Cancer treatments in palliative care

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Cancer treatments in palliative care

• Clare Warnock
• Practice development sister
• Weston Park Hospital

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Overview of session

• How does cancer treatment work
• The difference between normal cells and cancer
  cells
• How cancer treatments work on these differences
• Systemic anticancer therapy
• Different types of treatment
• How they are given
• Side effects
• Radiotherapy
• How it works
• How it is given
• Side effects

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The differences between a cancer cell and a
normal cell

• Differentiation what it looks like
• Ability to spread direct and metastatic
• Growth
• Healthy cell reproduction
• Carefully controlled process
• Cell division triggered by the death of a cell
• Cell reproduction and cell death carefully
  balanced
• Different processes act in cancer cells so their
  reproduction is not constrained by these usual
  controls

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The rate of growth

• Doubling time
• Time it takes for a cancer to double in size
• 30 times
• One billion cells (marble size)
• Can be detected by X- ray or palpation
• 10 more doublings
• One trillion
• Usually the point at which life cannot be
  sustained
• For much of its growth cancer is undetectable
• The doubling time (rate of growth) for different
  cancers varies greatly from hours to years
• Cancer growth is often a sustained and constant
  process rather than a rapid one

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Growth curve for cancer
Lethal limit
Treatment
Limit of detection
Immune system can handle
Cure
Palliative
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Cancer as a chronic disease

• Chronic diseases
• Shaped by periods of acute and intensive illness
  followed by periods of remission
• People with cancer are living for longer with a
  chronic, but life threatening, illness
• Challenges the portrayal/ perception of cancer
• Challenges the concept of palliative in
  relation to cancer and its treatment
• Concept of the survivor having increasing
  relevance in cancer care

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Cancer treatments

• Cancer treatments capitalise on the
  characteristics of cancer cells
• In particular
• more frequent cellular division
• poor ability to repair damage compared with
  normal cells
• Radiotherapy and Chemotherapy are often most
  effective when cells are dividing
• This is one reason why they have a greater effect
  on cancer cells compared with healthy cells

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Systemic anti-cancer therapy (SACT)

• Chemotherapy
• Biological therapy

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The action of chemotherapy

• Chemotherapy is a systemic treatment
• This means it can effect all the cells in the
  body
• Chemotherapy drugs interfere with the process of
  cell replication
• Different chemotherapy drugs achieve this is
  different ways
• Many work at specific stages in the process of
  cell replication
• This is often referred to as the cell cycle

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How does anti-cancer therapy work
Growth inhibiting factors

Growth promoting factors
The cell cycle clock
G0 Resting phase
Tumour suppressor Genes that control cell
division
Genes that promote cell division (proto-oncogenes)

production of growth stimulating factors
production of growth inhibiting factors
Green chemotherapy action
Yellow biological therapy action
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How does chemotherapy work?

• Some drugs work at specific parts of the cell
  cycle, others can work at any point
• Actions include
• Preventing cell division (M phase) by fusing the
  old and new cells together
• Inhibiting enzymes involved in DNA synthesis
• Interfering directly with DNA

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How does biological therapy work

• Targeted therapy
• Range of modes of action
• Inhibit the signalling pathway that causes cell
  division
• Prevent the formation of tumour blood vessels
• Prevent the production of particular enzymes
  which stop the cell from dividing
• All have the effect of slowing or stopping tumour
  growth

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Examples of targeted therapy

• Tyrosine Kinase Inhibitors (TKIs)
• Erlotinib/Tarceva
• Sunitinib/Sutent
• Imatinib/Glivec
• Monoclonal Antibodies (MABs)
• Rituximab
• Bevacizumab (avastin)
• HER2 positive
• Herceptin

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The aims of SACT

• Maximise the damage to cancer cells
• Minimise the damage to healthy cells
• How is this achieved?
• Giving combinations of drugs
• Drugs that work in different ways increases
  cancer cell kill
• Giving drugs with different side effects reduces
  overall side effect profile
• Cycles of administration
• Giving chemotherapy at planned intervals
• Increases the chance of catching cells in the
  sensitive phase
• Allow healthy cells to repair

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Intention of treatment

• Curative
• Aims to eradicate measurable disease
• Treatment often intensive and associated with
  greater toxicity
• Improved outcomes by maintaining intensity and
  avoiding delays in treatment and dose reductions
• Palliative
• Aim to extend survival, alleviate disease and
  improve quality of life
• Careful balance between quality of life and
  treatment outcomes
• Side effects, duration of response, time in
  hospital, disruption of ADLs

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Health and safetyReducing exposure to a minimum

• Chemotherapy is mutagenic, teraterogenic and
  carcinogenic
• Primary routes of exposure
• Absorption through skin, inhalation, ingestion
• Patients excrete the drugs over the next 7 days
• Provision of protective clothing
• Gloves and aprons
• universal precautions when handling body fluids
• Guidelines
• preparation, handling, disposal and spillages
• Pregnancy dont handle or administer
  chemotherapy

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Administration method and route

• Intravenous
• bolus
• infusion
• infusor (ambulatory chemotherapy)
• Intrathecal
• Intramuscular
• Intravesical

