Med3C Alejandro - Oncology Onco

Course: Oncology Lec: Dra. Alejandro Week: 1-3

Topic: Approach to the Pat ient with Cancer
Source: Lecture, Trans, Harrison

Definitions .................................................................................................................... 4
Table of Contents Tumor markers............................................................................................................. 4
Depression ........................................................................................................4
Approach to the Patient with Cancer..................................... 1 Medical Therapy ............................................................................................................... 4
Epidemiology .................................................................................. 1 Psychosocial intervention ................................................................................................. 4
9 Modifiable Risk Factors ................................................................................ 1 Unproven approaches to treatment ................................................................................. 4
Patient Management ....................................................................... 2 Long term Follow-Up /Late Complications ..................................................... 5
Priorities of the Physician ................................................................................ 2 Supportive care ................................................................................................. 5
Routine History and Physical Examination .................................................... 2 Pain ................................................................................................................................... 5
Diagnosis .......................................................................................................... 2 Several sources ............................................................................................................. 5
Invasive tissue biopsy .......................................................................................................2 Assessment of pain ....................................................................................................... 5
Fine Needle Aspiration .....................................................................................................2 Cancer Pain Therapy .................................................................................................... 5
Acceptable ....................................................................................................................2 Nausea/Vomting ............................................................................................................... 5
Metastatic dse process .................................................................................................2 Emesis .......................................................................................................................... 5
3 Forms of Emesis ........................................................................................................ 5
Defining Extent of Dse and Prognosis ............................................................. 2 Effusions ........................................................................................................................... 6
Staging ...............................................................................................................................2
Asymptomatic malignant effusion ............................................................................... 6
Pathologic staging ........................................................................................................2
Symptomatic effusions ................................................................................................. 6
Clinical staging .............................................................................................................2
Malignant pleural effusions with or without malignant cells ..................................... 6
TNM (tumor, node, metastasis) .......................................................................................2 Symptomatic condition ................................................................................................ 6
Other classifications ..........................................................................................................2
Nutrition ........................................................................................................................... 6
Physiologic reserve of the Patient .................................................................... 3 Assess nutritional status and Intervention .................................................................. 6
T81-4 Karnofsky Performance Index & T81-5 The ECOG Performance Scale ................3 Effect of malnutrition ................................................................................................... 6
Other Features related to Management ........................................................... 3 Treatment ..................................................................................................................... 6
Making treatment plan..................................................................................... 3 Psychosocial Support ........................................................................................................ 7
Important to consider .......................................................................................................3 During treatment ......................................................................................................... 7
Treatment approach .........................................................................................................3 After treatment ............................................................................................................. 7
Plan must either ...........................................................................................................3 Death and Dying ............................................................................................................... 7
Management of Dse & Treatment Complications ........................................... 3 Path of Unsuccessful Treatment (3 phases) ................................................................ 7
Most common side effects of treatment ...........................................................................3 Effect on the physician ................................................................................................. 7
New symptoms ..................................................................................................................3 End of Life Decisions ........................................................................................................ 7
Critical Components of Cancer Management ..................................................................4 2011 ASCO Guidelines ..................................................................... 7
1. Assessment of response to treatment .......................................................................4
2. Careful PE .................................................................................................................4

Approach to t he Patient with Cancer

EPIDEMIOLOGY
• Age – the most significant risk factor
o 2/3 of cases are over age of 65
• Gender – lifetime risk of developing cancer
o Men 45% risk
o Women 37%
nd
• Cancer – 2 leading cause of death behind heart dse
o #1 cause of death in <85yo
• More deadly in blacks
• Lung cancer
o Most common cancer
o Most common cause of cancer death in the
world
• Breast cancer
nd
o 2 most common cancer worldwide
nd
o 2 for females
th
o 5 leading cause of death -
behind lung, stomach, liver, Similar incidence in
Cancers (in general) are more and less
and colorectal cancer. more common in In less developed
countries More common in Africa
developed countries;
• Prostate cancer developed countries more Common in Asia
nd
o 2 for males only

