Palliative Care Approaches for Advanced Cancer

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• Palliative Care Approaches for Advanced Cancer
• May 28, 2009
• Matthew L. Hill, D.O.

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Palliative Care Defined

• An approach that improves the quality of life of
  patients and their families 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, psychosocial and spiritual.

World Health Organization
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US Mortality, 2006
No. of deaths
of all deaths
Rank
Cause of Death

• 1. Heart Diseases 631,636 26.0
• 2. Cancer 559,888 23.1
• 3. Cerebrovascular diseases 137,119 5.7
• 4. Chronic lower respiratory diseases 124,583
  5.1
• 5. Accidents (unintentional injuries) 121,599
  5.0
• 6. Diabetes mellitus 72,449 3.0
• 7. Alzheimer disease 72,432 3.0
• 8. Influenza pneumonia 56,326 2.3
• Nephritis 45,344 1.9

Includes nephrotic syndrome and
nephrosis. Source US Mortality Data 2006,
National Center for Health Statistics, Centers
for Disease Control and Prevention, 2009.
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Lifetime Probability of Developing Cancer, Men,
2003-2005
Site
Risk
All sites 1 in 2 Prostate 1 in 6 Lung
and bronchus 1 in 13 Colon and rectum 1 in
18 Urinary bladder 1 in 27 Melanoma 1 in
39 Non-Hodgkin lymphoma 1 in 45 Kidney 1 in
57 Leukemia 1 in 67 Oral Cavity 1 in
72 Stomach 1 in 90
For those free of cancer at beginning of age
interval.
Source DevCan Probability of Developing or
Dying of Cancer Software, Version 6.3.0
Statistical Research and Applications Branch,
NCI, 2008. http//srab.cancer.gov/devcan
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Lifetime Probability of Developing Cancer, Women,
US, 2003-2005
Site
Risk
All sites 1 in 3 Breast 1 in 8 Lung
bronchus 1 in 16 Colon rectum 1 in
20 Uterine corpus 1 in 40 Non-Hodgkin
lymphoma 1 in 53 Urinary bladder 1 in
84 Melanoma 1 in 58 Ovary 1 in
72 Pancreas 1 in 75 Uterine cervix 1 in
145
For those free of cancer at beginning of age
interval.
Source DevCan Probability of Developing or
Dying of Cancer Software, Version 6.3.0
Statistical Research and Applications Branch,
NCI, 2008. http//srab.cancer.gov/devcan
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Trends in Five-year Relative Survival () Rates,
US, 1975-2004
1984-1986
1996-2004
Site
1975-1977
     

• All sites 50 54 66
• Breast (female) 75 79 89
• Colon 52 59 65
• Leukemia 35 42 51
• Lung and bronchus 13 13 16
• Melanoma 82 87 92
• Non-Hodgkin lymphoma 48 53 65
• Ovary 37 40 46
• Pancreas 3 3 5
• Prostate 69 76 99
• Rectum 49 57 67
• Urinary bladder 74 78 81

5-year relative survival rates based on follow
up of patients through 2005. Source
Surveillance, Epidemiology, and End Results
Program, 1975-2005, Division of Cancer Control
and Population Sciences, National Cancer
Institute, 2008.
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Palliative Care

• provides relief from pain and other distressing
• symptoms
• affirms life and regards dying as a normal
  process
• intends neither to hasten or postpone death
• integrates the psychological and spiritual
  aspects
• of patient care

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Palliative Care

• offers a support system to help patients live
  as
• actively as possible until death
• offers a support system to help the family cope
• during the patients illness and in their own
• bereavement
• uses a team approach to address the needs of
• patients and their families, including
• bereavement counseling

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Palliative Care

• will enhance quality of life, and may also
• positively influence the course of illness
• is applicable early in the course of illness,
  in
• conjunction with other therapies that are
• intended to prolong life, such as
• chemotherapy or radiation therapy, and
• includes those investigations needed to better
• understand and manage distressing clinical
• complications

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Case

• R. L. is a 67 yo m is seen for abdominal pain and
  unexplained weight loss progressive over two
  months.
• Pain is right-sided. Constant 4-7/10. No prior
  hx of similar pain. Some relief with
  acetaminophen. No relation w/food intake, though
  increased bloating noted after eating. Anorexia.
  No dysphagia. No N/V. Stools unchanged.

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Case

• PmHx DVT four months prior
• Dyslipidemia
• HTN
• No prior surgeries
• FaHx Negative for thrombosis or malignancy
• SoHx Married, two healthy children.
• Lives in DSM. Retired teacher.
• Remote 20 pk/yr smoking hx. No etoh.
• No prior chemical exposures.
• Was walking 3 miles/4 days/wk.

