Aspek Bioetika

Manajemen Terapi
Terintegrasi

Dr. dr. Awal Prasetyo, M.Kes, Sp-THT-KL

Curriculum Vitae
Taman Kradenan Asri H-11 Semarang
50221
Telpon: 024-8503635 HP:08122810954
Email: awalpras@yahoo.com
SD Dewantara Semarang (1979)
SMP Domenico Savio Semarang (1982)
Awal
Prasetyo

SMA 3 Semarang (1985)

Drs. Med.-FK UNDIP (1990)
Dokter-FK UNDIP (1993)
M.Kes (Pathobiologist)-UNDIP (2002)
Sp.THT-KL-FK UNDIP (2009)
S3 (Doktor)-UGM (2014)

Model Tradisional Manajemen

Terapi
Komunikasi linear/satu arah
Pendekatan biomedik untuk
menangani problem medis
Dilanjutkan dengan
peresepan
Terapi simptomatik

Pasien sebagai PENYAKIT atau

ORGAN

Gaya Komunikasi Gold

Standard

Perubahan Peran Dokter

Komunikasi berpusat pada pasien

Pendekatan biopsikososial
Sebagai fasilitator/pendengar
Sebagai ahli pengubah perilaku
Bernegosiasi terhadap perubahan

Pasien sebagai PRIBADI atau

INDIVIDU

Kontinum Sehat-Sakit

Terapi Standar ke Terapi

Individual

Terapi Berpusat ke Pasien &

Aspek Bioetika Terapi
Terintegrasi

The 4 Basic Principles of

Bioethics:
1) Respect for Autonomy (Person)
2) Non Maleficence
3) Beneficence
4) Justice

http://www.slideshare.net/ashriniadanihulu/bio-ethics-2014

1) Respect for Autonomy

Self rule, self government, free from
interference and from limitation.
Do not deprive of freedom.
Beauchamps and Childress: a twofold
principles
a. Negative obligation: autonomous action
should not be subjected to controlling
constrains by others.
b. Positive obligation: requires respectful
treatment in disclosing information and
fostering autonomous decision making.

Respect for autonomy needs:

1) Tell the truth
2) Respect privacy of others
3) Protect confidential information
4) Obtain consent for intervention with
patients
* When asked, help others make important
decisions

Respect for autonomy will end up in

INFORMED CONSENT
In order to get good & right informed consent,
need:
a)Voluntariness: He/She wills the action
without being under control of another
influence.
b)Competent to make decisions
c) Free of coercion
d)Free of persuasion
e)Free of manipulation
f) Right and complete informations

2) Nonmaleficence
The principle of nonmaleficence refers to the
duty to refrain from causing harm: primum
non nocere (above all, do no harm)
The Hippocratic imperative to Physicians:
BRING BENEFIT & DO NO HARM
Beauchamps & Childress underlines the
necessity
NOT TO INFLICT evil or harm:
Do not kill
Do not cause pain or suffering
Do not incapacitate
Do not cause offenses

 Some time we can not escape from

hurting or doing harm to our patient in
order to bring good.
In this case, it will be judged according

Principle of Double
Effects.
to the

It is allowed only if:

a)The intention is the good effect and
nor the bad
b)The action itself is a good action or
indifferent

3) Beneficence
The principle of beneficence
assert
the duty to
help others furthers their
important and legitimate
interest:
a)One ought to prevent evil or
harm
b)One ought to remove evil or
harm
c)One ought to do or promote

Or in more positive way:

a) Protect and defend the rights of others
b) Prevent harm from occuring to others
c) Remove conditions that will cause harm
to others
d) Help person with disabilities
e) Rescue person in danger
It is not enough refraining from doing
bad thing
(nonmaleficence) but we have to
promote the goodness or legitimate

4) Justice
The Principles of justice underlines concern
about
how social benefits and
burdens should be distributed.
Justice requires that equals be treated
equally, and unequals be treated unequally
but in proportion to their relevant
inequalities.

We give according to their

rights.

The distributive justice:

To each person an equal share
To each person according to need
To each person according to effort
To each person according to
contribution
To each person according to merit
To each person according to free
market exchange

Etiopatogenesis &
Diagnosis Dini Kanker
Nasofaring

Dr. dr. Awal Prasetyo, M.Kes, Sp-THT-KL

..dan masih banyak lagi yang lainnya

23

Alur Runtut & Logis tentang

Penyakit & Sifat Khas Penyakit
(Konsep Pikir Patologik)

Nasopharynx

Insidensi
Etiologi
Patogenesis
Gambaran patologi (MORFOLOGI) & klinik
(MANIFESTASI KLINIK)
Komplikasi & kecacatan
Prognosis
Underwood JCE. Sistem pencernaan. Dalam: Patologi umum dan sistemik Vol 2. Edisi 2.
Editor Sarjadi. EGC, Jakarta, 1999

