This document discusses integrative oncology and comprehensive care for cancer patients. It defines integrative medicine as combining biomedical care with complementary therapies to heal the whole person - body, mind and spirit. The document notes high rates of complementary and alternative medicine use among cancer patients and barriers to discussing these therapies with oncologists. It emphasizes treating the individual patient and their disease, and the importance of lifestyle factors like diet, exercise and weight in cancer prevention and survival.
SHARE Presentation: Integrative Medicine and Cancer with Dr. Heather Greenleebkling
Oncology doctors are considering new ways in addition to conventional care to improve cancer outcomes. Examples of integrative medicine include acupuncture, mind-body approaches, and botanicals. Dr. Heather Greenlee of Columbia University Mailman School of Public Health will discuss new guidelines developed within the Society for Integrative Oncology.
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
This document summarizes the management of high grade gliomas. It discusses the classification, molecular markers, diagnostic evaluation, treatment including surgery, radiation, chemotherapy, prognostic factors and response assessment for these aggressive brain tumors. Key points include the distinction between glioblastoma and anaplastic astrocytoma/oligodendroglioma, the role of maximal safe resection followed by concurrent chemoradiation using temozolomide as the standard of care, and important prognostic markers like MGMT promoter methylation status. Pseudoprogression and pseudoresponse on imaging are also reviewed.
1. Several molecular pathways are involved in breast cancer pathogenesis, including steroid hormone receptors, HER2/neu, cell cycle proteins, and growth factors.
2. Risk factors for breast cancer include increasing age, female gender, family history, genetic mutations, personal history of breast cancer or other breast diseases, reproductive factors, and hormone use.
3. High risk patients are identified using tools like the Gail model and managed through increased screening including breast self-exams, clinical exams, mammograms, and MRI. Preventive options include tamoxifen, raloxifen, and prophylactic surgeries.
This document discusses cancer cachexia, beginning with an introduction that notes weight loss in cancer patients is associated with poor quality of life and increased morbidity. It then defines cachexia as a complex metabolic syndrome characterized by loss of muscle and fat mass. The pathophysiology section explains cachexia is multifactorial, involving anorexia, abnormal metabolism, and cytokine changes. Management involves treating the underlying cancer, nutritional intervention such as supplements by various routes, and pharmacological treatments including progestational agents, corticosteroids, and cytokine inhibitors, with some promising animal research on combinations. The document concludes by recommending various steps to address cachexia in clinical practice.
The RAPIDO trial tested a new experimental treatment for locally advanced rectal cancer that involved short-course radiotherapy followed by chemotherapy before surgery, compared to the standard treatment of long-course chemoradiotherapy followed by surgery and then chemotherapy. The results showed that the experimental treatment led to a lower rate of disease-related treatment failures and distant metastases, along with a doubled rate of pathologic complete responses, without increasing toxicities or compromising survival rates. This provides evidence that the experimental approach may be a new standard of care for high-risk locally advanced rectal cancer.
This document discusses the options and challenges for reirradiating recurrent brain tumors. It may be considered for gliomas or brain metastases if the prior radiation tolerance doses of critical structures like the optic pathways, brainstem and whole brain have not been exceeded. Differentiating tumor recurrence from treatment effects like necrosis or pseudoprogression is important prior to reirradiation. Short interval since prior radiation and large tumor volume predict poor outcomes. With smaller recurrences in favorable locations, reirradiation using techniques like stereotactic radiosurgery may be offered if the radiation interval is over 6 months. A multidisciplinary discussion weighing risks and benefits is needed for each case.
SHARE Presentation: Integrative Medicine and Cancer with Dr. Heather Greenleebkling
Oncology doctors are considering new ways in addition to conventional care to improve cancer outcomes. Examples of integrative medicine include acupuncture, mind-body approaches, and botanicals. Dr. Heather Greenlee of Columbia University Mailman School of Public Health will discuss new guidelines developed within the Society for Integrative Oncology.
Geriatric Oncology
1. Relationship between aging and cancer
2. Constructs of frailty and multimorbidity
3. Evidence for geriatric assessment in older adults living with cancer
Hypofractionation in early breast cancer is no more a research scholars topic. Multiple studies with robust data have proven its utility. It may hold an important role in many countries with constrained resources. This is a short presentation incorporating important completed and ongoing trials. Feel free to use this.
This document summarizes the management of high grade gliomas. It discusses the classification, molecular markers, diagnostic evaluation, treatment including surgery, radiation, chemotherapy, prognostic factors and response assessment for these aggressive brain tumors. Key points include the distinction between glioblastoma and anaplastic astrocytoma/oligodendroglioma, the role of maximal safe resection followed by concurrent chemoradiation using temozolomide as the standard of care, and important prognostic markers like MGMT promoter methylation status. Pseudoprogression and pseudoresponse on imaging are also reviewed.
1. Several molecular pathways are involved in breast cancer pathogenesis, including steroid hormone receptors, HER2/neu, cell cycle proteins, and growth factors.
2. Risk factors for breast cancer include increasing age, female gender, family history, genetic mutations, personal history of breast cancer or other breast diseases, reproductive factors, and hormone use.
3. High risk patients are identified using tools like the Gail model and managed through increased screening including breast self-exams, clinical exams, mammograms, and MRI. Preventive options include tamoxifen, raloxifen, and prophylactic surgeries.
This document discusses cancer cachexia, beginning with an introduction that notes weight loss in cancer patients is associated with poor quality of life and increased morbidity. It then defines cachexia as a complex metabolic syndrome characterized by loss of muscle and fat mass. The pathophysiology section explains cachexia is multifactorial, involving anorexia, abnormal metabolism, and cytokine changes. Management involves treating the underlying cancer, nutritional intervention such as supplements by various routes, and pharmacological treatments including progestational agents, corticosteroids, and cytokine inhibitors, with some promising animal research on combinations. The document concludes by recommending various steps to address cachexia in clinical practice.
The RAPIDO trial tested a new experimental treatment for locally advanced rectal cancer that involved short-course radiotherapy followed by chemotherapy before surgery, compared to the standard treatment of long-course chemoradiotherapy followed by surgery and then chemotherapy. The results showed that the experimental treatment led to a lower rate of disease-related treatment failures and distant metastases, along with a doubled rate of pathologic complete responses, without increasing toxicities or compromising survival rates. This provides evidence that the experimental approach may be a new standard of care for high-risk locally advanced rectal cancer.
This document discusses the options and challenges for reirradiating recurrent brain tumors. It may be considered for gliomas or brain metastases if the prior radiation tolerance doses of critical structures like the optic pathways, brainstem and whole brain have not been exceeded. Differentiating tumor recurrence from treatment effects like necrosis or pseudoprogression is important prior to reirradiation. Short interval since prior radiation and large tumor volume predict poor outcomes. With smaller recurrences in favorable locations, reirradiation using techniques like stereotactic radiosurgery may be offered if the radiation interval is over 6 months. A multidisciplinary discussion weighing risks and benefits is needed for each case.
Principles of medical_oncology dr. varunVarun Goel
- The document discusses several key principles of medical oncology including that cancer treatment is multidisciplinary, early stage cancers are more curable than late stage, and the best treatment is often found in clinical trials.
- It describes the basic tenets of chemotherapy including that it can be used for induction treatment of advanced cancers or as adjuvant treatment after local therapy to treat high risk of recurrence. The intent of chemotherapy can be curative or palliative.
- Several models of tumor growth and response to chemotherapy are explained including the Skipper-Wilcox model, concepts of combination chemotherapy, and the Goldie-Coldman model regarding emergence of drug resistance with increased tumor size.
Breast cancer quiz (For Radiation Oncology residents)Bharti Devnani
1. The document outlines the rules and structure of a breast cancer quiz with 4 rounds: a visual round, multiple choice round, clinical trial identification round, and true/false round.
2. The visual round involves identifying devices, images, and celebrities related to breast cancer. The multiple choice round contains questions about breast cancer criteria, definitions, and screening recommendations.
3. The clinical trial round tasks teams with naming clinical trials from descriptions of trial details. The true/false round presents statements about breast cancer topics like DCIS, male breast cancer, and Mammaprint to identify as true or false.
