PALLIATIVE MEDICINE and DISEASE-MODIFYING MANAGEMENT FOR CANCER

MADONNA R. BACORRO, M.D. SHPM fellow UP-PGH

TOPICS FOR DISCUSSION:

Chemotherapy in Palliative Care Radiotherapy in Symptom Management Surgical Palliation Orthopaedic Principles and Management Interventional Radiology

 The optimal management of cancer requires a multidisciplinary team approach in which palliative care physicians and surgical, radiation, and medical oncologists play an important part

 Patients may experience physical, emotional, psychological, and spiritual distress at any time during the course of the illness, and involving palliative care physicians from diagnosis ensures that patients are referred for specialist palliative care when they need it.

OBJECTIVES:
To understand the respective roles of the oncologists in the team To know about the cancers which oncologists treat and the expectations and side-effects of their treatments To be able to recognize patients in our care who might benefit from cancer treatment and refer them to an appropriate oncologist

CANCER

mutation

inherited

Occur by chance

Acquired by exposure to certain virus or carcinogens

1) antimetabolites 2) alkylating drugs 3)antitumour antibiotics 4) plant alkaloids

CYTOTOXIC DRUGS
ANTIMETABOLITES
5-fluorouracil fludarabine methotrexate gemcitabine Alkylating drugs Cyclophosphamide ifosfamide Chlorambucil melphalan

CYTOTOXIC DRUGS
ANTI-TUMOUR ANTIBIOTICS 5-fluorouracil fludarabine methotrexate gemcitabine PLANT ALKALOIDS Cyclophosphamide ifosfamide Chlorambucil melphalan

CHEMOTHERAPY
Most effective when cancer load is:
A) small and growth factor is increased B) when cytotoxic drugs with different mode of action are given together (COMBINATION Chemotherapy)

Mesothelioma

Prostate

effectiveness of chemotherapy
the survival time from commencement of treatment the time from commencement of treatment to cancer progression the cancer response rate:
A) complete remission- which is the proportion of treated patients whose cancer either becomes undetectable B) partial remission - reduces in size by at least 50 per cent C) stable disease- stays the same size D) progressive disease- continues to grow during treatment

the quality of life.

TOXICITY OF CHEMOTHERAPY
1) BONE MARROW 2) GIT 3) SKIN
4) KIDNEYS 5) NERVOUS SYSTEM 6) LUNGS 7) HEART

BONE MARROW
FATIGUE ( associated w/ anemia) Mx: BT or EPO-replacement Low neutrophil count= weak immune system
Only sign is ongoing infection and fever Acute medical emergency and immediate admission

GIT
Lining of GI is being shed and replaced after days of treatment Nausea, vomiting,mucositis, diarrhea Indication for admission: for hydration and alimentation Choices of meds: a)nausea and vomitingdomperidone, dexa in reducing dose, ondansetron for 5-10d b)Diarrhea c)mucositis- mouth wash if with no infection

SKIN
Photosensitivity, urticaria, hyperpigmentation, dermatitis Alopecia and avulsion of nails Hand and foot syndrome= 5FU (withdraw)

To treat or not to treat

1) 2) 3) 4) ComorbiditiEs Blood tests Age Performance status

PERFORMANCE STATUS SCALES

1) Karnofsky Scale 2) ECOG/WHO Scale

Karnofsky scale
No complaints; no evidence of disease 100

ECOGa/WHO scale
0 Normal activity No restrictions

TABLE FOR ecog

90 1

Able to carry on normal activity; minor signs or symptoms of disease Some signs or symptoms of disease; Normal activity with effort Cares for self; unable to carry on normal activity or to do active work

80

70

Requires occasional assistance but is able to care for personal needs

60

Restricted but ambulatory; able to carry out light work Ambulatory and selfcaring but unable to carry out light work; up more than 50% of waking hours Limited self-care; symptomatic, confined to bed or chair more than 50% of waking hours Completely disabled; totally confined to bed; may need hospitalization

Karnofsky scale
Requires considerable assistance and frequent medical care Disabled; requires special care and assistance Severely disabled; hospitalization indicated although death not imminent Very sick; hospitalization necessary; requires active supportive treatment Moribund; fatal processes progressing rapidly Dead 50 5

ECOGa/WHO scale
Dead

TABLE FOR ecog

40

30

20

10

Serum tumour markers used in clinical practice

Immunochemical markers in common use

Radiotherapy in symptom management

RADIOTHERAPY
Damage to DNA hyperfractionation-- > 6 weeks-8weeks life -- goal: complete eradication of tumor

 ACUTE EFFECT seen during and may persist for several weeks after radiotherapy d/t loss of surface epithelial cells LATE EFFECTS rarely <9mos after treatment Major cause of treatment related loss of function and even mortality

Acute and late effects of radiation

SITE 1)Skin ACUTE EFFECT Erythema desquamation LATE EFFECT Atrophy, fibrosis telengiectasia necrosis 2) GIT Nausea, anorexia diarrhea stricture perforation malabsorption Chronic enteritis, colitis, proctitis 3) bladder Sterile cystitis reduced volume

Telengiectasia, bleeding
Urethral or ureteric stricture fistula 4) Oral cavity mucositis Mucosal atrophy

Acute and late effects of radiation

SITE 5) pharynx ACUTE EFFECT Dry mouth Taste loss LATE EFFECT Telengiectasia, bleeding Dental carries Mandibular necrosis 6) lung pneumonitis fibrosis

7)CNS

Transient demyelination (Lhermittes sign)

