Classes of natural waters.
\r\n\tThe emergence of novel prion strains in animals, which include the only evidenced zoonotic prion C-BSE causing vCJD in humans, has created an important public health concern. Currently, new threats to human and animals may develop because of the plausible zoonotic properties of scrapie, L-BSE and the recently emerging chronic wasting disease in Europe.
\r\n\tThis book will gather experts in prion diseases and present new scientific advances in the field and relations with other amyloid neuropathologies.
As more than 60% of rainfall, the primary source of water for agriculture is lost to evapotranspiration [1], with the continuous increase in human population and its resultant increase in water demand which is expected to nearly double its size in the next 50 years, the exploitation of the available water resources and the advent of climate change with its global warming effect on available water for crop production, the search for new, sustainable and drought‐proof water resources is inevitable [2]. He further stated that since agricultural activities consume more than 60% of the total water demand, using treated wastewater for irrigation can reduce depletion of groundwater significantly. In Refs. [1, 3], it was stated that water‐scarce countries especially the Middle East countries located in the arid and semi‐arid zones will have to rely more on the use of non‐conventional irrigation water resources such as saline aquifers to partly alleviate water scarcity. Although, the present freshwater resources may soon be insufficient to meet the growing demand for food [4], most of these drought‐proof water resources contain dissolved solids and chemicals such as salts. The application of these water resources for irrigation purposes often result to the detrimental effect of salinization of soils, environmental degradation and low crop yield.
Salinization is one of the land degradation processes rendering millions of hectares of land unproductive for crop cultivation. It was stated in Ref. [5] that salinization is one of the most serious land degradation problems facing the world. According to El‐Swaify [6], salinity is when an ‘excessive’ amount or concentration of soluble salts occurs in the soil, either naturally or as a result of mismanaged irrigation water. Although, he further reported that salt‐affected soils are most abundant in arid regions worldwide, the extent of saline soils is variable [7], whereas Yan et al. [5] stated that soil salinity vary in time and space. Salts are often introduced into soil and water systems via the use of excessive inorganic fertilizers which are leached or washed away as runoff into underground water bodies used for irrigation purposes. According to El‐Swaify [6], salts in soil and irrigation water may be either naturally present as products of geochemical weathering of rocks and parent materials or derived directly from sea water flooding, spray or intrusion into groundwater sources and/or caused by irrigation mismanagement, particularly when internal soil drainage is impeded. Due to the presence of salts, most saline lands are virtually uncultivated in the dry season because of strong salinity and lack of water in good quality and quantity [7]. According to Gleick [8], almost half of the human population suffers insufficient access to portable water, and water scarcity in agriculture has been considered to be a global crisis [9].
Hence, desalination, which is any process that removes salt from water [10] to produce desalinized water, is increasingly considered a source of water for agriculture [4]. Even though soil salinity has been affecting agriculture for thousands of years, significant research has been conducted only in the past 100 years [11]. Thus, this review highlights some of the effects of salinity on soil and crop growth and yield, and some possible methods of desalinization of water and soil resources for optimum utilization in a crop production system.
Different salts, cations and anions vary in their effects on plants and soils, and as such differences in ionic compositions of soil solutions and waters with similar electrical conductivity values may lead to dissimilar effects [6]. Salinity may adversely affect soil structure and other physical properties, and this could finally be transmitted to crop growth and development. For instance, the breakdown of soil structure can exacerbate salt effects on crops through increased surface crusting, germination inhibition and reduced permeability, porosity and aeration [6]. In Ref. [12], it was reported that soil infiltration rate was greatly affected by sodicity and electrolyte concentration of the irrigation water. In Ref. [13], it was reported that increasing salinity and sodicity resulted in a progressively smaller, more stressed microbial community which was less metabolically efficient. Saline soils have been reported to contain sufficient salts at the root zone to impair crop growth [7]. Also, Corwin et al. [14] noted salinity as one of the most significant soil properties influencing cotton yield in a response model. In Ref. [15], it was reported that the emergence of sunflower and maize was affected by salinity and that the higher the salinity, the lower the leaf area and the dry matter production.
