Oncology in palliative care • Chemotherapy • Radiotherapy • Symptom relief • Toxicity and nursing safety

The Role of Chemotherapy and Radiotherapy in Palliative Care

How cancer treatment can relieve symptoms, prevent complications and support goal-concordant care

Learning objectives

• Distinguish curative, adjuvant, neoadjuvant, maintenance and palliative treatment intent.
• Explain how chemotherapy and radiotherapy relieve symptoms and prevent complications.
• Recognize major drug classes, treatment effects, contraindications and toxicities.
• Describe external-beam, brachytherapy and systemic radiation approaches.
• Provide nursing care, patient education, infection/bleeding precautions and emergency escalation.
• Integrate treatment with palliative goals, prognosis, shared decisions and Uganda resource realities.

1. Treatment intent comes before treatment choice

Intent	Meaning	Palliative relevance
Curative	Eliminate disease with a realistic chance of long-term control.	Palliative care should still control symptoms and support the patient during treatment.
Adjuvant	After surgery/radiation to reduce recurrence risk.	Discuss expected benefit, toxicity, time and patient priorities.
Neoadjuvant	Before surgery/radiation to shrink or downstage disease.	May improve function or make definitive treatment possible.
Maintenance/control	Keep disease stable or delay progression.	Requires ongoing review of benefit, burden, cost and quality of life.
Palliative	Shrink or slow disease, relieve symptoms, prevent complications or sometimes prolong life without aiming to cure.	Appropriate when expected benefit is meaningful and consistent with goals; not “less active” care.

A palliative treatment may be worthwhile when it reduces pain, bleeding, obstruction, breathlessness or neurological risk with acceptable burden. It may be inappropriate when harms, travel, cost or delay outweigh realistic benefit.

2. Chemotherapy: what it does

Chemotherapy uses anti-cancer medicines that damage or inhibit malignant cells while affecting some normal rapidly dividing cells. It may be systemic, regional or combined with radiation. Selection depends on cancer type, stage, biomarkers, prior therapy, organ function, performance status, infection risk, pregnancy and patient goals.

2.1 Major classes from the supplied reference

Class	Examples	Important toxicities/clinical notes
Alkylating/platinum agents	Cyclophosphamide, ifosfamide, cisplatin, carboplatin, oxaliplatin.	Myelosuppression, nausea, infertility; cisplatin nephrotoxicity/ototoxicity, ifosfamide encephalopathy/cystitis, platinum neuropathy.
Antimetabolites	5-fluorouracil, capecitabine, methotrexate, cytarabine, gemcitabine.	Mucositis, diarrhoea, myelosuppression, liver effects; capecitabine hand-foot syndrome; methotrexate renal/marrow toxicity.
Antitumour antibiotics/anthracyclines	Doxorubicin, daunorubicin, bleomycin.	Doxorubicin cardiomyopathy/extravasation; bleomycin pulmonary toxicity; marrow suppression and mucositis.
Topoisomerase inhibitors	Etoposide, irinotecan, topotecan.	Myelosuppression; irinotecan can cause early or delayed severe diarrhoea.
Mitotic inhibitors	Vincristine, vinblastine, paclitaxel, docetaxel.	Peripheral neuropathy, ileus, myelosuppression, alopecia and hypersensitivity; vincristine is never given intrathecally.
Hormonal/endocrine therapy	Tamoxifen, aromatase inhibitors, anti-androgens, GnRH agents, corticosteroids.	Thrombosis, menopausal symptoms, bone loss, metabolic and mood effects; often better tolerated but still requires monitoring.
Targeted and immune therapies	Monoclonal antibodies, kinase inhibitors, checkpoint inhibitors.	Infusion reactions, immune-related organ inflammation, rash, diarrhoea, endocrine dysfunction and drug interactions.

The list is not a prescribing guide. Modern regimens often combine classes and require protocol-specific laboratory, ECG, pregnancy and organ-function checks.

3. Palliative chemotherapy: indications and limits

Potential benefits

• Shrink a painful tumour, relieve nerve/airway/vascular compression or reduce bleeding.
• Improve bowel, bladder, swallowing, breathing or mobility by reducing tumour burden.
• Prevent recurrence or delay progression when the patient remains well enough to benefit.
• Provide time for meaningful goals if expected survival and quality of life improve.