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Case

• All NKDA
• Meds Zocor, HCTZ, warfarin, MVI, no herbals
• ROS First colonoscopy was done after DVT and
  was negative. Others negative.
• PE AF, HR 70, RR 12, BP 125/80, 59, 160 h
  rrr
• l ctab
• a s, normoactive bs, TTP RUQ w/liver 3 cm
  below ccm
• e trace right pte

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Case

• Labs CBC CMP nl except ALT 60
• amylase/lipase normal
• CT imaging 4 cm mass at the head of the
• pancreas with associated lymphadenopathy
• and multiple liver lesions c/w mets
• Next?

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2009 Estimated US Cancer Cases
Men766,130
Women713,220
27 Breast 14 Lung bronchus 10 Colon
rectum 6 Uterine corpus 4 Non-Hodgkin
lymphoma 4 Melanoma of skin 4 Thyroid 3
Kidney renal pelvis 3 Ovary 3
Pancreas 22 All Other Sites
Prostate 25 Lung bronchus 15 Colon
rectum 10 Urinary bladder 7 Melanoma of
skin 5 Non-Hodgkin 5
lymphoma Kidney renal pelvis 5 Leukemia
3 Oral cavity 3 Pancreas 3 All Other
Sites 19
Excludes basal and squamous cell skin cancers
and in situ carcinomas except urinary
bladder. Source American Cancer Society, 2009.
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2009 Estimated US Cancer Deaths
Men292,540
Women269,800
26 Lung bronchus 15 Breast 9 Colon
rectum 6 Pancreas 5 Ovary 4 Non-Hodgkin
lymphoma 3 Leukemia 3 Uterine
corpus 2 Liver bile duct 2 Brain/ONS 25
All other sites
Lung bronchus 30 Prostate 9 Colon rectum
9 Pancreas 6 Leukemia 4 Liver
intrahepatic 4bile duct Esophagus 4 Urinary
bladder 3 Non-Hodgkin 3
lymphoma Kidney renal
pelvis 3 All other sites 25
ONSOther nervous system. Source American Cancer
Society, 2009.
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Pancreatic Cancer

• Peak incidence in 70-80s
• M F
• Smoking
• Increased BMI
• beta-naphythylamine benzidine
• ? chronic pancreatitis
• melanoma/pancreas (p16), BRCA-2
• FAP (5q), Peutz-Jeghers (19p), Li-Fraumeni (p53)

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Pancreatic Cancer

• Presentation
• weight loss
• abdominal pain
• nausea dyspepsia
• jaundice
• depression
• sudden onset of DM2 in 50 yo

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Pancreatic Cancer

• Staging
• high-resolution CT
• EUS
• chest imaging, CA19-9
• resectable, borderline resectable, unresectable

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Pancreatic Cancer

• Staging
• high-resolution CT
• EUS
• chest imaging, CA19-9
• resectable, borderline resectable, unresectable
• Survival
• resectable - 20 5y OS
• borderline resectable 8-12 mos.
• unresectable 3-6 mos.

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Palliative Care

• Performance Status ECOG

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Case

• R. L. our 67 yo otherwise healthy male
• Stage IV pancreas cancer
• ECOG 2
• Discussion

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Case

• Initial appointment no decisions necessary
• What about his pain?

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Palliative Care

• Initial appointment no decisions necessary
• What about his bloating?

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Palliative Care

• One week return.
• Pain controlled. Decreased bloating.
• Appetite better, but weight down 2 pounds.
• Goals defined
• R.L. opts for therapy
• Infusaport placed (changed to LMWH)

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Palliative Care

• Baseline staging completed.
• Baseline CA19-9 drawn.
• R. L. initiated on
• gemcitabine IV over days 1, 8, 15 every 28d.
  
• erlotinib 150 mg po daily
• Planned to see in clinic qow

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Palliative Care

• Cycle 2, day 1.
• under treatment for an erlotinib rash
• 4 MSIR/d, 1 MSER/night w/good control
• wt. stable, no n/v/constipation
• lightheaded after last chemo
• PE hr 90, bp 100/70, rash, otherwise negative
• Labs cmp okay, 3000 neuts, hgb 10.9

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Palliative Care

• Cycle 2, day 1.
• Med. review
• Zocor, HCTZ, lovenox, MSIR, MSER,
• pancrelipase, doxycycline, clindamycin
• cream, MVI, colace, senna, no herbals

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Palliative Care

• Cycle 2, day 15.
• Emesis 1-2/d, relief with prochlorperazine
• Denies reflux, no HAs
• Pain controlled, reports good qol
• Exam BP 110/75, hr 80, rash resolved
• Labs - cmp okay, neuts 1500, hgb 9.0, plt 110K
• Issues nausea/vomiting
• cytopenias

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Palliative Care

• Nausea - etiologies
• chemotherapy/radiation-induced
• medication-induced
• check blood levels if applicable
• may need to rotate opioids
• constipation
• gastropathy
• gastric outlet obstruction