Desalination describes a range of processes which are used to reduce the amount of dissolved solids in water [16]. Also, Nofal [17] defined desalination as the removal of excess salt and other minerals from water in order to get fresh water suitable for drinking water, animal consumption and irrigation purposes. It is used to produce clean water from water sources containing dissolved chemicals, and in most cases, water sources are salty, producing fresh water from sea water or brackish water [16]. They further stated that natural waters may be classified approximately according to their total dissolved solid (TDS) values as listed in Table 1. Desalination is a water saving alternative to brackish water irrigation even though its diffusion as a viable method of water treatment has been limited by high costs and concern about the lack of plant nutrients in desalinated water [17]. In Ref. [4], it was also confirmed that desalination not only separates the undesirable salts from the water but also removes ions that are essential to plant growth. Although, a recent report concludes that the costs of desalination remain prohibitively expensive for full use by irrigated agriculture [18], for high value cash crops like green‐house vegetables and flowers, its use may be economically feasible [4]. According to Smith and Shaw [16], low‐cost methods of desalination by distillation are also available.
Type of water | Total dissolved solids (mg/L) |
---|---|
Sweet waters | 0–1000 |
Brackish waters | 1000–5000 |
Moderately saline waters | 5000–10,000 |
Severely saline waters | 10,000–30,000 |
Seawater | More than 30,000 |
Due to the impact of climate change which has led to uncertainty in the amount and duration of rainfall for crop production, 69% of global water supply is being channelled for irrigation purpose [19]. As a result, present fresh water resources may soon be insufficient to meet the growing demand for food [4]. Although, at present, sea water desalination provides 1% of the world’s drinking water, desalinized water is increasingly considered a source of water for agriculture [4]. In some countries, farmers have already adopted the use of desalinized brackish water for crop production. For instance, Mechell and Lesikar [20] reported that ∼22% of water desalinated in Spain are used for agricultural irrigation purposes, whereas an Australian survey found that 53% of the population envisioned desalinated water usage for irrigation of vegetables as highly likely.
Desalination is a water saving alternative to brackish water irrigation [17]. By implication, it could increase the possible sources of water for irrigation, and as such enhance sustainable all‐year round crop production. According to Ref. [4], the low level of salinity of desalinized water is an extra benefit, because the salts [especially Sodium (Na+) and Chlorine (Cl−)] damage soils, stunt plant growth and harm the environment. Hence, desalinized water could improve the quality of irrigation water thereby reducing the possibilities of the incidence of soil salinity with its consequent adverse effect on crop growth and yield via its deteriorating effects on soil properties. Furthermore, desalination could increase the size of land area for cultivation, the number of crops (including salt sensitive crops) cultivated, improve crop quality, increase crop productivity and increase the broad band of water use for other purposes [17]. Desalination has been reported to improve farmers’ income [17].
According to Refs. [10, 21], techniques used in a desalination process essentially separates saline water into two parts, hence, two streams of water are produced.
Treated water that has low concentrations of salts and minerals.
Concentrate or brine, which has salt and mineral concentrations higher than that of the pre‐treated water.
It is often associated with electrical generation plants, from which both electricity and waste heat are available [16]. Some of these desalination methods could be relatively expensive, whereas others such as desalination by distillation could be low‐cost methods. According to Refs. [10, 21], the two major types of technologies used for desalination can be broadly classified into thermal technologies (multi‐stage flash distillation, multi‐effect distillation and vapour compression distillation) and membrane technologies (electrodialysis/electrodialysis reversal and reverse osmosis), with reverse osmosis, and distillation followed by condensation being two main desalination methods [16]. In Ref. [10], it was stated that both technologies need energy to operate and produce fresh water. However, the most appropriate method can be selected on the basis of the total dissolved solids (TDS) value of the raw water (Table 2).
Process | Total dissolved solid value (mg/L) |
---|---|
Ion exchange (not described here) | 500–1000 |
Electrodialysis | 500–3000 |
Reverse osmosis (standard membranes) | 500–5000 |
Reverse osmosis (high‐resistance membranes) | Over 5000 |
Distillation | Over 30,000 |
Suitability of desalination process based on the total dissolved solids.
Source: Smith and Shawerji [16].
These technologies involve the eating of saline water and collecting the condensed vapour distillate to produce pure water [10]. In Ref. [21], it was reported that thermal distillation technologies are widely used in the Middle East, primarily because the region’s petroleum reserves keep energy cost low. However, thermal technologies have rarely been used for brackish water desalination, because of the high cost involved [10]. According to Refs. [6, 21], thermal technologies are grouped into three major large scale processes, i.e., multi‐stage flash distillation (MSF), multi‐effect distillation (MED) and vapour compression distillation (VCD). They stated that solar distillation, which is another thermal technology, is typically used for very small production rates.
