PAIN TREATMENT FOR CANCER

 Meperidine is contraindication for pain

 Pain is a common symptom of cancer, WHOM SHOULD BE delineate to it’s mechanism:
nociceptive, neuropathic, somatic, visceral or MIXED
 Local tumors cause spinal and supraspinal hyperreactivity, different tumors cause different
spinal pain reactivity, depending on stage pain is increasing
 Moderate to severe pain SHOULD start with STRONG AND SHORT ACTING OPIOID; once
stable converse to intermediate long acting opioid, with or without adjuvant therapy

WHEN DO YOU START OPIOID AND HOW DO YOU USE THEM APPROPRIATELY?

 Opioid (tidak ada dosis max) terbaik untuk nyeri berat  waspada obstipasi
 Cancer pain (nyeri kronis)  combination pain

Non Pharmacologic Treatment (about 5-10%)

 Phychotherapy
 Radiotherapy
 Physiotherapy
 etc

Step Ladder WHO for Pharmacologic Treatment

Mild pain : 0-4 (outpatient, no need opioid, need PCT asmef nsaid, adjuvant:
antiepileptic, anti depresant, evaluation and controlled: 3 days)

Moderate pain : 5-6

Severe pain : 7-10

 Assessment : Quantity, Quality, Intensity, Pain in special edition

Opioid in Indonesia :
 Morphine inj
 Oxycodone inj
 Fentanyl inj
 Morphine Immediate
 Morphine Slow Release Tablet
 Hidromorphone
 Fentanyl Patch
 Oxycodone tablet

How Do You Start Opioid:

 Opioid titration
 Assessment periodically
 Laxative
 Adjuvant treatment
 Management of BTP (Breakthrough Pain)
 Pharmacologic anf Non pharmacologic (?)

MINIQUIZ 1 : CANCER PAIN MANAGEMENT

Jika analgetik tidak memberikan perbaikan terhadap rasa nyeri apakah obat tetap diteruskan
(pasien menggunakan NGT, sebelumnya diberikan MST?)? No, change analgetic drug:

 MST CONSTINUS tablets should be swallowed whole and not broken, chewed or crushed.
Maka tidak dapat diberikan melalui NGT.
 The administration of broken, chewed or crushed tablets may lead to a rapid release and
absorption of a potentially fatal dose of morphine

Apakah obat analgetik apa yg tepat untuk menggantikan MST pada pasien yang menggunakan
NGT dengan nyeri berat?

 MIR : it works faster than MST and fentanyl patch. But fentanyl can be used after pain has
been controlled by fixed dose

Question?

 Parenteral morphine is choosen cause it can give effect in 15 minutes. It works faster than
fenthanyl patch and MST
 Besides she was on NGT and MST should not be crushed

Berapa dosis parenteral morfin?

 Dosis parenteral morfin : 50 mg/24jam

 Equivalent oral morfin : 150 mg
 The Levy rule states that the hourly fenthanyl patch strength in micrograms is half of the
total daily dose of sustained release morphine in milligrams
 So, fentanyl dose is : 150 mg/2 = 75 mcg
ANTICIPATORY CHEMOTHERAPY INDUCED NAUSEA VOMITTING
Cisplatin : highly emetogenic therapy

MINIQUIZ 2 : THALASSEMIA
 Diagnosis Thalassemia mayor dilakukan pada usia antara 6 bulan – 2 tahun, Thalassemia
Intermedia TDT antara 2 tahun – 6 tahun
 Penyebab utama kematian pada Thalassemia : Gagal Jantung

Screening Thalassemia :

Kehamilan

 Dilakukan pada ibu hamil saat pertama kali kunjungan

 Bila ibu pengidap atau karier thalassemia  skrining dilanjutkan pada ayah janin
 Jika ayah janin normal  skrining janin (diagnosis prenatal) tidak disarankan
 Jika ayah janin merupakan pengidap atau karier thalassemia  disarankan melakukan
konseling genetik, jika perlu skrining pada janin (diagnosis prenatal)
 Screening steps during pregnancy  recommendation c

Bila pada skrining thalassemia ditemukan Thalassemia beta carrier/trait/minor  lakukan

konseling :

