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BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
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BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer

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  • 1. Palliative and supportive care in lung cancer
    Dr. Răzvan Curcă
    Emergency County Hospital Alba Iulia, Romania
  • 2. Palliative care (PC)
    Seeks to manage the symptoms of advanced and terminal illness
    Views people as a whole individual rather than a disease process to be treated
    Delivers holistic care through multidisciplinary team working
    MORE ON THIS SUBJECT ON SUNDAY AT 8:30 A.M.
  • 3. Model of palliative cancer care
  • 4. Main physical problems in advancedlung cancer patients
    Pain
    Dyspnea
    Local airway symptomes: cough, hemoptysis, and postobstructive pneumonia
    Brain metastases
    Palliative emergencies- spinal cord compression, superior vena cava syndrome, hypercalcemia
    Silvestri GA, et. Al: Caring for the Dying Patient With Lung Cancer, Chest, September 2002, 122:1028-1036
  • 5. Comprehensive assesment in PC&SC
  • 6. Ideal therapy in advanced lung cancer
    Improve overall survival
    Improve quality of life
    No or minimal toxicity
    Nearly all of the recommendations in this guideline are based on clinical trials that demonstrate improvements in OS using chemotherapy, with improvement (or lack of detriment) in QOL.
    Azzoli, CG, Baker S, Jr, Temin, S, et al. ASCO Clinical Practice Guideline update on chemotherapy for stage IV NSCLC. JClinOncol 2009; 27:6251.
  • 7. Early Palliative Care for Patients withMetastatic Non–Small-Cell Lung Cancer
    Temel JS, Greer JA, Gallagher E, Admane S, Pirl WF, Jackson VA, Dahlin C, Muzikansky A, Jacobsen J, Lynch TJ
  • 8.
  • 9. Study objectives
    Primary objective: Change from baseline to 12 weeks in the score on the Trial Outcome Index (TOI), which is the sum of the scores on the lung cancer subscale (LCS) for 7 cardinal symptomes and the physical well-being and functional well-being subscales of the FACT-L QoL scale.
    Secondary objectives:
    Mood change from baseline to 12 weeks in the score on Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire 9 (PHQ- 9)
    Percentage of patients receiving aggressive end-of-life care (chemotherapy within 14 days before death, no hospice care, or admission to hospice 3 days or less before death)
    Overall survival
  • 10.
  • 11. There was no difference in the use of antidepressant agents!
  • 12. Effects on end-of-life care
    Fewer patients in the PC vs. the standard care group received aggressive end-of-life care.
    Aggressive End of Life Care
    Standard Care 54% p = .05
    Standard Care + PC 33%
  • 13. Less aggressive end-of-life care
    More resuscitation directives in advance (54% vs. 33%, p = 0.05).
    Early referral to hospice (median duration of hospice care, 11 vs. 4 days, P = 0.09)
    Fewer chemotherapy within 14 days before death
    BUT less aggressive end-of-life care did not adversely affect survival!
  • 14.
  • 15. Study Limitations
    • Small Study
    • 16. 1 Center (MassGenH)
    • 17. Relatively Non-Diverse Population
    • 18. Some patients in the non-Palliative Care group received ‘Palliative Therapies’ (but this eventually reduced the magnitude of the observed benefit!)
  • The Authors Concluded:
    Early integration of palliative care for patients with metastatic NSCLC led to significant improvements in both quality of life and mood.
    Patients receiving early palliative care had less aggressive care at the end of life, but longer survival.
  • 19. NEJM Speaker’s Editorial“Palliative Care — A Shifting Paradigm”
    Well designed, well-executed study with clinically relevant end points.
    Early palliative medicine referral improved survival with almost 3 months along with better QOL.
    Same survival advantage as palliative platinum-based chemotherapy.
    This study is an example of research that shifts a long-held paradigm that PC is the alternative to life-prolonging or curative care — “what we do when there is nothing more that we can do”— rather than as a simultaneously delivered adjunct to disease-focused treatment.
    Kelley AS, Meier DE. Palliative Care — A Shifting Paradigm. NEJM 2010; 363:781-782.
  • 20. Early PC in advanced lung cancer