Local oedema

myelitis

necrosis cataract Entropion or ectropion Dry eye

8) eye

keratitis

Indications for radiotherapy in symptom palliation

Symptom Pain Bone pain Visceral pain Bone metastases Soft tissue metastases Cause

Neuropathic pain

Bone metastases
Soft tissue primary or metastases Intrinsic tumour in nerve tissue

Local pressure Spinal canal compression Cranial nerve palsies Obstruction Bronchus Intrinsic bronchial tumour Extrinsic lymphadenopathy Extradural metastases Bone metastases Skull base bone metastases

Meningeal metastases

Indications for radiotherapy in symptom palliation

Oesophagus Superior vena cava Intrinsic bronchial tumour Extrinsic lymphadenopathy Primary mediastinal tumour

Primary lung or oesophageal tumour Metastatic mediastinal lymphadenopathy

Hydrocephalus Limb swelling Bleeding Haemoptysis Haematuria Vaginal bleeding Rectal bleeding Primary bronchial tumour Metastatic bronchial or lung tumour Primary tumour in kidney, ureter, bladder, prostate Primary tumours of vagina, cervix or uterus Metastases in vagina Primary anal or colorectal tumours Malignant meningitis Primary or metastatic brain tumour Metastatic lymphadenopathy

SIDE EFFECTS OF RADIATION:

MOST COMMON SYMPTOMS
1) MILD SKIN REACTIONS 2) NAUSEA

MANAGEMENT
Aqueous cream Metoclopromide, 5 -HT antagonists

3) RADIATION-INDUCED ACUTE DIARRHEA Dietary advice,loperamide, Codeine Phosphate

4) RADIATION CYSTITIS
5) OROPHARYNGEAL MUCOSITIS

Alpha-blocker, K citrate, cranberry juice

Or, prophylactic anti-candidal preparationsal hygiene, chlorhexidine mouthwash Dental hygiene, for local relief of pain

6) DENTAL CARRIES AND OSTEONECROSIS OF THE JAW

7) PNEUMONITIS (dry cough and dyspnea) Systemic steroids and antibiotics for 2-3 wks

Surgical palliation
Ricardo J. Gonzalez, MD Assistant Professor of Surgery University of Colorado

Palliation
Relieve symptoms for patients beyond cure when nonsurgical measures are not feasible, not effective, or not expedient Palliation means patient should be better at the completion of the procedure or treatment It is axiomatic that one cannot palliatively improve an asymptomatic patient using a scalpel. R. G. Martin, 1982

GASTRO INTESTINAL MALIGNANCIES PALLIATIVE PROCEDURES

Orthopedic principles and management

Skeletal metastases
principles of treatment are: 1) pain relief 2) preservation/restoration of skeletal integrity 3) preservation/restoration of function 4) elimination or prevention of neurologic compromise.

main role of the orthopaedic surgeon

treatment of the complications of skeletal metastases Pain -- commonest form of presentation of skeletal metastases , occurring in two-thirds of patients with radiographically detectable lesions -- may develop before the lesion becomes detectable on radiographs

orthopaedic surgeons role

not usually involved in the treatment of painful skeletal metastases but he may be involved in their diagnosis as patients with bone pain are frequently referred initially

 Magnetic resonance imaging --the most sensitive method of detecting early metastases, especially in the spine skeletal scintigraphy-- still probably the investigation of choice in assessing the degree of skeletal dissemination

The orthopaedic surgeon is usually not involved in the treatment of the painful uncomplicated lesion although he may have made the diagnosis but becomes involved when one of the following complications arise

Facts:
commonest site of pathological fracture is in the femur three aspects to the treatment of pathological fractures.
1) The orthopaedic management 2) localized irradiation 3) the treatment of the causative tumour

Harrington classification
Class I: The lateral cortices and superior and medial acetabular walls are structurally intact Class II: The medial wall is deficient. Class III: The lateral cortices and the medial and superior acetabular walls are deficient.

indications for endoprosthetic replacement in the management of skeletal metastases are: resection of a solitary metastasis, usually secondary to renal carcinoma, with the aim of achieving a wide margin of healthy tissue around the tumour transcervical femoral fractures some metastases or pathological fractures involving the epiphysis or metaphysis of long bones, where other forms of treatment are not practical and some failures of previous fixation

Multiple fractures
Some patients present with several pathological fractures and each must be treated on its merits. This may require the stabilization of several fractures

Contraindications to surgery
terminally ill patient a high risk of fixation failure due to the extent of bone destruction presence of infection

INTERVENTIONAL RADIOLOGY

Procedure

Examples of indications

Interventional radiological procedures

Drainage Dilation/stenting Malignant obstruction of renal and biliary tract, pleural effusions, ascites Malignant gastrointestinal, biliary, ureteric and airway obstruction, superior or inferior vena caval obstruction, etc.

Feeding

Venous accessHickman lines peripherallyinserted central catheter (PICC) lines

Percutaneous gastrostomy

Extraction Infusion Embolization

Retrieval or resiting of venous lines Regional, selective infusion of chemotherapeutic agents Hormone producing metastases, primary hepatocellular carcinoma, skeletal metastases, etc. Coeliac ganglion in pancreatic cancer Vertebral metastasis, osteoporosis Liver, renal, bony, and soft tissue tumours

Neurolysis Vertebroplasty Tumour ablation

REFERENCE:
OXFORD TEXTBOOK OF PALLIATIVE MEDICINE
4TH EDITION

THANK YOU!!!