9 Modifiable Risk Factors Lung 2 fold Liver 2 fold Cervical

1. Smoking
2. Alcohol consumption
Stomach cancer
Breast 3 fold – much more
3. Obesity
Cervical 2 fold common in Asia Breast
4. Physical inactivity
Prostate 2.5 fold than N. America
5. Low fruit and vegetable consumption
or Africa
6. Unsafe sex
Esophageal 2-3
7. Air pollution
Colorectal 3 fold fold Liver
8. Indoor smoke from household fuels
9. Contaminated injections

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Med3C Alejandro - Oncology Onco

PATIENT MANAGEMENT
Priorities of the Physician
1. Diagnosis Staging
2. Tumor burden (extent/staging) • Process of evaluation by noninvasive and invasive diagnostic
3. Physiologic reserve of the patient tests and procedures
#2&3 are major determinants of treatment outcome • Knowledge of predilection of particular tumor for spread to
adjacent or distant organs helps direct
Routine History and Physical Examination o E.g. Breast à lung, liver, bone, brain
o ***Supraclavicular LN - if left always think GI; if right
1. Duration of Chronicity of the disease
think lung, breast, less GI
sx
• Info obtained defines
2. Past Alert to presence of underlying dse o Extent – local or spread (regional or metastatic)
medical May affect choice of tx or side effects of tx Pathologic  staging  
history • info obtained during a surgical procedure; histo exam of all
3. Personal & Occupational exposure to carcinogens; tissues removed during
Social history Habits such as smoking and alcohol • E.g. intraop palpation, resection of regional LN and/or
consumption w/c may influence course of adjacent tissue, inspection and biopsy of organs commonly
dse and tx involved in dse spread
4. Family Underlying familial cancer predisposition o If LN be sure the standard & sufficient number of
LN are being sampled (e.g. 12 for breast cancer
history Point out need to begin surveillance or other
assessment)
preventive therapy for unaffected siblings of
• Operations range from simple (LN biopsy) to more extensive
pt (thoracostomy, mediastinoscopy, laparotomy)
5. Review of ~Early sx of metastatic dse or paraneoplastic • At time of separate procedure or definitive surgical resection
Systems syndrome Clinical  staging    
**DM and Cancer – has impaired immune defence system • Based on physical examination, radiographs, isotrophic scans,
CT scans and other imaging procedures
Diagnosis
Invasive tissue biopsy TNM (tumor, node, metastasis)
• Most heavily relied on • Most widely used system of staging
• Dx should never be made without obtaining tissue • Codified by the International Union Against Cancer and
• No non-invasive diagnostic test is sufficient American Joint Committee on Cancer
Fine Needle Aspiration • Anatomically based
Acceptable    
• Acquires adequate tissue à careful eval of tumor’s
o Histology T1–4
o Grade • The higher the number the greater the size of mass
o Invasiveness
o Further molecular diagnostic info (cell markers,
intracellular proteins, molecular markers) N0 N1
• Exceptions • Absence or presence of nodal involvement
o Thyroid nodules
o Hepatoma– need a big sample mass
M0 M1
Metastatic  dse  process    
• Defined as cancer on biopsy but has no apparent primary site • Absence or presence of distant metastasis
• Define 1° site based on:
o Age
o Sex
o Site of involvement Various permutation of T, N, and M scores sometimes including tumor histologic
grade (G) are broken into stages, usually designated by the roman numerals I
o Histology
through IV.
o Tumor markers • Tumor burden increases and curability decreases
o Personal & family history
with increasing stage.
• Particular attention on ruling out the most treatable
• BEST = multidisciplinary approach collaboration of different
Other classifications
specialists, consults, pt and family
• Dukes classification – colorectal cancer
• FIGO – gynaecologic cancers
Defining Extent of Dse and Prognosis • Ann Arbor – Hodgkin’s disease
• Curability of tumor usually is inversely proportional • Certain tumors cannot be grouped, e.g. hematopoetic
to the tumor burden. o Leukemia, Myeloma, Lymphoma – disseminated, do
• Ideal to diagnose by screening before sx appear not spread like solid tumors
o H/e, most present w/cancer-related sx by mass
effect or tumor production of cytokine or hormone