This document discusses target delineation and radiation treatment planning for pituitary adenomas. It begins with an introduction to pituitary adenomas, noting that they are mostly benign tumors comprising about 10% of intracranial tumors. Radiation therapy plays an important role in managing functioning and non-functioning adenomas. The document then discusses indications for radiation therapy such as when medical therapy fails or for large adenomas causing vision problems. It provides details on target volumes including the GTV encompassing the enhancing tumor and nearby structures included in the CTV and PTV. Key neighboring structures like the optic chiasm and cavernous sinus are also identified. Radiation dose, techniques like IMRT and stereotactic radiosurgery, and
This document discusses management of prostate cancer through different treatment modalities including active surveillance, radical prostatectomy, radiation therapy, and hormonal therapy. It provides treatment recommendations based on cancer stage and risk level as well as 5-year outcomes. For low risk prostate cancer, active surveillance, radical prostatectomy, or radiation therapy are recommended depending on life expectancy. Radiation therapy techniques like 3D-CRT, IMRT, and brachytherapy are covered. Dose escalation studies showing improved outcomes with higher radiation doses are also summarized.
Nasopharyngeal carcinoma has unique features including association with Epstein-Barr virus and a high risk of distant metastases. Definitive radiotherapy is the primary treatment, with intensity-modulated radiotherapy improving outcomes. Concurrent chemoradiotherapy provides significantly improved progression-free and overall survival compared to radiotherapy alone for locally advanced disease based on a landmark randomized trial. Brachytherapy may be used as a boost for early-stage tumors following external beam radiotherapy.
Gastric cancer discussion slides final version.pptnew.pptzoezettemarc
1) Peri-operative chemotherapy with ECX before and after surgery improves overall survival compared to surgery alone in resectable gastric cancer based on the MAGIC trial.
2) The ACTS-GT trial showed adjuvant S-1 chemotherapy improves 3-year survival compared to observation alone after D2 gastrectomy for stage II-III gastric cancer.
3) Combination chemotherapy improves survival over best supportive care alone in advanced gastric cancer, with regimens including anthracyclines and cisplatin or oxaliplatin showing better efficacy.
Metronomic chemotherapy involves the chronic administration of chemotherapy drugs at low, minimally toxic doses on a frequent schedule with no prolonged breaks. This strategy aims to control cancer by targeting tumor vasculature and is an attractive option in resource-limited areas due to its low cost, oral administration, and minimal side effects compared to conventional chemotherapy. Combining metronomic chemotherapy with drug repositioning and targeted therapies may lead to improved cancer control through multi-pronged effects on cancer cells, vasculature, and the immune system. However, determining the optimal biological dose and identifying surrogate markers pose challenges to realizing the full potential of this approach.
Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...ensteve
1) The document discusses complete response rates for patients with advanced rectal cancer receiving pre-operative chemoradiotherapy. It reports a complete pathological response rate of 17.5% in its study.
2) Patients who had a complete pathological response were found to have excellent long-term survival and no recurrence of cancer, with a median follow-up time of over 5 years.
3) A complete clinical response seen before surgery does not guarantee there is no remaining cancer, as viable tumor cells may still be present. The nature of the surgery should not be determined based on clinical response alone.
This document provides an overview of non-Hodgkin lymphomas (NHL). Key points include:
- NHL are a heterogeneous group of malignancies characterized by abnormal proliferation of B, T, or NK cells.
- The main subtypes seen in India are B-cell lymphomas (80-85%) and T-cell lymphomas (15-20%).
- Diagnostic workup involves clinical evaluation, laboratory/radiologic testing, and tissue biopsy for classification.
- Staging and risk stratification inform treatment selection which may include chemotherapy, immunotherapy, radiation, stem cell transplant, or observation depending on the NHL subtype and stage.
This document discusses cancer screening for seniors and whether it makes sense. It notes that reasons not to screen everyone include costs, potential harms from false positives or procedures, and factors related to life expectancy and health status. It provides examples of famous people who died of pancreatic cancer and notes that screening for pancreatic cancer is not recommended. It asks questions about the most common cancers, typical cancer ages, beneficial screening tests, and best screening advice. It discusses stopping screening at age 75 but continuing for those expected to live 10 more years. It provides resources on cancer screening guidelines.
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
Principles of radiotherapy in gastric carcinomaAnil Gupta
This document discusses principles of radiotherapy for gastric carcinoma. It summarizes that post-operative radiotherapy can reduce local recurrence rates after surgery for gastric cancer, although no survival benefit has been proven. Newer radiation techniques like IMRT and VMAT may further reduce doses to organs-at-risk compared to 3D conformal radiotherapy. Pre-operative radiotherapy can also improve resectability in some inoperable cases.
This document discusses the treatment of lung cancer with radiation. Stage I-II lung cancers are typically treated with surgery and sometimes post-operative chemotherapy or radiation. Stage III cancers usually receive chemotherapy and radiation, sometimes followed by surgery. Stage IV cancers are treated with chemotherapy or radiation. Advanced techniques like CT-guided planning, adaptive radiotherapy using daily CT images, and stereotactic body radiation therapy can help target radiation doses precisely to tumors while minimizing exposure to healthy lung tissue. Radiation is generally well-tolerated but can cause short-term effects like cough and long-term effects like fibrosis. Careful treatment planning aims to limit radiation doses to normal lungs.
Radiation Therapy in the Management of Lung Cancerflasco_org
This document discusses modern radiation therapy techniques for lung cancer, focusing on non-small cell lung cancer (NSCLC). It summarizes that stereotactic ablative radiotherapy (SABR) is now the standard of care for inoperable stage I NSCLC, providing local control and survival rates comparable or superior to surgery with less toxicity. For stage III NSCLC, concurrent chemotherapy and radiation improves survival compared to sequential treatment, though local control remains challenging and toxicities can be significant. Ongoing studies are exploring dose escalation using intensity-modulated radiation therapy (IMRT) and proton therapy to improve outcomes while reducing normal tissue damage.
Ca breast management (according to NCCN guidelines)Pirah Azadi
Breast cancer is the second leading cause of cancer deaths worldwide, with over 1 million new cases annually. The document outlines guidelines for managing breast cancer according to stage from the National Comprehensive Cancer Network (NCCN). For early stage cancers, treatment involves surgery such as lumpectomy with or without radiation. For advanced stages, management includes chemotherapy, hormone therapy, targeted therapy and surgery as appropriate. Reconstruction options are discussed as well as follow up care and risk reduction strategies.
The document summarizes results from a study comparing pembrolizumab (Pem), a drug that enhances the immune system, to extreme chemotherapy (Extreme) in treating recurrent or metastatic head and neck squamous cell carcinoma (HNSCC). It found that Pem combined with chemotherapy increased overall survival compared to Extreme, with a hazard ratio of 0.77 and median survival of 13.0 months versus 10.7 months. For PD-L1 positive tumors, Pem monotherapy also increased overall survival compared to Extreme. The authors concluded that Pem combined with chemotherapy or Pem monotherapy for PD-L1 positive tumors are appropriate first-line treatments for recurrent or metastatic HNSCC.
Several institutions have studied stereotactic body radiation therapy (SBRT) for primary lung cancer. Indiana University studies showed a maximum tolerated dose of 66 Gy for T2 lesions delivered over 3 fractions, with 1-year local control rates of 98%. Other studies from Aarhus University, Kyoto University, Air Force General Hospital in Beijing, and University of Marburg demonstrated 1-2 year local control rates ranging from 85-95% using SBRT dose fractions between 30-60 Gy delivered over 1 to 10 fractions.
This presentation provides an overview of the standard of care and new advances in the treatment of high-grade glioma, specifically glioblastoma multiforme (GBM) and anaplastic astrocytoma. The key points discussed include:
- The current standard of care for GBM is maximal safe surgical resection followed by concurrent radiation therapy and temozolomide chemotherapy, then adjuvant temozolomide.
- The landmark EORTC/NCIC trial established temozolomide combined with radiation as the standard of care, improving median survival from 12 to 14.6 months.
- MGMT promoter methylation status is the strongest predictor of outcome, with methylated tumors responding better
This document summarizes a presentation on using innovative medical music therapy interventions to create and preserve legacies for patients. It discusses how creative arts therapies can reduce anxiety, depression, and pain for palliative patients. Specific music therapy techniques are outlined, including songwriting, music listening, and improvisation. An example is provided of a music therapist working with a dying 13-year-old patient and her family to record songs to leave a legacy. The therapist also supported families during and after patient deaths through playing meaningful music.
Principles of medical_oncology dr. varunVarun Goel
- The document discusses several key principles of medical oncology including that cancer treatment is multidisciplinary, early stage cancers are more curable than late stage, and the best treatment is often found in clinical trials.
- It describes the basic tenets of chemotherapy including that it can be used for induction treatment of advanced cancers or as adjuvant treatment after local therapy to treat high risk of recurrence. The intent of chemotherapy can be curative or palliative.
- Several models of tumor growth and response to chemotherapy are explained including the Skipper-Wilcox model, concepts of combination chemotherapy, and the Goldie-Coldman model regarding emergence of drug resistance with increased tumor size.