Insidensi

Sebaran
Usia
Jenis Kelamin
Perbandingan Insidensi KNF
Perbandingan Pria : Wanita
Perbandingan Tipe Histologik

INSIDENSI KNF PRIA & WANITA (Globocan 2012-IARC)

Keganasan KL
kedua terbanyak
(22,3%)
(Prasetyo, 2011)

INSIDENSI KNF PRIA & WANITA (Globocan 2012-IARC)

40-49 th (30%) &

50-59 th (25,9%);
:=2:1
(Prasetyo, 2011)

Age Distribution of Head & Neck

Cancer
In Semarang 2010-2014
(Hidanti & Prasetyo, 2015)

TOP 5 RANK OF
HEAD AND NECK CANCER (ICD
10)
In Semarang 2010-2014 (Hidanti &
Prasetyo, 2015)
Male

Ran Cancer Total

k
Code

Female

(%)

Ran Cancer Tota

k
Code
l

(%)

C. 11

66

24

C. 11

34

12

C. 30

34

12

C. 30

30

11

C. 32

22

C. 02

12

C. 09

13

C. 07

C. 02

12

C. 09

Malignant Neoplasm of Nasopharynx

(C.11)
1st Rank in Male and Female
In Semarang 2010-2014
(Hidanti & Prasetyo, 2015)

Perbandingan Insidensi KNF

Peneliti
Bernadette
Brennan,
2006
Yu, MC &
Yuan JM.,
2002
Prasad,
1995;
Witte &
Bryan, 1998

11/15/16

Negara/Ras
Amerika Utara,
Eropa Barat,
Inggris, Jamaica,
Jepang
Cina Selatan

Angka
1 kasus per 100.000

Ras Mongoloid

18-25% dari seluruh

keganasan di tubuh

Eskimo

Pria 13,5 & wanita

3,7 per 100.000
penduduk
7 kasus per 100.000

Asia Tenggara

30-50 per 100.000

Peneliti

Armstrong,
B.W.,
et
al., 1979
Hsien, Y.C.,
2009
Hsien, Y.C.,
2009
Hsien, Y.C.,
2009
Soeripto, 1988;
Soekamto, S.M.,
11/15/16
Sandhika
W&

Negara/Ras
Angka
Hongkong
20 per 100.000
Taiwan & Singapura 18,1 & 7,4 per
100.000
Pria & wanita etnis 17,3 & 7,3 per
Cina di Malaysia
100.000
1974
Pria etnis Cina di
4,1 per 100.000
Brunei
Pria etnis Cina di
15,9 per 100.000
Singapura
Peninsular Malaysia 19,6 per 100.000
Indonesia

5 sampai 15 per
100.000

Perbandingan Pria : Wanita

Peneliti

Negara/
Ras
Etnis Cina
di
Malaysia
Penduduk
asli
Malaysia
Aburisis,
Sudan
2008
(20002005)
Gandaraw Nigeria
a, 2009
(19912005)
11/15/16
Kentjono,
Surabaya

Usia
Tersering

Rasio Pria:
Wanita
16,5:7,2

2,3:0,7

11-82 tahun
2:1
(mean 45,5
tahun)
Rerata 39 th & 2,1:1
terbanyak 4049 th
80% KNF pada usia produktif

Perbandingan Tipe Histologik

Peneliti

Negara/Ras

Aburisis, DO, 2008 Sudan

Gandarawa, 2009
Susan, AD., 2003

Nigeria,
Jamaica
(1988-1998)

Prasetyo, A., 2012 Semarang

11/15/16

Perbandingan
Tipe
Histologik
WHO-3 (73,8%)
WHO-2
(26,2%)
WHO-1 (0%)
WHO-1 (92,5%)
WHO-3 (66%)
WHO-2 (29%)
WHO-1 (0%)
WHO-3 (53%)
WHO-2 (37%)
WHO-1 (10%)

Etiologi
Etiologi & Faktor Risiko

CAUSES OF DISEASE
CONGENITAL
Inherited or familial
Congenital

ACQUIRED
Injury
Inflammations
Mechanical
Metabolic
Circulatory
Endocrine
Degeneration & infiltrations
Tumours
Other varians

Etiologi & Faktor Risiko KNF

Risiko
Life Style

Paparan
lingkungan

Risiko Genetik

Infeksi EBV

KNF

11/15/16

Risiko Life style:

Perokok aktif
Konsumsi nitrosamine/makanan awetan/
ikan asin/ikan/daging bakar
Konsumsi alkohol, Mengunyah
sirih/tembakau
Konsumsi snack/makanan mengandung
MSG
Radang kronik hidung/tenggorok
Risiko Genetik :
Mutasi gen mayor (somatogenetik)
Mutasi gen minor (polimorfisme
CYP2E1, HLA kelas I)
Riwayat keluarga penderita
KNF/kanker lain
11/15/16

