Download Palliative Care Delivery in South Trinidad

Dr Dylan Narinesingh and Team
Presenters : Dr P.Sylvester and Dr N.Bhim
PALLIATIVE CARE DELIVERY IN
SOUTH TRINIDAD
Outpatient
Palliative
setting
Inpatient
Inpatient setting
 Assess and treat symptomatically
 Family meeting concerning options for home
care vs hospice care
 Home care not feasible  referral to Hospice
 Family advised to visit place to meet health care
providers at the Hospice
 Then patient is transported from SFGH  Hospice
Outpatient setting
Zometa
DHF
Clinic
Paliative
care
clinic
Xeloda
Zometa
 Intravenous bisphosphonate
 Indicated for Rx with metastatic bone disease
 Multiple Myeloma
 Prevents SRE and relieves bone pain
 Administered every 4 to 5 weeks
Zsuzsanna Nagy : Zoledronic acid (ZOMETA) : a significant improvement in the treatment
of Bone metastases. Pathology and Oncology Research Vol 11, No 3, 2005.
Initial clinic visit for Zometa
 Counselling
 side effects
 Calcium supplements
 Monthly blood tests to review prior to administering (RFT’s
and Ca2+)
 Informing physician on dental procedures
 Severity of Bone pain
 Pain management according to the WHO Analgesic ladder
 Palliative radiotherapy @ NRC
http://www.zometa.com/dosing-and-administration/dosing-for-solid-tumours-and-multiple
myeloma/treat-every-3-to-4-weeks.jsp
Palliative Radiotherapy
 Patients referred to be assessed at National
Radiotherapy Centre on Tuesdays
 Clinical mark-up planning
 Radiation dose of 8Gy x 1 Fraction or 20Gy x 5
Fractions (administered to the area that gives
the patient the most pain)
Chow E, Harris K, Fan G : Journal of Clinical Oncology, Vol 25, No 11 (April 10), 2007: pp.
1423-1436
Palliative Xeloda clinic
 Indicated in Metastatic Colorectal Cancer 1 and
Breast Cancer2
 Initial visit
 Counseling patient on side effects and how to manage




them
Blood test to review before prescribing ( CBC, RFT,
LFT)
Vitamin B6 to be taken daily
Patients seen every 3/52
Reassessment after 3 cycles
1. http://www.xeloda.com/about/prescribed-for/mcrc
2. Blum JL, Jones SE, Buzdar AU, et al. Multicenter phase II study of capecitabine in
paclitaxel-refractory metastatic breast cancer. J Clin Oncol. 1999;17(2):485-493.
District Health Facilities
 Princes Town / Couva / Siparia
 Providing best supportive care
 Team effort comprising Physicians, Nurses
and counselors
 Provide education and counseling of Patient and
relatives
Paliative Care clinic
 Situated at SFGH outpatient Oncology Clinic
every 2/52
 Dr S. Chamely  Palliative care physician
 Patients receiving home care
Hospice care in South
Trinidad
 Soon to be established at Petrotrin Medical
Centre
ZOMETA AUDIT
Overview
 Audit period 10/7 (October 4th, 2011 to
October 19th , 2011)
 Inclusion Criteria
 Metastatic bone disease
 Duration of treatment with Zometa >3mths
 Total population approx. 100 patients
Demographics
 Sample size 34 patients: 28 males and 6
females
 Age Distribution:
Age
Group
<50
50-59
60-69
70-79
>80
No. of
Patients
0
6
11
15
2
%
0
17.6
32.4
44.1
5.9
Primary site of cancer
•Prostate
Breast
15%
Other
15%
•Breast
•Other
Prostate
70%
ZOLEDRONIC ACID AUDIT DATA
COLLECTION SHEET

Date:_____________

Name:__________________________________________________________________

DOB (age):

Gender: M F

Ethnicity:

Address:________________________________________________________________________________________________

Cancer Type: Breast Prostate Lung Colon/Rectum Kidney Lymphoma (HL/NHL)
Melanoma Brain Head & Neck Gastric Esophagus