    Improved overall survival
    Improved quality of life
    No toxicity
    IN ADDITION TO STANDARD CHEMOTHERAPY!
  • 21. “ There’s not a place in the world where I’ve found people eager to die.
    If [palliative care] is marketed as end-of-life care, there is the same reluctance;
    if it’s marketed as a way to have a much better life and help you live longer, then it’s much more acceptable.”
    Dr. Frank Ferris
    Director, International Programs, San Diego Hospice & Palliative Care
  • 22.
  • 23. Consequence: defining BSC
    BSC (best supportive care) is an old term (‘80s), but very familiar to many oncologists
    It is “politically correct term” used for “no chemo” in clinical trials with chemotherapy vs. no chemotherapy design
    What is the difference between BSC and SC ??
  • 24. Why was BSC introduced?
    It’s easier to be accepted by the patients in order to be included in clinical trials with that specific design (“best” is supposed to be better than standard care).
    It could be more acceptable by ethics comitees and regulatory bodies.
  • 25. BSC - implications
    Usually, the BSC arm is found to be inferior to the chemotherapy arm with respect to objective tumor response and survival.
    Possible conclusion: it’s always preferable to receive chemo than to be referred to PC!
  • 26. BSC – future directions
    After Temel’s study it will be mandatory to define precisely all PC&SC interventions in clinical trials in order to prevent flaws in results.
    Integration of new assessment instruments frequently used in PC (eg. ESAS).
    Necessity for defining and implementing quality standards for PC&SC (defining Best).
  • 27.
  • 28. Killing the symptom without killing the patient
    Maybe the most challenging cases are advanced lung cancer pts. with severe dyspnea
    The main question: are opioids safe in this clinical setting?
  • 29. Management of dyspnea in advancedlung cancer patients
  • 30. Opioids in the therapy of dyspnea
    It sounds like “malpraxis” for many oncologists from Balkan countries, because of a restrictive legislation promoting opiophobia among many physicians
    Lack of proper PC&SC training during medical studies and residency induce also opiophobia (e.g. in Romania- no PC training in almoust all Medicine Universities, only a few months during residency, few PC specialists and trainers)
    Regulatory barriers in access to opioids
  • 31. European consumtion of morphine
  • 32. Bureaucratic barriers in opioid access
    The countries with the most limited opioid formularies tended also to have the greatest number of regulatory barriers to accessibility.
    Among the Western European countries, Turkey and Greece had more limited formularies and more accessibility barriers compared with the other countries.
    Among the East-European countries, there was much greater heterogeneity. Some countries like the Czech Republic, Croatia and Hungary had formulary availability and accessibility that was as good as most of the Western European countries.
    In contrast, several countries including Montenegro, Macedonia, Bosnia–Herzegovina, Albania and Ukraine had very restricted formularies and multiple barriers to accessibility.
    N. I. Cherny, J. Baselga et al. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative Ann Oncol 2010: 21(3): 615-626
  • 33. Pivotal trials of opioids for dyspnea
    Bruera E, MacEachern T, Ripamonti C, et al. Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med 1993
    Mazzocato C, Buclin T, Rapin C-H. The effects of morphine on dyspnea and ventilatory function in elderly patients with advanced cancer: a randomized double-blind controlled trial. Ann Oncol 1999
    Allard P, Lamontagne C, Bernard P, et al. How effective are supplementary doses of opioids for dyspnea in terminally ill cancer patients? A randomized continuous sequential clinical trial. J Pain Symptom Manage 1999
  • 34. Opioids in the therapy of dyspnea
    Studies show that appropriate doses of opioids do not cause respiratory depression.
    Caution is adviced for pts.:
    > 65 years
    During dose titration of the opioid
    With abnormal renal function
    With concomitant use of sedatives
    Close monitoring is very important.
  • 35. Opioids in the therapy of dyspnea
    Thomas JR, von Gunten CF. Clinical management of dyspnoea. Lancet Oncol 2002;3(4):223-8.
  • 36. Systematic review of medical interventions for cancer-related dyspnea
    The administration of subcutaneous morphine resulted in a significant reduction in dyspnea Visual Analog Scale (VAS) compared with placebo.
    No difference was observed in dyspnea VAS score when nebulized morphine was compared with subcutaneous morphine, although patients preferred the nebulized route.
    Ben-Aharon I, Gafter-Gvili A, et al. Interventions for Alleviating Cancer-Related Dyspnea: A Systematic Review, J Clin Oncol May 10, 2008:2396-2404
  • 37. Role of supplemental oxygen
    Oxygen was not superior to air for alleviating dyspnea, except for patients with hypoxemia.
    In PC, the use of supplemental oxygen is expensive and may carry adverse effects including restriction of activities, possible impairment of quality of life, and psychological dependence.
    Ben-Aharon I, Gafter-Gvili A, et al. Interventions for Alleviating Cancer-Related Dyspnea: A Systematic Review, J Clin Oncol May 10, 2008:2396-2404
  • 38. Role of supplemental oxygen
    A recent double-blinded randomized clinical trial, published in 2010, confirm the results of the systematic review
    239 pts. were randomized between oxygen and room air, administered via nasal cannula
    Confirms that air movement over the face, nose, and nares helps relieve dyspnea whether it is via nasal cannula, fan, or an open window.
    Abernethy, AP, McDonald, CF, Frith, PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet 2010; 376:784.
  • 39. Role of benzodiazepines
    The addition of benzodiazepines to morphine was significantly more effective than morphine alone, without additional adverse effects*.
    Cochrane review 2010- Benzodiazepines are indicated as a second or third-line treatment, when opioids and non-pharmacological measures have failed to control breathlessness.
    Main effect is mainly by alleviation of anxiety, frequently asscociated with shortness of breath, which frequently is worsening dyspnea.
    *Navigante AH, Cerchietti LC, Castro MA, et al: Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage 31:38-47, 2006
  • 40. Take home messages
    Early PC & SC in advanced lung cancer pts. led to significant improvements in both quality of life and survival in addition to standard chemotherapy.
    Defining and implementing quality standards for PC&SC is of paramount importance for future clinical research
    Mainstay therapy for dyspnea in lung cancer patients are opioids, benzodiazepines and non-pharmacological interventions.
  • 41. Thank You for Your Attention!
    Aerial view of Alba Iulia Fortress, Romania

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