Chemotherapy and Palliative Care. Dr. A. Swan General Practitioner in Oncology Dept. of Oncology, DECH May 7, 2010

Transcription

1 Chemotherapy and Palliative Care Dr. A. Swan General Practitioner in Oncology Dept. of Oncology, DECH May 7, 2010

2 Outline Questions Medical Treatments Chemotherapy Targeted therapy Hormonal therapy Bisphosphonates Side Effects

3 Chemo in Palliative Care A Personal Survey If you had an incurable disease and no symptoms from it, would you want chemotherapy? If you had an incurable disease and were having symptoms from it, would you want chemotherapy? What side effects from chemotherapy do you think you may experience? What questions would you have for the oncologist?

4 Life is the game that must be played. ~Edwin Arlington Robinson

5 Now we must play the game differently We must strategize!

6 How do you select patients for treatment? ECOG performance scale Age Type of cancer Melanoma vs. small cell lung Sites of involvement Bowel -?risk of perforation? Brain radiation versus chemo Comorbidities MUGA scan may be limiting factor Bloodwork (LFTs,, platelets, Cr)

7 ECOG Performance Scale Grade 0 - Fully active, able to carry on all pre-disease performance without restriction Grade 1 - Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work Grade 2 - Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours Grade 3 Capable of only limited selfcare,, confined to bed or chair more than 50% of waking hours Grade 4 - Completely disabled. Cannot carry on any selfcare.. Totally confined to bed or chair Grade 5 - Dead

8 How do you select the chemo? No tissue, no issue ER/PR, Her-2-neu status Side effect profile Preexisting neuropathy? Social circumstances Oral versus IV Financing? Targeted therapies? Genetics EGFR and KRAS testing

9 Understanding Chemo How do you write the orders for it? (BSA) What is the nadir and when does it happen? (When are we out of ammunition and need to reload) How do I easily find out about the recipe? What are those codes? What really is a cycle?

10 BC CANCER AGENCY se/default.htm

11 Approaching from a Different Route (Oral Chemo)

12 Oral Chemo Capecitabine (Xeloda) colon Chlorambucil Etoposide Temodol Cyclophosphamide (?)

13 Targeted Weapons

14 What are Targeted Therapies Herceptin Breast cancer Sutent, Nexavar, Torisel Renal cancer Tarceva Lung cancer Think of the rash! May indicate response. Try topical clindamycin 2% w hydrocortisone 1% bid. May need minocycline 100mg bid x 4 weeks.

15 How do genes help us? EGFR Epidermal growth factor receptor is sometimes overexpressed in NSCLC Erlotinib (Tarceva)) is an EGFR inhibitor and can have antitumor effect Especially in patients that have an activating mutation of the EGFR gene

16 KRAS Panitumumab, Cetuximab are other antibodies that work against EGFR, particularly in colon cancer. In studies, patients with non-mutated (wild-type) KRAS gene may have better benefit from these.

17 Herceptin Certain breast cancers only. Usually more aggressive tumors. Herceptin works as an antibody against HER2 Every 3 weeks for 18 cycles. Watch EF!

18 Hormonal treatments Tamoxifen Tamoxifen used in pre-menopausal setting Watch for risk of endometrial cancer DO PAPS! If abnormal bleeding, refer to gyne. Watch for clots Tried in melanoma?

19 Aromatase Inhibitor AIs = Arimidex, Aromasin, Femara, Faslodex Post menopausal patients. Treatment typically 5 years as well (controversial may last longer) Indefinate in metastatic setting. Watch for bone loss. Supplement with Ca and vit D. Bone density annually. Watch for hyperlipidemia.

20 Bisphosphonate Use in Bony Mets Zometa for bony mets (ex: prostate) Breast cancer patients sometimes receive Aredia (Pamidronate) Osteonecrosis of the jaw HINT: Patients sometimes think the bisphosphonate is their chemo.. They may tell you they received chemo.

21 What about prognosis? Will this increase my life expectancy? Visceral mets in breast cancer vs. bony mets Will this increase my quality of life?

22 The Constant Balance Disease versus treatment complications

23 Supportive Care Protocols Know what you are treating! Is it the mets,, obstruction, infection, chemo- induced? Use the protocols for management Ditto for chemo-induced arthralgias/myalgias (Gabapentin/Prednisone)

24 Peripheral Neuropathy We care if it is interfering with function (ex: can they button buttons, is their gait affected?) Stay warm Gabapentin may help May need recipe switch or dose reduction Dose of chemo may be based on grade

25 What is PPE? Palmar-Plantar Plantar Erythrodysesthesia Erythema,, swelling, pain, paresthesia, desquamation Bag balm, vaseline Pyridoxine mg daily

