combined modality multidisciplinary approach to cancer treatment

7/27/2019 Combined Modality Multidisciplinary Approach to Cancer Treatment

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COMBINED MODALITY

MULTIDISCIPLINARY APPROACH TO

CANCER TREATMENT

Dr. Villa

January 20, 2014

Group 4

Basic principle in therapy:

To cure the disease

To control the disease

To palliate the patient’s symptoms with

minimum functional and structural impairment

Major Disciplines in the Management of Cancer

Surgery - qualified surgeons

Radiotherapy- qualified radiooncologists

Chemotherapy/ Hormonal Therapy/

Immunologic Therapy - qualified

internists/medical oncologists (i.e. adult

patients)

Current Anti-Cancer Approaches

Surgery Remove known tumor/masses

Chemotherapy Kills rapidly dividing tumor

cells

Radiation therapy Kills rapidly dividing tumor

cells (local treatment, no systemic effect)

Targeted therapy Specifically inhibit required

process in tumor cell growth

SURGERY

Most of the time, lobectomy is done to ensure

that the entire tumor and its circulation is out.

In patients who cannot tolerate having a lung

removed, no matter how small the tumor is,

surgery is not advised. Especially for female non-

smokers.

RADIATION THERAPY

Destruction of cancer cells using ionizing

radiation

Supplementary surgery and palliate pain (in bone

metastasis)

Complications: skin reactions, mucositis,

hoarseness of voice, hypothyroidism, low

blood counts, lung fibrosis, heart

complications, secondary cancers

A primary treatment

Before surgery to shrink a tumor

After surgery to eliminate any remaining cancer

cells To treat cancer that has spread to other areas of

the body

Types of Radiation

External Beam Radiation Therapy (EBRT):

delivers high doses of radiation to lung cancer

cells from outside the body, using a variety of

machine-based technologies.

High Dose Rate(HDR) Brachytherapy (Internal

Radiation): delivers high doses of radiationfrom implants placed close to, or inside, the

tumor(s) in the body

Advantages of EBRT

Accurately targets a tumor with higher doses

of radiation, while minimizing damage to

healthy lung tissue and nearby organs. As a



result, EBRT helps to lower the risk of side effects

typically associated with radiation treatment

for lung cancer, such as difficulty breathing or

heart damage

Some additional advantages of external beam

radiation therapy include:

- fast, painless outpatient procedure- does not carry the standard risks or

complications of surgery, such as surgical

bleeding, post-operative pain, or the risk of

stroke, heart attack, blood clot and external

treatment

- unlike chemotherapy, which circulates

throughout the body, ERBT is targeted to the

area being treated

CHEMOTHERAPY

Drug treatment to kill fast-growing cancer cells

- acts on DNA, RNA or proteins of signal

transduction

Examples: Capecitabine(Xeloda), Doxurubicin,

Oxaliplatin, Paclitaxel

Effects: systemic in nature

- Side Effects: low blood counts, nausea/vomiting,

alopecia, local reactions, mucositis, cardiotoxicity

etc.

Cell Cycle

Tumor Growth Kinetics

Tumor cell growth is logarithmic

Mechanism of Action

Most chemotherapeutic drugs work by impairing

mitosis (cell division), effectively targeting fast-

dividing cells

Cell Kill

Only a percentage of the cancer cells are killed

with each course of chemotherapy. Therefore,

repeated doses – or cycles of chemotherapy

must be done.

Tumor growth is exponential and kills constant

fraction of tumor cells.

Sites of Action of Cytotoxic Agents

Manner of Administration

1. Adjuvant therapy Cure

2. Neoadjuvant therapy R0 resection, Cure

3. Palliative Control, Quality of Life



CLASSIFICATION of CHEMOTHERAPY DRUGS

CYCLE SPECIFIC

● Antimetabolites

interfere with nucleic acid synthesis

attack during S phase of life cycle

Examples: Cytatabine, Floxuridine,

Fluorouracil, hydroxyurea,methotrexate, thioguanine

● Enzymes

useful only for leukemias

Example: Aspariginase

● Plant Alkaloids

cycle specific to M Phase

prevent mitotic spindle formation

Examples: Vinblastine, Vincristine

CYCLE NON-SPECIFIC

● Alkylating Agents

disrupt deoxyribonucleic acid(DNA)