Pancreatic

Other______________________________

Histology:________________________________________________________________________________

Date Diagnosed with Cancer:___________________________

Date Diagnosed with Bony Metastases:_________________________

Imaging Modality used for diagnosis: X-rays Bone Scan MRI CT

Site of Bony Metastates: Pelvis Spine (Cervical Thoracic Lumbar Sacral) Rib
Cage Skull Scapula Clavicle Femur Humerus Other____________________

Spinal Cord Compression (at time of diagnosis): Y N

RT administered for SCC: Y N
/ /
Black
Record No._____________
_____yrs
Asian
Liver
East Indian Caucasian
Cervix
Endometrial
Mixed_____________
Ovarian
Malignant
CUP

Bone Pains: Y N

Site of Bone Pains: ___________________________________________

RT administered for Bone Pain: Y

Receiving Palliative Chemotherapy/Hormonal Therapy: Y

Date Zoledronic Acid started:________________________________________________

Baseline Creatinine and Calcium levels:_______________________________________

Duration of Treatment (months):_____________________________________________

Date Zoledronic Acid Discontinued:__________________________________________

Reason for discontinuation: Renal Failure Hypocalcaemia Osteonecrosis of
Jaw Atypical Fracture
Other__________________

Did patient experience any adverse skeletal-related event (SRE) or hypercalcemia of
malignancy (resulting in admission) whilst receiving Zoledronic Acid: Y N

Specify:_________________________________________________________________

Dose Reduction of Zometa: Y

Reason for Dose Reduction: Renal Impairment
N
N
N
Other_________________________

Objective Improvement in Quality of Life

Compare Before and After Zoledronic Acid administered:

Describe in patient’s (and/or caregiver’s) own
words: _______________________________________________________________________

Objective improvement in mobility:

ECOG/Karnofsky/Lansky Performance Status Before Zoledronic Acid:______________

ECOG/Karnofsky/Lansky Performance Status After Zoledronic Acid:________________

Number of Doses/Cycles given before improvement noticed:_______________________

Objective improvement in bone pain (see NIPC rating scales):

Numeric Rating Scale Before Zoledronic Acid: _________________________________

Verbal Pain Intensity Scale Before Zoledronic Acid:______________________________

Numeric Rating Scale After Zoledronic Acid: __________________________________

Verbal Pain Intensity Scale After Zoledronic Acid:_______________________________