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Palliative Care

• Nausea - etiologies
• CNS metastases
• metabolic abnormalities
• volume depletion, hypercalcemia
• psychogenic
• non-specific

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Palliative Care

• Nausea - treatment
• dopamine receptor antagonist
• prochlorperazine, haloperidol, metoclopramide
• 5-HT3 antagonist ondansetron, palonosetron
• anticholinergic - scopolamine
• antihistamine meclizine
• cannabinoid - dronabinol
• corticosteroid dexamethasone
• alternative acupuncture, palliative sedation

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Palliative Care

• Cycle 2, day 15.
• Med review
• Zocor, lovenox, MSIR, MSER, pancrelipase,
• doxycycline, clindamycin cream, MVI, colace,
• senna, no herbals
• Nausea/vomiting

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Palliative Care

• Cycle 2, day 15.
• Emesis 1-2/d, relief with prochlorperazine
• Pain controlled, reports good qol
• Exam BP 110/75, hr 80, rash resolved
• Labs - cmp okay, neuts 1500, hgb 9.0, plt 110K
• Okay for chemo., s/u for 2 PRBCs (?EPO)

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Palliative Care

• Erythropoiesis-stimulating agents
• Meta-analysis
• 13,933 cancer patients
• 53 trials randomized, controlled
• endpoints mortality during study and OS
• overall increased RR mortality 17
• limited to chemo., RR mortality 10

The Lancet. 2009 373 (9674) 1532-1542
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Palliative Care

• Cycle 3, day 1.
• CT AP shows stable disease, CA19-9 pending
• Taking MSER q12h and 4-5 MSIR daily
• No BM for 3d before CT, titrated up colace/senna
• Appetite down, occasional water brash
• Exam VSS, weight down 4 lbs.
• Labs cmp okay, 2000 neuts, hgb 10.9, plt 110K
• Issues increased pain, reflux, constipation

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Palliative Care

• Constipation etiologies
• medication-induced
• impaction
• obstruction
• volume depletion
• metabolic
• endocrine
• inactivity

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Palliative Care

• Constipation prevention
• goal 1 non-forced bm q1-2d
• senna docusate - 2-3 tabs bid-tid
• increase fluid intake
• increase fiber if adequate fluid intake
• increase activity if reasonable

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Palliative Care

• Constipation treatment
• bisacodyl 10-15 mg tid
• polyethelene glycol bid
• lactulose 30-20 ml bid-qid
• sorbitol 30 ml q2h then prn
• magnesium citrate 8 oz daily
• phosphasoda or tap water enemas

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Palliative Care

• Constipation treatment
• mineral oil retention enema
• metoclopramide 10-20 mg po qid
• manual disimpaction premedicate
• methylnaltrexone (Relistor)
• peripherally acting opioid antagonist
• 0.15 mg/kg sq qod

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Palliative Care

• Cycle 3, day 15.
• Feels good. Appetite up with absence of reflux.
  
• Pain controlled. Taking polyethelene glycol
  every
• 2-3 days. Good QOL.
• Exam VSS, wt. up 5 lbs., no new findings.
• Labs cmp okay, 1000 neuts, hgb 9.1, plt 88K
• Chemo held d/t cytopenias.
• CBC to repeat in 3-4 day for possible PRBC.

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Palliative Care

• Cycle 4, day 1.
• Pain worse, radiates to back, now on MSER 30
• q12h and requiring poly. glycol daily. Wt.
  down 5
• lbs. Increased fatigue and anorexia. Rare
  emesis.
• Exam AF, HR 105, BP 95/70, looks weak, no new
• findings, ECOG III
• Labs na 131, k 3.5, alt 100, 3K neuts, hgb 10,
  plt
• 120 K, CA19-9 pending

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Palliative Care

• Cycle 4, day 1.
• Issues
• pain
• volume depletion
• fatigue
• anorexia
• Sent upstairs for IVF, chemo held

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Palliative Care

• Pain an unpleasant sensory and emotional
  experience associated with actual or potential
  tissue damage, or described in terms of such
  damage
• Cancer Pain
• 25 of newly diagnosed
• 33 undergoing treatment
• 75 with advanced disease

International Association for the Study of Pain
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Palliative Care

• Pain assessment
• Location referral pattern, radiation
• Intensity peak level (0-10) in last 24h
• Quality aching/stabbing (somatic), gnawing/
• cramping (visceral), burning/tingling
  (neuropathic)
• Aggravating/alleviating factors
• Associated symptoms

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Palliative Care

• Pain assessment
• Interference with activities
• Prior pain therapies
• Current management and effectiveness
• Medical history
• Psychosocial aspects
• Exam and laboratory/imaging studies

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Palliative Care

• Pain etiology
• Cancer
• Cancer therapy (chemo., XRT, surgery)
• Procedure related
• Non-cancer related
• Nociceptive
• Neuropathic

