Symptom control in the terminally ill lung cancer patient PowerPoint Presentation

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Symptom control in the terminally ill lung cancer patient Ülkü Yılmaz Turay Associated Prof, MD Atatürk Chest Disease and Surgery Education and Training Hospital

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‘One of the worse aspects of cancer pain is that it is a constant reminder of the disease and of death… My dream is for a medication that can relieve my pain while leaving me alert and with no side effect Jeanne Stover Clinical Practice Guideline Management of Cancer Pain 1991-1992

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Presentation plan Definitions; terminally ill patient, palliative, supportive, end of life care, Symptoms in terminally ill lung cancer patient and management of these symptoms, Where should terminally ill lung cancer patient look after.

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Symptoms ın lung cancer Primary cancer ıtself Locoregional metastases within the thorax Extrathoracic metastases Paraneoplastic syndromes Constitutional symptoms Cough Dyspnea Hemoptysis Pain Recurrent nerve palsy Phrenic nerve palsy Superior sulcus tumor Horner syndrome Pain (Thorax, pleura) VCSS Pericardial involvement Eusophageal involvement Pain(bone metastasis Liver metastasis Intraabdominal lymph nodes Brain, spinal cord metastases Exrtrathoracic lymph node involvement Skin metastases Paraneoplastic smyyndromes HOA Neurological, oplastic syndromes Fatigue, anorexia/cachexia Anxiety, depression

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Definition of terminally ill patient Year to months Months to week Weeks to days Last year of life: Performance status; ECOG>3, KPS<50 Hypercalcemia Central nervous system metastases Delirium Superior vena cava syndrome Spinal cord compression Cachexia Malignant effusions Liver failure Kidney failure Other serious comorbid conditions www.nccn.org

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Definition of terminally ill patient Akciğer kanserli olgularda son dönem; ölümden önceki 8 hafta olarak alınmıştır.

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Symptoms in the terminal stage of lung cancer Chest 2007 131: 394-397

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Palliative care-Supportive care Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. WHO 2002 Supportive care Palliative care End of life

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Palliative care Am J Respir Crit Care Med 2008;177: 912-927 Death Curative treatment Palliative care Curative treatment Curative treatment Palliative care Palliative care Palliative care

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Palliative chemotherapy Nearly half of the patients had received chemotherapy in the last month of life, One patients out of five received treatment in the last two weeks. Oncologist 2006:11;1095-9

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Skor Skor Eur J Cancer 2009

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Symptom management of terminally ill cancer patients complicated by several factors Older age Malnutrition, low albumin Frequent autonomic failure Decreased renal function Borderline cognition Lower seizure treshold(brain involvement, opioids) Long-term opioid therapy Multiple drug therapy

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Symptom assessment How do we measure? Symptom assessment scale Why do we need to measure? Able to compare To find all symptomps Quality assurance/advocacy Association between symptom severity and survival Cancer 2010;116:137-45

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Symptom assessment Edmonton Symptom Assessment Scale

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Yaşam Kalitesi Quality of life assessment EORTC QLQ-LC 30 Lung cancer symptom scale (LCSS) J Clin Oncol 2007;25:5381-5389 QOL

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QOL

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QOL

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Patient suffering from pain, what should we do? 1- Assessment of pain History, Validated assessment tool, Physical examination including neurological

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Patient suffering from pain, what should we do? 2- Diagnose the pain Origin; primary disease, treatment, other Pain due to progression of disease Post-chemotherapy pain Post-radiotherapy pain Post-operative thoracic pain Type of pain Mecanism of pain Different dimensions of pain experience and other symptoms Lung cancer 2010;68:10-15

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Patient suffering from pain; Types of pain Nociceptive pain Somatic pain ( parietal pleura) Visceral pain (mechanoreceptive ischemic stimulus)

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Neuropathic pain Radiculopathy Mononeuropathy Peripheral neuropathy Plexopathy Postherpetic neuralgia Malignant brachial pleksopathy Patient suffering from pain;

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Assessment of pain intensity Visual analog scale Numeric scale Categorical scale No pain Worst possible No pain Worst possible 1 2 3 4 5 6 7 8 9 10 No Weak Moderate Severe Very severe Extreme pain pain pain pain pain pain

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Symptomatic pain treatments By the clock By the mouth By the ladder

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WHO Analgezic ladder Non opioid: Paracetamol AINS +/- Adjuvants Step 1 Step 2 Step 3 Codeine, Tramadol +/- non-opioids +/- Adjuvants Reference: Oral morphine Hydromorphine Methadone Phentanyl +/- non-opioids +/- Adjuvants

