Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CASE 1: Management of metastatic disease in a resource-limited setting Dr Sitna Mwanzi Medical Oncologist Aga Khan University Hospital 22nd April 2016 Objectives • Case presentation • Diagnostic challenges • Treatment challenges Case Presentation • 35 year old female • 3 month history of cough, progressive difficulty in breathing and chest pain • Associated 5kg weight loss • On and off fever • Non smoker, does not take alcohol • Married with two children, home maker • No chronic illnesses • Reviewed at local hospital: • CXR as shown • Pleural removal done – suggestive of TB • Started on anti TB medication • No improvement after 1 month • Referred to tertiary hospital Review at referral hospital • • • • • Found to have large nodes in the armpit(axilla) CXR – persistent of pleural fluid Testing of fluid – positive for cancer cells Mammography – 3cm lump Ultrasound of abdomen – multiple liver metastases • Biopsy of lymph nodes – invasive ductal carcinoma, ER and PR positive, Her 2 negative Goals of treatment • Break ‘bad news’ – ‘I am afraid the news is not good……you have breast cancer……and it has spread to your lungs and liver…….’ • Manage symptoms – physical and psychological • Reduce disease burden to prolong survival and improve quality of life For this patient • Further tests – CA 15 -3 (tumor marker) – Blood count, liver and kidney function tests – ? Bone scan ? Role of PET/CT • Treatments – Palliative treatment (see overleaf) – Ongoing psychological support Palliative treatment June 2012 Jan 2013 April 2014 October 2014 March 2015 Jan 2016 • Pleural fluid drained; • 1st line chemo (ACx6) • Tamoxifen • Anastrazole • Exemestane and everolimus • 2nd line chemo (Xeloda) • 3rd line chemo (Docetaxel) Diagnostic Challenges • Similar symptoms to other diseases can delay diagnosis • Multiple tests required (x rays, CT scans, mammogram, bone scan, biopsy, blood tests) • Need for repeated testing during follow up Treatment Challenges • Multiple lines of treatment needed (good news and bad news) • Other modalities of managing symptoms – – – – – Fluid tapping Radiotherapy Bone modeling drugs Pain killers Psychological support • Cost of treatment • Side effects Treatment Challenges • Drug holidays • When to stop • Treatment closer to patient’s home • International referrals for metastatic disease Advocate for… • Patient and health care worker awareness – It could be cancer – Metastatic disease ≠ Death • Improved public and private health care facilities • Improve public private partnerships • Cancer drugs in the essential drug list • Increased cover by NHIF and other insurance companies