FOCUSSING ON CYTOTOXIC TREAT-MENT ALONE IS NOT ENOUGH Per Hartvig,  European Society of Oncology Pharmacy, ESOP and    Uni...
European Society of Oncology    pharmacy, ESOP <ul><li>AIM of ESOP is To support optimal treatment of cancer patients  </l...
MasterClass in Oncology    Pharmacy,  Ishöj, Dk, Nov 5th to 9th <ul><li>Oncology Pharmacy Production service </li></ul><ul...
Adverse effects of cytotoxic    drugs in patients <ul><li>Acute toxicity  Nausea, hair loss etc, </li></ul><ul><li>&quot;O...
Handling of cytotoxic of drugs <ul><li>&quot;Safe handling and preparation of cytotoxic drugs using gloves, protective cuf...
Exposure to cytotoxic drugs   <ul><li>Biomarkers </li></ul><ul><ul><li>Bacterial fluctuation test </li></ul></ul><ul><ul><...
Health risk of cytotoxic drugs   <ul><li>Increased rate of spontaneous abortions was 1.33 in 897 per year  </li></ul><ul><...
Health risk of cytotoxic drugs <ul><li>Only increased risk for spontaneous abortions </li></ul><ul><li>Underestimation of ...
<ul><li>FOCUSSING ON CYTOTOXIC TREATMENT ALONE IS NOT ENOUGH……..   </li></ul>
Supportive care <ul><li>Pain </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Fatigue </li></ul><ul><li>Diarrhoea <...
Role of the oncology  pharmacist <ul><li>A member of the cancer care team </li></ul><ul><li>Formulate a treatment plan for...
Treatment of nausea and vomiting <ul><li>Nausea and vomiting due to cancer and cancer treatment most feared side effect </...
Treatment of Cytotoxic induced emesis Perugia document 2004 <ul><li>Phase ___  Cytotoxics _  Recommended drugs </li></ul><...
Questions still to be answered: <ul><ul><li>Why so intense  ? </li></ul></ul><ul><ul><li>Why so long, even after eliminati...
Triggers for emesis <ul><li>GI tract - chromaffin cells in the fundus of ventricle </li></ul><ul><li>Nucleus vestibularis ...
Acute phase of cytotoxic emesis <ul><li>Starts on day one and have a short duration  </li></ul><ul><li>often compatiple wi...
Delayed cytotoxic induced emesis <ul><li>Neuropeptides increase the release of neuro-transmitters which may trigger emesis...
Late phase–anticipatory emesis <ul><li>Occurs month to years after cytotoxic drugs </li></ul><ul><li>Occurs by rememberanc...
Knowledge nessecary for better emesis control in cancer <ul><li>Different mechanisms over time </li></ul><ul><ul><li>Acute...
Cytotoxic drug induced  fatigue -still a treatment challenge for the suffering cancer patient <ul><li>Prevalence is very h...
Treatment of fatigue <ul><li>Virtually NONE </li></ul><ul><li>Multidimensional disorder requiring a combination of interve...
Fatigue in cancer patients <ul><li>Mechanisms in fatigue </li></ul><ul><ul><li>Cytokines as IL-1   and IL-6 with activati...
Exercise to combat fatigue <ul><li>One week after treatment </li></ul><ul><li>Next treatment  </li></ul>
Fatigue and other side effects
The Oncology Pharmacist <ul><li>The role of the oncology pharmacist </li></ul><ul><ul><li>Patients must be informed about ...
Patients need information   <ul><li>Information FROM patients (needs assessment, feedback for quality improvement, values ...
Feed back from patients <ul><li>No one to talk to about anxieties and concerns </li></ul><ul><li>Tests/treatments not clea...
Research finding from Germany <ul><li>Most patients want more information </li></ul><ul><li>Many, but not all, patients wa...
Patient Information Needs   <ul><li>Illness and symptoms </li></ul><ul><li>Tests and treatment options </li></ul><ul><li>S...
Patients questions at diagnosis <ul><li>What is wrong with me? </li></ul><ul><li>What is causing the problem? </li></ul><u...
Patients questions on treatment <ul><li>What are the options? </li></ul><ul><li>Benefits and harms? </li></ul><ul><li>Will...
Quality Standards for Patient   information <ul><li>Use patients’ questions as starting point </li></ul><ul><li>Address pa...
Questions reflecting    pharmaceutical care <ul><li>Are you interested to learn about side-effects and interactions relate...
Role of Oncology pharmacist <ul><li>60% of all patients like to get informations from pharmacists.  </li></ul><ul><li>75% ...
<ul><li>FOCUSSING ON CYTOTOXIC TREATMENT ALONE IS NOT  </li></ul><ul><li>ENOUGH……….. </li></ul><ul><li>Thank You all  </li...