This process of distillation involves the use of several (multi‐stage) chambers [10]. According to Ref. [21], this process sends the pre‐treated saline water through multiple chambers as illustrated in Figure 1 [22]. In the MSF process, each successive stage of the plant operates at progressively lower pressures. In Ref. [21], it was explained that the pre‐treated saline water is heated and compressed to a high temperature and high pressure, and the pressure is reduced as the water progressively passes through the chambers, causing the water to rapidly boil. In other words, the pre‐treated water is first heated under high pressure as it is passed into the first ‘flash chamber\', where the pressure is released, causing the water to boil rapidly, resulting in sudden evaporation or ‘flashing\', which continues in each successive stage, because the pressure at each stage is lower than that of the previous stage [10]. The vapour produced by the flashing is then condensed on a heat exchanger tubing that runs through each stage and collected as fresh water. Generally, only a small percentage of the pre‐treated saline water is converted into vapour and condensed [10].
An illustration of the multi-stage flash distillation (MSF) process (Source: Buros, 1990).
The MED process has been used since the late 1950s and the early 1960s [10]. According to Ref. [21], the MED employs the same principles as the MSF process except that instead of using multiple chambers of a single vessel, MED uses successive vessels (Figure 2), i.e., MED occurs in a series of vessels, using the principles of evaporation and condensation at reduced ambient pressure [21]. Here, water is produced by a series of evaporator vessels at progressively lower pressures. Water boils at lower temperatures as pressure decreases, such that the water vapour of the first vessel serves as the heating medium for the second, and so on [10]. According to Ref. [21], the multiple vessels make the MED process more efficient, while [10] stated that the more the vessels, the higher the performance ratio of the MED.
A schematic diagram of a multi-effect distillation (MED) process (Source: [
The VCD can function independently or in combination with other thermal distillation processes such as the MED [10, 21]. According to Ref. [23], the heat for evaporating the pre‐treated saline water comes from the compression of vapour, rather than the direct exchange of heat from steam produced in a boiler (Figure 3). It usually involves the use of a mechanical compressor to generate heat for evaporation [10]. Vapour compression distillation unit are commonly used to produce fresh water for small‐ to medium‐scale purposes such as resorts, hotels and industrial applications [21].
An example of a vapour compression distillation (VCD) process (Source: [
This involves the use of solar energy for water desalination as shown in Figure 4. Also, Buros [21] stated that although the designs of solar distillation units vary greatly, the basic principles are the same. They explained that the sun provides the energy to evaporate the saline water, and the water vapour formed from the evaporation process then condenses on a clear glass covering before it is collected as fresh water in the condensate trough. The clear glass or plastic covering is used to transmit radiant energy and also to allow water vapour to condense on its interior surface before it is collected as fresh water. Alike VCD, solar desalination is generally used for small‐scale operations [21].
An example of a solar still distillation process (Source: [
According to Ref. [21], there are several membrane treatment processes, including reverse osmosis, nanofiltration, ultrafiltration and microfiltration. These processes involve the use of a barrier, which is a membrane, and a driving force. The membranes contain pores which differ in sizes according to the type of process (Figure 5). It was explained in Ref. [21] that membrane technologies often require that the water undergo chemical and physical pre‐treatment to limit blockage by debris and scale formation on the membrane surfaces. The general characteristics of membrane processes are presented in Table 3. Membrane technologies can be subdivided into two broad categories: electrodialysis/electrodialysis reversal (ed/edr) and reverse osmosis (RO) [10]. According to Ref. [21], the driving force used in electrodialysis or electrodialysis reversal is an electrical potential, whereas that used in reverse osmosis is a pressure gradient.
