Palliative Chemotherapy
Dr. Oscar S. Breathnach
Consultant Medical Oncologist
Palliative Care Multidisciplinary Study Day
Beaumont Hospital
Sept. 19th, 2013
You have been diagnosed with
ADVANCED
CANCER
CANCER
PATIENT
[ mind-body-spirit ]
Cultural
Environment
FAMILY / FRIENDS
OUTCOME
MEDIA / INTERNET
Belief Systems
Life Events
MEDICAL / NURSING
STAFF
Cancer, an age-related event
in a population with
Less Births / Prolonged Survival
When cure is not a reality
•
•
•
•
•
•
•
•
Suspecting the cancer
Suspicions confirmed
Staging the cancer
Advanced stage
Opinion re chemotherapy
Personal and family reactions
Hope vs reality
Chemotherapy
Objectives
PERSON:
• Live longer
• Quality of Life
• Dignity
STATE:
• Cost-effectiveness
• Standards of care
MEDICAL STAFF:
• Maintain quality of life
• Minimise toxicity
• Prolong survival
• Progression-free
survival
• Minimise diseaserelated toxicity
• Balance between all
the various factors
Palliative Chemotherapy
• Other patients / families (the waiting room)
• Anti-cancer agents
• Support personnel:
– oncologists, nurses, physios, OTs, dieticians, social
workers, psycho-oncology, palliative care team, health
care assistants, ward clerks, catering staff, cleaners,
etc
•
•
•
•
The Hospital building
The Internet’s message of hope / options
The Myths
History / transmitted memories
3 Lives -:- 3 Pathways
• Relatively asymptomatic
• Symptomatic, but reversible
• Profoundly symptomatic, non-reversible
Considerations re Treatment
•
•
•
•
Performance Status
Range of agents
Therapeutic target
Measuring benefit
– Symptoms
– Radiology
– Function
• When to break / stop
Survival curve percentiles and their corresponding scenarios.
Kiely B E et al. JCO 2011;29:456-463
©2011 by American Society of Clinical Oncology
Selected Toxicities
Erlotinib and Docetaxel
(indirect retrospective contrast)
80
70
60
50
40
30
20
10
0
i on
Infec
t
ue
Fatig
oea
Diar
rh
Stom
atitis
ing
Vom
it
Naus
e
a
Erlotinib
Placebo (BR21)
Docetaxel
Emerging Targets: NSCLC, adenoca.
Metastatic: NSCLC, 1st line
• Histology / Molecular profile
– EML4-ALK mutation
– EGFR mutation
– K-ras
Study
Agents
LUX LUNG 3 Cisplat-Pem
Afatinib
IPASS
Carbo-Pac
Gefitinib
EURTAC
Cis/Doc or Gem
Erlotinib
(7% of adenocarinoma)
(17% of adenocarcinoma)
(22% of adenocarcinoma)
RR
22%
56%
41%
71%
15%
58%
PFS (mos)
6.9
11.1 (13.6)
5.5
9.0
5.2
9.7
Lux Lung 3: common mutations
Toxicity Profile
Afatinib
vs
Cis/Pem
Grade 3/4 Toxicity
(%)
Grade 3/4 Toxicity
(%)
Diarrhoea
14.4
0
Rash/acne
16.2
0
8.7
0.9
11.4
0
Nausea
0.9
3.6
Fatigue
1.3
12.6
Stomatitis/mucositis
Paronychia
Lux Lung 3
Ms. A.A
• Small cell
• Lives with partner, children abroad
• Nervous
• Extreme dyspnoea
• Haemoptysis
Nov. 13th, 2012
Pre-
and
Post
4 cycles of chemotherapy
Post sequential chest radiation
8 months post diagnosis
5 months post completion of chemotherapy
Ms. M.C.
• Breast lesion x 4yrs
• Single; no children
• Bleeding chest wall; increasing left arm
pain, with decreasing sensation
• Deliberated over radiation and
chemotherapy
Pre-Treatment
Progressive disease:
Dx date +5 months
Further chemotherapy:
Dx date +12 mths
Considerations
•
•
•
•
•
•
•
•
The Person
The Realistic outcomes
Realistic optimism
The person’s objectives
Focus on Quality / Prolongation of life
When not to treat
Beyond treatment
Those remaining
Choose Wisely