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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 Tempat / Tanggal Lahir Alamat Telp. Pekerjaan

: Dr Irza Wahid SpPD KHOM : Padang / 23 November 1967 : Jalan Kolam Indah Raya No A6 Cendana Mata Air Padang : 075161952 08126605439 : Staf Subagian Hematologi Onkologi Medik Bagian Ilmu Penyakit dalam FK Unand / RS Dr M Djamil
Nama Sekolah SD Yos Sudarso Padang SMP Negeri 1 Padang SMA Negeri 1 Padang FK Unand Padang FK Unand / BLU RS Dr M Djamil Padang FK Unand / BLU RS Dr M Djamil Padang FKUI / RSCM / RSKD Jakarta 1973 -1980 1980 -1983 1983 -1986 1986 1993 01/07/1998 10/07/ 2003 Waktu

Nama Pendidikan No 1 2 3 4 5 6 SD SMP SMA Kedokteran Umum Program Pendidikan Dokter Spesialis I Ilmu Penyakit Dalam Program Pendidikan Dokter Spesialis II Konsultan Hematologi Onkologi Medik

01/01/2004 31/12/2006

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

Holistic intent

Acute Chronic

Psycho-oncology Multidisciplinary Complementary therapies

WHO model of palliative care services

Palliative Care Anticancer Treatment

Diagnosis

Death

1st modification WHO model

Anticancer Treatment phase curative intent

Palliative Phase

Bereavement Phase Death

Diagnosis

2nd Modification WHO model

Anticancer Treatment Phase curative intent

Palliative Phase

Diagnosis Palliative Treatment non curative intent

Death

3rd Modification WHO model

Supportive Care Phase Anticancer Treatment Phase curative intent Diagnosis Palliative Treatment non-curative intent

Palliative Phase

Death

4th Modification of WHO model


Dying Care

Supportive Care Phase

Anticancer Treatment Phase curative intent

Palliative Phase

Diagnosis Palliative Treatment non-curative intent

Death

Bereavement preparation

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 14 AHR etc

Supportive Care Toxicity Targets

Metabolic Hematologic

Neurologic

Myelosuppression Hemostasis abn. Nausea/vomiting Constipation/diarrhea Mucositis

Gastrointestinal

Peripheral neuropathy Cognitive

Pulmonary Renal Cutaneous


Cardiovascular

Cardiac event

Alopecia Rash

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

16 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?
17 AHR

Nutrition & the Cancer Patient


Good Nutrition Important for : Improved immune function Better tolerance to therapies Increased quality of life

18 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
19 AHR

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

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
21 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 <0.001) significant decrease in transfusion requirements (P = 0.0057) significant improvement in QOL (P <0.01) trend towards an increase in survival (12-month estimated rates: 60% vs 49% for placebo)*
22 AHR

Littlewood T, et al. J Clin Oncol. 2001;11:2865-2874.

23 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

24 AHR

Epidemiology of First-Time VTE


Variable
Seasonal Variation

Finding
Possibly more common in winter and less common in summer 25% to 50% idiopathic 15%-25% associated with cancer 20% following surgery (3 months) 6-month incidence, 7%; Higher rate in patients with cancer Recurrent PE more likely after PE than after DVT 30-day incidence 6% after incident DVT 30-day incidence 12% after PE Death strongly associated with cancer, age, and cardiovascular disease

Risk Factors

Recurrent VTE

Death After Treated VTE

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

Management - Preventive - Curative


Non Farmacologic Farmacologic Antitrombotic

VTE Recurrence
Predictors of First Overall VTE Recurrence
Baseline Characteristic
Age Body Mass Index Neurologic disease with extremity paresis Malignant neoplasm With chemotherapy Without chemotherapy

Hazard Ratio
(95% CI)

1.17 (1.11-1.24) 1.24 (1.04-1.7) 1.87 (1.28-2.73)

4.24 (2.58-6.95) 2.21 (1.60-3.06)

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

Stages of Chronic Venous Insufficiency


1. 2. 3. Varicose veins Ankle/ leg edema Stasis dermatitis

4.
5.

Lipodermatosclerosis
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

Dopamine

Histamine

Serotonin

Endorphins

Emetic center
Substance P Cannabinoid

GABA

Levels of Emetogenicity

Highly Emetogenic Chemotherapy (HEC) (> 90%)

Cisplatin Mechlorethamine

Moderately Emetogenic Chemotherapy (MEC) (3090%)

Cyclophosphamide Doxorubicin Paclitaxel 5-Fluorouracil Vincristine Bleomycin

Low Emetogenic Chemotherapy (10-30%)


Minimally Emetogenic Chemotherapy (< 10%)


Levels of Emetogenicity Modifying Factors


Age

Younger patients vomit more than older patients Women vomit more than men

Gender

Alcohol history

Patients with a history of heavy alcohol use vomit less than those without such a history
Patients with a history of morning sickness or motion sickness are more likely to vomit

Nausea/vomiting history

High Dose Metoclopramide The First Highly Effective Antiemetic

Metoclopramide
(n=11)

Placebo
(n=10)

P 0.001 0.028

Metoclopramide
(n=11)

Prochlorperazine
(n=10)

P 0.005 NS

Emetic Episodes Hours of Vomiting Hours of Nausea

1 0.9 0.2 0-16.8 0 0-16.2

10.5 5-25 3.6 2-17 3.7 0-19.2

1.5 0-6 0.5 0-16.5 0.1 0-17.2

12 5-16 4.5 1.5-17.6 5 0-20

0.042

NS

Gralla, NEJM 305:905, 1981

Increase in Complete Protection with Dexamethasone


89 Patients Receiving Cisplatin > 50 mg/m2
Ondansteron/ Dexamethasone
91%
89% 81% 39%

Ondansteron
Vomiting
Nausea Nausea/Vomiting Preference

p
0.0005
0.0025 0.0008 0.003

64%
66% 56% 14%

Roila, J Clin Oncol 9:675, 1991

Serotonin Antagonist Dose-Response Curve

Grunberg, in Tonato, ESMO Monographs, 1996

Step Ladder WHO

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