26 Nausea and Vomiting Goal is NO nausea or vomiting Antiemetics are based on emetogenicity of chemo Zofran 8 mg po day of chemo Dexamethasone 4 mg po bid x 3 days post and usually evening prior Metoclopramide 10 qid prn Lorazepam 0.5-2mg po/sl Haloperidol mg po

27 Chemotherapy Induced Diarrhea Grade based on # of stools, cramping (NCI criteria) Increase intake of clear fluids, BRAT (bananas,rice,apples,toast)) diet may help Loperamide 4 mg followed by 2 mg Lomotil 1-22 tabs q hrs Octreotide ug 150ug sc tid

28 Oral Mucositis Soft/extra soft toothbrush Plenty of fluids (2L/day) Antacid (Maalox) may provide be a temp coating agent Artificial saliva/ky jelly as lubricating agent Benzydamine (Tantum)) as topical analgesic Lidocaine,benzocaine as topical anesthetics May add fluconazole for fungal infection

29 Hypercalcemia Hypercalcemia may be associated with increased osteoclastic activity (bony mets) Increased calcium levels resulting from malignancy caused by a PTH-related protein is a second mechanism. This protein acts on the skeleton to increase bone reabsorption; ; it acts on the kidney to decrease excretion of calcium. The gene that produces this protein is present in many malignant tissues.

30 Get ECG. QT interval shortening is common, and, in some cases, the PR interval is prolonged. At very high levels, the QRS interval may lengthen, T waves may flatten or invert, and a variable degree of heart block may develop. Hydrate Pamidronate

31 Case A A 60 year old female who had breast cancer in 2007 now presents with extensive liver metastatic disease, poor performance status. Total bilirubin 241 with markedly raised liver enzymes. At first look, it seemed hopeless

32 Past History Breast cancer, MRM Oct Pathology: 3 cm tumour Grade 3 No axillary LN +ve/8 ER +ve PR +ve NO Adjuvant treatment

33 Current status Progressive weakness, yellow discoloration of sclera and skin, Clinical Exam. Severe Jaundice, liver cm under costal margin. ECOG p/s III U/S extensive metastatic disease in the liver, there was no intra or extra biliary dilatation reported.

34 Current status LAB: Bili jumped from 241 to 334 in 4 days ALP 186 ALT 250 GGT 850 CBC was normal

35 Current status Now she is with hepatic compromise, poor p/s what are the options? Chemotherapy Hormonal treatment Herceptin Supportive care

36 Chemotherapy Liver function is already compromised Performance status is poor We don t t have much time to waste Ideally, she needs urgent chemotherapy with Herceptin which will work quickly when compared to hormonal treatment alone

37 BUT When liver enzymes are up and bilirubin is >3 x normal, many chemo agents are contraindicated except Cisplatin,, Carboplatin and Gemcitabine. Due to poor p/s she was not fit for any of the above agents. Risk was > benefits

38 We are left with Anastrozole And Herceptin Her 2 neu Test was not available. She was started on Anastrozole on 6 th October Requested Her 2 neu test which takes at least 4 weeks to come back

39 Time is ticking From 2 nd to 6 th October bili rises from 241 to 334. On Anastrozole,, over 21 days bili rises from 334 to 464 Otherwise there was no other clinical change in patients status.

40 Is Anastrozole failing? No, its slow acting treatment need some more time to assess response. Actually, in this patient, it is slowing down the pace of rising biliuribin. Herceptin result was back - positive Herceptin was added with Anastrozole On 27 October

41 Post 4 th herceptin Billi was down from 464 to 93 Performance status improved from ECOG 3 to 2 Subjective feelings were improved. Now she was ready to add chemotherapy agent Taxol. Added on Jan 26th

42 Post 4 th herceptin Re assessment U/S was not able to detect any change in metastatic disease but it revealed biliary obstruction which was actually missed on base line u/s. ERCP detected biliary obstruction, stent put in Base line CT scan had shown extensive metastatic disease

43 Post 4 th Taxol/Herceptin CT depicts responsive disease! Current LFTs Normal Bili 13, ALKP 75, ALT 17, AST 25,GGT 44 P/S ECOG 1 Side effects mild to moderate neuropathy from paclitaxel. Plan Continue T/H, observe neuropathy and 3 monthly MUGA scan to monitor cardiomyopathy associated with Herceptin.

44 How do we know if it s s working? Tumor marker levels - occasionally helpful for tracking IF they were elevated in the past CA125 ovarian CA15-3 metastatic breast CA 19-9 pancreatic CEA colon LDH lymphomas/melanomas Alpha fetoprotein - seminomatous

45 How do we know if it s s working? CT imaging usually after cycle 2 or 3 Clinical impression Mixed responses

46 Peace Whether you in the woods or on the battlefield, always watch for peace. You know the real meaning of peace only if you have been through the war Kosovar

47 It isn't enough to talk about peace, one must believe it. And it isn't enough to believe in it, one must work for it. Eleanor Roosevelt