Transcript Palliative Care for Breast and Cervical Cancer

Palliative Care for Breast and
Cervical Cancer
Dr Esther Cege Munyoro
Head, Pain and Palliative Care Unit
Kenyatta National Hospital
•Kenya's tertiary referral
hospital-it houses the
Nairobi University medical
school and the KMTC
•Has a bed capacity of
about 2000
•At any one time we have
about 3000 patients.
•The hospital has a heavy
chronic diseases and
cancer burden due to
various reasons.
Palliative Care
• The current WHO Definition states:
“Palliative Care is an approach that improves
the quality of life of patients and their
families facing problems associated with lifethreatening illness, through the prevention
and relief of suffering, the early identification
and impeccable assessment and treatment of
pain and other problems, physical,
psychosocial and spiritual.” (WHO 2002)
What is Quality of life
...….an inverse relationship between the
expectation of an individual and the actual
situation in which they find themselves. The
smaller the gap between the two, the better
the quality of life.
Calman(1984)
Increasing quality of life
The Calman gap: quality of life deficit
Hopes and Aspirations
Modified expectation
GAP
Improved circumstances
Reality
CONSULTATION TIME
TIME
5
Conceptual Shift for Palliative Care
Life Prolonging Care
Medicare
Hospice
Benefit
Life Prolonging
Hospice Care
Care
Palliative Care
illness
Death
Old
New
Measurement QOL; Four Core Domains
• Psychological
 Depression
 Anxiety
 Adjustment to disease
• Social
 Personal and sexual relationships.
 Engagement social and leisure
activities.
 Stigma
• Occupational
 Ability and desire to carry out paid
employment.
 Ability to cope with household
duties.
• Physical
 Pain ,mobility , sleep
 Appetite and nausea
 Sexual functioning.
ADVANCE DISEASE
• As with most incurable cancers, pain control is
the dominant issue and must be addressed.
Judicious use of narcotics, radiation, and
nonnarcotic pain remedies is essential.
• More effort needed to increase availability of
all modalities of pain management country
wide.
FACTS ABOUT CERVICAL CANCER
Women should not die of cervical cancer...but
they do. Most cases of cervical cancer are
preventable and, if caught early are highly
curable. Despite this, cervical cancer is the
second most common cause of cancer death in
women worldwide. Unfortunately,
cure is less likely when the disease is diagnosed
at an advanced stage as is common in Kenya.
Complications of cervical cancer
• Complications of cervical cancer can occur as a side effect
of treatment or as the result of advanced cervical cancer.
• Early menopause
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hot flushes
vaginal dryness
loss of sex drive
mood changes
stress incontinence (leaking urine when you cough or sneeze)
night sweats
thinning of the bones, which can lead to brittle bones
(osteoporosis)
Narrowing of the vagina due to Radiotherapy
• two main treatment options. The first is to apply hormonal
cream to your vagina. The second is to use a vaginal dilator,
which is a tampon-shaped device made of plastic. Many
women find discussing the use of a vaginal dilator
embarrassing, but it's a standard and well-recognised
treatment for narrowing of the vagina.
Lymphoedema
• If the lymph nodes in your pelvis are removed, it can
sometimes disrupt the normal workings of your lymphatic
system.
• This can cause certain body parts to become swollen – usually
the legs, in cases of cervical cancer.
• There are exercises and massage techniques that can reduce
the swelling. Wearing specially designed bandages and
compression garments can also help.
• Sexual dysfunction is a common
• It may persist after treatment is completed, but
sexual assessment and/or counseling are not
routinely provided.
• One study found that 78% of the women wanted to
discuss sexual matters but did not ask questions
because they feared rejection or thought the setting
was inappropriate for such discussion.
• This finding indicates that discussion about sexual
functioning would be welcomed by patients if
conducted in a sensitive manner.
Advanced cervical cancer
Pain
If the cancer spreads into your nerve endings,
bones or muscles, it can often cause severe pain.
BleedingIf the cancer spreads into your vagina, bowel or
bladder, it can cause significant damage, resulting in
bleeding. Emergency radiotherapy is sometimes
needed to control the bleeding
Kidney failure
In some cases of advanced cervical cancer, the
cancerous tumour can press against the ureters,
blocking the flow of urine out of the kidneys.
