Supportive & palliative care in the management of cancer patients

Irza Wahid

Div of Hematology Medical Oncology

Dept of Internal Medicine,

School of Medicine, Univ of Andalas

Dr. M Djamil Hospital

Nama : Dr Irza Wahid SpPD KHOM

Tempat / Tanggal Lahir : Padang / 23 November 1967

Alamat : Jalan Kolam Indah Raya No A6

Cendana Mata Air Padang

Telp. : 075161952 08126605439

Pekerjaan : Staf Subagian Hematologi Onkologi

Medik Bagian Ilmu Penyakit dalam

FK Unand / RS Dr M Djamil

No

Nama Pendidikan Nama Sekolah Waktu

1 SD SD Yos Sudarso Padang 1973 -1980

2 SMP SMP Negeri 1 Padang 1980 -1983

3 SMA SMA Negeri 1 Padang 1983 -1986

4 Kedokteran Umum FK Unand Padang 1986 1993

5 Program Pendidikan Dokter

Spesialis I Ilmu Penyakit Dalam

FK Unand / BLU RS Dr M Djamil

Padang

01/07/1998 10/07/ 2003

6 Program Pendidikan Dokter

Spesialis II Konsultan Hematologi Onkologi Medik

FK Unand / BLU RS Dr M Djamil

Padang

FKUI / RSCM / RSKD Jakarta

01/01/2004 31/12/2006

7 Program S3 Biomedik FK Unand FK Unand 01/07/2008 sekarang

Kanker Multidisiplin Diagnosis s/d Tatalaksana - Bedah - Radioterapi - Hematologi dan Onkologi Medik - Lain lain

Terminology

Supportive care

Palliative Care

Supportive Care

Services that are provided in addition to curative treatments for cancer patients (Dept of Health 2000)

Care given to improve the quality of life of patients who have a serious or life-threatening disease. The goal of supportive care is to prevent or treat as early as possible the symptoms of a disease, side effects caused by treatment of a disease, and psychological, social, and spiritual problems related to a disease or its treatment. Also called palliative care, comfort care, and symptom management. (National Cancer Institute, USA)

Supportive Care

Patient focused Support of patients from screening through

treatment and into palliative phase Management of cancer symptoms and side

effects of treatment Acute Chronic

Holistic intent Psycho-oncology Multidisciplinary Complementary therapies

WHO model of palliative care services

Palliative Care

Anticancer Treatment

Diagnosis Death

1st modification WHO model

Palliative Phase

Bereavement Phase

Diagnosis Death

Anticancer

Treatment phase curative intent

2nd Modification WHO model

Palliative Phase

Diagnosis Death Palliative Treatment

non curative intent

Anticancer

Treatment Phase curative intent

3rd Modification WHO model

Palliative Phase

Diagnosis Death Palliative Treatment

non-curative intent

Supportive Care Phase

Anticancer

Treatment Phase curative intent

4th Modification of WHO model

Palliative

Phase

Diagnosis Death Palliative Treatment

non-curative intent

Supportive Care Phase Anticancer

Treatment Phase curative intent

Dying Care

Bereavement

preparation

14

AHR

Supportive Care

Totality of medical, nursing , psychological, rehabilitative support.

From onset of the disease ,through various herapeutic phases for longterm cure /until death

Scope of supportive care: Heterogenous

Management of cancer manifestation : Malnutrition, pain, Infection.

Prevention of therapeutic side effects

Management of therapeutic side effects cardiac, renal , liver, fluid, electrolyte, hypercoagulation, thrombosis, nausea/vomitus, dyspepsia, diarrhea, fracture etc

Psychological and spiritual support. :depression , anxiety etc

Supportive Care Toxicity Targets

Metabolic

Hematologic

Myelosuppression

Hemostasis abn.

Gastrointestinal

Nausea/vomiting

Constipation/diarrhea

Mucositis

Cardiovascular

Cardiac event

Neurologic

Peripheral neuropathy

Cognitive

Pulmonary

Renal

Cutaneous

Alopecia

Rash

16

AHR

Metabolic Changes During Cancer

Hypermetabolism (may depend on cancer type)

Increased resting energy expenditure

Increased muscle atrophy

Decreased protein synthesis

Insulin resistance & glucose intolerance

Increased glucose production

17

AHR

Nutritional support?

Cancer cachexia seems resistant to intervention with enteral or parenteral nutrition

Likely due to metabolic changes increased tumour or host production of proinflammatory cytokines

Need to overcome metabolic changes

What about specific dietary nutrients?

18

AHR

Nutrition & the Cancer Patient

Good Nutrition Important for :

Improved immune function

Better tolerance to therapies

Increased quality of life

19

AHR

Prevalence of anaemia in cancer

Anaemia is the most common haematological disorder in patients with cancer

approximately 20%60% of patients with cancer will have anaemia at presentation

Treatment for cancer can induce or exacerbate anaemia: the extent of this varies according to the

type of tumour and treatment

ANEMIA Parameter : Kadar hemoglobin Metode Sahli Pria dewasa : Wanita dewasa : Hamil : Hb < 13 : < 12 : < 11 gr %