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Med3C Alejandro - Oncology Onco

Physiologic reserve of the Patient

• Determinant of how a patient is likely to cope with • Poor prognisis
physiologic stresses imposed by cancer and o KPS: <70
treatment. o ECOG PS ≥3
• Difficult to assess directly ∴surrogate markers o Unless the poor permace is a reversible
o Age, Karnosfky performance status or Eastern consequence of the tumor
Cooperative Oncology Group (ECOG) performance
status
o Usu based more on activity than age

T81-4 Karnofsky Performance Index & T81-5 The ECOG Performance Scale
KARNOFSKY SCALE KARNOFSKY ECOG ECOG SCALE
Normal; No complaints; No evidence of disease 100 0 Fully active, able to carry on all predisease
performance without restriction
Able to carry on normal activity; Minor signs or 90 1 Restricted in physically strenuous activity but
symptoms of dse ambulatory and able to carry out work of a light
Normal activity with effort; Some signs or 80 or sedentary nature, e.g. light housework, office
symptoms of dse work
Cares for self; Unable to carry on normal activity 70 2 Ambulatory and capable of all self-care but
or do active work unable to carry out any work activities. Up and
Requires occasional assistance but is able to care 60 about more than 50% of waking hours.
for most personal needs
Requires considerable assistance and frequent 50 3 Capable of only limited self-care; confined to
medical care bed or chair more than 50% of waking hours
Disabled; Requires special care and assistance 40
Severely disabled; Hospitalization is indicated, 30 4 Completely disabled. Cannot carry on any self-
although death is not imminent care. Totally confined to bed or chair.
Very sick; Hospitalization necessary; active 20
supportive treatment is necessary
Moribund; Fatal processes progressing rapidly 10
Dead 0 5 Dead

Other Features related to Management Plan  must  either    

• Biologic features of tumor Increasingly being related to • Follow a standard protocol precisely or
prognosis. o Ad hoc modifications likely to compromise results
• Influence response to therapy and prognosis • Be part of ongoing clinical research protocol evaluating new
o Expression of particular oncogenes treatment.
o Drug-resistance genes
o Apoptosis-related genes Management of Dse & Treatment Complications
o Genes involved in metastasis 1. Disease complications
• (+) Selected cytogenetic abns ~influence survival 2. Treatment complications - cancer therapies are toxic
• Tumors with higher growth fractions a. Toxicity less acceptable if palliative care
o Assssed by expression of proliferation-related 3. Psychosocial complications
markers (e.g. proliferating cell nuclear antigen)
behave more aggressively Most common side effects of treatment
• Nausea/ vomiting
Making treatment plan • Febrile neutropenia
Important to consider • Myelosuppression
• Stage of the disease
• Prognosis New symptoms
• Patients wishes • Develop in the course of cancer treatment
• Assumed to be reversible until proven other wise
Treatment approach • Ex. Mistaking a reversible condition for tumor complication:
• Curative intent – ex. dse is early stage remove by surgical o Intestinal obstruction ~d/t reversible adhesions
removed to attain cure. o Anorexia, weight loss and jaundice d/t
• Palliative – alleviate sx of disease to ↑quality life of patient reversible intercurrent cholecystitis
• Coop among professional involved - ulmost importance • Ex. Mistaking treatment consequence for tumor complication
• Neoadjuvant – tx either chemotx or chemoRT delivered o Systemic infections d/t tx immunosuppresion
before definitive surgical treatment o Drugs that produce CNS sx that look like
o Chemo & RT ~sequentially or concurrently delivered metastatic or paraneoplastic dso (SIADH)
o Goal is to get clear negative margins à impact on
survival/prognosis
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Med3C Alejandro - Oncology Onco