An illustration of the range of nominal membrane pore sizes for reverse osmosis (RO), nanofiltration (NF), ultrafiltration (UF), and microfiltration (MF) (Source: [
Membrane process | Membrane driving force | Typical separation mechanism | Operating structure (pore size) | Typical operating range (μm) | Permeate description | Typical constituents removed |
---|---|---|---|---|---|---|
Microfiltration | Hydrostatic pressure difference or vacuum in open vessels | Sieve | Macropores (>50 nm) | 0.08–2.0 | Water + dissolved solutes | TSS, turbidity, protozoan oocysts and cysts, some bacteria and viruses |
Ultrafiltration | Hydrostatic pressure difference | Sieve | Mesopores (2–50 nm) | 0.005–0.2 | Water + small molecules | Macromolecules, colloids, most bacteria, some viruses, proteins |
Nanofiltration | Hydrostatic pressure difference | Sieve + solution/diffusion + exclusion | Micropores (<2 nm) | 0.001–0.01 | Water + very small molecules, ionic solutes | Small molecules, some hardness, viruses |
Reverse osmosis | Hydrostatic pressure difference | Solution/diffusion + exclusion | Dense (<2 nm) | 0.0001– 0.001 | Water + very small molecules, ionic solutes | Very small molecules, colour, hardness, sulfates, nitrate, sodium, other ions |
Dialysis | Concentration difference | Diffusion | Mesopores (2–50 nm) | – | Water + small molecules | Macromolecules, colloids, most bacteria, some viruses, proteins |
Electrodialysis | Electromotive force | Ion exchange with selective membranes | Micropores (<2 nm) | – | Water + ionic solutes | Ionized salt ions |
This is a voltage‐driven membrane process in which an electrical potential is used to move salts through a membrane, leaving fresh water behind as product water [10]. In Ref. [21], it was explained that the membrane used for ED/EDR are built in such a way that they only allow passage of either positively or negatively charged ions, but not both. Here, ionic molecules, such as sodium, chloride, calcium and carbonate in saline water, that are known to cause adverse effects on soil and crop productivity are removed from the treated water as the cations are attracted to the negative electrode, whereas the anions are attracted to the positive electrode while passing through selected membranes. According to Ref. [10], the membranes are usually arranged in an alternate pattern, with anion‐selective membrane followed by a cation‐selective membrane. He further explained that during this process, the salt content of the water channel is diluted, while concentrated solutions are formed at the electrodes. Concentrated and diluted solutions are created in the spaces between the alternating membranes, and these spaces bound by two membranes are called cells [10]. The pre‐treated saline water passes through all the cells simultaneously to provide a continuous flow of desalinated water and a steady stream of concentrate from the stack [10]. Although the ED was originally conceived as a seawater desalination process, it has generally been used for brackish water desalination [10].
According to Refs. [10, 21], the EDR functions in a similar way as the ED. However, El‐Swaify [6] explained that the only exception to the EDR operating on the same general principle as the ED unit is that both the product and the concentrate channels are identical in the EDR, whereas Buros [21] also explained that the polarity or charge of the electrodes is switched periodically in the reverse process. Immediately following reversal, the product water is removed until the lines are flushed out and the desired water quality restored [10]. They explained that the reversal in flow of ions helps to remove scaling, slimes and other debris from the membranes before they accumulate in large amount, thus extending the system’s operating life.
In relation to thermal processes, reverse osmosis is a relatively new process that was commercialized in the 1970s [10, 24]. Currently, it is the most widely used method for desalination in the United States [10]. This process of desalination uses a pressure gradient as the driving force to move high pressure pre‐treated saline water through a membrane that prevents the salt ions from passing, thus, yielding the product water stream and a concentrated brine stream as shown in Figure 6, respectively [10, 21]. In other words, reverse osmosis utilizes hydraulic pressure to offset osmotic pressure and induces mass transport of water across a semi‐permeable membrane [25]. This is simply applying pressure (in excess of the osmotic pressure) to the saline water [16]. Osmotic pressure (π) is calculated using the Van’t Hoff equation:
Basic components of a reverse osmosis membrane treatment process (Source: [
where
According to Ref. [10], high pressure pumps supply the pressures between the range of 150 psi for slightly brackish water to 800–1000 psi for salt water, to enable the water to pass through the membrane and have the salt rejected. It is worthy to note that the membrane is easily torn and needs to be supported carefully [16]. Due to the fact that the membrane of the reverse osmosis process consists of small pores, the salt water needs to be filtered first to remove particles which might damage the membranes, while chemical additives may be added to prevent biological growth and scaling [16, 21]. This is very important as the membrane surfaces must remain clean [10].
The individual spiral reverse osmosis membrane element through which the high pressure pre‐treated saline water flows are constructed in a concentric spiral pattern that allow alternating layers of pre‐treated water and brine spacing, reverse osmosis membrane and a porous product water carrier (Figure 7) [21]. The porous product water carrier allows the fresh water to flow into the centre of the membrane element to be collected in the product water tube. According to Ref. [10], the reverse osmosis processes are used for desalinating brackish water (TDS > 1500 mg/L) and seawater. Although membrane desalination processes using reverse osmosis or nanofiltration are diffusion‐controlled membrane processes [25], also, Krishna [10] explained that unlike nanofiltration, which is a membrane process that is used for the removal of divalent salt ions such as calcium, magnesium and sulphate, reverse osmosis is used for the removal of sodium and chloride.