Breast cancer quiz (For Radiation Oncology residents)Bharti Devnani
1. The document outlines the rules and structure of a breast cancer quiz with 4 rounds: a visual round, multiple choice round, clinical trial identification round, and true/false round.
2. The visual round involves identifying devices, images, and celebrities related to breast cancer. The multiple choice round contains questions about breast cancer criteria, definitions, and screening recommendations.
3. The clinical trial round tasks teams with naming clinical trials from descriptions of trial details. The true/false round presents statements about breast cancer topics like DCIS, male breast cancer, and Mammaprint to identify as true or false.
This document discusses target delineation and radiation treatment planning for pituitary adenomas. It begins with an introduction to pituitary adenomas, noting that they are mostly benign tumors comprising about 10% of intracranial tumors. Radiation therapy plays an important role in managing functioning and non-functioning adenomas. The document then discusses indications for radiation therapy such as when medical therapy fails or for large adenomas causing vision problems. It provides details on target volumes including the GTV encompassing the enhancing tumor and nearby structures included in the CTV and PTV. Key neighboring structures like the optic chiasm and cavernous sinus are also identified. Radiation dose, techniques like IMRT and stereotactic radiosurgery, and
This document discusses management of prostate cancer through different treatment modalities including active surveillance, radical prostatectomy, radiation therapy, and hormonal therapy. It provides treatment recommendations based on cancer stage and risk level as well as 5-year outcomes. For low risk prostate cancer, active surveillance, radical prostatectomy, or radiation therapy are recommended depending on life expectancy. Radiation therapy techniques like 3D-CRT, IMRT, and brachytherapy are covered. Dose escalation studies showing improved outcomes with higher radiation doses are also summarized.
Nasopharyngeal carcinoma has unique features including association with Epstein-Barr virus and a high risk of distant metastases. Definitive radiotherapy is the primary treatment, with intensity-modulated radiotherapy improving outcomes. Concurrent chemoradiotherapy provides significantly improved progression-free and overall survival compared to radiotherapy alone for locally advanced disease based on a landmark randomized trial. Brachytherapy may be used as a boost for early-stage tumors following external beam radiotherapy.
Gastric cancer discussion slides final version.pptnew.pptzoezettemarc
1) Peri-operative chemotherapy with ECX before and after surgery improves overall survival compared to surgery alone in resectable gastric cancer based on the MAGIC trial.
2) The ACTS-GT trial showed adjuvant S-1 chemotherapy improves 3-year survival compared to observation alone after D2 gastrectomy for stage II-III gastric cancer.
3) Combination chemotherapy improves survival over best supportive care alone in advanced gastric cancer, with regimens including anthracyclines and cisplatin or oxaliplatin showing better efficacy.
Metronomic chemotherapy involves the chronic administration of chemotherapy drugs at low, minimally toxic doses on a frequent schedule with no prolonged breaks. This strategy aims to control cancer by targeting tumor vasculature and is an attractive option in resource-limited areas due to its low cost, oral administration, and minimal side effects compared to conventional chemotherapy. Combining metronomic chemotherapy with drug repositioning and targeted therapies may lead to improved cancer control through multi-pronged effects on cancer cells, vasculature, and the immune system. However, determining the optimal biological dose and identifying surrogate markers pose challenges to realizing the full potential of this approach.
Rectal Cancer and Radiotherapy:What is the Clinical Implication of a Complet...ensteve
1) The document discusses complete response rates for patients with advanced rectal cancer receiving pre-operative chemoradiotherapy. It reports a complete pathological response rate of 17.5% in its study.
2) Patients who had a complete pathological response were found to have excellent long-term survival and no recurrence of cancer, with a median follow-up time of over 5 years.
3) A complete clinical response seen before surgery does not guarantee there is no remaining cancer, as viable tumor cells may still be present. The nature of the surgery should not be determined based on clinical response alone.
This document provides an overview of non-Hodgkin lymphomas (NHL). Key points include:
- NHL are a heterogeneous group of malignancies characterized by abnormal proliferation of B, T, or NK cells.
- The main subtypes seen in India are B-cell lymphomas (80-85%) and T-cell lymphomas (15-20%).
- Diagnostic workup involves clinical evaluation, laboratory/radiologic testing, and tissue biopsy for classification.
- Staging and risk stratification inform treatment selection which may include chemotherapy, immunotherapy, radiation, stem cell transplant, or observation depending on the NHL subtype and stage.
This document discusses cancer screening for seniors and whether it makes sense. It notes that reasons not to screen everyone include costs, potential harms from false positives or procedures, and factors related to life expectancy and health status. It provides examples of famous people who died of pancreatic cancer and notes that screening for pancreatic cancer is not recommended. It asks questions about the most common cancers, typical cancer ages, beneficial screening tests, and best screening advice. It discusses stopping screening at age 75 but continuing for those expected to live 10 more years. It provides resources on cancer screening guidelines.
The combined use of radiation therapy and chemotherapy in cancer treatment is a logical and reasonable approach that has already proven beneficial for several malignancies.
Principles of radiotherapy in gastric carcinomaAnil Gupta
This document discusses principles of radiotherapy for gastric carcinoma. It summarizes that post-operative radiotherapy can reduce local recurrence rates after surgery for gastric cancer, although no survival benefit has been proven. Newer radiation techniques like IMRT and VMAT may further reduce doses to organs-at-risk compared to 3D conformal radiotherapy. Pre-operative radiotherapy can also improve resectability in some inoperable cases.
This document discusses the treatment of lung cancer with radiation. Stage I-II lung cancers are typically treated with surgery and sometimes post-operative chemotherapy or radiation. Stage III cancers usually receive chemotherapy and radiation, sometimes followed by surgery. Stage IV cancers are treated with chemotherapy or radiation. Advanced techniques like CT-guided planning, adaptive radiotherapy using daily CT images, and stereotactic body radiation therapy can help target radiation doses precisely to tumors while minimizing exposure to healthy lung tissue. Radiation is generally well-tolerated but can cause short-term effects like cough and long-term effects like fibrosis. Careful treatment planning aims to limit radiation doses to normal lungs.
Radiation Therapy in the Management of Lung Cancerflasco_org
This document discusses modern radiation therapy techniques for lung cancer, focusing on non-small cell lung cancer (NSCLC). It summarizes that stereotactic ablative radiotherapy (SABR) is now the standard of care for inoperable stage I NSCLC, providing local control and survival rates comparable or superior to surgery with less toxicity. For stage III NSCLC, concurrent chemotherapy and radiation improves survival compared to sequential treatment, though local control remains challenging and toxicities can be significant. Ongoing studies are exploring dose escalation using intensity-modulated radiation therapy (IMRT) and proton therapy to improve outcomes while reducing normal tissue damage.
Ca breast management (according to NCCN guidelines)Pirah Azadi
Breast cancer is the second leading cause of cancer deaths worldwide, with over 1 million new cases annually. The document outlines guidelines for managing breast cancer according to stage from the National Comprehensive Cancer Network (NCCN). For early stage cancers, treatment involves surgery such as lumpectomy with or without radiation. For advanced stages, management includes chemotherapy, hormone therapy, targeted therapy and surgery as appropriate. Reconstruction options are discussed as well as follow up care and risk reduction strategies.
The document summarizes results from a study comparing pembrolizumab (Pem), a drug that enhances the immune system, to extreme chemotherapy (Extreme) in treating recurrent or metastatic head and neck squamous cell carcinoma (HNSCC). It found that Pem combined with chemotherapy increased overall survival compared to Extreme, with a hazard ratio of 0.77 and median survival of 13.0 months versus 10.7 months. For PD-L1 positive tumors, Pem monotherapy also increased overall survival compared to Extreme. The authors concluded that Pem combined with chemotherapy or Pem monotherapy for PD-L1 positive tumors are appropriate first-line treatments for recurrent or metastatic HNSCC.
Several institutions have studied stereotactic body radiation therapy (SBRT) for primary lung cancer. Indiana University studies showed a maximum tolerated dose of 66 Gy for T2 lesions delivered over 3 fractions, with 1-year local control rates of 98%. Other studies from Aarhus University, Kyoto University, Air Force General Hospital in Beijing, and University of Marburg demonstrated 1-2 year local control rates ranging from 85-95% using SBRT dose fractions between 30-60 Gy delivered over 1 to 10 fractions.
This presentation provides an overview of the standard of care and new advances in the treatment of high-grade glioma, specifically glioblastoma multiforme (GBM) and anaplastic astrocytoma. The key points discussed include:
- The current standard of care for GBM is maximal safe surgical resection followed by concurrent radiation therapy and temozolomide chemotherapy, then adjuvant temozolomide.