 Konseling individu
 Konseling pasangan thalassemia minor yang akan menikah  at risk group
The Choices Available to an at Risk Couple

Partners in a relationship, who are aware that they are carriers of beta thalassemia, today have
a number of choices with regard to having a family :

 Not to have children at all, or

 Not to have their own children but to adopt children, or
 To proceed to have children with artificial insemination with donated sperm from a non-
carrier donor, or
 To have their own child anyway and proceed with the pregnancy without finding out of the
feotus, or
 To proceed with a pregnancy and have prenatal diagnosis with the choice of terminating the
pregnancy if the foetus is affected, or
 Even when the foetus is diagnosed with beta thalassemia major or another severe
hemoglobin disorder, to continue with the pregnancy, or
 To have pre-implantation genetic diagnosis (PGD)

EARLY DETECTION IN CANCER

Breast Cancer

American Cancer Society Recommendation

Moderate Risk :

 Age 40-44 years  screening breast cancer earlier

 Age 45-54 years  mammography every years
 Age > 55 years  mammography every 2 years

High Risk  mammography every years since 40 years old.

Cervical Cancer  screening 3 tahun setelah sexual intercourse pertama. Terapi: cryotherapy

Lung Cancer

 Tanda dan gejala :batuk, bone pain , kejang, hemiplegi, paraplegi, chest pain.
 Faktor risiko 1# : Rokok
 Lung cancer screening is currently not advised even for people at higher risk. Such as those
who smoke.
 National 10 years study (launched in 2002) looking at whether a new x-ray method called
spiral CT scanning can reduce lung cancer deaths.
 The US Preventive Services Task Force recommends yearly lung cancer screening with low-
dose computed tomography (LDCT) for people who have a history of heavy smoking, and
smoke now or have quit within the past 15 years, and are between 55 and 80 years old.

Colon Cancer

“starting at 50 and continuing through age 75”

Moderate risk:

 Every man and woman 50 years old begin testing for colon cancer.
 Sigmoidoscopy every 5 years
 Colonoscopy every 10 years.
 Double-contrast barium enema every 5 years

High Risk  begin at 40 years old or earlier if family history with colon cancer

Dapat dicegah

Gejala hanya muncul kalau CA sudah advance : konstipasi, BAB darah, nyeri perut, dll

Prostate Cancer

 Beginning at age 50, men should be offered the Prostate Specific Antigen (PSA) blood test
and a digital rectal examination (DRE) every year
 African American men are at increased risk for prostate cancer and should be tested
beginning at age 45.
 Men with a father, brother, or son wth prostate cancer before age 65 should be tested
HEMOPHILIA
 Kelainan perdarahan bawaan yang paling sering ditemukan
 Hemophilia A (defisiensi factor VIII)  lebih banyak kasus
 Hemophilia B (defisiensi factor IX)
 X-linked recessive, mutasi genetic (30%)
 Gen factor VIII/IX terletak di sisi distal lengan panjang (q) kromosom X
 Perempuan sebagai carriers
 Gejala dapat timbul sejak merangkak (hemartrosis 70-80%)
 Komplikasi : pseudotumor
 Identify : Clotting Time
Masa Perdarahan/Bleeding Time (BT) :

 Mendeteksi fungsi hemostasis primer

 Tidak perlu dilakukan bila secara klinis telah ditemukan petekie yang sistemik

Prothrombin Time (PT) dan Activated Partial Thromboplastin Time (aPTT) :

 Mendeteksi fungsi hemostasis sekunder (sistem koagulasi).

Manifestasi Klinis

 Perdarahan delayed bleeding

 Bentuk perdarahan
o Hemartrosis : paling sering
o Hematoma (perdarahan otot) : illiopsoas bleeding
o Life threatening bleeding : perdarahan intracranial, GIT, mata, leher, rongga mulut
(retrofaringeal)
o Perdarahan mukosa : epistaksis, perdarahan gusi, hematuria
Acquired Hemophilia

Rare autoimmune disorder characterized by :

 Deficiency or inactivation of factor VIII

 History bleeding
 Occurs in patients with a personal and family history negative for hemorrhages

Individuals of any age can be affected

 Extremely rare in children

 Incidence increases with age and mostly affects elderly individuals (60-80 years of age) 
elderly and peri and post partum women