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Palliative Care

• Pain treatment
• Inflammatory NSAIDS, glucocorticoids
• Nerve compression glucocorticoids
• Bone pain NSAIDS, XRT, nerve block,
• bisphosphonates, radioisotopes,
  glucocorticoids,
• chemotherapy, pain specialist referral

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Palliative Care

• Pain treatment
• Neuropathic
• anticonvulsants (gabapentin, pregabalin,
• carbamazepine),
• antidepressants (nortriptyline, doxepin,
• venlafaxine)
• topical anesthetic (lidocaine patch)
• referral to pain specialist

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Opioid Equivalences
meperidine propoxyphene not rec. d/t CNS toxic
metabolites
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Palliative Care

• Pain possible new treatment option
• Randomized, double-blind, placebo-controlled
• 114 cancer patients with 1-4 episodes of break-
• through pain per day
• fentanyl pectin nasal spray vs. placebo
• benefit seen in pain intensity at 5 min.
  (plt0.05)
• pain relief seen at all points to 60 min.
  (plt0.001)
• no significant nasal side effects reported

J Clin Oncol. 2009 27 15s.
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Palliative Care

• Pain treatment
• Physical
• Bed, bath and walking supports
• Positioning instruction
• Physical therapy
• Massage
• Heat and/or ice
• TENS
• Acupuncture/acupressure
• Ultrasonic therapy

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Palliative Care

• Pain treatment
• Cognitive
• Imagery/hypnosis
• Distraction training
• Relaxation training
• Active coping training
• Cognitive behavioral training
• Spiritual care
• Graded task assignments

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Palliative Care

• Pain treatment
• Interventional
• Regional w/infusion pump
• epidural
• intrathecal
• regional plexus
• Vertebroplasty/kyphoplasty
• Radiofrequency ablation for bone lesions
• Neurostimulation

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Palliative Care

• Pain treatment
• Interventional
• Neurodestructive
• HN peripheral nerve block
• Upper extremity brachial plexus neurolysis
• Thoracic wall epidural or intercostal
  neurolysis
• Abdominal celiac plexus block, thoracic
  splanchnicectomy
• Pelvic superior hypogastric plexus block
• Rectal intrathecal neurolysis, midline
  myelotomy or superior
• hypogastric plexus block

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Palliative Care

• Fatigue A condition marked by extreme
  tiredness and inability to function due lack of
  energy. Fatigue may be acute or chronic.
• Cancer fatigue
• Most distressing symptom
• 70-100 patients

National Cancer Institute
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Palliative Care

• Fatigue - assessment
• Screening score 0 (no fatigue) to 10 (worst
• fatigue imaginable)
• Onset, pattern duration
• Aggravating or alleviating factors
• Interference with function
• Consider disease recurrence/progression
• Evaluate medications/supplements

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Palliative Care

• Fatigue - assessment
• Contributing factors
• Pain
• Emotional Distress
• Depression and/or anxiety
• Anemia
• Sleep disruption
• OSA
• RLS
• Insomnia

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Palliative Care

• Fatigue - assessment
• Contributing factors
• Malnutrition
• Metabolic
• Activity level
• Medication toxicity/SE
• Endocrine
• Comorbidity
• Infection

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Palliative Care

• Fatigue - treatment
• Limit naps
• Structured daily routine
• Schedule activities at times of higher energy
• Distraction games/socializing/music/reading
• Increase activity level
• Psychosocial treatments cognitive behavioral
• therapy, support groups, stress mgmt.

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Palliative Care

• Fatigue - treatment
• Attention restoring therapy (nature)
• Dietary consultation
• Cognitive Behavioral therapy for sleep
• sleep hygiene
• sleep restriction
• stimulus control
• Acupuncture

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Palliative Care

• Fatigue - treatment
• Psychostimulants
• modafanil
• 642 patients beginning chemotherapy
• modafinil 200 mg/d or placebo
• pts. w/severe fatigue (gt6/10) benefited
• (p0.03)
• pts. on drug were less sleepy (p.002)
• no effect on depression (p0.83)

J Clin Oncol 2008 26504s.
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Palliative Care

• Fatigue - treatment
• Psychostimulants
• modafanil
• methylpenidate
• Treat anemia
• Consider sleep aid
• Consider corticosteroids

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Palliative Care

• Cycle 4, day 1 (delayed one week).
• Pain much better after celiac block. Appetite
  marginally better with pain control weight down
  two lbs.. More energy during the day. Fair QOL.
• Exam VSS, appears weaker, exam w/o change
• Labs Last CA19-9 doubled, electrolytes okay,
• ALT 150, Tbili 2.0, 4.2K neuts, hgb 10.3, plt
  130K
• Chemo held, imaging ordered

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• Thank You.