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Focussing on cytotoxic treatment alone is not enough

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PharmaCon2007 Congress, Dubrovnik, Croatia "New Technologies and Trends in Pharmacy, Pharmaceutical Industry and Education" http://www.pharmacon2007.com
Abstract is available at http://www.pharmaconnectme.com

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Focussing on cytotoxic treatment alone is not enough

  1. 1. FOCUSSING ON CYTOTOXIC TREAT-MENT ALONE IS NOT ENOUGH Per Hartvig, European Society of Oncology Pharmacy, ESOP and University hospital pharmacy, Uppsala, Sweden
  2. 2. European Society of Oncology pharmacy, ESOP <ul><li>AIM of ESOP is To support optimal treatment of cancer patients </li></ul><ul><li>Objectives: </li></ul><ul><ul><li>To develop oncology pharmacy by </li></ul></ul><ul><ul><li>Education and training </li></ul></ul><ul><ul><li>Safe handling and administration of drugs </li></ul></ul><ul><ul><li>Quality management </li></ul></ul><ul><ul><li>Research and development </li></ul></ul><ul><ul><li>Pharmaceutical care </li></ul></ul>
  3. 3. MasterClass in Oncology Pharmacy, Ishöj, Dk, Nov 5th to 9th <ul><li>Oncology Pharmacy Production service </li></ul><ul><li>Safe handling of cytotoxic drugs </li></ul><ul><li>Clinical oncology pharmacy </li></ul><ul><li>Cancer care needs and future developments </li></ul><ul><li>Pharmaceutical care needs in oncology </li></ul>
  4. 4. Adverse effects of cytotoxic drugs in patients <ul><li>Acute toxicity Nausea, hair loss etc, </li></ul><ul><li>&quot;Oversensitivity&quot; Rash, airway </li></ul><ul><li>obstruction, edema </li></ul><ul><li>Teratogenic Misscarriage, still </li></ul><ul><li>birth, malformations </li></ul><ul><li>Mutagenenic DNA damage </li></ul><ul><li>Cancerogenic Secondary cancer </li></ul>
  5. 5. Handling of cytotoxic of drugs <ul><li>&quot;Safe handling and preparation of cytotoxic drugs using gloves, protective cuffs, special gowning, mouth mask and glasses in a special vertical air laminar flow box do not give enhanced mutagenic activity in urine of personnel&quot; </li></ul><ul><ul><ul><ul><ul><li>B Kolmodin-Hedman, P Hartvig, M Sorsa, K Falck </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Arch Toxicol 54: 25-33, 1983 </li></ul></ul></ul></ul></ul>
  6. 6. Exposure to cytotoxic drugs <ul><li>Biomarkers </li></ul><ul><ul><li>Bacterial fluctuation test </li></ul></ul><ul><ul><li>Sister chromatid exchanges </li></ul></ul><ul><ul><li>Thioethers in urine </li></ul></ul><ul><ul><li>Chromosmal abberations in lymphocytes </li></ul></ul><ul><ul><li>Direct assay of drug: HPLC with TOF-MS </li></ul></ul><ul><ul><li>(MS/MS) </li></ul></ul>
  7. 7. Health risk of cytotoxic drugs <ul><li>Increased rate of spontaneous abortions was 1.33 in 897 per year </li></ul><ul><li>Epidemiological studies only establish relation between exposure and outcome not CAUSE </li></ul>
  8. 8. Health risk of cytotoxic drugs <ul><li>Only increased risk for spontaneous abortions </li></ul><ul><li>Underestimation of risk may cause major health effects </li></ul><ul><li>Overestimation causes may redirect limited resources away from larger risks </li></ul><ul><li>Effective risk communication necessary: </li></ul><ul><ul><li>&quot;People are more afraid of low relative risks&quot; </li></ul></ul>
  9. 9. <ul><li>FOCUSSING ON CYTOTOXIC TREATMENT ALONE IS NOT ENOUGH…….. </li></ul>
  10. 10. Supportive care <ul><li>Pain </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Fatigue </li></ul><ul><li>Diarrhoea </li></ul><ul><li>Constipation </li></ul><ul><li>Cachexia </li></ul><ul><li>Fewer </li></ul><ul><li>Infection </li></ul><ul><li>Mucositis </li></ul><ul><li>Alopecia </li></ul><ul><li>Neutropenia </li></ul><ul><li>Anxiety </li></ul><ul><li>Sleep problems </li></ul><ul><li>Social interferences </li></ul><ul><li>Phycological distress </li></ul><ul><li>Sleep disturbances </li></ul>
  11. 11. Role of the oncology pharmacist <ul><li>A member of the cancer care team </li></ul><ul><li>Formulate a treatment plan for each patient </li></ul><ul><li>Optimise supportive treatment for every patient </li></ul><ul><li>Expert on cytotoxic drug preparation </li></ul><ul><li>Pharmacologic consultant </li></ul><ul><li>Information to patients and personnel </li></ul>
