Medicine — Cancer and Palliative Care, NMC MBBS licence examination syllabus (Nepal Medical Council).
Cancer principles and palliative care
Two skills: recognising the symptoms that must not be explained away, and treating the person once the diagnosis is made.
A licensing examination does not expect you to stage tumours or select chemotherapy. It expects two things that matter far more at the front door. The first is recognising the presentations that should prompt investigation rather than reassurance — because almost every late cancer diagnosis involved a red flag that had a plausible benign explanation available. The second is knowing how to control symptoms and talk honestly to someone whose disease cannot be cured.
The second of those is often treated as a soft skill and taught last. It is neither soft nor optional: uncontrolled pain, unmanaged constipation and an unspoken prognosis cause enormous avoidable suffering, and all three are within the competence of any doctor.
🩺 Where this lives: Cancer pain is widely undertreated, and the commonest reason is fear of opioids — among clinicians as much as patients. Concern about addiction, respiratory depression and "starting morphine too early" leads to doses that never reach effectiveness and to as-required prescriptions that leave patients chasing pain after it has returned. Oral morphine is inexpensive, on the WHO essential medicines list, and transforms the last months of a life when used properly. In much of the world the barrier is not availability of the drug but willingness to prescribe it adequately.
💡 A note on doses. This chapter contains no doses, no opioid conversion ratios and no breakthrough dose fractions. Conversion between opioids and between routes is a recognised source of fatal error, published ratios differ, and breakthrough calculations are guideline-specific. Take every number from national guidance or a palliative care service. It also gives no staging systems or survival figures. Breaking bad news is covered in the Ethics chapter, opioid pharmacology in Analgesics, and neutropenic sepsis and tumour lysis in the Haematology chapter.
The red flags
Late cancer diagnoses rarely involve a patient with no symptoms. They usually involve a symptom that had a reasonable alternative explanation — weight loss attributed to stress, rectal bleeding to haemorrhoids, a cough to smoking, a hoarse voice to a cold. The discipline is to notice when you are reaching for the comfortable explanation and to investigate anyway. Unexplained weight loss deserves particular emphasis, because it is both the commonest red flag and the most rationalised.
Oncological emergencies
THE ONE THAT IS MISSED MOST OFTEN
SPINAL CORD COMPRESSION
In anyone with known cancer — and particularly with
cancers that spread to bone — BACK PAIN IS CORD
COMPRESSION UNTIL PROVEN OTHERWISE.
The warning features:
Back pain, often worse lying flat or on straining
LEG WEAKNESS or unsteadiness
A SENSORY LEVEL
URINARY RETENTION or incontinence, or new constipation
THE CRITICAL POINT: function lost before treatment is
usually NOT REGAINED. A patient who is still walking when
treated often keeps walking; a patient who has been
paraplegic for two days usually stays paraplegic. This is
why it is measured in hours, and why "review on the ward
round tomorrow" is the error.
Suspect it, arrange urgent imaging and specialist
referral, and start treatment per protocol without
waiting.
THE OTHERS
NEUTROPENIC SEPSIS — fever on chemotherapy means
antibiotics immediately, before the count is known.
See the haematology chapter.
HYPERCALCAEMIA — thirst, polyuria, constipation,
confusion, dehydration. Common, treatable, and
frequently attributed to the cancer itself.
SUPERIOR VENA CAVA OBSTRUCTION — facial and arm swelling,
distended neck and chest veins, breathlessness worse on
bending forward.
TUMOUR LYSIS — after treatment starts; see the
haematology chapter.
Each of these is treatable, and each is missed by
attributing new symptoms to "the cancer" rather than
examining the patient.
Pain control
💡 Exam angle: the three principles are examinable almost verbatim — by the mouth, by the clock, by the ladder. Oral route where possible; regular dosing rather than as-required, with a breakthrough dose available on top; and stepping up the analgesic ladder as needed. The other reliably examined point is that a laxative is prescribed with every opioid, because opioid constipation does not improve with time and causes real suffering.
