Download Top 10 Oncologic Knowledge Tips every palliative care provider

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