Number of doses/cycles of Zoledronic Acid given before improvement noticed:________
KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS
RATING (%) CRITERIA
Able to carry on
normal activity
and to work; no
special care
needed.
Unable to work;
able to live at home
and care for most
personal needs;
varying amount of
assistance needed.
Unable to care for
self; requires
equivalent of
institutional or
hospital care;
disease may be
progressing rapidly.
100
Normal no complaints; no evidence of disease.
90
Able to carry on normal activity; minor signs or symptoms of disease.
80
Normal activity with effort; some signs or symptoms of disease.
70
Cares for self; unable to carry on normal activity or to do active work.
60
Requires occasional assistance, but is able to care for most of his
personal needs.
50
Requires considerable assistance and frequent medical care.
40
Disabled; requires special care and assistance.
30
Severely disabled; hospital admission is indicated although death not
imminent.
20
Very sick; hospital admission necessary; active supportive treatment
necessary.
10
Moribund; fatal processes progressing rapidly.
0
Dead
ECOG PERFORMANCE STATUS
Grade
ECOG
0
Fully active, able to carry on all pre-disease performance without
restriction
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
2
Ambulatory and capable of all selfcare but unable to carry out any
work activities. Up and about more than 50% of waking hours
3
Capable of only limited selfcare, confined to bed or chair more than
50% of waking hours
4
Completely disabled. Cannot carry on any selfcare. Totally confined
to bed or chair
5
Dead
0–10 Numeric Pain Rating Scale
Duration of Treatment
12
10
8
No of patients
6
4
2
0
<6mth
6-12mths
13-18mths
19-24mths
>24mths
Dose reduction
Chart Title
Y
N
44%
56%
Spinal Cord Compression
Y
21%
N
79%
Bone Pain
Y
N
38%
62%
Improvement in pain scores
Percentage of patients
64.7%
23.5%
11.8%
Yes
No
No pain
Improvement in pain
 Average no. of doses before decrease in pain
noticed 2.5 doses
 Average decrease in numeric pain rating:
approximately 3.5pts
Improvement in mobility
Percentage of patients
55.9%
44.1%
Yes
No
Improvement in mobility
 Average no. of doses before change noticed:
2months
 Average increase in performance status by
ECOG Scale approximately 2pts
 Average increase in performance status by
Karnofsky Scale approximately 20pts
Skeletal Related Events
Nil adverse events
SRE
DISCUSSION
What is Zometa?
 Zometa (Zoledronic acid) belongs to a class
of drugs known as bisphosphonates.
 Zometa fights against skeletal destruction in
advanced tumours and multiple myeloma
Mechanism of action
Mechanism of action
 In addition to being a potent inhibitor of bone
resorption, Zometa also possesses anticancer
properties that could contribute to its overall
efficacy in the treatment of metastatic bone
disease
 Zometa is administered as an IV infusion
every 3-4 weeks in MM and advanced solid
tumours
SRE
 Skeletal Related events can shorten the
survival in patients with advanced prostate
and breast CA
Prostate CA
 49% of patients with advanced prostate Ca
and bone metastases will experience a SRE
within the first 2yrs
 Average time to first SRE is 10.7mths
 Average frequency of SRE was approximately
every 8 mths
Breast CA
 68% of patients with advanced breast Ca and
bone metastases will suffer a SRE within 2yrs
 The average length of time to first time SRE
was 7mths
 The frequency of SREs occur approximately
every 3mths
 In view, of data collected in audit thus far.
 At a cost of $2400.00TT per dose of Zometa
vs an average $1100.00TT per hospital bed
per night.
 How cost effective is the use of Zometa in
Palliative care in our setting?
References
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1. Coleman RE. Metastatic bone disease: clinical features, pathophysiology and treatment
strategies. Cancer Treatment Rev. 2001;27:165-176.
2. Lipton A, Theriault RL, Hortobagyi GN, et al. Pamidronate prevents skeletal complications and
is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases:
long term follow-up of two randomized, placebo-controlled trials. Cancer. 2000;88:1082-1090.
3. Saad F, Lipton A, Cook R, Chen Y-M, Smith M, Coleman R. Pathologic fractures correlate with
reduced survival in patients with malignant bone disease. Cancer. 2007;110:1860-1867.
4. ZOMETA Summary of Product Characteristics. Novartis Pharma AG.
5. Andre F, Slimane K, Bachelot T, et al. Breast cancer with synchronous metastases: trends in
survival during a 14-year period. J Clin Oncol. 2004;22:3302-3308.
6. Rosen LS, Gordon D, Kaminski M, et al; Zoledronic Acid Breast Cancer and Multiple Myeloma
Study Group. Long-term efficacy and safety of zoledronic acid compared with pamidronate
disodium in the treatment of skeletal complications in patients with advanced multiple myeloma
or breast carcinoma: a randomized, double-blind, multicenter, comparative trial. Cancer.
2003;98:1735-1744.
7. Kohno N, Aogi K, Minami H, et al. Zoledronic acid significantly reduces skeletal complications
compared with placebo in Japanese women with bone metastases from breast cancer: a
randomized, placebo-controlled trial. J Clin Oncol. 2005;23:3314-3321.
8. Aapro M, Abrahamsson PA, Body JJ, et al. Guidance on the use of bisphosphonates in solid
tumours: recommendations of an international expert panel. Ann Oncol. 2008;19:420-432.
9. Van Poznak CH, Temin S, Yee GC, et al. American Society of Clinical Oncology executive
summary of the Clinical Practice Guideline update on the role of bone-modifying agents in
metastatic breast cancer. J Clin Oncol. 2011;29:1221-1227.