WHY "AS REQUIRED ONLY" FAILS
A patient on as-required analgesia has to wait until the
pain returns, ask for the drug, wait for it to be given,
and then wait for it to work. They spend a substantial part
of every day in pain, and they learn to anticipate it with
anxiety.
REGULAR DOSING keeps a background level of analgesia, with
a BREAKTHROUGH dose available for episodes on top. This is
the single change that most improves cancer pain control.
ANTICIPATE THE SIDE EFFECTS RATHER THAN REACTING TO THEM
CONSTIPATION — prescribe a laxative from the start, with
every opioid, every time. It does not wear off.
NAUSEA — common early and usually settles; an antiemetic
may be needed for the first days.
DROWSINESS — usually settles within days as tolerance
develops.
ADDRESS THE FEARS EXPLICITLY
Addiction in the context of cancer pain is not the
problem clinicians fear, and undertreatment is a real
and common harm.
Morphine does not mean "the end has come" — patients and
families frequently believe this, and it stops them
accepting it.
Respiratory depression is rare when opioids are titrated
against pain rather than given as a bolus to an
opioid-naive patient.
NEUROPATHIC PAIN — burning, shooting, with numbness or
altered sensation — responds POORLY to opioids alone and
needs adjuvant drugs. See the analgesia chapter.
AND REMEMBER THE NON-DRUG MEASURES: positioning, treating
constipation, radiotherapy for bone pain where available,
and simply explaining what is happening.
The other symptoms
Two things are worth saying plainly. Constipation is almost universal and almost always undertreated — it causes pain, nausea, confusion and distress, and it is entirely preventable. And the symptom that troubles a patient most is frequently not the one you assumed: fear, insomnia, financial worry, or what will happen to their children. Asking what troubles them most takes seconds and often redirects the whole consultation.
What palliative care is
💡 Exam angle: two misconceptions get examined. Palliative care is not only for the last days of life — it runs alongside active treatment and can begin at diagnosis. And "nothing more can be done" is always false: cure may be impossible, but symptom control, honest conversation and dignity are always available. Where specialist services are scarce, good basic palliative care is delivered by ordinary clinicians, which is precisely why it belongs in a licensing syllabus.
Clinical reasoning: four presentations
🔍 Case 1 — back pain in a known cancer
PresentationA man with known prostate cancer develops worsening back pain over a week and now finds his legs heavy on the stairs. He is given analgesia and booked for review at the next clinic in ten days.
DangerCord compression, and a ten-day delay.
ReasoningBack pain with leg weakness in someone with a bone-seeking cancer is cord compression until excluded. Function lost before treatment is usually not regained, which makes this a matter of hours.
AnswerUrgent imaging and specialist referral the same day, with treatment started per protocol. Ask specifically about sensory level and bladder function.
🔍 Case 2 — pain that never quite settles
PresentationA woman with metastatic cancer is prescribed morphine "as required" for pain. She reports being in pain most of the day, waiting for doses, and has not opened her bowels for five days. No laxative has been prescribed.
Two errorsAs-required dosing, and no laxative.
ReasoningAs-required prescribing leaves the patient chasing pain that has already returned. Opioid constipation is predictable, does not wear off, and is itself causing pain and distress.
AnswerConvert to regular dosing with a breakthrough dose available, prescribe a laxative, and review. Take all doses and conversions from national guidance.
🔍 Case 3 — attributed to the cancer
PresentationA patient with advanced cancer becomes increasingly confused, thirsty and constipated over a fortnight. The team records "deterioration due to disease progression" and plans comfort measures only.
Missed diagnosisHypercalcaemia.
ReasoningThirst, polyuria, constipation and confusion are the classic picture, it is common in malignancy, and it is treatable. Attributing new symptoms to the cancer without examining or testing is how reversible problems get missed at the end of life.
AnswerCheck calcium and renal function, treat per protocol, and reassess. Palliative intent does not mean investigations stop — it means they are chosen for whether they will improve how the patient feels.
🔍 Case 4 — "nothing more can be done"
PresentationA patient with incurable disease is told there is nothing more that can be done and is discharged without symptom review, follow-up, or any discussion of what to expect. He returns days later in severe pain.
ErrorConfusing "not curable" with "not treatable".