Critical Components of Cancer Management Depression

1.  Assessment  of  response  to  treatment   • Recognition and tx -important components
• Usu req periodic repeating of imaging test that were abnormal • Incidence ~25%
at staging o ~Greater w/greater disability
• If normal à repeat biopsy of previously involved tissue à • Likely in a patient with
document complete response by pathologic criteria. o Depressed mood (dysphoria) and or loss of
o Biopsy not required if macroscopic residual dse interest in pleasure (anheadonia) for at least 2
2.  Careful  PE   weeks, plus
• All sites of dse physically measured and recorded in a flow o 3 or more of ff sx
chart by date § Appetite change
Definitions   § Sleep problems
• Complete response: disappearance of all evidence of dse § Psychomotor retardation or agitation
• Partial response: § Fatigue
o > 50% reduction in the sum of the products of the § Feelings of guilt or worthlessness
perpendicular diameters of all measurable lesions or § Inability to concentrate
o 30% decrease in sums of longest diameter of lesions § Suicidal ideation
(response evaluation criteria in solid tumor, RECIST) • Indicates need for therapy
• Progressive dse:
o Appearance of any new lesions or Medical Therapy
o >25 % increase in the sum of the products of the • SSRIs – fluoxetine (10-12 mg/d), sertraline (50-150 mg/d),
perpendicular diameters of all measureable lesions paroxetine (10-20 mg/d)
or • TCAs – amitriptyline (50-100 mg/d), despiramine (75-150
o 20% increase in sums of longest diameter (RECIST) mg/d)
• Stable disease: tumor shrinkage or growth that does not • Allow 4-6 weeks for response
meet any of these criteriea • Continue at least 6 months after resolution
• Some unmeasurables
o Sites of involvement – bone Psychosocial intervention
o Pattern of involvement – lymphangitic lung, diffuse • Support groups
pulmonary infiltrates. • Psychotherapy
• No response is complete without biopsy • Guided imagery
documentation of their resolution.
o H/e, partial responses may exclude their assessment Unproven approaches to treatment
unless clear objective progression has occurred • When conventional medicine is unlikely to be curative
Tumor  markers     • Pt usu well educated and may be early in dse cours
• May be useful in patients management in certain tumors • Unsubstantiated anecdotes & may be harmful
• Tumors produce or elicit production of markers measured in • Appearance of unexpected toxicity may be indication that a
serum or urine supplemental therapy is being undertaken
• Rising and falling usu assoc w/↑sing or ↓ing tumor burden
• Not in themselves specific enough to permit a diagnosis of
malignancy to be made.
o H/e, once a malignancy has been diagnosed and
shown assoc w/elevated levels à tumor marker can
be used to assess response

T81-6 Tumor Markers

TUMOR MARKERS CANCER NON-NEOPLASTIC CONDITIONS
Hormones
Human chorionic Gestational trophoblastic disease, gonadal germ cell Pregnancy
gonadotropin tumor
Calcitonin Medullary cancer of the thyroid
Catecholamines Pheochromocytoma
Oncofetal Antigens
Alphafetoprotein Hepatocellular carcinoma, gonadal germ cell tumor Cirrhosis, hepatitis
Carcinoembryonic antigen Adenocarcinomas of the colon, pancreas, lung, breast, Pancreatitis, hepatitis, inflammatory bowel disease,
ovary smoking
Enzymes
Prostatic acid phosphatase Prostate cancer Prostatitis, prostatic hypertrophy
Neuron-specific enolase Small cell cancer of the lung,neuroblastoma
Lactate dehydrogenase Lymphoma, Ewing's sarcoma Hepatitis, hemolytic anemia, many others
Tumor-Associated Proteins
Prostate-specific antigen Prostate cancer Prostatitis, prostatic hypertrophy
Monoclonal immunoglobulin Myeloma Infection, MGUSa
CA-125 Ovarian cancer, some lymphomas Menstruation, peritonitis, pregnancy
CA 19-9 Colon, pancreatic, breast cancer Pancreatitis, ulcerative colitis
CD30 Hodgkin's disease, anaplastic large cell lymphoma —
CD25 Hairy cell leukemia, adult T cell leukemia/lymphoma —