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Oral anticancer therapy

• Increase in oral treatments over past 5 years
• Misconception that a tablet isnt going to cause
  as many problems as intravenous
• Many have potentially distressing and life
  threatening side effects
• Self medicating
• Patient information and compliance essential
• Risk of patients continuing with treatment when
  experiencing side effects
• Health and safety issues include -
• Always wear gloves when handling oral
  chemotherapy
• Never crush tablets or open capsules
• Safe storage vital, away from children

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Side effects

• The incidence and occurrence of side effects is
  drug and dose related
• It is essential to know the regime specific facts

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Nausea and vomiting

• Acute - occurs within minutes to hours and
  resolves within 24 hours
• Delayed - 16 to 24 hours post chemotherapy,
  persists for hours to days
• Anticipatory - conditioned response
• Ematogenic potential
• How likely a drug is to cause nausea and vomiting

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Nausea and vomiting

• Medium to high ematogenic potential eg cisplatin
  and doxorubicin
• Antiemetics prescribed as part of the protocol
  for the regime
• graniestron, ondansetron and apprepitant
• IV and oral steroids (dexamethasone)
• lower ematogenic potential ie fluorouracil
• as required antiemetics prescribed e.g.
  domperidone
• Encourage patients to report symptoms before next
  treatment so we can get the management right

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Neutropaenia

• Low count of neutrophils used as an indicator
  of infection risk
• Neutrophils ingest and kill bacteria and viruses
  in circulating blood
• Normal range - 2.5 to 6.0 X109/l
• Less than 1.0 X 109/l neutropaenia
• Less than 0.5 X 109/l serious risk of bacteraemia
• Normal process of controlling bacterial infection
  is diminished
• can lead to life threatening infections
• When and where to seek support
• WPH assessment unit nurse

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Neutropaenic sepsis

• White blood count of less than 1.0 X 209/l and
  one of the following
• Oral temp gt380c
• Any unexplained deterioration in the absence of
  fever
• HOWEVER we ask patients to ring if the have a
  temperature above 37.5 OR feel unwell
• Treatment
• RING WPH and come in for review
• Urgent blood test required
• Deterioration can be rapid

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Thrombocytopaenia

• Low platelets
• Increased risk of bleeding
• Care issues
• Monitor for any signs of bleeding, bruising,
  petichae
• Avoid invasive procedures
• Patient information ring and blood test
• May need platelet transfusion

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Altered bowel habit

• Diarrhoea
• Potentially life threatening complication
• Severe diarrhoea may require hospital admission
  to prevent dehydration
• Anti-diarrhoeal medication loperamide
• If not controlled patient must contact WPH
• Constipation
• Vinca alkaloids
• Exacerbated by graniestron
• Risk of paralytic ileus
• May need laxatives

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Other common side efects

• Sore mouth
• Hair loss
• Fatigue
• Cardiac toxicity acute and chronic
• NB Capecitabine and 5FU infusor, coronary artery
  spasm 999 call
• Peripheral neuropathy
• Renal toxicity
• Fertility effects

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Hand foot syndrome

• Palmar plantar erythrodyesthesia
• Incidence increasing due to new drugs
• Symptoms
• dysesthesia, parasthesia in the palms and soles
• Swelling on the pads and distal phalanges
• Vesicles and desquamation over the pressure areas
• Blistering and necrosis
• Can be intensely painful and disrupt ADLs
• Diminishes once treatment has ended

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Skin reactions

• Marked skin reactions can occur with some
  chemotherapy agents particularly TKIs such as
  Tarceva
• Patients are advised to use moisturising cream to
  try and prevent the skin from becoming to dry
• Avoid strong sunlight and use a high SPF
  sunscreen
• It may appear like acne but it should not be
  treated with acne medication
• Some patients may require steroids or antibiotics
  

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• Radiotherapy

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Radiotherapy

• Radiotherapy is a local treatment
• Targeted to specific sites in the body
• Radiotherapy uses ionising radiation to damage
  DNA
• Ionising radiation that is able to disrupt the
  chemical structure of the material through which
  it passes
• It excites cell molecules changing the atomic and
  molecular structure

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Factors affecting radiosensitivity

• Radiotherapy works more effectively for
  particular types and sites of cancers
• One factor affecting radio-sensitivity is the
  phase of the cell cycle
• The process of cell reproduction
• Tends to work during phases of the cell cycle
  when DNA synthesis can be disrupted or
  replication disturbed
• G1, G2, M
• It affects all the cells in the treatment site
  but has a greater effect on cancer cells
• Cancer cells are more likely to be in the cell
  cycle

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The cell cycle
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How is it given?

