Cancer treatments in palliative
care
Clare Warnock
Practice development sister
Weston Park Hospital
Overview of session
• How does cancer treatment work
– The difference between normal cells and cancer cells
– How cancer treatments work on these differences
• Systemic anticancer therapy
– Different types of treatment
– How they are given
– Side effects
• Radiotherapy
– How it works
– How it is given
– Side effects
The differences between a cancer cell
and a normal cell
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Differentiation – what it looks like
Ability to spread – direct and metastatic
Growth
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Healthy cell reproduction
– Carefully controlled process
– Cell division triggered by the death of a cell
– Cell reproduction and cell death carefully balanced
Different processes act in cancer cells so their
reproduction is not constrained by these usual controls
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The rate of growth
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Doubling time
– Time it takes for a cancer to double in size
30 times
– One billion cells (marble size)
– Can be detected by X- ray or palpation
10 more doublings
– One trillion
– Usually the point at which life cannot be sustained
For much of its growth cancer is undetectable
The doubling time (rate of growth) for different cancers
varies greatly from hours to years
Cancer growth is often a sustained and constant
process rather than a rapid one
Growth curve for cancer
Lethal
limit
Treatment
Limit of
detection
Immune
system can
handle
Cure
Palliative
Cancer as a chronic disease
• Chronic diseases
– Shaped by periods of acute and intensive illness
followed by periods of remission
• People with cancer are living for longer with a
chronic, but life threatening, illness
• Challenges the portrayal/ perception of cancer
• Challenges the concept of “palliative” in relation to
cancer and its treatment
• Concept of the “survivor” having increasing
relevance in cancer care
Cancer treatments
• Cancer treatments capitalise on the characteristics of
cancer cells
• In particular
– more frequent cellular division
– poor ability to repair damage compared with normal
cells
• Radiotherapy and Chemotherapy are often most
effective when cells are dividing
– This is one reason why they have a greater effect on
cancer cells compared with healthy cells
Systemic anti-cancer therapy (SACT)
• Chemotherapy
• Biological therapy
The action of chemotherapy
• Chemotherapy is a systemic treatment
– This means it can effect all the cells in the body
• Chemotherapy drugs interfere with the process of
cell replication
• Different chemotherapy drugs achieve this is
different ways
• Many work at specific stages in the process of cell
replication
– This is often referred to as the cell cycle
How does anti-cancer therapy work
Growth promoting
factors
Growth inhibiting
factors
The cell cycle clock
G0
Genes that promote
cell division
(proto-oncogenes)
production
of growth
stimulating factors
Resting
phase
G2
Later growth phase
M
Mitosis
S
DNA synthesis
G1
Early growth phase
Green = chemotherapy action
Yellow = biological therapy action
Tumour
suppressor
Genes that control
cell division
production of
growth inhibiting
factors
How does chemotherapy work?
• Some drugs work at specific parts of the cell cycle,
others can work at any point
• Actions include
– Preventing cell division (M phase) by fusing the old
and new cells together
– Inhibiting enzymes involved in DNA synthesis
– Interfering directly with DNA
How does biological therapy work
• Targeted therapy
• Range of modes of action
– Inhibit the signalling pathway that causes cell
division
– Prevent the formation of tumour blood vessels
– Prevent the production of particular enzymes
which stop the cell from dividing
• All have the effect of slowing or stopping tumour
growth
Examples of targeted therapy
• Tyrosine Kinase Inhibitors (TKI’s)
– Erlotinib/Tarceva®
– Sunitinib/Sutent®
– Imatinib/Glivec®
• Monoclonal Antibodies (MAB’s)
– Rituximab
– Bevacizumab (avastin)
• HER2 positive
– Herceptin
The aims of SACT
• Maximise the damage to cancer cells
• Minimise the damage to healthy cells
• How is this achieved?