Paparan
lingkungan

Infeksi
EBV

KNF

Paparan lingkungan :
Debu kayu/ Debu penyamakan kulit
Gas mustard, solar
Radiasi pengion/sinar matahari
Pestisida/insektisida, Bahan finishing furniture
Cat/tiner/gas asam, Asap kayu bakar
Perokok pasif, Asap/uap logam berat/ Bahan kimia
Risiko Life style

Risiko
Genetik

11/15/16

Infeksi EBV

KNF

Salted fish 3X/bulan (OR=1,9)

Daging asap /riwayat merokok
tembakau tidak berhubungan
dengan KNF (p>0,05)
(Xiuchan Guo, 2009)

Mutasi gen mayor

(Regio kromosom 4p15.1-q12)
Mutasi gen minor
(polimorfisme CYP2E1,
HLA kelas I: Alele A2, A33, B46, B58)
Riwayat keluarga penderita KNF/kanker lain
(Indonesia/Jawa?)
Riwayat keluarga (filial 1, 2 & 3) KNF
(OR=3,1)
11/15/16

Domestic wood cooking

fires 10 th (OR=5,8)
Paparan inhalasi
occupational
solvents 10 tahun
(OR=2,6)
(Xiuchan Guo, 2009)

KNF

Etiologi KNF
Hipotesis Kumar
(2003)
Riwayat kanker pada
keluarga: 3-5 X

Makan ikan asin, ikan/daging

asap/bakar, mie instan, awetan,
MSG: 4-8 X
:

11/15/16

Asap rokok, kayu, dsb: 2-5X

Infeksi nasofaring: 33 X

41

Patogenesis
Dasar Karsinogenesis Molekuler
Mekanisme Karsinogenesis

Agen perusak DNA

(akuisita/lingkunga
n):
Bahan kimia
Radiasi
Virus

SEL NORMAL
Keberhasilan repair DNA
Kerusakan
DNA
Mutasi pada
genom sel
somatik

Aktivasi gen
promotor
pertumbuhan

Kegagala
n
repair
DNA

Perubahan gen
pengatur
apoptosis

Mutasi herediter
dalam:
Gen pengaruhi repair
DNA
Gen pengaruhi
pertumbuhan atau
Inaktivasi gen apoptosis
supresor
kanker/tumor

Ekspresi produk gen

yang berubah
dan hilangnya gen regulator
Ekspansi klonal

Gambar. Alur skematik

dasar karsinogenesis
molekuler

Mutasi tambahan
(progresi)
Heterogeneita
s
Neoplasma
maligna

11/15/16

Mekanisme
Karsinogenesis

DNA
Transcription

Kelainan
genetik

Genotype
RNA function &
structure

Transkripsi
RNA

Protein sequence

Translasi

RNA
Translation
Protein

Protein structure
Protein Function
Phenotype

11/15/16

Asam
amino
Sintesis protein
GF
Reseptor

Molekul sinyal
transduksi;

Gambaran Klinik &

Morfologik

Tahapan Diagnosis KNF

Gold Standard Diagnosis KNF
Dimensi Diagnostik KNF

TAHAPAN DIAGNOSIS KNF

5 SIGNS: NOSE, EAR, EYE, NECK,
CRANIAL
ANAMNESIS
PEMERIKSAAN
FISIK
PEMERIKSAAN
PENUNJANG

Simpulan atas identifikasi data

subyektif
& obyektif pada
keluhan problem fisik individu,
mengandung informasi tentang

DIAGNOSIS

GOLD STANDARD DIAGNOSIS KNF

WHO (2005) (Chan, J.K.C., et al., 2005)
Karsinoma asal mukosa nasofaring dengan bukti
adanya diferensiasi skuamosa, meliputi;
1) Squamous Cell Carcinoma/WHO-1
(keratinizing squamous cell carcinoma)
[ICD-O codes 8071/3]
2) Nonkeratinizing Carcinoma
(Differentiated/WHO-2 or
Undifferentiated/WHO-3)
(WHO-2/WHO-3) [ICD-O codes 8072/3]
3) Basaloid squamous cell carcinoma
11/15/16
[ICD-O codes 8083/3]

Keratinizing squamous cell carcinoma

(HE:100X)

Nonkeratinizing carcinoma (well)

differentiated (HE:100X)

Nonkeratinizing carcinoma undifferentiated (HE:400X)

[ICD-O codes 8072/3]

DIAGNOSIS
Klinik
Etiologik
Anatomik (Makroskopik &
Mikroskopik)

Progno
sis
Manajem

Etiologi & Prognosis: Dimensi

Diagnostik

DIMENSI DIAGNOSTIK
KNF
Gold standard : HISTOPATOLOGI
Klinik
: TNM, STAGING
Etiologik : EBV DOMINAN, NON EBV
Prognostik : AD BONAM, DUBIA, AD
MALAM

Standar Profesi & Sertifikasi PERHATI-KL 2007

11/15/16

54

SALAM SEHAT