Supportive care in cancer
Chittima Sirijerachai Supportive care in cancer
• Supportive Care in Cancer is the prevention and management of the
adverse effects of cancer and its treatment from diagnosis through
anticancer treatment to post-treatment. Supportive care in cancer
• alleviates symptoms and complications of cancer
• reduces or prevents toxicities of treatment
• allows patients to tolerate and benefit from active therapy more easily
• supports communication with patients about their disease and prognosis Side effects of chemotherapy
• Nausea, vomiting
• Mucositis
• Changes in taste, food aversions, sensitivity to odors
• Decreased appetite, anorexia • Myelosuppression: Febrile neutropenia • Other side effects- specific to chemotherapy Chemotherapy-Induced Nausea and Vomiting (CINV)
• Classification • anticipatory • acute • delayed • breakthrough • refractory • Chemotherapeutic regimens can be classified as having high, moderate, low, or minimal risk of emetogenicity. • Incidence and timing of CINV vary according to patient factors and chemotherapeutic agents. Chemotherapy-Induced Emesis: Risk Factors
• Patient-related risk factors include: • Younger age • Female gender • Prior CINV • Anxiety • High pretreatment expectation of severe nausea
• Treatment-related risk factors include: • High drug dose • High emetogenicity of chemotherapy drugs Causes of CINV
In addition to emesis induced by chemotherapy, CINV can be caused by:
• Partial or complete bowel obstruction
• Brain Metastases
• Electrolyte imbalance: hypercalcemia, hyperglycemia, hyponatremia, uremia
• Concomitant drugs, including opiates
• Gastroparesis induced by a tumor or chemotherapy (such as vincristine)
• Psychophysiologic factors, including anxiety as well as anticipatory nausea and vomiting Emetogenic risk of IV chemotherapy
High Carmustine, BCNU Cyclophosphamide >1500 mg/m2 (risk >90%) Cisplatin Dacarbazine Carbolatin (AUC >4) Ifosfamide > 2g/m2
Moderate Azacitidine Idarubicin (risk 30-90%) Bendamustine Ifosfamide < 2g/m2 Busulfan Melphalan Carboplatin (AUC<4) Methotrexaten >250 mg/m2 Cyclophosphamide <1500 mg/m2 Mitoxanthrone >12mg/m2 Cytarabine > 200 mg/m2 Doxorubicin Daunorubicin Epirubicin Emetogenic risk of IV chemotherapy
Low Brentuximab vedotin Doxorubicin(liposomal) (risk 10-30%) Carfilzomib Etoposide Cytarabine 100-200 mg/m2 Gemcitabine
Minimal Asparaginase Decitabine (risk <10%) Bleomycin Fludarabine Bortezomib Vinblastine Cytarabine <100 mg/m2 Vincristine Emetogenic risk of oral chemotherapeutic agents
Hexamethylmelamine HIGH Procarbazine Cyclophosphamide Vinorelbine MODERATE Etoposide Imatinib Temozolomide Capecitabine LOW Fludarabine Chlorambucil 6-Thioguanine MINIMAL Hydroxyurea Methotrexate L-Phenylalanine mustard Gefitinib Antiemetic agents
1. Serotonin receptor antagonist (5-hydroxytryptamine; 5-HT3 receptor antagonist): • 1st generstion: ondansetron, dolasetron, granisetron and tropisetron • 2nd generation: palonosetron 2. Corticosteroids : dexamethasone, methylprednisolone
3. Neurokinase-1 (NK-1) receptor antagonist: aprepitant, netupitant
4. Dopamine antagonist: metoclopramide, domperidone, olanzapine
5. Combined drug: NEPA (netupitant 300 mg + palonosetron 0.50 mg) 6. Cannabinoids Principles of Care for Acute Highly and Moderately Emetic Settings
- Use the lowest tested fully effective dose.
- The antiemetic efficacy and adverse effects of serotonin antagonist agents are
comparable in controlled trials.
- Intravenous and oral formulations are equally effective and safe.
- Always give dexamethasone with a 5-HT3 antagonist before chemotherapy. Recommended doses of antiemetics
Mucositis
• Predisposing factors: • Younger patients • Poor oral hygiene • Poor nutritional status • Common chemotherapeutic agents : • Cytarabine • Doxorubicin • Etoposide (high dose) • hydroxyurea • Melphalan (high dose) • Methotrexate Oral care protocol
• Before commencement of chemotherapy • treatment of caries and dental disease; and • education regarding the importance of orodental hygiene, how to maintain oral hygiene and to develop a daily routine of oral care • Post therapy • clean teeth and gums after meals and before sleep with tooth brush or swab as tolerated; • if dentures are worn, remove and clean them daily and leave out while at rest; • avoid painful stimuli such as hot food and drinks, spicy food, alcohol and smoking; • report any redness, tenderness or sores on the lips or in mouth; • provide comfort measures such as lubrication of the lips, topical anaesthesia and analgesics; • prompt treatment of mucositis symptoms and oral infections. Oral mucositis
Do Don’t • Oral care protocol • Antimicrobial lozenges • Oral cryotherapy • Antimicrobial mouth wash • recombinant human • Sucralfate mouth wash keratinocyte growth factor-1 • G-CSF, GM-CSF (SC or topical) (KGF-1/palifermin) • Pain controlled analgesia: • Xylocaine viscous • Morphine (topical or oral) Mucositis
• Infection complication:
• Oral candidiasis
• Clotrimazole troche, nystatin suspension
• + oral fluconzole • Herpes simplex virus infection • Oral or parenteral acyclovir