Anda di halaman 1dari 43

TATALAKSANA

KANKER PARU

dr. Reza Kurniawan T., SpP RS Paru dr. H.A. Rotinsulu

PEDOMAN TATALAKSANA

Jenis histologi

Derajat atau Stadium klinis penyakit

Tampilan atau Performace status”

Tatalaksana komplikasi

JENIS HISTOLOGI

JENIS HISTOLOGI

Staging SCLC

Limited / Tingkatan terbatas :

- Tumor ditemukan dalam satu paru

- Penjalaran ke KGB paru yang sama.

Extensive / Tingkatan luas :

- Tumor telah menyebar keluar dari satu

paru atau ke organ lain di luar paru

Staging NSCLC

Kalisifikasi berdasarkan 3 komponen prognosis:

Tumor (T)

Nodes (N)

Metastasis (M)

Saat ini: TNM versi 7 thn 2007 versi 8 thn

2015

International Association for the Study of Lung Cancer (IASLC), 2007

International Association for the Study of Lung Cancer (IASLC), 2007

PERFORMANCE STATUS

KARNOFSKY

WH0

BATASAN

90

100

0

Aktivitas normal

70

80

1

Ada keluhan tapi masih akif, dapat mengurus diri sendiri

50

60

2

Cukup aktif; kadang memerlukan

 

bantuan

30

40

3

Kurang aktif, perlu perawatan

10

20

4

Tidak dapat meninggalkan tempat tidur

0 10

5

Tidak sadar

PENGOBATAN KANKER PARU

Pengobatan Standar selama ini adalah :

Pembedahan

Radioterapi

Kemoterapi

Targeted therapy

Terapi tersebut biasanya diberikan secara kombinasi atau Multi-modality

Pendekatan pengobatan lain yaitu terapi pendukung dikenal dengan BSC atau Best Supportive Care

PEMILIHAN OBAT KEMOTERAPI

Platinum based ( Sisplatin atau Karboplatin )

Umumnya kombinasi 2 obat anti-kanker (Etoposid, Dosetaksel, Gemsitabin, Paklitaksel, Vinorelbin)

Pilih efek samping (Toksisitas) obat yang minimal

Respon terapi dinilai dengan kriteria RECIST

Tersedia di Fornas dan e-katalog

PENGOBATAN KANKER PARU

JENIS KARSINOMA SEL KECIL

1. Stage terbatas

Kemoterapi + radiasi dada

dan profilaxis cranial irradiation (PCI)

EP : sisplatin/karboplatin dengan etoposid (rotinsulu)

Reseksi bedah diikuti dengan kemoterapi atau kemoterapi plus radiasi jika tidak ada pembesaran KGB

atau kemoterapi plus radiasi jika tidak ada pembesaran KGB Pedoman Nasional Penanganan Kanker – Kanker Paru,

Pedoman Nasional Penanganan Kanker Kanker Paru, Kemenkes RI, 2015

2. Stage lanjut

Kemoterapi kombinasi

Radiasi paliatif pada lesi primer dan lesi metastasis

Rekuren:

Terapi radiasi paliatif

Kemoterapi paliatif

Uji klinik

Pedoman Nasional Penanganan Kanker Kanker Paru, Kemenkes RI, 2015

PENGOBATAN KANKER PARU

JENIS KARSINOMA BUKAN SEL KECIL

Stadium I:

Reseksi bedah

Radiasi: bila bedah tidak dapat dilakukan

Kemoterapi: bila bedah tidak dapat dilakukan

Kombinasi terapi memberi hasil lebih baik

Pedoman Nasional Penanganan Kanker Kanker Paru, Kemenkes RI, 2015

Stadium II :

Reseksi bedah

Radiasi:

bila bedah tidak dapat dilakukan atau pascabedah (adjuvant) dilakukan bila ada sisa tumor atau keterlibatan KGB intratoraks

Kemoterapi:

bila bedah tidak dapat dilakukan atau pascabedah (adjuvant) jika ada keterlibatan KGB intratoraks

Kombinasi terapi memberi hasil lebih baik

Pedoman Nasional Penanganan Kanker Kanker Paru, Kemenkes RI, 2015

Stadium III-A:

Kemoterapi neoadjuvat

Reseksi bedah (bila tumor masih operabel)

Radiasi pada pasien yang tidak dapat dilakukan bedah atau pascabedah

Kombinasi terapi memberikan hasil lebih baik.