- The landmark EORTC/NCIC trial established temozolomide combined with radiation as the standard of care, improving median survival from 12 to 14.6 months.
- MGMT promoter methylation status is the strongest predictor of outcome, with methylated tumors responding better
This document summarizes a presentation on using innovative medical music therapy interventions to create and preserve legacies for patients. It discusses how creative arts therapies can reduce anxiety, depression, and pain for palliative patients. Specific music therapy techniques are outlined, including songwriting, music listening, and improvisation. An example is provided of a music therapist working with a dying 13-year-old patient and her family to record songs to leave a legacy. The therapist also supported families during and after patient deaths through playing meaningful music.
Integrative Nutrition: Integrative Health Week 2014Cara Feldman-Hunt
This document discusses integrative nutrition and functional medicine. It begins by stating the objectives of being able to describe the benefits of an integrative nutrition model and key areas impacted by food and nutrients. It then defines functional medicine as taking a systems-oriented approach to address the underlying causes of disease using various evidence-based practices. Nutrition is a critical component of both integrative and functional medicine approaches. The document provides examples of functional nutrition plans that can be used for various health conditions like chronic pain, GI issues, obesity, and depression.
Laura Mann Center Integrative Lecture Series: Fall 2014Cara Feldman-Hunt
The document discusses the history and impact of the Penny George Institute for Health and Healing (PGIHH) at Allina Health, an integrated health system in Minnesota. Key points:
1) PGIHH was founded in 2003 and is now the largest integrative health program integrated within a health system. It focuses on prevention, wellness, and lifestyle-related diseases.
2) Studies show PGIHH services significantly reduce patient pain, anxiety, and length of hospital stays. For example, oncology patients saw a 46.9% reduction in pain and 56.1% reduction in anxiety.
3) PGIHH aims to transform healthcare delivery through a holistic, preventative approach.
Living with Advanced Breast Cancer: Challenges and Opportunitiesbkling
- Metastatic breast cancer poses significant challenges as it is incurable and can recur even after early-stage treatment, with over 500,000 deaths worldwide annually. Living with metastatic disease differs profoundly from early-stage experiences.
- Two surveys of over 1,000 metastatic breast cancer patients across countries found high levels of fear, confusion and depression upon diagnosis. While most received family support, many felt stigma and isolation. Information seeking helped patients cope.
- More research funding and clinical trials inclusive of quality of life are needed. Counting metastatic cases is important to assess needs and allocate resources for supportive care and treatments that meaningfully extend survival and quality of life for these patients. Guidelines can help patients navigate a still deadly disease.
This document discusses relevant endpoints for clinical trials involving patients with advanced breast cancer. It notes that these patients are a heterogeneous population with different disease characteristics and needs. While traditional endpoints like progression-free survival are important, patient-reported outcomes that measure symptom control, physical functioning, and quality of life are also critical given the focus on long-term management of the disease. The document recommends that phase III trials incorporate patient-reported outcomes to better assess new treatments' impact on symptoms and functioning from the patient perspective.
2013 Cancer Survivorship Conference at Jefferson University Hospitalsjeffersonhospital
Jefferson's Cancer Survivorship Program will help you understand what it means to be a cancer survivor and what to expect from your cancer diagnosis, treatment and follow-up care. This Program is for current patients, cancer survivors and loved ones who have lived with a cancer diagnosis or have undergone cancer treatment at Jefferson.
Integrative medicine/oncology combines conventional cancer care with evidence-based complementary therapies to enhance quality of life for cancer patients. The document discusses the evolution of integrative medicine from alternative medicine to its current focus on patient-centered care and maximizing innate healing through mind-body practices, nutrition, and therapies like acupuncture and massage. It also emphasizes the importance of research to understand how complementary therapies can safely benefit patients and potentially synergize with conventional care.
Integrative medicine - The link between red meat and cancerraynoronha
The media has recently reported the warnings from scientist regarding red meat consumption. This presentation uncovers the findings and provides guidelines for healthcare professionals and the public.
Integrative medicine expert and media and marketing veteran Glenn Sabin explains why inbound content marketing and storytelling is the most pragmatic approach to building patient volume and sales for integrative healthcare clinics, centers and brands.
Reflexology involves applying pressure to specific points on the feet that are believed to correspond to different parts of the body. It aims to increase energy flow by stimulating these reflex points. While research is limited, reflexology has a long history dating back thousands of years in ancient Egypt, India, and China. It may be related to acupuncture through its focus on stimulating dynamic meridian lines, but does not use needles like acupuncture.
Reflexology is a technique that manipulates reflex points on the feet and hands that correspond to specific organs and body parts. It aims to relieve energy blocks believed to affect health. Originating in ancient Egypt and Asia, reflexology massage is a holistic method focused on pressure points. Benefits include relaxation, detoxification, improved circulation, homeostasis, and prevention of health problems by targeting the body's 10 zones represented on the hands and feet. Reflexology is a simple, non-invasive, and efficient therapy that can aid various conditions.
Complementary and alternative medicine pptSuny Bisshojit
This document discusses medicinal plants and their use as traditional medicines. It notes that medicinal plants have properties similar to conventional drugs and have been used for thousands of years. Some key points made include that 80% of the world's population uses plants as their primary medicine source, and many modern drugs were developed from plant-based compounds, including aspirin, opium, and quinine. The document also provides examples of plants commonly used in traditional medicines from different regions and their therapeutic effects.
This document discusses natural therapies for post-treatment cancer symptoms. It outlines a multi-disciplinary integrative approach and focuses on promoting general health and wellness through nutrition, physical activity, stress management and avoiding toxic exposures. It identifies various vitamins and dietary supplements that may help mitigate common post-treatment symptoms like fatigue, insomnia, mental fogginess, constipation and joint pain. It also discusses evaluating factors of health like inflammation and nutrient status to further reduce cancer risks.
Breast cancer is the second leading cause of death and second most common cancer in women. It occurs when abnormal cells in the breast grow in an uncontrolled way and form tumors. The breasts contain lobes and lobules which produce milk, connected by ducts. The two main types are ductal carcinoma, originating in the ducts, and lobular carcinoma, originating in the lobules. Risk factors include gender, age, family history, obesity, lack of exercise, alcohol consumption, and hormone therapy. Screening methods include breast self-exams, clinical exams by a doctor, and mammography. Treatment options depend on cancer stage and may involve surgery, radiation, chemotherapy, and hormone therapy. With early detection and treatment, the
A primary care physician is important for cancer survivors for several reasons:
1) Primary care physicians can provide whole person care beyond just cancer, including preventative care, management of other health conditions, and annual checkups.
2) Oncologists focus narrowly on cancer care while primary care physicians take a broader view of patient health.
3) More patients have access to primary care physicians than oncologists, and primary care physicians can help coordinate care between specialists like oncologists.
4) Establishing care with a primary care physician and having a survivorship care plan facilitates smooth transitions in care after cancer treatment is completed.
Cancer Survivorship Care: Global Perspectives and Opportunities for Nurse-Le...Carevive
The 18th CNSA Annual Winter Congress, held Perth, Australia will featured On Q Health’s co-founder Dr. Carrie Stricker as a keynote speaker. The theme for this year’s edition is “Cancer Nursing: Expanding the Possibilities” and will focus on exploring the opportunities that exist in cancer nursing in 2015 and beyond.
Integrative medicine/oncology combines conventional cancer treatments with evidence-based complementary therapies to improve quality of life for cancer patients. The document discusses the evolution of integrative medicine from alternative medicine to its current focus on patient-centered care and maximizing innate healing through mind-body practices, nutrition, and therapies like acupuncture and massage. It also emphasizes the importance of research to understand how complementary therapies can safely benefit patients and identify potential drug interactions.
Nikhil Wagle, MD, discusses new research and how it is leading the way toward improved treatments for ER+ metastatic breast cancer.
Wagle is a physician with the Breast Oncology Program in the Susan F. Smith Center for Women's Cancers at Dana-Farber. He is also a researcher affiliated with Dana-Farber and the Broad Institute.
This presentation was originally given as part of the Metastatic Breast Cancer Forum, held on Oct. 17, 2015 at Dana-Farber Cancer Institute in Boston, Mass.
Oncology clinical pharmacy from practice to researchNoha El Baghdady
The document provides an overview of the history and current state of oncology clinical pharmacy from practice to research. It discusses how clinical pharmacists can play important roles in patient care by developing pharmaceutical care plans, managing side effects of cancer treatment, preventing and treating complications, and counseling patients. Clinical pharmacists are also involved in research by conducting clinical trials, publishing original research and reviews, and developing evidence-based guidelines. Overall, the involvement of clinical pharmacists in direct patient care and research has been shown to improve outcomes and reduce healthcare costs.