When to reconsider

• Rapid deterioration, poor performance status, uncontrolled infection, severe organ failure or no response to prior lines.
• Toxicity, repeated admissions, unaffordable travel, inability to monitor safely or treatment inconsistent with the patient’s goals.
• No realistic benefit within the patient’s expected time frame, or treatment that worsens quality of life more than it helps.

Use shared decision-making: explain disease, intent, likelihood of benefit, time to benefit, side effects, alternatives, cost/logistics, what happens without treatment and a review/stop plan.

4. Radiotherapy: what it does

Radiotherapy uses ionizing radiation to damage tumour DNA. It may be curative, adjuvant or palliative. Palliative courses are often shorter than curative courses, but dose and fractionation are specialist decisions.

Modality	Description	Palliative uses
External-beam radiotherapy (EBRT)	Radiation delivered from a machine to a planned target.	Bone pain, spinal cord compression, brain metastases, bleeding, airway/vascular compression and selected obstruction.
Brachytherapy	Sealed radioactive source placed in or near the tumour.	Selected cervical, endometrial, prostate, oesophageal or other localized symptoms.
Systemic radioisotope therapy	Radioactive medicine travels to target tissue.	Selected metastatic bone or thyroid-related disease where available.

5. Palliative radiotherapy emergencies

• Spinal cord compression: urgent neurological examination, MRI/referral, corticosteroid per protocol, immobilization if unstable and oncology/radiotherapy/surgical review.
• Brain metastasis/raised intracranial pressure: neurological monitoring, corticosteroid/urgent imaging and specialist review; radiotherapy may reduce tumour/edema.
• Superior vena cava obstruction: upright positioning, airway/neurological assessment, tissue diagnosis/staging and radiotherapy/chemotherapy or stenting when appropriate.
• Bleeding: radiotherapy may palliate haemoptysis, vaginal, bladder or surface tumour bleeding; stabilize first.
• Painful bone metastasis: assess fracture/spinal instability; radiotherapy can relieve focal pain but does not replace immobilization or analgesia.

6. Common chemotherapy adverse effects and nursing care

Effect	Assessment and nursing care	Urgent escalation
Myelosuppression	Monitor blood counts, temperature, infection signs, fatigue, bleeding, mouth and perianal area. Teach hand hygiene and fever instructions.	Fever/rigors, hypotension, new cough, confusion or bleeding—possible neutropenic sepsis.
Nausea/vomiting	Give prescribed antiemetic, small meals, hydration, mouth care and monitor electrolytes.	Persistent vomiting, dehydration, blood, aspiration or severe abdominal pain.
Mucositis	Inspect mouth, gentle soft toothbrush/saline care, pain relief, avoid irritants and support nutrition.	Unable to drink, bleeding, fever or airway/swallowing compromise.
Diarrhoea	Record frequency, stool, fluid balance, medicines and skin; replace fluids and follow protocol.	Severe watery/bloody diarrhoea, fever, renal injury, shock or neutropenia.
Alopecia/skin changes	Prepare patient, scalp/skin care, psychosocial support and infection monitoring.	Blistering, rapidly spreading rash, facial swelling or breathing difficulty.
Neuropathy	Assess sensation, gait, falls, pain and function; protect feet and review neurotoxic drugs.	Rapid weakness, severe falls, autonomic symptoms or inability to walk.
Organ toxicity	Review renal, hepatic, cardiac, pulmonary and hearing tests as protocol requires.	Chest pain, severe dyspnoea, jaundice, oliguria, confusion or arrhythmia.

7. Common radiotherapy effects

• Skin: erythema, dryness, peeling, pain; wash gently, avoid unapproved creams, friction, heat and sun exposure over the field.
• Fatigue: balance rest and activity, manage anaemia/nutrition and plan transport.
• Mucositis/dysphagia: mouth care, analgesia, texture modification, hydration and swallow review.
• Diarrhoea/abdominal symptoms: monitor hydration, stool, infection and electrolyte loss; seek review for blood or severe pain.
• Bone marrow suppression: more likely with large fields; monitor blood count and infection/bleeding.
• Late effects: fibrosis, strictures, endocrine dysfunction, neuropathy, infertility, organ injury and rare second cancers; explain only what is relevant and supported.

