Download Management of metastatic disease in a resource

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