Evidence-based guidelines for the nutritional management of adult oncology pa...milfamln
Webinar Objectives
1. The participant will be able to discuss the validity of malnutrition screening and nutrition assessment tools and their utilization in clinical oncology settings
2. The participant will be able to better utilize the Nutrition Care Process to provide appropriate and high-quality nutrition care to oncology patients
3. The participant will be able to describe the evidencebased relationships between nutritional status and morbidity and mortality outcomes in oncology
Hospice care and palliative care: Is there a difference between the two, and if so, what?
Many people still think that palliative care means hospice care. But today, hospice is only a small part of palliative care.
The goal of palliative care is to prevent or treat the symptoms and side effects of a disease; and it should be part of the picture from the first day a serious illness is diagnosed.
Dr. Jim Meadows, Director of Hospice and Palliative Care at Tennessee Oncology, will discuss this important topic. How does a family and a health care team best work together to guide a patient through a terminal illness? How does everyone continue to support quality, patient-centered, end-of-life care?
I didn't know this option of Palliative care existed prior to my mother's passing earlier this year of colorectal cancer. However, I do now know about it and want to share it with all of you
Fertility preservation in cancer patientsQuoc Ty Tran
This national survey of physicians found that while most discuss the impact of cancer treatment on fertility, barriers remain. Physicians with more knowledge and favorable attitudes about fertility preservation were more likely to discuss it. The main barrier to discussion was patients being too ill to delay treatment. Female physicians and those whose patients inquire about fertility were more likely to refer patients. Future directions include improving physician education and developing interventions to facilitate discussion.
In this webinar, Dr. Azad discusses colorectal cancer recurrence. She addresses things to do to help reduce the risk of recurrence, in addition to what steps should be taken if colon or rectal cancer returns.
Public webinar presentation on breast cancer. This presentation gives an overview of breast cancer in Malaysia, the risk factors and ways to reduce risk of breast cancer, early detection and its importance on survivorship besides exploring treatment options.
Precision Medicine: Opportunities and Challenges for Clinical TrialsMedpace
The momentum and muscle behind "finding the right drug for the right patient at the right dose" has further escalated with President Barack Obama’s announcement of a $215 million dollar Precision Medicine Initiative earlier this year. In this webinar, Dr. Frank Smith will explore advances in precision medicine and how it is affecting clinical research. As a pediatric hematologist/oncologist, he will use his extensive clinical and research background as a backdrop for the discussion.
Topics will include:
The evolution of "personalized medicine" to "precision medicine"
How state-of-the-art molecular biology is creating new diagnostic and prognostic strategies
How these new strategies are helping inform the design of clinical trials
Case study: How precision medicine is improving clinical trials in hematology and oncology
- The document discusses an integrated approach to cancer prevention and treatment through lifestyle changes.
- It presents a model showing how lifestyle factors like nutrition, exercise, stress, and social support can affect cancer development over many years and influence whether cancer progresses or not.
- Evidence from studies on nutrition, exercise, stress management, and social support suggest that adopting a healthy lifestyle may reduce cancer risk and slow cancer progression. The Prostate Cancer Lifestyle Trial found significant benefits of lifestyle changes for men with early-stage prostate cancer.
Cancer Survivorship Challenges and OpportunitiesGaynorOncology
This document discusses cancer survivorship challenges and opportunities. It provides statistics on cancer survivors such as over 60% being over age 65 and the most common cancer sites being breast, prostate, and colorectal. It then discusses trends in improved 5-year survival rates for many cancer sites from 1975-2003. The document outlines goals for cancer survivors including monitoring biomarkers, maintaining wellness through lifestyle factors like nutrition and exercise, and becoming active participants in their care. Biomarkers discussed include fasting insulin levels, IGF-1, and drug metabolism biomarkers. The roles of lifestyle factors like meditation, yoga, exercise, music, spirituality, and nutrition including soy and vitamin D are also summarized.
This document discusses the relationship between estrogen and breast cancer. It summarizes research showing that sufficient estrogen levels are important for breast health and that the risk of breast cancer increases with estrogen deficiency associated with aging. While some studies have linked hormone replacement therapy (HRT) to increased breast cancer risk, this document argues that these studies used synthetic hormones rather than bioidentical hormones and did not consider differences in hormone levels and cycling. The document concludes that, when administered properly, bioidentical estrogen therapy may reduce breast cancer risk by inhibiting growth and inducing apoptosis of cancer cells.
This document summarizes research on nutritional support and hydration for patients near the end of life. It finds that while patients have autonomy to choose artificial nutrition/hydration, such interventions often provide little benefit and can cause harm. Studies show artificial nutrition does not improve outcomes or quality of life and may increase risks like infection. Near death, most patients experience reduced hunger and intake, with few reporting hunger until death. Non-invasive comfort measures usually meet nutritional needs better than medical interventions in the dying process.
There are a variety of reasons mesothelioma patients and their loved ones seek information about Complementary and Alternative Medicine (CAM) therapies. Some lack faith in our current medical system or Western medicine in general. Others prefer to avoid the negative reactions or long-term effects of traditional cancer treatments such as surgery, chemotherapy and radiation therapy. We welcome Dr. Snehal Smart as the guest speaker to discuss these topics in our March support group. For more information on this topic, visit us at www.asbestos.com
Many common myths about cancer are untrue. Cancer is not contagious, though some viruses and bacteria can cause cancers. Biopsies are very unlikely to cause cancer to spread. While family history increases cancer risk, it does not guarantee someone will develop cancer. Recent treatment advances have resulted in fewer side effects. Positive thinking can improve quality of life for cancer patients but does not affect cancer itself. No cures are being hidden and cancer is not always a death sentence as survival rates have improved for many types of cancer.
Chair and Presenters, Sumanta Kumar Pal, MD, FASCO, Pedro C. Barata, MD, MSc, FACP, David F. McDermott, MD, and Tian Zhang, MD, MHS, prepared useful Practice Aids pertaining to renal cell carcinoma for this CME/MOC/NCPD/AAPA/IPCE activity titled “Advancing Personalized Care in RCC: Navigating Rapid Therapeutic Expansion and Sequencing Strategies.” For the full presentation, downloadable Practice Aids, and complete CME/MOC/NCPD/AAPA/IPCE information, and to apply for credit, please visit us at https://bit.ly/3uvvd5X. CME/MOC/NCPD/AAPA/IPCE credit will be available until February 25, 2025.
The document provides information on various screening tools and guidelines for substance use. It includes the following:
- Descriptions of the AUDIT-10 and DAST-10 screening tools, including risk level cut-offs and corresponding intervention levels.
- Low-risk drinking guidelines from the NIAAA.
- Information on the potential short-term and long-term effects of substances like alcohol, cocaine, opiates, and marijuana.
- Details on standard drink equivalents and calculating alcohol by volume to better track drinking levels.
- Tips for a brief negotiated interview process and change planning based on screening results.
Initial screening shows that 80% of people are at low risk for alcohol abuse and do not require further screening. High-risk drinking, which is defined as more than 4 drinks per day or 14 drinks per week for men and more than 3 drinks per day or 7 drinks per week for women and those over 65, can lead to social, legal, medical, domestic, employment, and financial problems as well as reduced life expectancy and increased risk of accidents and death from drunk driving. Consuming any amount of alcohol during pregnancy can cause serious birth defects.
This document outlines the 5 steps of a Brief Negotiated Interview (BNI) algorithm to address a client's substance use: 1) Raise the subject and discuss pros and cons, 2) Provide information on guidelines and risks then elicit client thoughts, 3) Use a readiness ruler to gauge readiness to change and reinforce positives, 4) Negotiate a change plan by identifying strengths and supports, having the client write steps, and offering resources, 5) Offer additional resources and close the interview by summarizing the discussion.
The document summarizes standard drink sizes in the United States and their alcohol content. It provides examples of different types of drinks - such as beers, wines, and spirits - that contain approximately the same amount of pure alcohol (0.6 fluid ounces) and count as one standard drink. It emphasizes that knowing standard drink sizes can help people make informed decisions about drinking and stay within recommended limits.
This document outlines a 15-step process for providers to conduct a Brief Negotiated Interview with patients regarding their alcohol and drug use. It involves raising the subject with the patient, providing feedback on their risk level, enhancing their motivation to change, and negotiating a plan for reducing substance use risks. The provider is to check off steps as they are completed and bill appropriately using Medicaid codes for alcohol and drug screening and brief intervention sessions lasting 15-29 minutes or 30+ minutes.