Dissected view of a spiral reverse osmosis membrane element (Source: [
According to Ref. [26], following mass balance equations are commonly used to describe reverse osmosis and nanofiltration membrane process performance. Equation (2) indicates mass balance for water flow:
where
Equation (3) describes mass balance for solute flux:
where
Forward osmosis is used to describe the use of osmosis as a salt‐water separation mechanism through an engineered membrane. It is an emerging membrane treatment process that belongs to the class of osmotically driven membrane processes [25]. It was first presented by Cath et al. [27] and could also be called direct osmosis. Unlike reverse osmosis where pressure is applied to the pre‐treated saline water and a low salinity permeate is produced, forward osmosis involves a semi‐permeable membrane which separates a high osmotic pressure ‘draw’ solution from the pre‐treated saline water with relatively lower salinity and osmotic pressure. Here, water is drawn across the membrane by natural osmosis, restricting the passage of salts at the membrane surface. In Ref. [25], it explained that when equal volumes of a dilute feed solution and a concentrated draw solution are separated by a semi‐permeable membrane, water flows into the concentrated draw solution, which has a higher osmotic pressure. This flow continues until chemical equilibrium is reached. The increase in water column height in the high osmotic pressure chamber at equilibrium equates to the difference in osmotic pressure between the dilute and concentrated solutions. Thus, forward osmosis uses the osmotic pressure differential (
where
Past research has shown that forward osmosis membranes are good barriers to a broad range of contaminants, including bacteria, protozoa, viruses and other dissolved organic and inorganic constituents in contaminated water [27]. Also, in comparison to other desalination processes such as the multi‐stage flash, multi‐effect distillation and reverse osmosis, McGinnis and Elimelech [28] estimated that the forward osmosis has relatively lowest relative energy consumption (Figure 8). The authors estimated that forward osmosis with a thermally decomposing draw solution [such as in the forward osmosis low temperature distillation (FO‐LT) process which incorporates the use of low‐quality heat for thermal decomposition of the draw solution and recovery using distillation columns] would use less than one‐third the work energy of reverse osmosis for desalination.
Estimated energy consumption for desalination processes (Source: [
According to Ref. [1], the amount of fresh groundwater or agricultural activities is negligible and exists only in some locations. He further stated that desalination of brackish and saline water seems to be promising, especially in the absence of any other alternative. In spite of this, the cost of desalinated water are still too high for full use of this resource in irrigated agriculture, with the exception of intensive horticulture or high‐value cash crops, such as vegetables and flowers grown in greenhouses [29]. In Refs. [1, 29], reverse osmosis was reported to be the preferred desalination technology for agricultural uses because of the cost reductions driven by improvements in membranes in recent years. An example of countries that have adopted the application of desalinated water for irrigated agriculture is Spain. According to Ref. [30], Spain has more than 300 treatment plants with most of the plants processing brackish water, and located in coastal areas or within 60 km of the sea. It was also noted in Ref. [29] that small and medium size brackish water desalination plants, with a capacity of less than 1000 m3/d (11.6 L/s), are common because they adapt better to individual farmer requirements and to the existing hydraulic structures. As irrigated agriculture does not require the strict standards that apply for drinking‐water requirements, opportunities appear to exist for the adoption of high‐quality desalinated water, and in this way, the final cost of a cubic metre of irrigation water can be reduced [29].
Salinity arises from various natural and human‐induced processes and is a major phenomenon that deteriorates soil properties, thus limiting the potentials of soils for sustainable crop production. Desalinated water is usually of high quality and can have less negative impact on soils and crops in comparison with direct use of brackish water. Thus, water desalination could have positive impacts on agriculture and the environment, such as increasing water availability and recycling poor‐quality water. The use of osmotic and distillation mechanisms to recover high quality water from wastewater effluents and saline waters could be high‐tech demanding especially when considering desalination of large volume of water for irrigation and other forms of utilization.
Although, the use of low‐tech distillation methods could be easily adopted by peasant farmers in rural communities, the use of reverse osmosis has been said to be the most suitable for irrigated agriculture. As some of the processes involved in desalinizing saline water for sustainable crop production could be expensive, it could also be cost‐effective, owing to the fact that desalination could save water for agricultural production, increase the amount and types of crops grown, the area of land cultivated and as such improve the quality of crop yield and farmers’ income.