• Ureteral obstruction secondary to
malignancy presents a distinct
and challenging management
scenario for the urologist.
ureteral stents and percutaneous
nephrostomy tubes (PCN) are the
treatments available locally
Vaginal discharge
• Another uncommon, but distressing,
complication of advanced cervical cancer is an
unpleasant-smelling discharge.
• Treatment options for vaginal discharge
include an antibacterial gel called
metronidazole and charcoal. Charcoal is very
effective in absorbing unpleasant smells.
BREAST CANCER
• According to statistics by the Kenya Network of
Cancer Organizations, breast cancer is now the
leading cancer in women in Kenya (34 per
100,000), followed by cervical cancer (25 per
100,000). Global statistics indicate that 1 in every
8 women will be diagnosed with breast cancer in
their life time.
Questions asked
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Why did God do this to me.
Why are my children not looking after me.
Will I ever be able to work again.
Why did the Doctor tell me to go home yet I am
worse off then when I came to hospital.
• Why is my Arm swelling, Why does it have no
feelings, why can I not move my fingers.
LYMPHOEDEMA
• About 1 in 5 people (20%) will have
lymphoedema of the arm after breast cancer
• If no treatment is given for the lympoedema it
will get worse. It can be painful and over time
it gets difficult to move the arm.
• Important to send the patients to a trained
physiotherapist and support them as they deal
with the problem.
DEALING WITH BODY IMAGE
• Many women with
breast cancer also find
themselves dealing with
changes in their
appearance as a result
of their treatment.
Body image after breast cancer treatment
• Some changes may be short term, such as hair
loss. But even short-term changes can have a
profound effect on how a woman feels about
herself. A number of options are available to help
women cope with hair loss, including wigs, hats,
scarves, and other accessories.
• Other changes are more permanent, like the loss
of part or all of a breast (or breasts) after surgery.
Some women may choose breast-reconstructionafter-mastectomy while other chose breast forms.
Driving good ideas into practice:
• The makings of a nurse-led Stoma, Wounds
and Continence Clinic at a referral hospital in
Kenya
• “Good ideas are not adopted automatically.
• They must be driven into practice with
courageous patience.” Hyman Rickover
Elizabeth English as she donates a trolley to wheel stoma, wounds and continence
supplies around the hospital. In the picture are members of the Palliative Care
Team with Elizabeth: (l to r) Ann Mwangi, Catherine Abour, Esther Munyoro,
Jane Ndungu, Elizabeth English and Grace Wanyoike
Research important
• REDUCING BARRIERS TO CANCER TREATMENT
COMPLETION; THE KENYATTA NATIONAL
HOSPITAL AND AMERICAN CANCER SOCIETY
INITIATIVES.
• Study aimed in understanding the current level
of patients’ access to:
– Transportation,
– Lodging and
– Treatment literacy resources
• Data collection from 28th July 2015 to 10th
September 2015
Missed/delayed treatment
• Survey data showed that 29% of patients had
missed or delayed treatment and indicated
the most significant barriers to care included:
Money to pay for treatment
Money to pay for transportation to treatment
Accommodations once in Nairobi
What patients value the most while
accessing treatment at KNH
• Getting help about where to go for each
service within the hospital
• Getting answers about their disease, the
treatment and side-effects
• Getting help with transportation from their
permanent home outside Nairobi city (to and
from the hospital)
Biggest challenges in accessing care
• Being hungry and thirsty throughout the day
• Waiting for a long time to be seen
• Not having a place to rest throughout the day
Patient Navigation
• Formation of a Supportive Cancer Care
committee that is multidisciplinary.
• Website- Data collected discussion on
design
• Patient held records-Have approval for
trial with 100 patients
• Patient flow mapping- to be done later in
the year
• Information desk- already setup by CTC
• Navigators- Waiting bay now in CTC that
has an Oncology Nurse in charge
Patient Hostel
• The hostel will be within KNH grounds
• It will house 60 patients and have a day respite
for other cancer patients who just need to
refresh themselves.
• It will have a resource center for patients to get
information.
• The Pain and Palliative Care Unit will be
housed in the hostel.
• The hostel will have revenue generating ability
so that patients can get support without extra
financial burden.
Hostel Design
OUR GOAL
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