This document summarizes screening results for substance use risk levels and the short-term and long-term effects of cocaine, marijuana, and opiates. An initial screening shows 80% of people are at low risk and don't require further screening, while 15% are at mild risk, 2.5% at moderate risk, and 2.5% at severe risk. The short-term effects of cocaine include an intense high followed by depression, while long-term effects include heart attacks, strokes, and sleep and nutritional problems. Short-term effects of marijuana include anxiety and problems with attention and memory, and long-term effects include weight gain and lung cancer. Short and long-term effects of opiate use include drows
The document summarizes the chemical composition and effects of marijuana. It notes that marijuana contains over 460 active chemicals including THC and CBD, which are the primary psychoactive compounds. The potency of marijuana depends on various factors like genetics and cultivation methods. Marijuana today is generally more potent than in the 1970s, with buds containing 8-25% THC. High potency concentrates can exceed 70% THC. Regular or heavy teenage marijuana use is linked to problems like addiction, lower educational attainment, lower IQ, and increased risk of mental health issues. Even casual adult use has been shown to impact brain structure and functioning.
1) Distracted driving from phone use results in thousands of deaths yearly from distracted driving. Texting takes a driver's eyes off the road for about 5 seconds, like driving blindfolded for a football field. It is illegal in Vermont to use a handheld phone while driving.
2) Wearing a helmet during sports reduces the risk of head injury by 85%. Even low-speed falls can cause permanent brain damage. Children have high bike injury rates, and bike crashes are a top cause of death for children.
3) Seat belts save lives and reduce crash injuries, as motor vehicle crashes are a top cause of death for those aged 5-34. Use seat belts on every trip and properly
September 2012 integrative practitioner meeting minutesCara Feldman-Hunt
The September 2012 meeting minutes of integrative practitioners summarized the following:
1. The group agreed to shorten future meetings to 1.5 hours and include a self-care component at each meeting.
2. The October meeting will feature a presentation on Chi Walking.
3. Potential future meeting topics included homeopathy, research sharing, sustainability/avoiding burnout, financing models, and case reviews. Presenters on mindfulness, language of touch, and life coaching were also discussed.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. Integrative Oncology
Comprehensive Care of the Patient with
Cancer
Philip Trabulsy M.D.
Assistant Professor UVM COM
UVM Program In Integrative Health
Hematology Oncology Rounds UVM
September 18, 2012
2. Integrative Medicine and Health
“It is more important to know what sort of person has
a disease than to know what sort of disease a person
has.”
Hippocrates/Sir William Osler
“The good physician treats the disease; the great
physician treats the patient who has the disease.”
Sir William Osler, To his students
3. Integrative Medicine
What It’s Not
Alternative Medicine
• Typically promoted as a substitute for conventional
care
• Not been scientifically proven
• Scientific foundation lacking
• Some therapies disproved by scientific analysis
• Generally not taught in Medical Schools
• Not covered by third-party payors
NIH, NCCAM 2002
4. Integrative Medicine
What it is
Integrative medicine combines biomedical care with
appropriate complementary therapies, to heal and
preserve the health of the patient’s body, mind, and
spirit.
It emphasizes the individual’s capacity for self-healing
and offers an approach to care that is
personalized, collaborative, and comprehensive. This
approach is interdisciplinary and utilizes the skills of
other health care disciplines and professionals through
referral and consultation.
Consortium of Academic Health Centers for Integrative Medicine
5. Relationships
Research suggests that our presence as medical
or mental health clinicians, the way we bring
ourselves fully into connection with those for
whom we care, is one of the most crucial factors
supporting how people heal- how they respond
to our therapeutic efforts.
Dan Siegel: The Mindful Therapist, 2010
“ Care more for the individual patient than for the
special features of the disease… The kindly
word, the cheerful greeting, the sympathetic look
– these the patient understands”
Sir William Osler
6. Integrative Therapies
( Complementary and Alternative Medicine)
“ a group of diverse medical and health care systems, practices, and products
that are not presently considered part of conventional medicine”
• Biologically based :
dietary, nutreuceutical, herbal, homeopathy
• Mind-body : Hypnosis, guided
imagery, meditation, expressive arts: ie music
therapy
• Manual therapy :
Massage, chiropractic, osteopathic, physical therapy
• Energy therapies : Reiki, Healing/Therapeutic
Touch, QiGong, Reflexology
• Traditional medical systems : TCM, Ayurvedic
National Center for Complementary and Alternative Medicine( NCCAM)
7. Why Integrative Oncology?
• CAM use in adult oncology patients: 25-90%
• CAM use in pediatric oncology patients: 31-84%
• High risk women in genetic testing program: rate of 53% CAM use
• Hospitalized cancer patients supplement use of 73% in previous 30
days
• High rates of 68% in oncology pts, with 80% dietary use during
radiation therapy
Yates et al, Support Care Cancer 2005
Kelley KM, Eur. J Cancer 2004
Vapiwala et al, Cancer J 2006
8. Why Integrative Oncology?
Predictors of CAM use
n= 676, 302 non-ca volunteer, 219 ca pt., 156 professionals
-prevalence CAM use: 29%, 31%, and 39%
- female gender, 30-50yo (p <0.001)
- High school or higher education, private insurance, higher income
(p<0.001)
- No assoc. with ca. stage
Reasons for use: Non-Users
- 51% family , friends - 50% lack info
- 31% own choice, 9% media - 21% no interest
- 4% MD recommend - 12% no belief
- 61% immune support - 4.7% never needed it
- 27% well-being - 1.7% too expensive
- 6% prevent ca - 1.3% happy conventional
Chang et al. BMC Cancer 2011, 11:196
9. Why Integrative Oncology?
Communication Gaps
– CAM users : 30 % openly reported to MD
– 8/149 MD’s asked about CAM use
Provider perspective
• 17% encourage continue, 4% stop use, 60% neither
Patient perspective
• 37% encouraged continue, 16% stop use, 47% neither
• 35% MD did not ask, 4% not understand, 6% disapprove
Knowledge
• 59% faculty report lack knowledge base
• 78% faculty report not up to date on recent evidence
• > 50% would welcome further education
10. Why Integrative Oncology?
Patient Perspectives
– Locus of control - CAM is”safe,non-toxic”
– Empowerment - Loss faith in traditional
– Immune support
– Symptom management
– Fear
– Decrease stress
– Shouldering the hope
Richardson MA, et al., 2000 J Clin Oncol, 18: 2505
11. Disclosure of CAM use to the Oncologist
• 57% disclosure by cancer patients
• Majority of disclosures are incomplete (1 CAM)
• Prayer and relaxation most commonly reported
• Dietary supplement use reported 20-30%
• 85% Oncologists felt lack knowledge to recommend CAM
• 84% Oncologists concern for drug-interactions
Barriers
– Physicians indifference or opposition
– Did not think it important or that it was CAM
– Providers rarely asked
– Patient’s anticipation of a negative response from their physician
– Just asking directed question about CAM increased disclosure from 7%-43%
Hyodo et al, Cancer, 2003;97(11):2861-85
12. Pathways Study
• 1000 women AJCC stage I/II BC, prospective cohort
– 98% CAM use prior to Dx.
– >20% weekly green tea, omega-3fa , prayer, religion
– 86% use CAM post-diagnosis
• 47% botanicals
• 47% other”natural’ products
• 28% special diets
• 64% mind-body healing
• 27% manual, energy treatments
“CAM use before and after Dx is common. Emphasis on need to
discuss CAM use with all BC patients”
Greenlee et al., Breast Cancer Res Treat. 2009 Oct;117(3)
13. Don’t Ask, Don’t Tell
Optimizing Chemotherapy: Concomitant Medication Lists
M H Hanigan B Ldela Cruz SS Shord P J Medina J Fazili and D M Thompson
Clinical Pharmacology & Therapeutics (2011) 89 1, 114–119.
14.
15. Lifestyle and Cancer
• For the 12 common cancers about 35% of the
cases in the U.S. are preventable through a
healthy diet, being physically active and
maintaining a healthy weight. 37% for the
UK., 30% for Brazil and 27% for China.
