2 Prinsip Kemoterapi

Patient Doctor

Other doctors (consultant)

Cytopathologist

Radiologist

Laboratory

MANAGEMENT OF CANCER PATIENT

diagnosis and treatment patient depend on one clinician only

Medical Team (teamwork) Standard Facility Standard Protocol

Medical Record

Patient

Better Communication Unity of work rhythm

Minimal mistakeMaximal patient service

MANAGEMENT OF CANCER PATIENT

Oncology aspect

Patients & family aspect

Outcome & Side Effect Monitoring

Oncology Aspect

Diagnose:- pathology :* morphologic class : adenoCa ? * histologic grade * pattern of invasion - tumor biology ? : Her2Neu, CD20, p53, Bcl2 proliferation indeces

Diagnose: Staging

Medical Status: Risk group - Anamnesa (co-morbid) - Physic, Laboratory, ECG - Performance status (Karnosfky-ECOG)

Patients & family Aspect

Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemotherapy - informed consent

Outcome & Side Effect Monitoring

SurvivalObjective & Subjective Outcome

Diagnose & management

Outcome Side Effect

Mechanism chemotherapy in cellular level Reduction of tumor after Chemotherapy Rational , patient financial ?

Cell Cycle mechanism

Doubling Time

Check point controle mechanism

Target of Actions of drugs( Phase specificity ? / Non phase ?)

2.Tumor cell Apoptosis

Mechanisme of Actions

Mitochondrial pathway (Bcl2 family,p53)

Death receptor pathway (Fas-FasL, caspase family of protein)

1.Tumor cell proliferation

( influence on the response to chemotherapy )

MG2

G1S

Bleomycin

5 Fudrara C6-Hydroxyurea5 FUMETHOTREXATE

6-Thioguanine

6-Marcaptopurine

Mytomycin

Actinomycin D

Hydrocortisone Chalones

5 FUVinblastineVincristineColchicineGriseofulvin

Differentiation

Phleomycin

Cyclophosphamide

Purin antagonisHydroxy urea

Actinomycin

Cyclophosphamide

5 Fudr .5FU, Ara C. Mitomycin,Doxorubicin Thioguanine

18-30h6-20h

0,5-1h0.5-1h

2-10h

Doxorubicin

Alkylating agent AntimetabolicMitotic inhibitor, Antibiotic

No response Early recurrence Late recurrence

Tumor detectable(clinically)

Long-term Remission Not palpable

Immune resistanceof host(humoral&cellular)

Induction Consolidation Maintenance Cure

1012

109

106

103

(1kg)

(1 g)

(1 mg)

Number ofTumor cell

Tumor invisible(Remission)

(1 úg)

Tepat indikasi : kemoterapi tepat dipilih berdasar titik tangkap kerjanya berdasar patogenesis kanker sehingga dapat tercapai tujuan : 1.kuratif 2.mencapai bebas penyakit (DFI) yang lebih lama 3.neoadjuvant (mengecilkan volume tumor preoperasi- down staging) 4.mempertahankan atau meningkatkan quality of life (terapi paliatif)

Tepat cara pemberian obat : oral, IV, bolus, infusion dsb yang penting : penderita nyaman , tidak takut dan dengan kesadaran sendiri ingin melanjutkan kemoterapi Tepat monitoring efek obat : - penilaian hasil / respons terapi - kemampuan hidup (quality of life) dan - efek samping obat

Tepat jenis obat : sebaiknya lebih spesifik, selektif, mem- punyai Response rate tinggi, established, dan dapat dijangkau oleh penderita

Tepat dosis obat : sesuai Maximum Tolerated Dose ( Risk group )

1.Objective Response Evaluation2.Subjective Response Evaluation(3). Survival

CANCER OUTCOME of TREATMENT

OBJECTIVE RESPONSE EVALUATIONS

1. TUMOR SIZE : - Complete remission (CR) - Partial remission (PR) - No Changes (Stable Disease = St D) - Progressive Disease (PD)2. Marker Tumour : - CEA, CA15-3, MCA Breast Ca - CEA, CA19-9 Pancreas Ca, Colorectal Ca - HCG Chorio Ca - PSA Prostat Ca

3. Objective-Qualitative : - Change of Clinical sign : Brain Ca-neurology sign

SUBJECTIVE RESPONSE EVALUATION

Performance status : Karnofsky / ECOG

Palliative

CURATIVE : caution of safety of side effects

DIAGNOSE of Side Effect

PHARMACOLOGYWhen Side effect become: NADIR point (degree of SE)Onset of SE, Specificity of organ target

MANAGEMENT of Side EffectAnticipation & PreventionDose related side effect monitoringEarly treatment of side effect

SIDE EFFECT MONITORING

PROFILE EPISODE of FEBRIL NEUTROPENI

Chemotherapy day

Chemotherapy day

nadir1 6 11 16 21 26

FEBRILE NEUTROPENIACRITERIA :• NEUTROPENIA :

absolute count of neutrophill in circulating blood < 2000 cells/mm3

• FEVER :

body temperature > 38.50C in 3 x measurement per 24 hours

DEGREE OF NEUTROPENIA

• Mild : 2000 – 1000 cells/mm3• Moderate : 1000 – 500 cells/mm3• Severe : < 500 cells/mm3

TREATMENT of FEBRIL NEUTROPENI

Empiric antibacterial

Empiric antibacterial

Chemotherapy day

Chemotherapy day

nadir

G-CSFSterile room

1. Onset of SE : - Immediately ( < 1 Hour post Chemotx) Anaphylaxsis - early (1- 48 hours ) Nausea-Vomiting profuse - delayed (2 days -2 months ) leucopenia - Late (after 2 months ) myopathy, neuropathy

2.Organ Target : CNS, Cardiovascular, Respiratory, Gastroentestinal System

3.Level/degree of SE (IUCC,WHO, ECOG) : - grade 0-2 : tolerable ( safety enough ) - grade 3 (severe) : must be alert (Yellow light), need treatment ± - grade 4 (life threatening) : Hazard, early and adequate treatment

RESUME :

Better Communication Unity of work rhythmMinimal mistakeMaximal patient service

Oncology aspect Patients & family aspect

Outcome & Side Effect Monitoring

Diagnose:- pathology - biology cell type ?

Diagnose: Staging

Medical Status: Risk group

Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemtherapy - informed consent

SurvivalObjective & Subjective Outcome Side Effect : Diagnose & management

RESUME :