ADVANCED CANCERS WORKSHOP

Transcription

1 ADVANCED CANCERS WORKSHOP CCOPE CANCER CARE OUTREACH PROGRAM ON EDUCATION

2 Declaration of Conflict of Interest I have received a grant-in-aid to provide the study drug dexmedetomidine for an investigator led trial November 2012 to 2014 from Hospira Healthcare Corporation.

3 Case: Breast Cancer Learning Objectives: 1. Describe the role of the primary care physician along the advanced cancer care continuum and recognize how this relates to the roles of other healthcare providers, including specialists 2. Describe common treatment options and their expected side effects 3. Access available resources for palliative care

4 Case Scenario: Mrs. Jenny Dalewood Jenny is a 35 year old woman who presented to your office because she had found a lump in her right breast. Lumpectomy and sentinel lymph node biopsy revealed a Stage IIa right breast invasive ductal carcinoma with a 3cm grade 3 primary tumour, estrogen receptor (ER) negative, progesterone receptor (PR) negative, HER-2/neu negative with clear surgical margins and 0/6 sentinel nodes involvement. Staging investigations including a CT of the chest, abdomen and pelvis were negative for metastatic disease.

5 Case Scenario: Due to having high grade disease and being triple receptor negative, Jenny is told by her oncologist that she has a 43% chance of recurrence in the next 10 years which could be reduced to 19% by adjuvant chemotherapy. She receives adjuvant chemotherapy with the FEC-D protocol* followed by adjuvant radiotherapy to the right breast with a boost to the tumour bed. Your patient is otherwise healthy with no allergies. She and her husband, Rick, have no children as her husband is infertile.

6 Mrs. Jenny Dalewood 1. Jenny has been discharged following treatment. She is anxious about her cancer coming back and asks you what she should be looking for and how often she should come in for follow-up?

7 Case Progression: Two and a half years later Jenny develops minor neck pain on the right side. She comes in to see you about what she thought was a muscle strain, but on examination you find a lump in the right supraclavicular fossa that feels firm and is tender to palpation. 2. What are your next steps? What do you tell your patient?

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9 Case Progression: You sent her to your local surgeon who excises the lump. Pathology shows metastatic adenocarcinoma compatible with breast adenocarcinoma. Jenny has made a follow-up appointment to see you. She tells you that she does not have an appointment with the surgeon for 3 weeks because her surgeon is away on holiday. Jenny continues to have pain in the right supraclavicular region which now radiates down the right arm. She has been taking some Tylenol #3 that she had left over after some dental work. Jenny is hoping that you have the pathology results. 3. What do you share with Jenny?

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12 Mrs. Jenny Dalewood 4. Does she need just localized treatment with palliative radiotherapy or are there more widespread metastases requiring palliative chemotherapy for treatment?

13 Case Progression: The CT scan shows a conglomerate mass of nodes measuring 1.5 x 2.5 cm at level IV in her right neck, as well as several smaller abnormal looking nodes. The remainder of the CT scan and bone scan is negative for metastatic disease. Jenny arrives for her follow-up appointment with her husband, Rick. You have set aside extra time to give the bad news and asked your secretary that you not be disturbed during the appointment. Following the SPIKES protocol, you inform them of the diagnosis and suggested approach. It is good that the recurrence is localized. For that reason you will arrange an appointment with a radiation oncologist. He recommends that Jenny undergoes a course of radiation; but that this is unlikely to completely eradicate all of her disease in her neck and that she retains a high risk of developing additional recurrence in the future. 5. What should you discuss at your next appointment with Jenny?

14 Mrs. Jenny Dalewood Jenny agrees that her husband Rick would be her alternate decision maker, but she appears anxious, and wonders why you are asking. She says she wants everything done: I want to live. In response, you say it is your responsibility to ask about what your patient s wishes would be if they were suddenly in an accident or dying. You reassure her that she is not dying now, but if she was in the future and unable to make her own decisions, has she discussed what her wishes would be with her husband? Jenny says she doesn t like to talk about these things and that you are making her nervous. You provide her and her husband with a copy of the My Voice booklet and tell her that when she is ready, the first half of the book is to help with the discussion.