• This translates to 340,000 preventable cases of
cancer in the USA
– AICR 2009 Policy Report, GLOBOCAN 2008
16. Weight Guidelines
Weight Guidelines
•Balance caloric intake with physical
activity
•Avoid excessive weight gain
throughout lifecycle
•Achieve and maintain a healthy
weight if currently overweight
19. Obesity-Associated Malignancies
% Annual U.S. Ca Excess Body Fat
TYPE % Cases
• Breast 17 33,000
• Esophagus 35 5,800
• Pancreas 28 11,900
• Gallbladder 21 2000
• Colorectal 9 13,200
• Endometrial 49 20,700
• Kidney 24 13,900
AICR/WCRF “Policy and Action for Cancer Prevention” report 2009
20. September: National Gynecologic
Cancer Awareness Month
• Endometrial Cancer
– 47,000 cases/yr. in U.S. 8000 deaths
– 33,000 preventable
• Stay lean
• Avoid abdominal fat
• Active every day
» Ferav Jet al., GLOBOCAN 2008, Cancer Incidence and
Mortality: AIRC
21. Insulin Like Growth Factor-I
• Evidence implicates IGF-I signaling in development
and progression of many cancers, including breast
– High IGF-I levels predict increased risk
– Antiestrogens reduce IGF-I levels
– IGF-IR hyperactive and overexpressed
– IGF-IR targeted in therapies
• IGF-I caused gene expression changes in breast ca.
assoc. cell proliferation, metabolism and DNA repair
Creighton et al., JCO, 2008
22. Exercise and Cancer Survival
• 50% decreased risk cancer-specific mortality with 9-15 MET
hrs./wk. Nurses Health Study
(Holmes et al. 2005)
• 49% risk reduction of recurrence/death at 3 years. Study: 832
pts. Stage III colon ca. Adjuvant chemo + physical therapy
• 61% reduction death. 573 nurses, stage I-III colorectal ca,
18 METs/wk
Meyerhardt JCO August 2006
23.
24. Supplement Debate
“ There is strong evidence that a diet rich in
vegetables, fruit, and other plant-based foods may
reduce the risk of cancer, but there is no evidence
that supplements can reduce cancer risk… and some
evidence that indicates that high-dose supplements
can increase cancer risk “
Selenium and Vitamin E(SELECT) Study, Alpha-
Tocopherol, B-Carotene Study (ATBC), Women’s
Antioxidant Cardiovascular (WACS)
25. Supplement Research Difficulties
• Concentrated intake of a single form vs. combined forms
natural foods
• Higher exposure than through normal food
• Lack of other healthy dietary components ( poor habits)
• Recommendations
– Use in those with micronutrient deficiencies
– Observe appropriate doses
– If high dose mimic natural form of supplement: ie. Vit E as mixed
tocopherols, Vitamin A in mixed caratenoids vs. B-caraotene or Vit A
palmitate
– Aim to meet needs through diet alone
WCRF/AICR
26. The Antioxidant Debate
Disadvantages Advantages
• Antioxidants interfere with • Oxidation supports
mechanism of cytotoxic malignant proliferation
chemo or radiotherapy • Oxidation may diminish
• Use of antioxidants causes therapeutic benefit of
diminished treatment effect chemo/radiation
and protection of tumor • Antioxidants improve Rx
efficacy and protect from
toxicity of treatments
27. Antioxidant Advice
• Depends on goal of treatment
If Cure, proceed with caution
• Delay antioxidants until end of Rx
• Discontinue day before, of, after chemo
• Avoid during radiotherapy unless for specific toxicity ameliroation
If Palliation, encourage use for protection of normal
tissue, optimization of QOL
Abrams D. Integrative Oncology 2006
→ Antioxidant radiation and chemoprotectants
(mesna, amifostine) reportedly do not interfere with
anti-tumor effects of Rx
28. Vitamin D3 ( Cholecalciferol)
• Long recognized as involved in bone
health, now felt to be linked to:
– Depression/Schizophrenia
– Pain syndromes
– Insulin resistance
– Infections (URI/Tb)
– Impaired immunity
– Macular degeneration
– Pre-eclampsia
29. Vitamin D3 ( Cholecalciferol)
• Cancer Modulation
– Promotes apoptosis
– Suppresses malignant cell proliferation
– Inhibits effects prostaglandins
– Suppresses production cytokines
– Decrease expression aromatase > reduces estrogen
– Inhibits new tumor vascular growth and inhibits
metastases
– Krishnan AV,Feldman D. Mechanisms of Anti-cancer and
Anti-Inflammatory Actions of Vitamin D. Annual review of
pharmacology and toxicology Jan. 2010
30. Vitamin D3 ( Cholecalciferol)
• Epidemiologic studies have shown that low Vit D levels are
assoc. with increased prevalence of
breast, colorectal, prostate, and pancreas.
• A recent meta-analysis of 35 studies showed that a 10ng/ml
increase in25(OH)D was assoc. with 15% risk reduction in
colorectal ca, but not for prostate or breast.
• Breast cancer research showed inverse assoc. of Vit D level
when checked post-diagnosis but not in prospective studies
• One study actually found adverse effects of Vit D for certain
cancers ( > 80nmol) stressing need to examine the health
status, life stage, adiposity, estrogen exposure, and nutritional
status of the population in question
Toner et al.; The Vitamin D and Cancer Conundrum:Aiming at a Moving
Target, J Amer Dietic Assoc, NCI, NIH
31. VITamin D and OmegA-3 TriaL
VITAL Study
• Randomized, double-blind, placebo controlled
multi-center trial in 20,000 participants, 5 year
study, began 2010
• Women > 65, men> 60 w/o hx cancer, CVD,
CVD
• One or both, or placebo
• Endpoints cancer, cardiovascular events,
cognitive function, diabetes, fractures
34. Potential Benefits of Dietary Supplement Use
During Conventional Therapy
• Immune Modulators
Medicinal mushroom ( PSK)
– Solid tumors, mostly animal studies, some human
– RCT 207 pt., Stage II,III colorectal ca. 3gm/day PSK
• 5yr disease free survival and regional metastases significantly
reduced in treatment group.
– 8 RCT’s 8009 gastric ca. pt’s: PSK 3gms/day
• pt’s> increased survival p<.018, increase disease free survival
– Study 30 advanced lung ca. pt’s. > no change survival
Ohwada S. et al.,Br J Cancer 2004;90(5
Oba K. et al., Cancer Immunol Immunother 2007;56(6)
Gao Y. et al.,J Med Food 2005;8(2)
35. Potential Benefits of Dietary Supplement Use
During Conventional Therapy
• Immune Modulation
Avemar
– Methoxy-substituted benzoquinone shown immunomodulatory and
anti-tumor activity in animal and human clinical trials
– Triggers apoptosis by regulating Poly( ADP-ribose) polymerase without
harm normal cellc
– Non-random advanced adult colorectal ca.pt’s (n=104) +conventional
Rx
– After 6mos. Fewer recurrences (3% vs 17%), new mets (8% vs
23%), death (12% vs 32%) all p< .01
• RCT Stage III melanoma (n=42) receive decarbazine chemo
– increase time-to-relapse (9 vs 4 mos.), without change in relapse
rate, and with increase no. free of disease at 1 yr (55% vs 38%)
Boros LG et al., Ann NY Acad Science 2005;1051:529-42
Jakob F et al.,Br J Cancer 2003;89(3)
Demidov L et al., 18th UICC Inter CA Congress.Oslo, 2002
36. Potential Benefits of Dietary Supplement Use
During Conventional Therapy
Stomatitis/Mucositis
Glutamine
– Positive results reported in a number of adult and pediatric
studies with oral glutmamine as swish and swallow. Both
chemotherapy and radiation induced mucositis. No
untoward chemo effects
• One large phase III trial using 5-FU chemo did not show
benefit
Cerchietti LC et al., Int J Radiat Oncol Biol Phys 2006
Okuno SH et al., et al., Am J Clin Oncol 1999
37. Potential Benefits of Dietary Supplement Use
During Conventional Therapy
Peripheral Neuropathy
• Glutamine
– Wang et al. small RCT (n=86) 15gm 2x/day
– Significantly lower incidence Grade 3-4 neuropathy after 4 cycles (5%
vs 18% p=0.05)
– After 6 cycles (12% vs 32%; p=0.04)
– Need for oxaliplatin dose reduction lower in treatment arm
– No between-group difference in response to chemo or survival
• Results promising, but need for larger RCT
Wang WS et al., Oral glutamine is effective for preventing oxaliplatin
induced neuropathy in colorectal cancer patients. Oncologist 2007;12(3)
38. Potential Benefits of Dietary Supplement Use
During Conventional Therapy
Melatonin
• Recent meta-analysis of 8 RCT’s ( n=761) Solid tumor
cancers
– Melatonin sig. improved complete and partial remission
(16.5% vs 32.6%; p< 0.00001)
– ↑1-year survival (28.4% vs 52.2%;p=0.001)
– Dramatic ↓radio-chemo side-effects ( p< 0.001)
– Consistent across all cancers.