Example: Carboplatin, Cisplatin,

Cyclophosphamide, Thiotepa

● Antibiotics

bind with DNA to inhibit synthesis of

DNA and RNA -Examples:

Bleomycin, Doxorubicin, Idarubicin,

Mitomycin, Mitoxantrone

TARGETED THERAPY

Personalized treatment

Understanding the biology of the tumor helps

the treatment regimen. Treatment is patterned

to the behavior of the tumor or to the direct

mutation it undergoes.

The Target

Epidermal Growth Factor Receptor

Genotype analyzes the pathway involved to

identify what part of the growth process has a

problem

Target drugs are patterned according to the defect in

the pattern

Can be monitored properly by PET scan and to check

for proper response

Target Drugs:

- improves the outcome of the treatment

- Selective and not cytotoxic, patient

friendly

- Usually infused for 30mins

HER1/EGFR signalling increases VEGF ( Vascular

Endothelium Growth Factor) and matrix

metalloproteinase levels



Lung Cancer Mutation Consortium:

Single Driver Mutations in NSCLC

Mutation found in 54% of tumors completely tested.

EGFR Expression

Immunohistochemical staining is used to check

for EGFR expression.

Targeted Agents

Drug

Classification

Targeted Agent Target

Receptor

Tyrosine

Kinase

Inhibitor

Gefitinib

(Iressa)

Eriotinib

(Tarceva)

TKI

TKI

The patient must be positive for mutation to use

these two drugs. They are very expensive.

The most common side effect of Tarceva is rash.

Advise patient to use sunblock and protective

devices.

The more rash there is, the better the response

to the drug.

Any tumor beyond 3mm cannot grow without a

blood supply. They make their own blood vesselsby secreting VEGF (Strong compound produced

by the tumor that encourages the formation of

new blood vessels). This is the target of

Bevacizumab and Avastin (anti-VEGF).

HANDLING COMPLICATIONS of CHEMOTHERAPY

Alopecia

hair loss that occurs as chemotherapeutic drugs

destroy the rapidly growing cells of hair follicles

may be minimal or severe

occurs 2 to 3 weeks after treatment begins -

almost always temporary

Signs & Symptoms:

- hair loss that may include eyebrows, lashes, and

body hair

Interventions

minimize shock and distress by warning the

patient of this possibility

discuss with the patient why it occurs describe to the patient how much hair loss to

expect

emphasize to the patient the need for

appropriate head protection against sunburn

*very sensitive

inform the patient that new hair may be a

different texture or color

give the patients sufficient time to decide

whether to order a wig or to opt for other

measures

inform the patient that his scalp will becomesore at times due to follicles swelling

Anemia

occurs as chemo drugs destroy healthy cells and

cancer cells

RBCs are destroyed and can’t be replaced by the

bone marrow not able to recover



Signs & Symptoms:

dizziness, fatigue, pallor, and shortness of breath

after minimal exertion

low hemoglobin level and hematocrit

may develop slowly over several courses of

treatment

not automatic

Interventions:

monitor hemoglobin level, hematocrit, RBC

count; report dropping values

be prepared to administer a blood transfusion or

erythropoietin (usually for patients who do not

want to receive blood products eg Jehovah’s

witnesses)

Preventive Measures:

instruct the patient to take frequent rests,

increase his intake of iron-rich food, and take amultivitamin with iron as prescribed

if the patient has been prescribed a drug such as

epoetin, make sure he understands how to take

the drug and what adverse effects he should

watch for and report

Diarrhea

occurs because the rapidly dividing cells of the

intestinal mucosa are killed

Complications: weight loss, F & E imbalance,

malnutrition

Signs & Symptoms:

increase in the volume of stool compared with

the patient’s normal bowel habits

Interventions:

assess frequency, color and consistency of stool

encourage fluids; give IV fluids and potassium

supplements as ordered

advise patients not to take any medications like

Loperamide. We have to remember that the

patient has just been given chemotherapy andsometimes it is just an infectious diarrhea.