15 Case Progression: A course of palliative radiotherapy 50Gy in 20 fractions to the right cervical and supraclavicular nodes was administered over 5 weeks. There was some shrinkage of palpable nodes in her neck and some improvement of neuropathic pain in her right arm. Two months later you see Jenny with complaints of pain in her right upper back and shoulder area radiating into her neck. It is again radiating down her right arm. The pain is achy and everything feels tight, rated 4-7/10. Applying pressure on several areas helps, as does the use of heat or ice. Tylenol #3 gives minimal relief for up to an hour. Jenny has been unable to work for the last week. 6. What are your next steps?

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18 Case Progression: One week later Jenny s pain is better controlled but her lymphedema is becoming worse. Currently she is taking MS-IR 10 mg 5 times a day and breakthrough doses of 5mg twice a day along with gabapentin 300 mg tid. Pain is still radiating into her right arm, but not as severe. She is having nausea, abdominal cramps and has not had a bowel movement for 4 days. 7. What are your next steps?

19 Case Progression: One week later you see Jenny. Her pain and nausea are less, but she again has not had a bowel movement for 4 days. She says she can t tolerate the sennosides because of severe cramping. You remember that she has a history of irritable bowel syndrome. 8. What do you recommend now?

20 Case Progression: One and a half months later Jenny comes to the ER in pain crisis. The ER doctor notes marked swelling of her right arm. She has difficulty lifting the arm due to swelling and pain. She is tearful and cannot sleep because of the pain. For pain the ER Doctor doubles her M-Eslon 60 mg bid and MS-IR 5 mg every hour (fifteen times in the last 24 hours). She has noticed that she is a bit twitchy. A CT scan has been booked by her oncologist in another month to assess for response to palliative capecitabine. 9. What would you do now?

21 Case Progression: While in hospital, pain and swelling are still not well controlled. She is depressed and anxious. You ask that the medical oncologist see her in follow-up. In addition you start her on nortriptyline 10 mg qhs and over the next few days increase it to 30 mg qhs to see if this will help with her sleep and neuropathic pain. When she was admitted, she stated that she wanted full resuscitation and everything done. You ask if she has had a chance to discuss her wishes with her husband. She again says, I want to live. You write a progress note that the patient wishes full treatment and resuscitation. Your patient is started on palliative cisplatin and gemcitabine. Her pain and swelling in her right arm start to improve. She is sleeping better and less anxious and depressed. You are now managing her pain with hydromorphone SR 30 mg bid and Hydromorphone IR 6 mg q1h prn along with gabapentin 600 mg tid and nortriptyline 30 mg qhs.

22 Case Progression On follow-up in the office 3 months later, you are amazed that your patient is now again able to use her right arm and the lymphedema has now almost totally resolved. She has been tolerating the cisplatin and gemcitabine well. She no longer needs to take any breakthrough hydromorphone. However she is quite drowsy and her husband is concerned that she is sleeping most of the day. He also asks whether it is still necessary to continue the dalteparin injections every day. Although she has 80% coverage through extended benefits, it still costs her and her husband $300 per month. 10. What do you think is the problem? What are your next steps?

23 Mrs. Jenny Dalewood Medication side effects are causing the drowsiness: You reduce her gabapentin from 600 mg tid to 300 mg tid You reduce her hydromorphone SR to 24 mg q12 h with a corresponding reduction in hydromorphone IR to 4 mg q1h prn Over the next weeks you are able to gradually taper your patient off gabapentin, discontinue her nortriptyline and drop her hydromorphone dosage down to 12 mg PO bid before she again was requiring some breakthrough hydromorphone at a dose of 2 mg q1h prn

24 Case Progression: Over the next 6 months, your patient continues on cisplatin and gemcitabine and continues to do well. She was able to take a holiday by the lake in the Okanagan with her husband. However, now she comes in complaining of numbness and burning pain in her feet that is keeping her awake at night. Her oncologist has dose reduced her cisplatin by 20% at her last visit. 11. What do you think is the cause and what do you recommend?

25 Case Progression: The oncologist stops the cisplatin and carries on with single agent gemcitabine for another several months. Unfortunately, pain and swelling are again increasing in the right arm. The pain in the right arm is burning and feels like sharp needles and jabs. Despite increasing her hydromorphone back up to 30 mg bid, your patient is again requiring 5 or 6 breakthrough per day. Increasing the gabapentin further just made her drowsier. 12. What do you recommend now?