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Pain treatment: The use of opioids OPIOIDS Morphine 10 Hydromorphon 2 Oxycodon 6 Phentanyl 0.1 Methadone (değişken) MORPHINE Bioavailability %15-65 Oral dose = 3 x IV, IM dose Plasma halflife: 3 h

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Opioid titration Add 30 % of total dose Total dose+breakthrough pain 6 = Four hour dose

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Pain treatment: In patients who can’t take oral medications Transdermal preperations; Phentanyl Effective dose determined by a short acting opioid Not a first choice Swallowing difficulties, alteration of drug absorbtion or other intolerances to the oral route Stable pain Conversion from Morphine to phentanyl; No clear protocols have been established 1:70-100 Subcutan route; except methadone most drug used by subcutaneous infusion. Safe and effective for teminally ill patients. Rectal route

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Treatment of breakthrough pain 90 % BTP can be controlled with oral/sc route. Transmucosal, oral, nasal phentanyl: failure of oral/sc Available inTurkey: oral transmucosal phentanyl

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Side effects of opioids Sedation Respiratory depression Nausea-womiting Constipation Urinary retention Pruritus Hydrosis Cognitive impairment and neurotoxicity Tactile and visual hallucinations Generalized myoclonus Hyperalgezia Allodynia

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Management of opioid side effects Constipation Preventive measures: Stimulant laxative+stool softener ; senna, docusate 2 tb her sabah; 8-12 tb/gün Maintain adequate fluid intake Maintain adequate dietary fiber intake If constipation develops; Magnesiumum hydrokside 30-60 ml/day Bisakodyl Rectal supp Lactulose Sorbitol Neurological side effects Consider changing the opioid Decrease dose of opioid Hydration Eliminate other phsycothropic drugs

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Adjuvants Antidepressants: Amitriptyline Anticovulsants: Carbamazepine, phenytoin,, valproate, clonazepam Gabapentin, pregabalin Corticosteroids: dexamethasone NMDA (N-metyl D-aspartat)Antagonists; Ketamine

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Interventional procedures Spinal route (Epidural, intrathecal) Opioid; morphine Lokal anesthetics; bupivakaine, ropuvakaine Klonidin Percutaneous cordotomy

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Non-pharmacological approaches Psychological Anxiety Depression Insomnia Physical Cognitive, behavioral approaches

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Palliation of brain metastases Brain metastases; NSCLC % 35 SCLC % 50 TREATMENT: Whole-brain radiation therapy Corticosteroids

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Causes of dyspnea in lung cancer patients Dyspnea directly caused by cancer Pulmonary parenchyma involvement(primary, methastatic) Intrinsic or extrinsic airway obstruction by tumor Lymphangitic carcinomatosis Pleural effusion Pericardial effusion VCSS Tumoral embolism Phrenic nerve palsy Atelectasis Trachea-eusophageal fistula Chest wall involvement Dyspnea indirectly caused by cancer Pneumonia Cachexia Anemia Electrolit disturbances Pulmonary emboli Paraneoplastic syndromes Ascide Respiratory muscle dysfunction Pain Pneumothorax Caused by cancer therapy Surgery Radiation pneumonitis Chemotherapy induced pulmonary fibrosis/ pneumonia

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Symptomatic treatment of dyspnea Oxygen Pharmacologic therapy General supportive measures

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Symptomatic treatment of dyspnea: Oxygen In patients who are hypoxemic at rest on room air; decreased dyspnea In patient who are nonhypoxemic; Placebo ? Trigeminal nerve(V2 branch) stimulation ?

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Symptomatic treatment of dyspnea: Pharmacologic therapy Mechanism of action opioids in pharmacological management of dyspnea; Reduce the central processing of neural signals within the CNS Reduce oxygen consumptin in exercise and rest Reduce perception of dyspnea Pulmonary vasodilatation Relieve dyspnea by depressing hypoxic or hypercapnic ventilatory response Support Care Cancer 2008; 16: 329-37 Nat Clin Pract Oncol 2008;2: 90-100

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Symptomatic treatment of dyspnea: Opioids The optimal type, dose and mode of administration of opioids have not yet been determined. Opioid treatment in dyspneic patients; Start low dose and titrate Opioid history of patient Opioid –naive patint: 5 mg Morphine sulphat; subcutaneus. Increase hourly For patients receiving opioids, 25 % increase in baseline dose may provide relief for several hours .