Extravasation

inadvertent leakage of a vesicant solution into the

surrounding tissue

capable of burning or causing necrosis of skin and

surrounding tissues.

Signs & Symptoms:

initial signs and symptoms may resemble those of

infiltration: blanching, pain, and swelling

symptoms possibly progressing to blisters; to skin,

muscle, tissue and fat necrosis; and to tissue

sloughing

Blood return is an INCONCLUSIVE test &

shouldn’t be used to determine if IV catheter is

correctly seated in the peripheral vein. To assessperipheral IV placement, flush the vein with NSS

and observe site for swelling.

Ex. Extravasation of Doxorubicin

Interventions:

stop the infusion

check your facility’s policy to determine if

the IV catheter is to be removed or left in

place to infuse

corticosteroids or a specific antidote

notify the physicianWe usually do not remove the line

automatically. We have to flush it and aspirate

as much amount of drug that has been

infiltrated and give steroids.

instill the appropriate antidote according to

facility policy, usually you’ll give the antidote for

extravasation either by instilling it through the

existing IV catheter or by using a 1ml syringe to

inject small amounts subcutaneously in a circle

around the extravasated area

after the antidote has been given, remove the IV

catheterinstruct how to be managed at home


verify IV line patency and placement by flushing

with normal saline solution

remember, “When in doubt, take it out!”

use a transparent, semi permeable

dressing for inspection of site



Leukopenia

reduced leukocytes or WBCs

occurs as WBCs and cancer cells are

destroyed by chemo drugs

Signs & Symptoms:

susceptibility to infections

neutropenia

Interventions:

watch for nadir, the point of lowest blood cell

count

be prepared to administer colony-stimulating

factors

institute neutropenic precautions

teach the patient & caregiver about:

o good hygiene practices

o signs and symptoms of infection

o importance of checking the patient’stemperature regularly

o how to prepare low-microbe diet (avoid

fresh food)

o how to care for vascular access devices

Instruct the patient to avoid:

o crowds

o people with colds or respiratory infections

o fresh flowers/plants

o fresh fruit

maybe the carriers of some

microorganisms

Nausea and Vomiting

can appear in 3 different patterns

o Anticipatory

o Acute

o Delayed

Anticipatory Nausea & Vomiting

nausea and vomiting that’s a learned response

from prior nausea and vomiting after a dose of

chemotherapy high anxiety levels (acts as trigger)

Interventions:

post-treatment control of nausea and vomiting

may prevent future anticipatory episodes

Acute Nausea and Vomiting

Nausea and vomiting occurring within the first

24 hours of treatment

Interventions:

- Treat the patient with acute nausea and

vomiting with antiemetic drugs like: Dexamethasone

Granisetron

Lorazepam

Metoclopramide

Ondansetron

Delayed Nausea and Vomiting

Nausea or vomiting starting or continuing

beyond 24 hours after chemo has began

Interventions:

- The administration of serotonin antagonists,

corticosteroids, various antihistamines,

benzodiapines, and metoclopramide are usually

effective in treating patients

Stomatitis

Inflammation of the lining of the oral mucosa

Can spread into the esophagus and pharynx

Signs and symptoms:

- Painful mouth ulcers that range from mild to

severe appearing 3-7 days after certain chemo

drugs are given; usually due to antimetabolites

chemo drugs like 5-FU (5-Flourouracil)

Interventions:

- Instruct the patient to perform meticulous oral

hygiene

- Administer topical anesthetic mixtures as

appropriate

- If pain is severe, opioid analgesics may be

prescribed until the ulcers heal


- Instruct the patient to suck on dry ice chips while

receiving certain drugs that can cause stomatitis;



this decreases the blood supply to the mouth,

thus decreasing ulcer formation

Thrombocytopenia

Decrease platelet count, prone to bleeding

Signs and symptoms:- Bleeding gums

- Coffee-ground emesis

- Hematuria

- Hypermnorrhea

- Increased bruising

- Petechiae

- Tarry stools

Interventions:

- Monitor patient’s platelet count, critical point:

20,000 cell/mm

- Avoid unnecessary IM injections or venipuncture

- If an IM injection is necessary, apply pressure to

the site for at least 5mins, pressure dressing

- Instruct the patient to:

Avoid cuts and bruises

Shave with electric razor

Avoid blowing his nose

Stay away from irritants that would trigger

sneezing

Avoid using rectal thermometers

- Instruct the patient to report sudden headaches

(which could indicate potentially fatal

intracranial bleed)

PALLIATIVE CARE

An approach that improves the quality of life of

patients and family facing the problem

associated with life threatening illness, through

the prevention and relief of suffering by means

of early identification and impeccable

assessment and treatment of pain and other

problems, physical, psychological and spiritual.