• External beam
• Linear accelerator
• Treatment delivered by therapy radiographers
• Radiation created by, and remains in, the machine
• Brachytherapy
• Sealed and unsealed sources
• Sealed source radiation is located in the
  source
• Unsealed sources patient is temporarily
  radioactive

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Linear accelerator
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• Successful treatment depends on the therapeutic
  ratio
• optimising the dose to the cancer
• minimising damage to normal cells
• Controlling the treatment area
• Planning and accurate positioning

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Careful positioning
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How to achieve the therapeutic ratio

• Fractionation
• Division of the total dose into smaller doses
• e.g.60 Gy 30 for a curative regime
• Allows for normal cell repair
• Increases chances of catching cells when
  sensitive
• Allows re-oxygenation of the tumour
• Palliative regimes tend to be shorter and use
  lower doses

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Uses of Radiotherapy in palliative care

• Radiotherapy can be for curative or palliative
  intent
• Palliative treatments include
• Reduction in tumour mass with the intention to
• prolong survival and/or
• increase quality of life and/or
• symptom management
• Management of bone metastases
• Treatment of brain metastases
• Oncology emergencies e.g. Spinal cord
  compression, SVCO
• Fungating lesions
• Management of bleeding

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Pain and bone metastases

• Bone metastases are the most common secondary
  site of spread
• Most common cause of pain in malignancy
• Frequently arise from
• breast, prostate (combined 80 of incidence)
• lung, kidney, thyroid, multiple myeloma,
  gastrointestinal
• Pain may be due to
• Bone changes
• Pathological fracture
• Neuropathic pain if presses on adjacent nerve
• Spinal cord compression

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How external beam radiotherapy works on bone
metastases

• Cytotoxic effect on normal bone cells inhibits
  the release of chemical mediators of pain such as
  prostaglandins
• Some patients get relief in 24 hours
• Effect on cancer cells prevents further bone
  destruction, reduces tumour size and enables bone
  resorption
• The pain relief effect achieved between 2 and 8
  weeks of treatment

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Oncology palliative emergencies

• Radiotherapy plays a role in treating and
  managing symptoms from key palliative emergencies
  
• Spinal cord compression
• Early detection vital as functional outcome of
  treatment is related to function on presentation
• Superior vena cava obstruction
• Brain metastases

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Tumour size reduction

• Palliative radiotherapy can be used to reduce
  size of tumour and actual and/or potential
  problems
• inoperable/ recurrent local tumour or nodal
  compression
• A higher dose palliation programme may be needed
• Patient may have 30 45 Gy over 2 4 weeks
  using multiple fields
• Side effects are more likely to occur
• Incidence and severity will depend on dose given,
  site treated and other patient related factors

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Side effects of radiotherapy

• Categorised as systemic and local, acute and
  chronic (6 months after treatment)
• Local effects are specific to the area being
  treated
• Acute side effects tend to occur within the first
  2 weeks of treatment, increase in severity and
  peak 10 days after treatment completion
• Chronic side effects are usually caused by a
  decrease in blood supply to the tissue being
  irradiated leading to fibrosis, stenosis, or
  necrosis
• Palliative radiotherapy regimes are aimed at
  inducing fewer side effects (lower total doses,
  fewer fractions)

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Fatigue

• Fatigue has been reported as one of the most
  distressing side effects of treatment
• It is consistently identified as the most common
  and most distressing symptom in research into
  radiotherapy side effects
• It increases over the course of radiotherapy and
  may continue for months following completion
• Important to warn patients it may occur and there
  are physiological causes (not them!)
• Interventions include
• Rule out other causes, sleep hygiene, maintain
  activity gentle exercise
• May not be appropriate for all palliative care
  needs

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Skin reactions

• Skin reactions range from faint erythema to moist
  desquamation
• Relate to facors inlcuding
• Dose, location (skin folds, proximity to skin
  surface)
• Age, general health, smoking

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Skin care

• Washing skin using mild, unperfumed soap and warm
  water
• avoid friction - pat skin dry, loose cotton
  clothing
• During the first stage of a reaction applying
  moisturising cream can provide relief and prevent
  deterioration
• E45, Oilatum or Diprobase
• Avoid perfumed products
• Use an electric razor instead of wet shaving
• Protect skin from sun, wind and extreme
  temperatures
• Reactions are greatest at the end of radiotherapy
  when the patient has completed treatment
• Contact radiotherapy treatment area for advice on
  management

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Site specific side effects

• The incidence and severity of side effects is
  dose and treatment site related
• What side effects could patients experience when
  having radiotherapy to
• Brain
• Head and neck
• Chest
• Abdomen and pelvis

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The context of treatment

• It is essential to remember that an individuals
  experience of cancer and its treatment is shaped
  by contextual factors

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Context of treatments

• Previous treatment
• Diagnosis
• Disease trajectory
• Belief about cancer/DXR
• Knowledge and understanding
• Relationship with HCPs
• Symptoms
• Prognosis

• Home situation
• Family and friends
• Stage in life
• Work and social life
• Financial situation
• Body image
• Past experience
• Physical functioning
• Other illnesses

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Conclusion

• When used appropriately cancer treatments aim to
• increase survival, improve symptom management and
  quality of life
• Preventing, monitoring and managing side effects
  are essential if these aims are ot be achieved
• All HCPs play a role in this process
• Advice and information is available from WPH
• 0114 226 5000
• Nurse practitioner assessment unit
• Patients consultant team

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• Thank you for listening
• Hope you found the journey interesting!