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