Bleeding pattern is quite different

 Joint bleeding is infrequent

 Echymoses  most common manifestation, followed by muscle bleeding, GI and
genitourinary tract, and retroperitoneal
Prenatal Diagnosis

 Risk of miscarriage
 Chorionic villus sampling  between 11 and 14 weeks of pregnancy
 Amniocentesis  between 15th and 20th week of pregnancy
 Some centers only offer these procedures if the couple plans to terminate the pregnancy if
the fetus is found to have hemophilia

Prinsip Dasar Tata Laksana

1. Cegah dan obati perdarahan sedini mungkin

2. Perdarahan akut sebaiknya diatasi dalam waktu kurang dari 2 jam
3. Pasien biasanya dapat mengenali gejala awal timbulnya perdarahan, berupa sensasi
“tingling” atau “aura”
4. Pada kasus perdarahan berat (intracranial, saluran napas  apnea, dan saluran cerna),
berikan faktor pembekuan sesegera mungkin, sebelum melakukan pemeriksaan lainnya.
5. Hindari melakukan vena seksi, kecuali pada keadaan yang sangat mengancam jiwa (life
saving).

Tata Laksana Kedaruratan

1. Stabilkan airway-breathing-circulation
2. Pasang akses vena
3. Berikan FVIII  terapi definitive on demand (hemophilia A) atau FIX (hemophilia B) dengan
target kadar plasma 50-100%
4. Lakukan pemeriksaan penunjang yang diperlukan (radiologi/laboratorium)
5. Hubungi konsultan hematologi yang biasa menangani pasien dan konsultasi lain yang
relevan
Tata Laksana Lain

Terapi suportif

 Antifibrinolitik
 Analgesic  hindari NSAID karena mengganggu fungsi trombosit
 Fisioterapi

DDAVP (Desmopressin)  mild hemophilia

Gene therapy

Komplikasi Hemofilia

Terkait penyakit  Perdarahan :

 Kontaktur fleksi  Atrofi otot

 Artritis/artropatiNyeri kronik  Sindrom kompartemen
 Atrofi kronik  Gangguan neurologik
Artropati Hemofilik

Prinsip Umum Tatalaksana

 Cegah perdarahan
 Hindari obat-obatan yang mengganggu fungsi trombosit (asam asetil salisilat/asetosal dan
anti inflamasi non-steroid)  untuk nyeri: PCT/asetaminofen
 Hindari suntikan IM, pengambilan darah vena / arteri yang sulit
 Perdarahan akut  ditangani ASAP, dalam 2 jam
 Perdarahan berat, mengancam
nyawa  treat, bahkan sebelum
penilaian diagnostik selesai
 Sebisa mungkin  konsentrat
faktor pembekuan
 Sebelum ke RS (terutama
perdarahan sendi dan otot pasien)
dianjurkan : RICE
Terkait pengobatan 

 Inhibitor (antibody)
Inhibitor mulai terbentuk 50 hari setelah pajanan
Klasifikasi inhibitor :
a. High responding inhibitor  meningkat cepat dengan kadar cukup tinggi (>5 BU). Jika
tidak diterapi, titer dapat turun namun terjadi respons anamnestik rekuren dalam 3-5
hari setelah pemberian konsentrat
b. Low responding inhibitor  meningkat lambat dan lebih rendah (<5 BU) setelah
beberapa kali terpapar faktor VIII
Skrining

 Untuk anak-anak, inhibitor skrining setiap 3-12 bulan atau setiap 10-20 hari pajanan, dan
untuk orang dewasa sesuai klinis
 Inhibitor diskrining sebelum operasi, dan ketika respons klinis terhadap terapi adekuat sub-
optimal

Pencegahan
 Vaksin hepatitis A dan B, subkutan

Tatalaksana

 Penyakit hati kronik : terapi sesuai standar terapi untuk hepatitis kronik
 Pasien dengan gangguan fungsi hati dapat terjadi defisiensi faktor pembekuan lain (cek PT,
INR) atau hitung trombosit yang rendah

 Infeksi terkait transfusi :

a. FFP  hemophilia A
b. Cryo  hemophilia B
c. recombinant