Cancer is a major public health problem worldwide, and colorectal cancer is the third most diagnosed cancer among both men and women in the United States [1], Brazil [2] and, overall, it is the third more frequent malignant disease around the world (1.85 million of new cases/years; 10.2% of total malignancies), with a 2.27% cumulative risk of onset between 0 and 74 years [3].
The mortality from colorectal cancer varies with several factors from the genetic variations of disease to the developmental status of a nation. Tumor staging remains the main prognostic factor.
The last two decades have seen substantial progress in the treatments to metastatic disease offering significant improvements in survival. According to SEER, the 5-year relative survival rate for patients diagnosed from 2008 to 2012 was about 64% for all stages taken together, and it was 14% for patients with metastatic disease [4].
At the time of first diagnosis, approximately 25% of patients present stage IV, with liver metastases, and up to 50% will develop recurrence in the liver during the disease course [5]. Most of these patients have liver metastasis considered unresectable at presentation [6], but about 20–30% of patients have a resectable disease that is confined to the liver [3], and despite a metastatic diagnosis, a half these of patients may benefit from the surgical resection of liver metastasis with curative intent, with improvements in a 5-year survival [7].
Colorectal cancer survival disparities are largely driven by socioeconomic inequalities that result in differences in access to early detection tests, refinements in molecular diagnosis, and the receipt of timely, high-quality treatment [8].
Today, the median overall survival for patients with metastatic colorectal cancer being treated both in phase III trials and in large observational series or registries is about 30 months and is more than double that of 20 years ago [9]. These patients with unresectable disease remain incurable and the treatments are mainly palliative.
We performed a non-systematic literature review of the results of a search in PubMed® with terms “palliative care” and “colorectal cancer” published in the last 5 years without restrictions of language. We found 304 articles that were manually selected for reading and synthesis of this work.
Palliative care has appropriately been receiving increased attention in recent years, due to better comprehension of this field of action and due to incremental costs of antineoplastic therapy disproportionated with clinical results.
From practical standpoint, therapy is considered palliative when resection of all known tumor sites is no longer possible or advisable and chemotherapy have limited benefit rate. Since a cure, as commonly defined, is not possible, the goal of treatment and eventually the success of therapy become judged by the control of symptoms and alleviation of suffering, not more by survival advantages or longer disease-free intervals [10].
Providing optimal palliative care for the patient with advanced colorectal cancer is a complex and challenging process. The success rate depends on proactive multidisciplinary interventions, taken early in metastatic disease [11].
Palliative care can improve all phases of the disease, it allows better decisions in the end-of-life care and potentially reduces health-care expenditures, but the exact understanding of commonly used terms such as “supportive care,” “symptom control” “palliative care,” and “hospice care” was rarely and inconsistently defined in the palliative oncology literature [12].
The roots of palliative medicine may be traced since Hippocrates through medieval medicine until a more recent approach of Cicely Saunders and to a new concept of modern palliative care. It has evolved from a philosophy of care for the dying to an interprofessional discipline that addresses mainly the quality of life for patients and their families throughout the disease trajectory [13].
The best palliative care will ever require a multidisciplinary approach where treatment plans will be made in accordance with the wishes of the patient and his family with a goal of decreasing morbidity and focus on improving quality of life by addressing their physical, emotional, and spiritual needs, and on supporting their families [14].
The provision of optimal palliative care for these patients is a compound and demanding process and becomes more challenging when an incurable and asymptomatic primary progress to advanced metastatic colorectal disease [15].
Surgical resection may provide good palliation of symptoms and prevent future tumor-related complications as we saw before [15].
Better than dividing patients into strict treatment protocols and different models of care, this new concept supports the provision of patient care by a single discipline comprised of a team of health-care professionals with expertise in symptom management, psychosocial care, spiritual support, caregiver care, communication, complex decision-making skills, and end-of-life care [16].
The need for incorporating palliative care into routine oncology practice is still enormous, but the benefits of doing so are even more significant. Outside United States and some places in Europe, financially strained health systems will need cost-effective models of palliative care delivery. As the aging population increases, the number of people diagnosed with cancer, and degenerative disease will increase, raising the need for this kind of approach.
