PALLIATIVE CARE IN CANCER

PATIENT
Eko Winarto
 Medical care that focuses on alleviating the intensity of
symptoms of disease.

 Palliative care focuses on reducing the prominence

and severity of symptoms.
DEATH TRAJECTORIES. LUNNEY JR, ET AL. PROFILES OF OLDER MEDICARE DECEDENTS.
J AM GERIATR SOC 2002;50:1108-1112.
 2

Murray, S. A et al. BMJ 2008;336:958-959

 3

Murray, S. A et al. BMJ 2008;336:958-959

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;
 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, if indicated;
 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.
GOAL
 The goal is to improve the quality of life for individuals
who are suffering from severe diseases.

 Palliative care offers a diverse array of assistance and

care to the patient.
“CANCER CONTROL: KNOWLEDGE INTO
ACTION”
“Palliative care is an urgent humanitarian need
worldwide for people with cancer and other chronic fatal
diseases. Palliative care is particularly needed in places
where a high proportion of patients present in advanced
stages and there is little chance of cure.”
 Not a “one size fits all approach”
 Care is tailored to help the specific needs of the
patient
 Since palliative care is utilized to help with various
diseases, the care provided must fit the symptoms.
SYMPTOM PATIENTS (%) SYMPTOM PATIENTS (%)
 Pain 84  Edema 28
 Easy fatigue 69  Taste change 28
 Weakness 66  Hoarseness 24
 Anorexia 66  Anxiety 24
 Lack of energy 61  Vomiting 23
 Dry mouth 57  Confusion 21
 Constipation 52  Dizziness 19
 Early satiety 51  Dyspepsia 19
 Dyspnea 50  Dysphagia 18
 Weight loss 50  Belching 18
 Sleep problems 49  Bloating 18
 Depression 41  Wheezing 13
 Cough 38  Memory problems 12
 Nausea 36  Headache 11

Most Common Symptoms of Patients with Advanced Cancer Walsh D, Donnelly S, Rybicki L. Support Care Cancer
2000;8:175-179.
THREE CATEGORIES OF SUPPORT
 Pain management is vital for comfort and to reduce
patients’ distress. Health care professionals and
families can collaborate to identify the sources of pain
and relieve them with drugs and other forms of
therapy.
 Symptom management involves treating symptoms
other than pain such as nausea, weakness, bowel and
bladder problems, mental confusion, fatigue, and
difficulty breathing
 Emotional and spiritual support is important for both
the patient and family in dealing with the emotional
demands of critical illness.
A palliative care team delivers many forms of help to a
patient suffering from a severe illness, including :
 Close communication with doctors
 Expert management of pain and other symptoms
 Help navigating the healthcare system
 Guidance with difficult and complex treatment choices
 Emotional and spiritual support for the patient and their
family
 Successful palliative care teams require nurturing
individuals who are willing to collaborate with one
another.
 Researchers have studied the positive effects palliative
care has on patients. Recent studies show that patients
who receive palliative care report improvement in:
 Pain and other distressing symptoms, such as nausea or shortness of
breath
 Communication with their doctors and family members
 Emotional and psychological state
COUNTRIES WITH ESTABLISHED SYSTEMS
• Australia
• In 1987, Ian Maddocks accepted the world’s first Chair in Palliative Care at
Flinders University.
• Palliative care is recognized as a medical specialty in 2005.
• Around 320 palliative care services are operational.
• Japan
• Palliative care standards were first introduced in 1997.
• Palliative care education is included in the curriculum of most medical
schools in the country and all nursing schools.
• 120 services related to palliative care are available country-wide.
• Singapore
• 13 organizations providing palliative care.
• Palliative care module added to medical school curriculums.
COUNTRIES WITH ESTABLISHED SYSTEMS

• Malaysia
• In 1998, the Government began requiring every district and
general hospital to introduce a palliative care provision.
• Mongolia
• Palliative care incorporated into National health plan.
• Palliative care module included in medical school curriculum.
• New Zealand
• A palliative care education program has been established for
care assistants.
• 41 services are currently delivering palliative care throughout
the country.
COUNTRIES WITH LOCALIZED PROVISIONS

 China
 South Korea
 Philippines
 Vietnam
COUNTRIES WITH BUILDING CAPACITY

 Brunei Darussalam
 Fiji
 Papua New Guinea

The countries are aiming to create conditions for the

development of programs focused on palliative care.
COUNTRIES WITH NO PALLIATIVE CARE
 American Samoa  Northern Mariana Islands
 Cook Islands  Palau
 French Polynesia  Pitcairn Islands
 Guam  Samoa
 Kiribati  Soloman Islands
 Laos  Tokelau
 Marshall Islands  Tonga
 Micronesia  Tuvalu
 Nauru  Vanuatu
 New Calendonia  Wallis and Futuna
 Niue
PALLIATIVE CARE
 SIDE EFFECTS
ORAL ANTICANCER THERAPY

• The incidence and occurrence of side effects is drug and

dose related

• It is essential to know the regime specific facts

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
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
 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
NEUTROPAENIC SEPSIS
 White blood count of less than 1.0 X 20 9/l and one of the
following
 Oral temp >380c
 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
 Urgent blood test required
 Deterioration can be rapid
 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
ALTERED BOWEL HABIT
Diarrhoea
 Potentially life threatening complication
 Severe diarrhoea may require hospital admission to prevent
dehydration
 Anti-diarrhoeal medication – loperamide

Constipation
 Vinca alkaloids
 Exacerbated by graniestron
 Risk of paralytic ileus
 May need laxatives
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
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 ADL’s
 Diminishes once treatment has ended
SKIN REACTIONS

 Marked skin reactions can occur with some

chemotherapy agents
 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
PAIN IN CANCER
 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
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)
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
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
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
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