– No serious adverse events
– Dosage studied: 20mg/day, target dose slowly over 1-3
weeks
Wang YM et al., Cancer Chemother Pharmacol. 2012
May:69(5)
39. Complementary Cancer Care
Massage Therapy
• Numerous observational studies demonstrate reduction anxiety,
pain, fatigue, and stress
• Most common forms used in oncology include Swedish massage,
therapeutic massage, acupressure, and reflexology
• East Carolina School of Nursing (2000)
– 23 inpatients with breast/lung ca
– foot reflexology 15 min. vs usual care
– Significant reduction anxiety scores and 1 in 3 of pain measures
Cochrane review meta-analysis prior 2002. 8 RCT, n=357 Anxiety
decrease 8, pain 1/3, nausea 2/3
40. Massage Therapy
Mechanism of Action Theories
• Gate theory of pain
• Parasympathetic activity
• Endorphins, serotonin,?enkephalins
• Blood flow
• Lymphatic flow
• Interpersonal attention
41. Complementary Cancer Care
Massage Therapy
• 87 hospitalized cancer patients randomized to foot
massage or an appropriate control
– VAS scale: treatment > control for” immediate” pain
and anxiety ( p<0.03)
Grealish L et al. Cancer Nurs 2000:23
• RCT comparing acupuncture + massage for post-
operative cancer patients
– N=94 Ac+massage, n=48 usual care
– Intervention 1.4 pts. 0-10 scale vs 0.6 control
(p=.038) Depressive mood: intervention 0.4 (1-5
scale), control =/-0 (p=0.003)
Mehling et al. J Pain Symptom Manag 2007:33
42. Complementary Cancer Care
Massage Therapy
• Largest uncontrolled study at Sloan Kettering Cancer
Center. 1290 cancer pts. Symptom score decreased 50%.
– Both in/outpatients, self-reported pre/post survey 48hrs
RC multi-center trial - Massage vs simple touch
– N=380 (90% hospice, mod/severe pain)
– 30 min massage or ST over two weeks
– Both improved pain and mood
– Massage superior immediate pain and mood
– Effects not sustained for pain, QoL, analgesic use
• Kutner JS et al. Ann Intern Med 2008
43. Massage Therapy
• Systematic review of all RCT’s of non-cancer
subacute and chronic back pain
– Massage therapy demonstrated significant
improvements in pain, Qol, function, and possibly
a reduction in cost of care
Evidence-Based Practice Guidelines for Integrative Oncology
• Recommend use for anxiety, pain by oncology- trained
massage therapist. Grade 1C
44. Supportive Cancer Care
Energy Therapies
• eg. Healing Touch, Therapeutic Touch, Reiki, Qi
gong
• Prospective study massage, healing touch, or
“caring presence” during chemotherapy
– N=230, 44% stage III, 4/wk x 45 min
– Credentialed nurses
– MT,HT significant decrease HR( 7bm), SBP, pain
– HT significantly reduced distress, fatigue ( Profile of Mood )
– MT significant decrease NSAID use
– Drawback of high drop out 29%
Post-White J et al. 2003 Integrative Cancer Therapies, 2(4)
45. Supportive Cancer Care
Energy Therapies
• Single-blind randomized trial, HT vs. Mock
– Gyn / breast ca. pts. undergoing Radiation Rx
– N=78, 62 completed
– Pts. Separated by screen from practitioner
• Results
– HT higher overall scores for QoL( SF-36), mental health, emotional
functioning, health transition
– Mock Rx did show similar increases in physical functioning and health
transition, not QoL
– Drawback: statistical analysis was different between groups
Cook CAL et al., 2004 Alternative Therapies, 10 (3)
46. Supportive Cancer Care
Acupuncture
• Strong evidence supports the use of acupuncture for
post-op pain, chronic pain, OA knee, and headache
Berman BM et al. 2004 Ann Intern Med
• Acupuncture also shown to suppress N/V related to
surgery, pregnancy, and motion sickness
Ming JL et al., J Adv Nurs 2002 (39)
Strietberger K et al. Anaesthesia 2004 (59)
47. Supportive Cancer Care
Acupuncture
Cancer related pain:
• Randomized, blinded, controlled trial auricular
acupuncture
– N=90, true acup., sham acup., acupressure
– Pain intensity decrease true >sham, pressure by
36% at two months ( p<0.001)
– Majority >60% with neuropathic pain
Alimi D et al., J Clin Oncol 2003(21)
48. Supportive Cancer Care
Acupuncture
Cancer related pain
- Pilot study acupuncture treatment for arthralgias
related to aromatase inhibitor therapy
– N=21 post-menopausal women with breast ca.
– Randomized to acupuncture 2x/wk x 6wks
– Full body + auricular acupuncture+ local points
– Results: worst pain (5.3 to 3.3,p=0.01), pain severity ( 3.7 to 2.5
p=0.02),functional interference (3.1 to 1.7, p=0.02), phys.well-being
FACT-G ( 19.9 to 23.4 p=0.03)and WOMAC (80.9 to 47.4, p=0.04)
Crew KD et al., J Cancer Surviv 2007(1)
49. Supportive Cancer Care
Acupuncture
Chemotherapy-induced N/V
• Randomized controlled trial true electroacupuncture,
minimal needling w/ mock electroacupuncture or
antiemetics alone
– N=104 breast cancer patients receive high emetogenic
chemotherapy. Acup Rx 1x/day x 5 days
– Results: significant decrease # episodes emesis in
electroacupuncture group sig. less than the other 2 groups ( #
episodes 5, 10, 15 respectively ; p<0.001) minimal needling<
pharm alone
– Differences among groups not significant at 9 days
Shen J et al., JAMA 2000 (284)
50. Supportive Cancer Care
Acupuncture
Other reported benefits:
Equal to venlafaxine in relief hot flashes ( RCT)
Walker EM et al J Clin Oncol 2010 (4)
• 30% improvement in radiation-induced xerostomia ( case
series)
Johnstone et al., Cancer 2002 (26)
• Effective in hot flashes in men undergoing ADT for prostate
cancer ( case control study)
Beer et al., Urology 2010
• Safe in children with cancer related thrombocytopenia
(retrospective study)
Ladas et al., Support Care Cancer
51. Supportive Cancer Care
Mind-Body Medicine
• Guided imagery
• Hypnosis
• Breath work
• Mindfulness therapies
• Biofeedback
• Music therapy, expressive arts
• Cognitive therapies
• Yoga, Tai Chi, movement therapies
52. Mind-Body Approach
Hypnosis Before Breast Cancer Surgery
• N=200 pts. randomized to a)15 min hypnosis before
surgery or b) empathic listening (attention control).
Staff blind ( surgeon, anesthesia, nursing, research)
• Hypnosis group
– Less anesthesia; same post-op meds
– Less pain intensity, pain
unpleasantness, nausea, discomfort, fatigue, emot
ional upset
– Cost savings: $770 per pt. ( 10.5 min less in
surgery)
• 100 cases annual $77,271 savings ? Hire hypnotherapist
Montgomery GH et al., J Nat Canc Inst 2007 ( 99)
53. Recommended Web-Sites
• NCI/CAM www.cancer.gov/cam/health
• Memorial Sloan Kettering Cancer Center www.mskcc.org
• U of T MD. Anderson Cancer Center www.mdanderson.org
• Cochrane Review Organization www.cochrane.org
• Natural Standard www.naturalstandard.com
• Natural Medicines Database www.naturaldatabase.com
• American Botanical Council www.herbalgram.org
54. Insights
• Integrative practitioner can assist oncology teams
navigation across the bridge between conventional
and complementary worlds.
• Non- judgemental communication needs to exist
between practitioner-patient to enhance
honesty, openness, and trust.
• A number of complementary therapies have a
reasonable evidence-base.
• Education (faculty and resident) and use of reputable
resources will help in supporting the clinical-decision
making process.
55. Evidenced-Based Clinical Practice Guidelines for
Integrative Oncology: Complementary Therapies
and Botanicals
• Practice recommendations based on strength of the
evidence and the risks/benefits ratio
• Grading system modeled from the American College
of Chest Physicians Task Force on Grading
– Recommendations: strong ( grade 1),weak (grade 2)
Quality of evidence high (grade A), moderate ( grade B
), low( grade C )
Journal of the Society for Integrative Oncology Vol 7, No. 3, 2009
56. “Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference”
Robert Frost, New England Wisdom
57. “ The role of the physician is to
Cure sometimes,
Heal often,
Support always “
Ambroise Pare