  12. 12. Treatment of nausea and vomiting <ul><li>Nausea and vomiting due to cancer and cancer treatment most feared side effect </li></ul><ul><li>Nausea appear in different phase (acute, delayed and anticipatory) </li></ul><ul><li>New drug principles has improved treatment </li></ul><ul><li>Mechanism of cytotoxic induced nausea and vomiting still unclear </li></ul>
  13. 13. Treatment of Cytotoxic induced emesis Perugia document 2004 <ul><li>Phase ___ Cytotoxics _ Recommended drugs </li></ul><ul><li>1. Acute phase </li></ul><ul><li>Low 5FU, methotrexate Dexamethason </li></ul><ul><li>High Cyclophosphamide Sertrone + examethason Doxorubicin,epirubicin +aprepitant (NK1 ant) </li></ul><ul><li>Cisplatinum </li></ul><ul><li>2.Delayed emesis </li></ul><ul><li>Low Dexametason </li></ul><ul><li>High Dexamethason+aprepitant </li></ul><ul><li>3. Anticipatory emesis Prevention of acute and </li></ul><ul><li>delayed emesis-lorazepam </li></ul>
  14. 14. Questions still to be answered: <ul><ul><li>Why so intense ? </li></ul></ul><ul><ul><li>Why so long, even after elimination of cytotoxic drugs ? </li></ul></ul><ul><ul><li>Why occur emesis even without cytotoxic drugs - e.g. anticipatory emesis ? </li></ul></ul><ul><ul><li>Mechanism of action </li></ul></ul>
  15. 15. Triggers for emesis <ul><li>GI tract - chromaffin cells in the fundus of ventricle </li></ul><ul><li>Nucleus vestibularis in the centre for balance </li></ul><ul><li>Chemoreceptor triggerzon outside 4th ventricule </li></ul><ul><li>Centre of emesis in the brain </li></ul>
  16. 16. Acute phase of cytotoxic emesis <ul><li>Starts on day one and have a short duration </li></ul><ul><li>often compatiple with kinetics of cytotoxics </li></ul><ul><li>Sertrones, blocking 5HT3 receptors in the stomach and emesis centre are effective </li></ul><ul><li>New sertrones have longer duration due to higher receptor affinity and better kinetics </li></ul>
  17. 17. Delayed cytotoxic induced emesis <ul><li>Neuropeptides increase the release of neuro-transmitters which may trigger emesis </li></ul><ul><li>Cytotoxic drugs interfere with DNA in cells producing enzymes responsible for degradation of the neuropeptides </li></ul><ul><li>Cytotoxics increase levels of neuropeptides not degraded by loss of catabolising </li></ul><ul><li>enzymes </li></ul><ul><li>Blockade of neuropeptide receptors NK1 (aprepitant) are effective </li></ul>
  18. 18. Late phase–anticipatory emesis <ul><li>Occurs month to years after cytotoxic drugs </li></ul><ul><li>Occurs by rememberance of cytotoxics </li></ul><ul><li>No effective treatment available </li></ul><ul><li>Mechanism: Induction of wind-up weith formation of a protein for rememberance </li></ul><ul><li>Suggested methods </li></ul><ul><ul><li>effective treatment of early cytotoxic amnesia effect of benzodiazepines (lorazepam) </li></ul></ul><ul><ul><li>induced emesis </li></ul></ul>
  19. 19. Knowledge nessecary for better emesis control in cancer <ul><li>Different mechanisms over time </li></ul><ul><ul><li>Acute : Induce release of serotonin and dopamine </li></ul></ul><ul><ul><li>Delayed : Increased neuropeptide levels due to inhibition of catabolism </li></ul></ul><ul><ul><li>Late anticipatory: Sensitisation with formation of a ”memory protein” </li></ul></ul><ul><li>Although improved treatment, emesis still a problem following cytotoxic drugs. </li></ul>
  20. 20. Cytotoxic drug induced fatigue -still a treatment challenge for the suffering cancer patient <ul><li>Prevalence is very high > 80 % </li></ul><ul><li>There is no translation of ”fatigue” </li></ul><ul><li>The cancer patient perspective </li></ul><ul><ul><li>” I have been tired in the past but never so much as now” </li></ul></ul><ul><ul><li>” I now become tired very suddenly, My energy used to run out gradually instead of all at once now” </li></ul></ul><ul><ul><li>” I am physically worn out” </li></ul></ul>
  21. 21. Treatment of fatigue <ul><li>Virtually NONE </li></ul><ul><li>Multidimensional disorder requiring a combination of interventions </li></ul><ul><li>”… the best way to treat fatigue may be be to take into consideration and treat all components that contribute”( Kalman 1997 ) </li></ul><ul><li>(Drugs, Antidepressants ?) </li></ul>
