Top 10 Oncologic Knowledge Tips every palliative care provider
Download
Report
Transcript Top 10 Oncologic Knowledge Tips every palliative care provider
+
Top 10 Oncologic
Knowledge Tips every
palliative care provider
should know
Dr. Deb Harrold
June 2015
+
Disclosures
I have no conflict or disclosure to make for this presentation
+
Palliative Care is NOT All
about Cancer Care
……however…..
+
MANY MANY MANY new
advances in cancer care
”chronic” cancer patients
metastatic cancer does not equal DEATH
anymore
+
BRAIN
Which cancers
metastasize here…..
+
BRAIN
Which cancers metastasize here?
Melanoma
Lung – small cell>>>non-small cell
Breast
Renal
+
Brain
Remember Brain Cancers (ie. Glioblastoma, astrocytoma etc)
USUALLY do NOT metastasize elsewhere
+
Leptomeningeal
Say what?
+
Leptomeningeal
Disease
Say WHAT?
Cancer seeding of the meninges
+
Leptomeningeal Disease
Presents as dysfunction of cranial nerve or nerve root
Can happen anywhere in the meninges – therefore brain and
spinal cord
Most common with breast (lobular), lung, melanoma, GI and
lymphoma/leukemia
Diagnosis with MRI or CSF positive for malignant cells
Treatment – whole brain or spinal cord radiation, intrathecal
chemotherapy
Predictor of very poor outcome
+
Lung
Pathology!
+
Lung
Pathology…
Non- small cell lung cancer (adenoCA, squamous cell CA…)
and small cell lung cancer are VERY different
Offer/Advise to determine pathology early in disease
Bronchoscopy – biopsy or washings
Thoracic surgeon for thoracotomy or mediastinoscopy and biopsy
+
Non-Small Cell Lung Cancer
Median Survival = 59mo for stage 1A, 4mo for stage IV
Radiation sensitive
May receive radiation and chemotherapy
Mets often to bone
Location, location, location…..
Periphery = pain
Central = increase risk SOB, hemoptysis, SVC
Mediastinal nodes = increase risk of SVC
+
Small Cell Lung Cancer
Median Survival = limited stage 15-20 mo, extended stage 813mo
Highly Chemo-sensitive
Metastasizes to brain – may receive whole brain prophylactic
radiation! (don’t always assume they have a met already!)
May receive chemo and radiation
Location, location, location….
+
Bone
Which cancers
metastasize here…
+
BONE
What cancers metastasize here?
The RULE OF TWOs!
Breast, lung, thyroid, prostate, renal…oh and testicular, cervical,
and GI/colorectal!
Most common location
SPINE, pelvis, ribs, skull, upper arm and upper leg
NOTE –not in periphery!!! And not in the joints!!!
Diagnose with a bone scan and plain x-ray
Lytic lesions may not show up as well on bone scan
Multiple myeloma
+
Bone
Metastasis
Treatments
+
Bone
Metastasis
Fracture
Pain
+
Bone Metastases
Treatment
NOT necessarily NSAIDs
Nociceptive – use the WHO Ladder
Bisphosphonates
Clodronate (bonefos), Pamidronate (Aredia), Zoledronic Acid
(Zometa)
Evidence for prophylactic use AND decrease the risk of pathologic
fracture in Breast, Prostate, Myeloma
Used in many other cancers with mets to bone for decrease
complications and pain management
Denosumab
Monoclonal antibody inhibiting bone resorption
better outcomes (than Zoledronic Acid), higher cost
+
Bone Metastases
Treatment Continued
Radiation
External beam and systemic radiation
Single or multiple fractions – usually intense/brief
Decreases risk of pathologic fracture (long bones/vertebrae)
Watch for pain flare 7-10days peaks
Side effects (later in presentation)
Effective pain control x weeks or months
Hormonal Treatment
Surgery
Stabilization
Vertebroplasty/kyphoplasty
+
GI/GU
Neuropathic pain and
bowel obstruction
+
GI/GU
Neuropathic Pain
+
GI/GU
Bowel Obstruction
+
Hypercalcemia
…not always in the bones!
+
Hypercalcemia
…not always in the bones
Bone disease/destruction
Hyperparathyroidism
Paraneoplastic Syndrome
+
Hypercalcemia
Presentation/Treatment
Bones, Stones, Moans, Groans
Bone pain
Kidney stones (renal calculi)
Abdominal pain (moans)
Psychiatric groans (delirium)
Bisphosphonates
IV usually
Need consent!
+
Radiation and
Chemotherapy
Trials and
palliative treatment
+
Radiation and Chemotherapy
Trials and palliative treatment
Too aggressive???
Can always TRIAL it…don’t have to finish what you started
Palliative Radiation
SVC, spinal cord compression = oncologic emergencies
Pain control, wound control
Prophylaxis – obstruction of viscera (lung/bowel/ureter…etc)
Life extension – less convincing
Palliative Chemotherapy
Symptom control – less convincing – maybe small cell lung
Life Extension
Remember Brain CA (glioblastoma etc) – oral chemotherapy seems to
improve QofL
+ Palliative Radiation and
Chemotherapy CAN be
indicated in Hospice Resident
+
Radiation
101
+
Radiation
101
External beam, systemic/isotopes, implanted???
Side effects
Pain Flare – peaks 7-10d
Nausea – brain and GI/GU
Fatigue – brain and large area
Bowels – diarrhea and bleeding – GI/GU
Skin rash – location of beam and intensity
Bone marrow suppression – rarely – need large area (pelvis)
+
Chemotherapy
101
+
Chemotherapy
101
MANY regimes – NONE are equal!!!
Side effects
Tumor Lysis syndrome
Blood dyscrasia
Anemia
Neutropenia
Febrile neutropenia
Thrombocytopenia
Nausea/Vomiting
Diarrhea/Constipation
+
Questions?
[email protected]