210909913 Supportive Palliative Care 2011 Dr Irza Wahid Ppt

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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

Transcript of 210909913 Supportive Palliative Care 2011 Dr Irza Wahid Ppt

Page 1: 210909913 Supportive Palliative Care 2011 Dr Irza Wahid Ppt

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

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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

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Kanker Multidisiplin Diagnosis s/d Tatalaksana

- Bedah - Radioterapi - Hematologi dan Onkologi Medik - Lain lain

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Terminology

Supportive care

Palliative Care

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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)

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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

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WHO model of palliative care services

Palliative Care

Anticancer Treatment

Diagnosis Death

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1st modification WHO model

Palliative Phase

Bereavement Phase

Diagnosis Death

Anticancer

Treatment phase –

curative intent

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2nd Modification WHO model

Palliative Phase

Diagnosis Death Palliative Treatment

– non curative intent

Anticancer

Treatment Phase –

curative intent

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3rd Modification WHO model

Palliative Phase

Diagnosis Death Palliative Treatment

– non-curative intent

Supportive Care Phase

Anticancer

Treatment Phase –

curative intent

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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

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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

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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

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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

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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?

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Nutrition & the Cancer Patient

Good Nutrition Important for :

Improved immune function

Better tolerance to therapies

Increased “quality of life”

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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

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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

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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

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Increasing serum Hb levels may improve survival in patients with cancer

• In a placebo-controlled trial of 375 anaemic patients receiving

non-platinum–based 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)*

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

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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

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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

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Management

- Preventive - Curative

Non Farmacologic Farmacologic Antitrombotic

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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)

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Stages of Chronic Venous Insufficiency

1. Varicose veins

2. Ankle/ leg edema

3. Stasis dermatitis

4. Lipodermatosclerosis

5. Venous stasis ulcer

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Perception of Chemotherapy (1983)

Nausea and vomiting are the two most feared toxicities of

chemotherapy.

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

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Role of Emesis in Natural Selection

Vomiting is a physiologic process, not a pathologic process.

It is the body’s natural defense against ingestion of toxic substances.

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Neurotransmitters Involved in Emesis

Emetic center

GABA

Histamine

Endorphins

Cannabinoid

Dopamine

Substance P

Serotonin

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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

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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

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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

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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

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Serotonin Antagonist Dose-Response Curve

Grunberg, in Tonato, ESMO Monographs, 1996

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Step Ladder WHO

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