• Giving combinations of drugs
– Drugs that work in different ways increases
cancer cell kill
– Giving drugs with different side effects reduces
overall side effect profile
• Cycles of administration
– Giving chemotherapy at planned intervals
– Increases the chance of catching cells in the
sensitive phase
– Allow healthy cells to repair
Intention of treatment
• Curative
– Aims to eradicate measurable disease
– Treatment often intensive and associated with greater
toxicity
– Improved outcomes by maintaining intensity and
avoiding delays in treatment and dose reductions
• Palliative
– Aim to extend survival, alleviate disease and improve
quality of life
– Careful balance between quality of life and treatment
outcomes
• Side effects, duration of response, time in hospital, disruption
of ADL’s
Health and safety
Reducing exposure to a minimum
• Chemotherapy is mutagenic, teraterogenic and
carcinogenic
• Primary routes of exposure
– Absorption through skin, inhalation, ingestion
– Patients excrete the drugs over the next 7 days
• Provision of protective clothing
– Gloves and aprons
– universal precautions when handling body fluids
• Guidelines
– preparation, handling, disposal and spillages
– Pregnancy – don’t handle or administer
chemotherapy
Administration – method and route
• Intravenous
– bolus
– infusion
– infusor (ambulatory chemotherapy)
• Intrathecal
• Intramuscular
• Intravesical
Oral anticancer therapy
• Increase in oral treatments over past 5 years
• Misconception that a tablet isn’t going to cause as many
problems as intravenous
– Many have potentially distressing and life threatening side
effects
• Self medicating
– Patient information and compliance essential
– Risk of patients continuing with treatment when experiencing
side effects
• Health and safety issues include: – Always wear gloves when handling oral chemotherapy
– Never crush tablets or open capsules
– Safe storage vital, away from children
Side effects
• The incidence and occurrence of side effects is
drug and dose related
• It is essential to know the regime specific facts
Nausea and vomiting
• Acute - occurs within minutes to hours and
resolves within 24 hours
• Delayed - 16 to 24 hours post chemotherapy,
persists for hours to days
• Anticipatory - conditioned response
• Ematogenic potential
– How likely a drug is to cause nausea and vomiting
Nausea and vomiting
• Medium to high ematogenic potential eg cisplatin and
doxorubicin
• Antiemetics prescribed as part of the protocol for
the regime
– graniestron, ondansetron and apprepitant
– IV and oral steroids (dexamethasone)
• lower ematogenic potential ie fluorouracil
• “as required” antiemetics prescribed e.g.
domperidone
• Encourage patients to report symptoms before next
treatment so we can get the management right
Neutropaenia
• Low count of neutrophils – used as an indicator of
infection risk
• Neutrophils ingest and kill bacteria and viruses in
circulating blood
– Normal range - 2.5 to 6.0 X109/l
– Less than 1.0 X 109/l – neutropaenia
– Less than 0.5 X 109/l serious risk of bacteraemia
• Normal process of controlling bacterial infection is
diminished
– can lead to life threatening infections
• When and where to seek support
– WPH assessment unit nurse
Neutropaenic sepsis
• White blood count of less than 1.0 X 209/l and one of
the following
– Oral temp >380c
– Any unexplained deterioration in the absence of
fever
– HOWEVER – we ask patients to ring if the have a
temperature above 37.5 OR feel unwell
• Treatment
– RING WPH and come in for review
• Urgent blood test required
• Deterioration can be rapid
Thrombocytopaenia
• Low platelets
• Increased risk of bleeding
Care issues
• Monitor for any signs of bleeding, bruising, petichae
• Avoid invasive procedures
• Patient information – ring and blood test
– May need platelet transfusion
Altered bowel habit
Diarrhoea
• Potentially life threatening complication
• Severe diarrhoea may require hospital admission to
prevent dehydration
• Anti-diarrhoeal medication – loperamide
• If not controlled patient must contact WPH
Constipation
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Vinca alkaloids
Exacerbated by graniestron
Risk of paralytic ileus
May need laxatives
Other common side efects
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Sore mouth
Hair loss
Fatigue
Cardiac toxicity – acute and chronic
– NB Capecitabine and 5FU infusor, coronary artery
spasm – 999 call
• Peripheral neuropathy
• Renal toxicity
• Fertility effects
Hand foot syndrome
• Palmar plantar erythrodyesthesia
• Incidence increasing due to new drugs
• Symptoms:
– dysesthesia, parasthesia in the palms and soles
– Swelling on the pads and distal phalanges
– Vesicles and desquamation over the pressure areas
– Blistering and necrosis
– Can be intensely painful and disrupt ADL’s
• Diminishes once treatment has ended
Skin reactions
• Marked skin reactions can occur with some
chemotherapy agents particularly TKI’s such as
Tarceva
• Patients are advised to use moisturising cream
to try and prevent the skin from becoming to dry
• Avoid strong sunlight and use a high SPF
sunscreen
• It may appear like acne but it should not be
treated with acne medication
• Some patients may require steroids or antibiotics
Radiotherapy
Radiotherapy
• Radiotherapy is a local treatment
– Targeted to specific sites in the body
• Radiotherapy uses ionising radiation to damage
DNA
• Ionising = radiation that is able to disrupt the
chemical structure of the material through which
it passes
• It excites cell molecules changing the atomic
and molecular structure
Factors affecting radiosensitivity
• Radiotherapy works more effectively for particular
types and sites of cancers
• One factor affecting radio-sensitivity is the phase of
the cell cycle
– The process of cell reproduction
• Tends to work during phases of the cell cycle when
DNA synthesis can be disrupted or replication
disturbed
– G1, G2, M
• It affects all the cells in the treatment site but has a
greater effect on cancer cells
– Cancer cells are more likely to be in the cell cycle
The cell cycle
How is it given?
