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
Top Related