Gejala dan tanda

Hb hipoksia kompensasi kardiovaskular

* Pucat * angina pektoris * kardiomegali

Mukosa * claudicatio intermiten * palpitasi

Kulit * tinitus * dispneu

* berkunang * bising sistolik

* cepat lelah * gagal jantung

Gradasi anemia ringan : sedang : berat : > 8 : 6 8 : < 6 gr %

Morfologi mikro / normo / makrositer -- hipo/normo/hiperkrom

Patofisiologi defisiensi aplastik hemolitik perdarahan

Etiologi Cacing, low intake, kelainan imun, trauma, CANCER

21

AHR

Causes of anaemia in patients with cancer: Disease-related factors

Anaemia of chronic disease

Bone marrow involvement of malignancy

Haemolysis (RBC destruction)

Tumour-associated blood loss particularly with gastro-intestinal or uterine tumours

Nutritional deficiences iron, folate or vitamin B12

Renal insufficiency

Hypersplenism

22

AHR

Increasing serum Hb levels may improve survival in patients with cancer

In a placebo-controlled trial of 375 anaemic patients receiving non-platinumbased chemotherapy for a variety of malignancies, administration of recombinant EPO (rHuEPO) led to a:

significant increase in Hb levels (P

23

AHR

24

AHR

Table Infections During Granulocytopenia

Common sites : Alimentary canal Periodontitis / gingivitis Pharyngitis Esophagitis Perianal lesions Pneumonia Skin lesions Vascular access-related Common Organisms : Gram-negative Escheria coli Pseudomonas aeruginosa Gram-positive staphylococcus epidermidis staphylococcus aureus -hemolytic Streptococcus spp. Yeast Candida spp Fungi Aspergillus flavus and Aspergillus fumigatus Virus Herpes simplex

The sites and organism listed account for about 80% of infections

during granulocytopenia

Epidemiology of First-Time VTE

White R. Circulation. 2003;107:I-4 I-8.)

Variable Finding

Seasonal Variation Possibly more common in winter and less

common in summer

Risk Factors 25% to 50% idiopathic

15%-25% associated with cancer

20% following surgery (3 months)

Recurrent VTE

6-month incidence, 7%;

Higher rate in patients with cancer

Recurrent PE more likely after PE than

after DVT

Death After Treated VTE

30-day incidence 6% after incident DVT

30-day incidence 12% after PE

Death strongly associated with cancer,

age, and cardiovascular disease

Management

- Preventive - Curative

Non Farmacologic Farmacologic Antitrombotic

VTE Recurrence

Predictors of First Overall VTE Recurrence

Heit J, Mohr D, et al. Arch Intern Med. 2000;160:761-768

Baseline Characteristic Hazard Ratio

(95% CI)

Age 1.17 (1.11-1.24)

Body Mass Index 1.24 (1.04-1.7)

Neurologic disease with extremity

paresis 1.87 (1.28-2.73)

Malignant neoplasm

With chemotherapy

Without chemotherapy

4.24 (2.58-6.95)

2.21 (1.60-3.06)

Stages of Chronic Venous Insufficiency

1. Varicose veins

2. Ankle/ leg edema

3. Stasis dermatitis

4. Lipodermatosclerosis

5. Venous stasis ulcer

Perception of Chemotherapy (1983)

Nausea and vomiting are the two most feared toxicities of

chemotherapy.

Coates, Eur J Cancer Clin Oncol 19:203, 1983

Role of Emesis in Natural Selection

Vomiting is a physiologic process, not a pathologic process.

It is the bodys natural defense against ingestion of toxic substances.

Neurotransmitters Involved in Emesis

Emetic center

GABA

Histamine

Endorphins

Cannabinoid

Dopamine

Substance P

Serotonin

Levels of Emetogenicity

Highly Emetogenic Chemotherapy (HEC) (> 90%) Cisplatin

Mechlorethamine

Moderately Emetogenic Chemotherapy (MEC) (30-90%) Cyclophosphamide

Doxorubicin

Low Emetogenic Chemotherapy (10-30%) Paclitaxel

5-Fluorouracil

Minimally Emetogenic Chemotherapy (< 10%) Vincristine

Bleomycin

Levels of Emetogenicity Modifying Factors

Age Younger patients vomit more than older patients

Gender Women vomit more than men

Alcohol history Patients with a history of heavy alcohol use vomit

less than those without such a history

Nausea/vomiting history Patients with a history of morning sickness or

motion sickness are more likely to vomit

High Dose Metoclopramide The First Highly Effective Antiemetic

Gralla, NEJM 305:905, 1981

Metoclopramide (n=11)

Placebo (n=10)

P Metoclopramide

(n=11)

Prochlorperazine (n=10)

P

Emetic Episodes

1 0.9

10.5 5-25

0.001 1.5 0-6

12 5-16

0.005

Hours of Vomiting

0.2 0-16.8

3.6 2-17

0.028 0.5

0-16.5 4.5

1.5-17.6 NS

Hours of Nausea

0 0-16.2

3.7 0-19.2

0.042 0.1

0-17.2 5

0-20 NS

Increase in Complete Protection with Dexamethasone

89 Patients Receiving Cisplatin > 50 mg/m2

Roila, J Clin Oncol 9:675, 1991

Ondansteron Ondansteron/

Dexamethasone p

Vomiting 64% 91% 0.0005

Nausea 66% 89% 0.0025

Nausea/Vomiting 56% 81% 0.0008

Preference 14% 39% 0.003

Serotonin Antagonist Dose-Response Curve

Grunberg, in Tonato, ESMO Monographs, 1996

Step Ladder WHO