• External beam
– Linear accelerator
• Treatment delivered by therapy radiographers
• Radiation created by, and remains in, the machine
• Brachytherapy
– Sealed and unsealed sources
• Sealed source – radiation is located in the source
• Unsealed sources – patient is temporarily radioactive
Linear accelerator
• Successful treatment depends on the
therapeutic ratio
– optimising the dose to the cancer
– minimising damage to normal cells
• Controlling the treatment area
– Planning and accurate positioning
Careful positioning
How to achieve the therapeutic ratio
• Fractionation
• Division of the total dose into smaller doses
– e.g.60 Gy 30# for a curative regime
• Allows for normal cell repair
• Increases chances of catching cells when
sensitive
• Allows re-oxygenation of the tumour
• Palliative regimes tend to be shorter and use lower
doses
Uses of Radiotherapy in palliative care
• Radiotherapy can be for curative or palliative intent
• Palliative treatments include:
– Reduction in tumour mass with the intention to
• prolong survival and/or
• increase quality of life and/or
• symptom management
– Management of bone metastases
– Treatment of brain metastases
– Oncology emergencies e.g. Spinal cord compression,
SVCO
– Fungating lesions
– Management of bleeding
Pain and bone metastases
• Bone metastases are the most common
secondary site of spread
• Most common cause of pain in malignancy
• Frequently arise from
– breast, prostate (combined = 80% of incidence)
– lung, kidney, thyroid, multiple myeloma,
gastrointestinal
• Pain may be due to
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Bone changes
Pathological fracture
Neuropathic pain if presses on adjacent nerve
Spinal cord compression
How external beam radiotherapy works on
bone metastases
• Cytotoxic effect on normal bone cells inhibits the release
of chemical mediators of pain such as prostaglandins
– Some patients get relief in 24 hours
• Effect on cancer cells prevents further bone destruction,
reduces tumour size and enables bone resorption
– The pain relief effect achieved between 2 and 8
weeks of treatment
Oncology palliative emergencies
• Radiotherapy plays a role in treating and managing
symptoms from key palliative emergencies
• Spinal cord compression
– Early detection vital as functional outcome of
treatment is related to function on presentation
• Superior vena cava obstruction
• Brain metastases
Tumour size reduction
• Palliative radiotherapy can be used to reduce size of
tumour and actual and/or potential problems
– inoperable/ recurrent local tumour or nodal
compression
• A higher dose palliation programme may be needed
• Patient may have 30 – 45 Gy over 2 – 4 weeks using
multiple fields
• Side effects are more likely to occur
• Incidence and severity will depend on dose given, site
treated and other patient related factors
Side effects of radiotherapy
• Categorised as systemic and local, acute and chronic
(6 months after treatment)
• Local effects are specific to the area being treated
• Acute side effects tend to occur within the first 2
weeks of treatment, increase in severity and peak 10
days after treatment completion
• Chronic side effects are usually caused by a
decrease in blood supply to the tissue being
irradiated leading to fibrosis, stenosis, or necrosis
• Palliative radiotherapy regimes are aimed at inducing
fewer side effects (lower total doses, fewer fractions)
Fatigue
• Fatigue has been reported as one of the most
distressing side effects of treatment
• It is consistently identified as the most common and
most distressing symptom in research into radiotherapy
side effects
• It increases over the course of radiotherapy and may
continue for months following completion
• Important to warn patients it may occur and there are
physiological causes (not them!)
• Interventions include
– Rule out other causes, sleep hygiene, maintain
activity – gentle exercise
– May not be appropriate for all palliative care needs
Skin reactions
• Skin reactions range from faint erythema to
moist desquamation
• Relate to facors inlcuding
– Dose, location (skin folds, proximity to skin surface)
– Age, general health, smoking
Skin care
• Washing skin using mild, unperfumed soap and
warm water
– avoid friction - pat skin dry, loose cotton clothing
• During the first stage of a reaction applying moisturising
cream can provide relief and prevent deterioration
– E45, Oilatum or Diprobase
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Avoid perfumed products
Use an electric razor instead of wet shaving
Protect skin from sun, wind and extreme temperatures
Reactions are greatest at the end of radiotherapy when
the patient has completed treatment
• Contact radiotherapy treatment area for advice on
management
Site specific side effects
• The incidence and severity of side effects
is dose and treatment site related
• What side effects could patients
experience when having radiotherapy to
– Brain
– Head and neck
– Chest
– Abdomen and pelvis
The context of treatment
• It is essential to remember that an
individuals experience of cancer and its
treatment is shaped by contextual factors
Context of treatments
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Previous treatment
Diagnosis
Disease trajectory
Belief about cancer/DXR
Knowledge and
understanding
• Relationship with HCP’s
• Symptoms
• Prognosis
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Home situation
Family and friends
Stage in life
Work and social life
Financial situation
Body image
Past experience
Physical functioning
Other illnesses
Conclusion
• When used appropriately cancer treatments aim
to
– increase survival, improve symptom management
and quality of life
• Preventing, monitoring and managing side
effects are essential if these aims are ot be
achieved
• All HCPs play a role in this process
• Advice and information is available from WPH
– 0114 226 5000
– Nurse practitioner assessment unit
– Patient’s consultant team
• Thank you for listening……
• Hope you found the journey interesting!