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Med3C Alejandro - Oncology Onco

Long term Follow-Up /Late Complications • Review of oncologic, past medical, personal and social hx
• At the completion of treatment • Physical examination
o Sites originally involved are re-assesed
o Usually radio or other imaging 10 division visual analogue scale
o Any persistent abnormality is biopsied • 0 – no pain
• If dse persists à Multidisciplinary team discusesses a new • 1-3 mild
salvage treatment plan • 4-6 moderate
• If dse-free à pt followed regularly for dse recurrence • 7-9 severe
• No clear optimal guidelines for follow ups • 10 – worst pain
o National cancer care network (NCCN) • Condition is dynamic ∴reassess pt every 4 hours while awake
o Used to be monthly for 6-12mo then a subsequent and treat the cause as soon as possible.
year of each of the following
§ Every other month
§ Every 3 months
§ Every 4 months
§ Every 6 months
§ Annually
§ With a battery of exams à H/e, proven to
be not helpful in tx
o Now, moving towards less follow-ups with a
focus on Hx and PE
• As time passes likelihood of recurrence of primary cancer
diminishes
• For many, survival for 5 years w/o recurrence = Cure

Supportive care
• Success of cancer therapy depends on success of supportive
care  
• Major determinant of quality of life Cancer  Pain  Therapy  
• Failure to control sx of cancer and tx ~à tx abandonment • Do not withhold while searching for cause
• Palliative care is cost-effective w/organized approach • Pharmacologic intervention à relief for 85%
• Credo: Cure sometimes, extend life often and comfort always • Anti-tumor therapy
o Surgical relief of obstruction
Pain o Radiation therapy
• Occurs w/variable frequency o Strontium-89 or samarium-153 for bone pain
o 25–50% at diagnosis • Neurostimulatory techniques, regional analgesia or
o 33% assoc with treatment neuroablative procedure à effective for 12%
o 75% with progressive dse
Several  sources   Nausea/Vomting
70% by tumor itself Emesis    
• Invasion of bone, nerves, bv’s or mucous membranes or • Usu c/b chemotherapy
• Obstruction of a hollow viscus or duct • Severity can be predicted from the drugs used to treat
20% related to treatment • H/e, like pain emesis is easier to prevent than to treat
• Surgical or invasive medical procedure 3  Forms  of  Emesis    
• Radiation injury - mucositis, enteritis, or plexus or SC injury Based on timing wrt noxious result
• Chemotherapy injury
Acute • Occurs within 24 hours of treatment
o Mucositis
emesis • Most common variety ; best understood
o Peripheral neuropathy (seen in platinum based
form
therapy)
Delayed • Occurs within 1-7 days after treatment
o Phlebitis (Doxorubicin)
emesis • Rare
o Steroid-induced aseptic necrosis of femoral head)
• Usu follow cisplatin admin
10% unrelated to cancer or tx
  Anticipatory • Occurs before administration of
emesis chemotherapy
Assessment  of  pain  
• Represents a condition response to visual
• History of the pain
and olfactory stimuli previously associated
• Location
with chemotherapy delivery.
• Character
• Temporal features
• Provocative and palliative factors
• Intensity

Acute Emesis
stimulation of vomiting center in
Stimuli activate signals in chemoreceptor medulla (motor center responsible for
trigger zone in medulla, cerebral cortex emesis
(chemotx drugs) coordinating secretory and muscle
and peripherally in GIT contraction activity)