  22. 22. Fatigue in cancer patients <ul><li>Mechanisms in fatigue </li></ul><ul><ul><li>Cytokines as IL-1  and IL-6 with activation of the HPA axis and CRH </li></ul></ul><ul><ul><li>Stressinduced lower release of corticotropin releasing factor, CRH </li></ul></ul><ul><ul><li>Central changes in serotonin and noradrenergic transmission </li></ul></ul><ul><ul><li>The role of Substance P </li></ul></ul><ul><ul><li>EXERCISE ? </li></ul></ul>
  23. 23. Exercise to combat fatigue <ul><li>One week after treatment </li></ul><ul><li>Next treatment </li></ul>
  24. 24. Fatigue and other side effects
  25. 25. The Oncology Pharmacist <ul><li>The role of the oncology pharmacist </li></ul><ul><ul><li>Patients must be informed about fatigue in cancer and cytotoxic drug treatment </li></ul></ul><ul><ul><li>Fatigue must be included in a treatment plan </li></ul></ul><ul><ul><li>Treatment of patient´s side effects essential </li></ul></ul><ul><ul><li>Exercise good alternative to combat fatigue </li></ul></ul><ul><ul><li>Early and repeated information necessary to introduce exercise in daily life in cancer </li></ul></ul>
  26. 26. Patients need information <ul><li>Information FROM patients (needs assessment, feedback for quality improvement, values and preferences) </li></ul><ul><li>Information TO patients (prevention, self-care, treatment decisions, policy options) </li></ul>
  27. 27. Feed back from patients <ul><li>No one to talk to about anxieties and concerns </li></ul><ul><li>Tests/treatments not clearly explained </li></ul><ul><li>Not enough involvement in decisions </li></ul><ul><li>Insufficient information for family/friends </li></ul><ul><li>Insufficient information about recovery </li></ul>
  28. 28. Research finding from Germany <ul><li>Most patients want more information </li></ul><ul><li>Many, but not all, patients want to participate in decisions about their care </li></ul><ul><li>Clinicians underestimate patients’ desire for information </li></ul><ul><li>Clinicians are often unaware of patients’ preferences </li></ul>
  29. 29. Patient Information Needs <ul><li>Illness and symptoms </li></ul><ul><li>Tests and treatment options </li></ul><ul><li>Self-help and prevention </li></ul><ul><li>Services and sources of help </li></ul><ul><li>Quality of health care providers </li></ul>
  30. 30. Patients questions at diagnosis <ul><li>What is wrong with me? </li></ul><ul><li>What is causing the problem? </li></ul><ul><li>What are the tests for? </li></ul><ul><li>How certain is the diagnosis? </li></ul><ul><li>How does my experience compare with others with this problem? </li></ul>
  31. 31. Patients questions on treatment <ul><li>What are the options? </li></ul><ul><li>Benefits and harms? </li></ul><ul><li>Will treatment relieve the symptoms? </li></ul><ul><li>Is treatment essential? </li></ul><ul><li>Recovery time? </li></ul><ul><li>Impact on quality of life? </li></ul>
  32. 32. Quality Standards for Patient information <ul><li>Use patients’ questions as starting point </li></ul><ul><li>Address patients’ concerns </li></ul><ul><li>Include all treatment options </li></ul><ul><li>Honest about benefits and harms </li></ul><ul><li>Quantify where possible </li></ul><ul><li>Questions to ask the doctor </li></ul>
  33. 33. Questions reflecting pharmaceutical care <ul><li>Are you interested to learn about side-effects and interactions related to your oncology therapy? </li></ul><ul><li>Has your pharmacist informed you about these topics? </li></ul><ul><li>In which topics you are mostly interested to be informed by your pharmacist? </li></ul>
  34. 34. Role of Oncology pharmacist <ul><li>60% of all patients like to get informations from pharmacists. </li></ul><ul><li>75% of all patient, who like to get good informations have got no satisfaction. </li></ul><ul><li>Information about cytotoxics drugs as well as supportive drugs shall be added with information of alternative medicine (30% of all patients). </li></ul>
  35. 35. <ul><li>FOCUSSING ON CYTOTOXIC TREATMENT ALONE IS NOT </li></ul><ul><li>ENOUGH……….. </li></ul><ul><li>Thank You all </li></ul>

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