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27 Mrs. Jenny Dalewood Over 3 weeks she is rotated from hydromorphone to methadone at a dose of 10 mg q8h with hydromorphone 4 mg PO qid prn for breakthrough, requiring 0 to 2 breakthrough doses per day. Gabapentin was reduced to 300 mg tid and Nortriptyline was able to be discontinued. Both the neuropathic pain in her right arm and her peripheral neuropathy pain are improved. She is less drowsy and able to sleep well. She is able to go shopping for up to 5 hours and to enjoy going out for dinner with friends and with her husband.

28 Case Progression: Her oncologist has switched your patient from single agent gemcitabine to single agent vinorelbine. Three months later she comes in to see you, again with increased pain in her right shoulder and arm, but now also with right sided headache. For her right shoulder and arm pain, her pain specialist has increased her methadone to 12.5 mg q8h. Breakthrough hydromorphone does not seem to help. Ibuprofen 800 mg helped her headache. On exam there was noted to be palpable spasm of her right para-cervical muscles and trapezius. Full right lateral flexion of the neck was accompanied by pain radiating into the right arm. There was good range of motion of the right shoulder. She asks you about acupuncture. 13. What would you do now?

29 Case Progression: Your patient returns in several days with migraine headaches with nausea and vomiting. She experienced some photophobia. Also she noticed more difficulty walking, but did not have any falls. The CT scan is booked for next week. 14. What would you do now?

30 Case Progression: The CT scan shows a 2-3 cm mass in the right cerebellar hemisphere with a moderate amount of edema and displacement of the 4th ventricle. As well there are smaller lesions in the left cerebellar hemisphere, right occipital lobe and both frontal lobes. 15. What are the next steps?

31 Mrs. Jenny Dalewood Right cerebellar tumour was resected and pathology was consistent with metastatic breast cancer ER negative, PR negative and HER-2/neu negative. She received 10 fractions of palliative whole brain radiotherapy. She decided not to resume Vinorelbine. Dalteparin had been held while in hospital, but restarted postoperatively. She is now on a tapering dose of dexamethasone at 4 mg bid, methadone 15 mg q8h, hydromorphone 8 mg q1h prn for breakthrough, gabapentin 300 mg tid, venlafaxine XR 75 mg daily, rabeprazole 20 mg daily.

32 Case Progression: For several months your patient did well but she now presents to the emergency department with severe neck pain and new weakness and numbness in her right arm. She is admitted to the hospital s palliative care unit where her pain is managed with an increased dose of methadone and dexamethasone. An MRI of the spine shows abnormal changes within the central cervical and thoracic spinal cord between C4 and C7 and T2 to T5. Nodular changes affecting the distal spinal cord are suspicious for leptomeningeal metastases. While you are visiting her, she tells you that she has been offered more palliative radiotherapy. She and her husband ask you how much time you think she has left and whether or not you recommend radiation therapy? 16. What would you tell them?

33 Case Progression: After your discussion with your patient and her husband, they decide not to go ahead with palliative radiotherapy and opt for just comfort measures. 17. Is there anything else you should discuss?

34 Case Progression: Unfortunately, Jenny goes on to develop complete paralysis of both lower extremities and required a Foley catheter for urinary incontinence. She no longer wishes hospital care, including intravenous fluids and medication, and is transferred to hospice where she gradually declined. For the last few days she was non-responsive and died peacefully, 4 1/2 years after her initial diagnosis. You send a card expressing your condolences to her husband. You take some time to reflect on what a journey that Jenny and her husband have had over the past 5 years. Initially there was surgery, then chemotherapy and radiotherapy, more radiotherapy, palliative chemotherapy, neurosurgery and more radiotherapy.

35 Rick Dalewood The husband Rick, who is also your patient, comes in two weeks later having trouble sleeping. 18. What do you do?

36 Rick Dalewood Rick agrees to be contacted by a hospice volunteer. He thanks you for all that you have done for his wife over the last 5 years and that he could not have done it otherwise.

37 QUESTIONS?