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Med3C Alejandro - Oncology Onco

Types of receptors that participate in the process: 3. Pleurodesis

• Dopamine receptor a. 60 uniths of bleomycin or 1 g of doxycycline is
• Serotonin receptor infused into the chest tube in 50 ml of 5% dextrose
• Histamine receptor in water
• Opioid receptor i. Bleomycin - ~more effective than D, very
• Acetylcholine receptor expensive.
st
• Most effective drugs against highly emetogenic agents ii. Doxycycline – 1 DOC
iii. Talc - most commonly used by
Serotonin receptor antagonists pulmonologist; used if neither doxycycline
Most effective, Ondansetron, Granisetron, Ramisetron, nor bleomycin is effective; very painful;
st
highly emetogenic, Tropisetron Sedate the patient 1
but expensive b. Tube is clamped
Midly to moderate Prochlorperazine 5-10mg PO or 25 mg c. Patient is rotated on 4 sides (15 min each position)
emetogenics PR; Dexamethasone 10-20mg IV i. After 1-2hrs attach to suction for 24hrs
effective and may enhance the efficacy d. Disconnected from suction and allowed to drain by
of prochlorperazine gravity
Highly emotogenic Cisplatin, mechlorethamine, dacarbazine, e. If < 100 drains over the next 24 hours, chest tube is
and streptozocin; Combination of agents pulled and radiography taken 24 h later.
work best; Admin 6-24 h before tx f. If the chest tube continues to drain fluid at an
Effective Ondensetron, 8 mg PO q6h before unacceptably high rate, sclerosis can be repeated.
therapy and IV on day of therapy + Symptomatic pericardial effusions:
dexamethasone, 20 mg IV pre-treatment • Create a pericardial window or
Further ↓risk of Above + oral aprepitant (substance • Stripping the pericardium.
acute and delayed P/neurokinin 1 receptor antagonist 125 • If unamenable to surgery ~à sclerosis w/doxycycline and/or
vomiting mg D1, 80 mg D2&3) bleomycin.
Malignant ascites:
Delayed emesis • Repeated paracentesis of small volumes of fluid.
• May be related to bowel inflammation from therapy • If not effective insert peritovenous shunts.
• ~Control w/oral dexamethasone and metachlorpromide (used • Major complications: occlusion, leakage, and fluid overload
in PI, dopamine receptor antagonist that also blocks serotonin o Pt w/severe liver dse may develop DIC
at high dosages)
Nutrition
Anticipatory emesis • Cancer and tx ~à ↓nutrient intake of sufficient magnitude à
• Best strategy is to control emesis in early cycles of therapy à o Weight loss and
to prevent the conditioning from taking place. o Alteration of intermediary metab
• If unsuccessful à prophylactic day before treatment § Vicious cycle established
• Protein catabolism, glucose
intolerance and lipolysis
• Not reversible by provision of
Effusions calories
• May occur in the: § Tumor derived factors
o Pleural cavity • Bombesin
o Pericardium • Adenocorticotropic hormones
o Peritoneum § Host derive factors
• TNF
Asymptomatic  malignant  effusion     • Interleukin 1 and 6
• ~No treatment requirement • Growth hormone
Assess  nutritional  status  and  Intervention  
Symptomatic  effusions   • Define threshold for nutritional intervention as
Response to Treatment o >10% unexplained body weight loss
Systemic Therapy o Serum transferrin level <1500 mg/L (150 mg/dL)
Responsive Do not require local tx but respond to the o Serum albumin <34 g/L (3.4 g/dL).
tx for the underlying tumor  
Unresponsive May require local tx in patients w/life Effect  of  malnutrition  
expectancy of at least 6 months. • Cancer therapy is more toxic and less effective
  • H/e, unclear if nutritional intervention can alter natural history
Malignant  pleural  effusions  with  or  without  malignant  cells  
• 75 % d/t: Lung CA, Breast CA, Lymphomas Treatment    
• Exudative in nature • Enteral nutrition provided orally or by tube feeding is
o Effusions/ serum protein ratio > 0.5 preferred
o Effusions/ of serum LDH ratio > 0.6 • Parenteral nutrition if pathology affects GIT fnc
• Megestrol acetate
Symptomatic  condition     o Progestational agent, used to improve nutritional
1. Thoracentesis (performed 1 )
st status
a. Most improve in <1 mo o Used in breast cancer, but usu used in lung cancer
2. à Chest tube drainage - if sx recur w/in 2 weeks o Main problem is fluid retention
a. Fluid aspirated until flow rate is < 100 ml in 24 h
b. If <100 drains do pleurodesis

