherally acting antitussives, or local anesthetics) treatments, as well as endobronchial brachytherapy.

CONCLUSIONS

Compared with the 2006 CHEST Cough Guideline, the current recommendations and suggestions are more specific and follow a step-up approach to the management of cough among patients with lung cancer, acknowledging the low-quality evidence in the field and the urgent need to develop more effective, evidence-based interventions through high-quality research.

Palliative Care in Lung Cancer

Lung cancer is the most common cancer worldwide and is the leading cause of cancer death for both men and women in the USA. Symptom burden in patients with advanced lung cancer is very high and has a negative impact on their quality of life (QOL). Palliative care with its focus on the management of symptoms and addressing physical, psychosocial, spiritual, and existential suffering, as well as medically appropriate goal setting and open communication with patients and families, significantly adds to the quality of care received by advanced lung cancer patients. The Provisional Clinical Opinion (PCO) of American Society of Clinical Oncology (ASCO) as well as the National Cancer Care Network's (NCCN) clinical practice guidelines recommends early integration of palliative care into routine cancer care. In this chapter, we will provide an overview of palliative care in lung cancer and will examine the evidence and recommendations with regard to a comprehensive and interdisciplinary approach to symptom management, as well as discussions of goals of care, advance care planning, and care preferences.

Trajectories of Symptom Occurrence and Severity From Before Through Five Months After Lung Cancer Surgery

CONTEXT

Limited information is available about lung cancer patients' symptoms in the pre- and postoperative periods.

OBJECTIVES

Study purposes were to evaluate for changes in symptom occurrence and severity from the preoperative period to five months after surgery and to evaluate for predictors of the occurrence and trajectories of these symptoms.

METHODS

Patients completed the Memorial Symptom Assessment Scale before and at one and five months after surgery. Changes in the six most common physical symptoms and the most common psychological symptom were evaluated using multilevel growth mixture modeling. Age, gender, comorbidity, and receipt of adjuvant chemotherapy were included as covariates in the conditional models for symptom occurrence and severity.

RESULTS

The total number of symptoms increased significantly from the preoperative to the one month assessment. At five months, the number of symptoms was lower than at one month but significantly higher than at the preoperative assessment. The occurrence of five of the symptoms (i.e., pain, lack of energy, shortness of breath, feeling drowsy, and worrying) increased significantly from before through the first month after surgery and then decreased over time. Cough and difficulty sleeping persisted over the five months of the study. In general, the effect of the four covariates was to increase patients' overall symptom burden.

CONCLUSION

Changes in the occurrence and severity of these seven symptoms were variable. All seven symptoms occurred at relatively high rates and were of moderate severity. Findings can be used to identify patients who are at higher risk for more severe symptoms.