Is applicable early in the course of illness, in

conjunction with other therapies that are

intended to prolong life such as chemo or

radiation therapy

Palliative Management

1. Medical management

2. Pain Management

3. Nutritional management4. Lung cancer counseling and support groups

5. Issues on death and dying

Performance Status

- Basis for the Palliative management, needs to be

identified before you treat the patient for

palliative care

0 – Fully active without restriction

1 – activity restricted; ambulatory; light work

only

2 – Ambulatory; all self-care; no work activities;

up >50% waking hours

3 – limited self-care; confined to bed >60% of the

time

4 – Completely disable



Step 1.

MILD PAIN

•Aspirin (ASA)

•Acetaminophen(Acet)

•Nonsteroidalanti-inflamdrugs (NSAIDs)

•+/- adjuvants

Step 2.MODERATE PAIN

•Acet or ASA +

•codeine

•hydrocodone

•dihydrocodeine

•tramadol (notavailable withASA or Acet)

•+/- adjuvants

Step 3.

SEVERE PAIN

•morphine

•hydromorphone

•methadone

•levorphanol

•fentanyl

•oxycodone

•+/- nonopoidanalgesics

•+/- adjuvants

Medical Management

Pain Management

Lung cancer pain may result from:

- A tumor putting pressure on tissues, bones,

nerves, organs

- Poor blood circulation

- Infection or inflammation in the lungs

- Side effects of surgery, radiation therapy,

chemotherapy, other cancer treatments

- Metastasis, or cancer cells that have spread to

other sites in the body

- Stiffness from inactivity

- Pain that is completely independent from cancer

or cancer treatment (e.g. headaches, backaches,

muscle strains, arthritis or other common pain)

WHO Pain Management

These may be given in the form of:

Pills

Injections

Skin Patches

Implanted pain pumps that automatically deliver

a predetermined dose of pain medicine to the

spine

Remember to discuss any of the side effects, like

nausea, drowsiness, constipation, dry mouth and

itching.

Nutritional Management

Malnutrition results from:

- Depression, denial, loss of hope

- Lack of family support

- Cancer cachexia

•Thoracentesis

•Pericardiocentesis

Stage IV M1a

(Pleural effusion,pericardialeffusion)

•Chemotherapy for stage IV

•Pleurodesis•Pericardial window

Positive pleuralfluid

•Surgical resection followedby WBRTStage IV B - Brain

•Palliative chemotherapyStage IV B -

Adrenals

•Palliative radiation therapy•Bisphosphonate infusionBone metastasis

•Radiation therapy

•StentSuperior Vena

Cava obstruction

•EBRT

•LaserSevere Hemoptysis



- Signs and symptoms of lung cancer

- Side of effects of treatment

Modes of Nutrition:

o Enteral

o Parenteral

o Feeding tubes

Death and Dying

Grief Stage Terminally Ill Patient

Response

Denial This can’t be happening

to me!

Anger Why is this happening to

me?

Bargaining I promise I’ll be a better

person if…

Depression I don’t care anymore.

Acceptance I’m ready for whatever

comes.

Months to year/years

1. Encourage designation of health care

2. Explore fears about dying and address

3. Assess decision making capacity and surrogate

decision maker

4. Initiate discussion of personal values and

preference for end of life care

5. Initiate discussion of palliative care option

Days to weeks

1. Implement and ensure compliance with advance

care plan

2. Clarify and confirm patient’s decision about life

sustaining treatment including CPR

Notes by: Catague R, Dizor J, Sameon N

combined modality multidisciplinary approach to cancer treatment

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