8. Safe handling and administration of cytotoxic medicines

• Only trained staff should prescribe, prepare, administer or dispose of cytotoxic medicines.
• Use the facility’s chemotherapy checklist, PPE, designated preparation area, labels, double checks and extravasation protocol.
• Verify patient, protocol, cycle, drug, dose, route, body-surface/weight calculation, laboratory results, allergies, consent and premedication.
• Do not recap needles; use cytotoxic waste containers and report spills/exposure immediately.
• Educate patients about home precautions, body-fluid exposure, safe storage, fever, diarrhoea, bleeding and contact numbers.

9. Treatment emergencies

Emergency	Recognition	Immediate priorities
Febrile neutropenia	Fever or hypothermia after chemotherapy with neutropenia or suspected neutropenia.	ABCDE, cultures/labs without delay, broad-spectrum antibiotics within local target time, fluids/oxygen and oncology/ICU review.
Extravasation	Pain, burning, swelling, erythema or resistance at IV site.	Stop infusion, leave cannula for aspiration if protocol says, do not flush, notify oncology/pharmacy and use drug-specific antidote/thermal protocol.
Anaphylaxis/infusion reaction	Flushing, wheeze, hypotension, angioedema, fever or rigors.	Stop medicine, ABCDE, emergency anaphylaxis protocol and senior help.
Tumour lysis syndrome	Weakness, cramps, arrhythmia, seizures, oliguria after treatment.	Electrolytes/ECG, fluids and urgent oncology/nephrology management.
Severe mucositis/dehydration	Unable to drink, bleeding, fever, reduced urine or delirium.	Airway/swallow assessment, analgesia, fluids, infection review and admission if needed.

10. Shared decisions and palliative integration

1. Ask what the patient hopes treatment will achieve: cure, time, function, symptom relief or family event.
2. Explain treatment intent, likely benefit, time to benefit, uncertainties, side effects, travel/cost and alternatives.
3. Offer a time-limited trial with measurable goals and stop criteria when appropriate.
4. Continue palliative care during treatment: pain, nausea, breathlessness, nutrition, mood, spiritual and caregiver support.
5. Review after each cycle or radiotherapy course; stop or change treatment when burdens exceed benefit.

11. Uganda and resource-aware practice

• Discuss travel distance, transport, medicine availability, laboratory access, caregiver accommodation and financial toxicity.
• Use referral pathways to oncology/radiotherapy centres and community palliative teams; document the receiving contact.
• Where a service is unavailable, give honest information, maximize symptom control and avoid unsafe “replacement” remedies.
• Coordinate HIV, TB, nutrition, blood transfusion, surgery and palliative services when relevant.

12. Clinical cases

13. Quick self-test

1. What is the difference between curative, adjuvant and palliative intent?
2. Name four major chemotherapy toxicity patterns.
3. List three palliative indications for radiotherapy.
4. What are the first actions for extravasation?
5. What information must be discussed before palliative chemotherapy?

Answers

1. Curative aims for long-term elimination; adjuvant reduces recurrence after definitive treatment; palliative aims to relieve symptoms, prevent complications or control disease without aiming to cure.
2. Myelosuppression/infection, nausea/vomiting, mucositis, diarrhoea, neuropathy, cardiopulmonary/renal/hepatic toxicity and hypersensitivity.
3. Bone pain, spinal cord compression, brain metastases/raised pressure, bleeding, SVC obstruction, airway compression and selected obstruction.
4. Stop infusion, do not flush, leave access if protocol requires aspiration, notify oncology/pharmacy, follow the drug-specific protocol and document.
5. Goal/intent, realistic benefit and timing, risks, alternatives, cost/logistics, what happens without treatment, monitoring, stop criteria and palliative support.

Key take-home points

• Chemotherapy and radiotherapy can be active palliative treatments when benefits match patient goals.
• Intent, performance status, time to benefit and toxicity matter as much as tumour response.
• Radiotherapy is a key tool for bone pain, spinal compression, bleeding and tumour compression, but emergencies need urgent pathways.
• Fever, bleeding, extravasation, severe diarrhoea, tumour lysis and infusion reactions are emergencies.
• Palliative care should continue throughout oncology treatment and when treatment stops.

Further study and references

• Chemotherapy & Radiation Therapy — supplied Slideshare reference
• WHO: Palliative care
• WHO: Cancer
• Related lesson: Palliative-care emergencies
• Related lesson: Symptom-control assessment

Educational resource for supervised learning. Follow current Uganda oncology protocols, cytotoxic-safety standards and specialist advice.