Palliative Chemotherapy

Jason R. Beckrow, DOLighthouse Oncology

Objectives

• Objectives:– Understand the concept of treat with curative

intent vs. palliative intent.– Discuss the therapeutic goals of palliative chemo– Discuss targeted and palliative drug for various

malignancies.

Intentions of Treatment

Palliative

Curative

The Problem:Conventional Care Model

Fight or Quit

What do we mean by Palliative Chemotherapy?

GeriPal: A geriatrics and Palliative Care Blog

• Is there anyone amongst the readership that can direct me to a list, a compendium of purely "palliative" chemotherapy regimens?

• You can't find a protocol because there is no such thing. Chemotherapy produces symptoms, usually more symptoms than it relieves….Annonymous

“I Already Do Palliative Care” anonymous oncologist

Patients Reported Oncology Teams Often Do Not:

• Consider psychosocial care as a part of their patients’ cancer care.

• Understand their psychosocial needs, know about resources, or refer when needed.

• President’s Cancer Panel 2003, 2004

Community Oncology Offices

Cancer-FreeSurvival

Managed Chronic or Intermittent

Disease

TreatmentFailure

Treatment withIntent to Cure

PalliativeMedicine

Diagnosis andStaging

Death

• Where majority of cancer care is given today

• Where fewest psychological and social

services available

IOM President’s Cancer Panel, 2003, 2004Slide Courtesy of Jimmie Holland, MD

Memorial Sloan Kettering Cancer Center

Conventional Care

PresentationPresentationPresentationPresentation DeathDeathDeathDeath

Anti-disease TherapyAnti-disease TherapyAnti-disease TherapyAnti-disease Therapy

BereavementBereavementCareCare

BereavementBereavementCareCare

6m6m6m6m

Hospice Hospice CareCare

Hospice Hospice CareCare

Model of palliative cancer care.

Ferris F D et al. JCO 2009;27:3052-3058

©2009 by American Society of Clinical Oncology

The Relief of Suffering

Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself.

Eric Cassel, 1982

The Goals of Palliative Chemotherapy

• Symptom Relief• Attainment of Life Goals• Portability• Accessibility • Cost efficiency • Your thoughts….

Goals of Palliative Chemotherapy

Early Palliative Care Study ProceduresPalliative Care Guidelines

Illness understanding and education Inquire about illness and prognostic understanding Offer clarification regarding treatment goals

Distress Management

Symptom management Pain Pulmonary symptoms Fatigue and sleep disturbance Mood Gastrointestinal

Decision-making Assess mode of decision-making Assist with treatment decision-making

Coping with life-threatening illness Patient Family/family caregivers

www.nationalconsensusproject.org

Prepared and Hopeful

Oken, MM et al. Am J Clin Oncol 1982

…Principles of Oncology

Grade Activity0 Fully active, no restriction

1 Symptoms, restricted in strenuous activity

2 Ambulatory and capable of all self-care, no work activity. Up more than 50% of the day

3 Limited self care, confined to bed or chair >50% of the day

4 Completely disabled, unable to care for self, totally confined to bed or chair.

5 Dead

ECOG Performance Status

Conditions

• Breast Cancer• Lung Cancer• Prostate Cancer• Multiple Myeloma• Colo-rectal• Lymphoma

• Brain Mets• Bone Mets• Hypercalcemia• Chord Compression• SVC Syndrome• Hemoptysis

Common Non Cyto-toxic Cancer Meds

• Steroids• Biphosphanates

Prostate Cancer

• Androgen Deprivation– LHRH agonists– Anti androgens

• Taxanes• Crizotnib

Breast Cancer

• Hormonal Therapy– Tamoxifen– Aromatase Inhibitors

• Her-2 Receptivity – Trastuzamab– Lapatnib

• Cyto-toxics– Taxanes

Colon Cancer

• VEGF-Bevacizumab• EGFR

– Cetuximab– Pantiumumab

• Cyto-toxics– 5-FU– Capecitabin

Non Small Cell Lung Cancer

• Pemetrexed• Taxanes• Erlotnib• Bevacizumab

Small Cell Lung Cancer

• Platinum • Etoboside• Topotecan-Salvage• Whole Brain RT

Pancreatic Cancer

• Gemcitabine• Erlotnib

Multiple Myeloma

• Lenalidomide• Bortezomib• Chlorambucil• Pulse Decadron

Ovarian Cancer

• Platinum• Taxane

Non Hodgkin Lymphoma

• Rituxamab-CD 20 +• Cytoxan

Renal Cancer

• Sorafanib• Sunitnib