ReasoningCure may be impossible, but pain control, management of nausea and constipation, honest information and support are always available — and their absence causes preventable suffering.
AnswerAssess and treat symptoms actively, ask what troubles him most, discuss what to expect and who to contact, and arrange follow-up. See the Ethics chapter for how to hold that conversation.
Commonly confused
Confusion
The distinction
Why it matters
Plausible explanation vs investigation
Red flags are investigated anyway
Late diagnoses usually had one.
Back pain vs cord compression
In known cancer, assume compression
Lost function is not regained.
New symptoms vs "the cancer"
Hypercalcaemia and sepsis are treatable
Reversible problems get missed.
As-required vs regular dosing
Regular, with breakthrough on top
Otherwise the patient chases pain.
Opioid vs laxative
Prescribe them together, always
Constipation does not wear off.
Nociceptive vs neuropathic pain
Neuropathic responds poorly to opioids
It needs adjuvants.
Palliative vs terminal care
It runs alongside active treatment
It can start at diagnosis.
Not curable vs not treatable
Comfort and honesty are always available
"Nothing more can be done" is false.
Rapid revision
MUST-KNOW FACTS
1. Late cancer diagnoses usually had a red flag with a benign explanation.
2. UNEXPLAINED WEIGHT LOSS is the commonest and most rationalised red flag.
3. Bleeding from ANY orifice needs explanation.
4. A hard, fixed, growing lump or a non-healing ulcer.
5. CHANGE — in bowel habit, cough, mole, voice — persisting for weeks.
6. SPINAL CORD COMPRESSION is the emergency most often missed.
7. Back pain in known cancer is cord compression UNTIL EXCLUDED.
8. Warning signs: leg weakness, sensory level, urinary retention.
9. FUNCTION LOST BEFORE TREATMENT IS USUALLY NOT REGAINED.
10. It is measured in HOURS — not the next ward round.
11. NEUTROPENIC SEPSIS: fever on chemotherapy — antibiotics immediately.
12. HYPERCALCAEMIA: thirst, polyuria, constipation, confusion — treatable.
13. SVC OBSTRUCTION: facial and arm swelling, distended veins.
14. Do not attribute new symptoms to "the cancer" without examining.
15. PAIN: BY THE MOUTH, BY THE CLOCK, BY THE LADDER.
16. REGULAR dosing with a BREAKTHROUGH dose — not as-required alone.
17. PRESCRIBE A LAXATIVE WITH EVERY OPIOID.
18. Opioid constipation does NOT wear off.
19. Nausea and drowsiness usually settle within days.
20. Fear of addiction is not a reason to undertreat cancer pain.
21. Morphine does not mean the end has come — say so explicitly.
22. NEUROPATHIC pain responds poorly to opioids and needs adjuvants.
23. Take all doses and OPIOID CONVERSIONS from national guidance.
24. Nausea: find the cause — drugs, constipation, obstruction, raised ICP.
25. Breathlessness: treat reversible causes; a fan and positioning help.
26. CONSTIPATION is almost universal and almost always undertreated.
27. ASK WHAT TROUBLES THEM MOST — it is often not what you expected.
28. Fear, low mood, insomnia and financial worry are symptoms too.
29. PALLIATIVE CARE RUNS ALONGSIDE ACTIVE TREATMENT.
30. It can begin at diagnosis, not only in the last days.
31. "NOTHING MORE CAN BE DONE" IS ALWAYS FALSE.
32. Oral morphine is cheap and on the essential medicines list.
💡 Exam angle: three threads — investigate the red flag despite the comfortable explanation, treat back pain in known cancer as cord compression today, and prescribe analgesia regularly with a laxative rather than as required.
Syllabus points
Red flags and the comfortable explanation
Unexplained weight loss
Spinal cord compression
Why lost function is not regained
Hypercalcaemia and SVC obstruction
Not attributing new symptoms to the cancer
By the mouth, by the clock, by the ladder
Regular dosing with breakthrough
A laxative with every opioid
Addressing fear of opioids
Neuropathic pain and adjuvants
Nausea, breathlessness and constipation
Asking what troubles them most
What palliative care actually is
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