Breast Cancer
Supportive Care
May 2-6 2011
FUND FORUM
Symptoms and Prognosis
• Challenge of symptom
management:
– block toxicity without
compromising efficacy
Supportive Care Toxicity Targets
• Hematologic
• Myelosuppression
• Neurologic
• Peripheral neuropathy
• Cognitive
• Gastrointestinal
• Nausea/vomiting
• Constipation/diarrhea
• Mucositis
• Cardiovascular
• Thrombosis
• Cardiac
• Pulmonary
• Renal
• Cutaneous
• Alopecia
• Rash
Gastrointestinal: Nausea
and Vomiting
• Chemotherapy
• Radiation therapy-especially
brain, abdomen, pelvis
• Brain mets
• Bowel obstruction
• Electrolyte imbalance
• Other medication
Perception of
Chemotherapy (1983)
Nausea and vomiting are the two most
feared toxicities of chemotherapy
Coates, Eur J Cancer Clin Oncol 19:203, 1983
Nausea and Vomiting
• Physiologic process
– Body’s normal response to expel
toxins
• Delayed Nausea
– Occurs days after therapy with
certain chemotherapy agents
• Anticipatory Nausea
– occurs before treatment in patients
who have previously vomited after
chemotherapy
The best way to manage
nausea and vomiting caused
by cancer therapy is to
prevent it.
Natural History of Delayed
Nausea and Vomiting
Percent with
nausea or
vomiting
Hours after cisplatin
Kris, J Clin Oncol 3:1379, 1985
Percent of
patients
Expectation vs Reality
Moderately Emetogenic Chemotherapy
Grunberg, Cancer 100:2261, 2004
Levels of Emetogenicity Modifying Factors
• Age
– Younger patients vomit more than
older patients
• Gender
– Women vomit more than men
• Alcohol history
– Patients with a history of heavy
alcohol use vomit less than those
without such a history
• Nausea/vomiting history
– Patients with a history of morning
sickness or motion sickness are
more likely to vomit
Antiemetic Consensus
Guidelines - 2008
Risk
Acute
Delayed
High
3 drugs
2 drugs
Moderate
3 drugs
1 drug
Low
Single Agent
None
Minimal
None
None
Adapted from Koeller, Support Care Cancer 10:519, 2002
Effect of Physician Education on
Antiemetic Guideline Compliance
►Lecture by visiting expert
No change in behavior
►Distribution of written guidelines
Improved compliance x 2 months
►Direct feedback of patient experiences
Improved compliance x 4+ months
Mertens, J Clin Oncol 21:1373, 2003
Levels of Emetogenicity
• Highly Emetogenic Chemotherapy (HEC) (> 90%)
– Cisplatin
– Mechlorethamine
• Moderately Emetogenic Chemotherapy (MEC) (30-90%)
– Cyclophosphamide
– Doxorubicin
• Low Emetogenic Chemotherapy (10-30%)
– Paclitaxel
– 5-Fluorouracil
• Minimally Emetogenic Chemotherapy (< 10%)
– Vincristine
– Bleomycin
Highly emetogenic
(>90%)
DRUGS
– AC
– Cisplatin
– Higher dose
Cyclophosphamide
TREATMENT
3 drugs
• Dolasetron (Anzemet;
oral), granisetron
(Kytril), ondansetron
(Zofran), or palonosetron
(Aloxi)
• Dexamethasone for one
to three days
• Aprepitant (Emend) for
three days
Moderately emetogenic:
30-90%
DRUGS
– Carboplatin
– Cyclophosphamide
– Doxoubicin
– epirubicin
TREATMENT
two-drug combination
– Dolasetron (Anzemet;
oral form), granisetron
(Kytril), ondansetron
(Zofran), or
palonosetron (Aloxi)
– Dexamethasone, for one
to three days
Low risk emetogenic-1030%
DRUGS
– Docetaxel
– Paclitaxel
– Methotrexate
– 5-fluoriuracil
– Gemcitabine
– Methotrexate
– Topotecan
– trastuzumab
TREATMENT
ONE drug
– dexamethazone
Minimally emetogenic
(less than 10%)
Drugs
Vinorelbine
Treatment
– No treatment
required unless the
patient has
previously
experienced
vomiting with this
treatment.
With appropriate medications,
nausea and vomiting can be
prevented in nearly all patients
undergoing cancer treatment.
NEUTROPENIA
• Fever (temperature of 38
C or higher)
• Chills or sweating
• A sore throat or sores in
the mouth
• Any redness, swelling, or
pain, especially around a
cut, wound, or an
intravenous (IV) catheter
site
• Abdominal pain
• Diarrhea or sores around
the anus
• Pain or burning when
urinating or frequent
urination
• A cough or
breathlessness
• Unusual vaginal
discharge or itching
PREVENT INFECTION
• Delay the next round of chemotherapy or
recommend a lower dose.
• Prophylactic antibiotics
• Neutropenic fever
– Consider white blood growth factors during
subsequent cycles of chemotherapy.
– filgrastim (Neupogen), pegfilgrastim
(Neulasta), or sargramostim (Leukine or
Prokine).
Advice for Patients
• REST
• AVOID CROWDS
• AVOID People
who are ill
• Do not share
personal itemsutensils,
toothbrushes
• No Raw food;
wash foods well
• Good dental care
• Keep clean, use
skin lotion (avoid
dry, cracked skin)
• Use care with
sharp objects
• WASH your
hands
• Use gloves to
garden and clean
• Do not handle
animal waste
CANCER-RELATED FATIGUE
• Persistent sense of tiredness or
exhaustion
• Small effort, such as walking
across a room, can seem like too
much
• Affects ability to work, be involved
with their family, or socialize.
• May cause people to avoid or skip
cancer treatments
• May even affect their desire to live.
Fatigue management
• Exercise regularly
• Conserve energy
• Manage other conditions
–Pain
–Depression
–Sleep disorders