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Med3C Alejandro - Oncology Onco

Psychosocial Support
• Empathetic healh care team – sensitive and flexible to pt needs
During  treatment   After  treatment    
• Fear, anxiety and depression • Fear – assoc w/termination of tx
• Self image –compromised (deforming surgery, • Adjustment – new handicaps
hair loss) o Self perception of ↓job mobility or desirability as a worker
• Loss of control • Victims of job and/or insurance discrimination
o à Sense of vulnerability • Difficulty re-entering normal past life
o Enormous stress • Guilty feelings – financial status of family altered by pt; esp breadwinners
• Sexual dysfunction • Carry sense of vulnerability to colds, etc.
o Usually seen in men • Damocles syndrome: ever present fear of relapse which is the most pervasive
o Advise exercise; has been proven to help and threatening concern.
• If unsuccessful tx à other problems related to the end of life.

Death and Dying Effect  on  the  physician  

• Most common COD in cancer pt are “Burnout “ syndrome
o Infection (à circulatory failure) • Fatigue
o Respiratory failure • Disengagement from patients and collegues
o Hepatic failure • Loss of self fulfilment
o Renal failure What should the physician do?
• If intestinal blockage ~à inanition (exhaustion) and starvation • Stress reduction
• CNS dse ~à seizures, coma, central hypoventilation • Maintenance of a balance life
o 70% dyspnea pre-terminally • Setting realistic goals
• Pts do not all progress through
o all stages or End of Life Decisions
o in the same order or • Transition in treatment from curative to palliative may not
o at the same rate always be smooth
• Best to speak frankly with the pt and family regarding likely o Serious tx-related complications
course of dse o Rapid dse progression
o ~Difficult for physician too • Curative goal à justifies à vigorous/invasive medical support
o Critical features • H/e, If reversibility in doubt àpatient wishes determine level
§ Reassure that everything that can be done of medical care
to provide comfort will be done o Elicit before terminal phase & review periodically
§ They will not be abandoned
• Many prefer home or hospice over hospital
Path  of  Unsuccessful  Treatment  (3  phases)  

3. Stages of
2. adjustment – at
Acknowledgement
disclosure of
of incurable dse -
1. imminent death
when tumor recurs
Optimism - • Denial
• Goal of palliative
at hope of therapy embraced -
• Isolation
cure hope of being alive w/ • Anger
the dse • Bargaining
• Depression
• Acceptance
• Hope

2011 ASCO GUIDELINES

Don’t need to know dose, just agents & days/timing
• Ex: 34yo post-radical mastectomy combo radio adjuvant txdoxorubicin (anthracycline) and cyclophosphamide à high emetic risk and so
treatment s/b NK1 Antagonists
• Ex: Doxorubiicn with Paclitaxel – give tx that will cover higher emetic risk agent
• Ex: SCC of tongue, cisplatin day 1, 5FU day 1 and 5 – for the days that the high agent (cisplatin) is taken but corticosteroids for the low
agent (5FU) that is still needed on off days of cisplatin; if you have a treatment that is multiple day but the same dosage each day you can
opt for a patch for convenience
• Ex: Pancreatic cancer stage 4 – gemcitabine every week – give steroids only

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