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Symptomatic treatment of dyspnea Pharmacologic Nebulised opioids Nebulised furosemid Corticosteroids Bronchodilators General supportive care Fan Pulmonary rehabilitation

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Symptomatic treatment of dyspnea Benzodiazepines Lorazepam 0.5-1 mg oral Diazepam 5-10 mg oral Clonazepam 0.25-2 mg oral Phenothiazines Clorpromasine 7.5-25 mg oral-sc Metotrimeprasin 2.5-10 mg oral-sc Levomepromazine 6.25 oral Cancer Treat Rev 1998; 24:69 Nat Clin Pract Oncol 2008;2:90-100

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Cough Non-productive cough Codeine 10-20 mg X 4-6 Dekstrometorphan 10-20 mg X 3-6 Benzonatate Levodropropisine75 mg X 3 Dihydrocodeine 10 mg X3 Productive cough Hydration Physiotherapy Air humidification Acetylcysteine Bronchodilators Corticosteroids Nebulised lidocaine Nebulised morphine Nebulised phentanyl

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Fatigue Fatigue Correction of potential etiologies Depression Deconditioning Anemia Sleep disorders Fluid- Electrolytes Symptomatic therapies Pharmacologic therapy Psychostimulants Nonpharmacologic therapy; Support group, education Clin Lung Cancer 2006;4:241-249

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Pharmacological therapy of fatigue Methylphenidate Modafinil Dexmethylphenidate Dextroamphetamine Corticosteroiss Megestrol acetate Donepezil ? www.nccn.org J Natl Cancer Inst 2008;100:1155

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Anoxia/Cachexia The cancer –related anorexia/cachexia syndrome is characterized by anorexia and loss of body weight associated with reduced muscle mass and adipose tissue . In terminally ill patient; Treatment goals of the treatment are symptomatic rather than nutritional. Social aspects of eating over the nutritional benefit. Corticosteroids are capable of improving appetite, nausea and energy for brief periods of time. Megestrol acetate ??

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Hydration Artificial hydration when patients develop reduced oral intake because of profound anorexia, dysphagia or severe nausea and vomiting; Dehydration and electrolyte imbalance can cause confusion, restlessness, neuromuscular irritability, Improve comfort and life quality, Lead to clear the toxic drug metabolites, Parenteral hydration is minimum standart of care, continuing this treatment bond to life To cause to cease thirst recommended. J Clin Oncol 2005;23:2366-71

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Hydration Volumes of 1000-1500 cc/day are usually enough to maintain normal urine out put ; Decreased insensible water losses as a consequence of reduced physical activity, Decreased absolute water requirements Decreased clearance of free water because of an increase of ADH due to nausea and womiting J Clin Oncol 2005;23:2366-71 Methods of fluid administration: Intravenous Subcutaneus; hypodermoclysis Proctolysis

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Depression Depression is the most common mental health problem encountered in palliative medicine Treatment: Relieve uncontrolled symptoms Supportive psychotherapy Pharmacologic therapy NCCN Guideline-2009

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Delirium Delirium is the most common neuropsychiatric complication in patints with advanced cancer; Fluctuating levels of conciousness Changes in the sleep/wake cycle Psychomotor agitation Hallucinations Delusions Perception abnormalities

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Delirium Predisposing factors: Opioid-induced neurotoxicity Brain metastases Cancer treatment Psychotropic drugs (Tricyclic antidepressants, benzodiazepines) Metabolic (increased calcium, decreased sodium, renal failure) Paraneoplastic syndromes Sepsis Treatment Treatment of predisposing factors Clorpromasine, olanzepine,risperidon Haloperidol JAMA2008;300:2898-910 Midazolam Propofol

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End of life; patient expect Having symptomps under control Being able to breath comfortably Being able to feeding her/himself Preperation for death Having energy to do things one wants to do Good relationship with healthcare professionals Ann Intern Med 2000;132:825-32 J Pain Symptom Manage 2001 22:717-726

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Measures of aggressiveness of care in patients who died of lung cancer in 2002 Died in acute care hospital bad % 59.5 (58.3-60.8) At least one visit to the emergency room in last two week % 32.2 (31-33.4) Admitted to the intensive care unit in last two week % 5.5 (4.9-6.1) Received a chemotherapy injection İn the last 2 weeks % 4.6 (4.1-5.2)

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End of life patient care: Where? Components palliative care service Hospice Home care Out patient clinic Inpatient clinic

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Death is a natural event

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