As we see in the United States, as the cancer population grows, an already limited oncology workforce will be further strained. Cost- and resource-effective models of palliative care delivery will be required.
Volunteer work fills a large part of these gaps and can be the way out to overcome difficulties in access and funding [17], but adequate training of volunteers is essential to obtain the appropriate level of performance [16].
Community involvement needs to go beyond resource mobilization. In the current context of health systems, reaching higher levels of participation, involving the community as a partner in the implementation and support of these projects is something more complex and more difficult to achieve. Common barriers include the lack of mandatory preparatory work to understand the community’s social and political dynamics, the facilitators’ values and agenda [18].
Public expectations will rise and require that expectations will rise and require that palliative care be well integrated into all oncology care settings. All these factors will serve to promote the integration of expectations of a new way of oncology care.
The most important goals of palliative care are stablishing a good communication and offer an outstanding symptom control. Without adequate symptom control, no psycho-emotional measures can be adequately developed.
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].
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].
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.
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 nonsurgical modalities, is probably the best current option [31].
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 support to afford this model of care [38].
The difference between curative and palliative care lies in defining the main goal of treatment, since palliative treatments can extend life [39]. Palliative care is incorrectly associated with the suspension of all forms of antineoplastic therapy, but the persistence of inappropriate antitumor treatments in non-responding patients and overly aggressive care often affects a patient’s quality of life [40].
A report from a retrospective cohort study including all patients who died of colorectal cancer between 2004 and 2012 in Manitoba, Canada, provides the better evidence that early palliative care involvement is associated with decreased odds of dying in hospital and lower health-care utilization and costs in patients with colorectal cancer [41].
The goal of palliative care is improvement of quality of life. Good communication skills and flawless symptom control is associated with improved patient and family quality of life, greater treatment compliance, and may even offer survival advantages [42].
A 2016 meta-analysis evaluated 40 palliative care trials and concluded that this care was associated with improved patient quality of life and control of symptom burden [43].
The American Society of Clinical Oncology (ASCO) recommends the integration of palliative care into oncology practice [23], but despite the increasing evidence of the benefits of palliative care there is little consensus regarding strategies for integrating palliative care into the routine practice of oncology [44]. The lack of qualified professionals, the difficulties of access and the remuneration of professionals are still the biggest obstacles, especially in underdeveloped countries.
Palliative care has emphasized support for family caregivers. Although the family caregiver literature is even more limited than patient-focused studies, there is growing evidence of the benefits of palliative for family caregivers [15], but our current models of remuneration are insufficient to cover the care of the patient’s family members, and especially in the assistance to bereavement.
For palliative care to be truly integrated into oncology care, it will need to take on new forms, expanding for greater use in outpatient and community settings, survivorship clinics, and the most important, primary practice of oncology [45].
In an era of limited resources and incremental costs of health care, expanding palliative care capacity to meet clinical guidelines and population health needs seems to save costs. The major problem is a significant variance in estimates of the effects of treatment on costs, depending on the timing of intervention, the primary diagnosis, and the overall illness burden.
Because ASCO guidelines state that palliative care should be provided concurrently with other treatment from the point of diagnosis onward for all metastatic cancer, a broad evaluation is required to evaluate the cost effects of palliative care across the entire disease trajectory [46].
Colorectal carcinoma is a frequent entity, with many patients being diagnosed with metastatic disease “de novo” or having recurrences of the disease after primary treatment.
Although a fraction of patients may undergo resection of metastases with curative intent, the vast majority will remain eligible only for palliative treatment modalities, which may include surgery or systemic antineoplastic therapy.
Fundamentally, the practice of palliative care includes an impeccable control of symptoms, good communication, and psycho-emotional support for patients and their families.
The demand for palliative care to be integrated throughout the cancer trajectory, combined with a limited palliative care workforce, means that new models of care are needed.
Palliative care began in academic centers with specialty consultation services, and its value to patients, families, and health systems has been evident.
Volunteering can help fill most of the gaps in palliative care, but its implementation is still difficult and restricted to some more developed centers.
This chapter discusses evidence regarding the need for integration of palliative care into routine oncology care and describes the best practices recognized for dissemination of palliative care. The available evidence suggests that palliative care be widely adopted by clinicians in all oncology settings to benefit the patients with cancer and their families. Efforts are needed to adapt and integrate palliative care into community practice.
The benefits of palliative care can only be realized through effective dissemination of these principles of care, with more primary palliative care delivered by oncology clinicians.
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