Kemoterapi 4 6 siklus pada pasien yang tidak dapat dibedah

Pedoman Nasional Penanganan Kanker Kanker Paru, Kemenkes RI, 2015

Stadium III-B:

Pilihan pengobatan tergantung pada klinis dan tampilan umum pasien

Radiasi: pada lesi primer, lesi metastasis dan KGB

supraklavikula

Kemoterapi 4-6 siklus

Kombinasi dengan radiasi memberikan hasil yang

lebih baik

Pedoman Nasional Penanganan Kanker Kanker Paru, Kemenkes RI, 2015

Stadium IV:

Radiasi paliatif

Kemoterapi paliatif

Kombinasi terapi tergantung kondisi klinis

Pedoman Nasional Penanganan Kanker Kanker Paru, Kemenkes RI, 2015

New Response Evaluation Criteria in Solid Tumours: Revised RECIST Guideline, European Journal of Cancer ,

New Response Evaluation Criteria in Solid Tumours: Revised RECIST Guideline, European Journal of Cancer, 2009

Bila progresif / rekuren

Kemoterapi lini kedua:

Monoterapi doksetaksel

Monoterapi pemetreksat

Kombinasi dua obat baru (non platinum rejimen)

TERGETED THERAPY

Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitor

(EGFR-TKI)

Epidermal Growth Factor Receptor (EGFR)

Epidermal Growth Factor Receptor (EGFR)  EGFR is a receptor located at the cell membrane 

EGFR is a receptor located at the cell membrane

Activated by binding of specific

ligand (EGF, TGFα)

EGFR will undergo dimerization (homo or heterodimer), which in turns activates Tyrosine kinase

Epidermal Growth Factor Receptor (EGFR)

Tyrosine Kinase inhibitor

Epidermal Growth Factor Receptor (EGFR) Tyrosine Kinase inhibitor

EGFR mutation incidence

EGFR mutation incidence

OPTIMAL: 1L Erlotinib vs chemotherapy in EGFR Mut+ NSCLC

Chemo naїve

Stage IIIB/IV NSCLC

EGFR activating Mut+ (exon 19 deletion or exon 21 L858R mutation)

ECOG PS 02

(n=165)

or exon 21 L858R mutation)  ECOG PS 0 – 2 (n=165) 1:1 R Phase III,

1:1

R
R
21 L858R mutation)  ECOG PS 0 – 2 (n=165) 1:1 R Phase III, open-label, active-controlled

Phase III, open-label, active-controlled

Primary endpoint

Secondary endpoints

PFS

OS

ORR

TTP

DoR

HR QoL

Erlotinib

150mg/day

Gemcitabine (1,000mg/m 2 d1,8) + carboplatin (AUC5 d1) q3w, up to 4 cycles

Stratification factors

Mutation type

Histology

Smoking status

Zhou C, et al. J Clin Oncol 2012;30 (Suppl. 15 Pt I):485s (Abs. 7520)

OPTIMAL : PFS Result

OPTIMAL: PFS Results

OPTIMAL : PFS Result OPTIMAL: PFS Results Wang J, et al. Chicago Multidisciplinary Symposium in Thoracic

EURTAC: 1L Tarceva vs chemotherapy in EGFR Mut+ NSCLC

Chemo naїve

Stage IIIB/IV NSCLC

EGFR exon 19 deletion or exon 21 L858R mutation

ECOG PS 02

(n=173)

Phase III, open-label, active-controlled

0 – 2 (n=173) Phase III, open-label, active-controlled Erlotinib 150mg/day R 1:1 Platinum-based doublet

Erlotinib

150mg/day

R 1:1
R
1:1
open-label, active-controlled Erlotinib 150mg/day R 1:1 Platinum-based doublet chemotherapy q3wks x 4 cycles*

Platinum-based doublet chemotherapy

q3wks x 4 cycles*

Primary endpoint

PFS

Secondary endpoints

ORR

OS

Stratification factors

Mutation type

ECOG PS

EGFR mutation analysis in serum

*Cisplatin 75mg/m 2 d1 / docetaxel 75mg/m 2 d1; cisplatin 75mg/m 2 d1 / gemcitabine 1,250mg/m 2 d1,8; carboplatin AUC6 d1 / docetaxel 75mg/m 2 d1; carboplatin AUC5 d1 / gemcitabine 1,000mg/m 2 d1,8

Rosell R, et al. Lancet Oncol 2012;13:23946

EURTAC : PFS Result

OPTIMAL: PFS Results

EURTAC : PFS Result OPTIMAL: PFS Results Wang J, et al. Chicago Multidisciplinary Symposium Rosell R,

TATALAKSANA KOMPLIKASI

TATALAKSANA KOMPLIKASI Cancer pain

Cancer pain

TATALAKSANA KOMPLIKASI Cancer pain
TATALAKSANA KOMPLIKASI Cancer pain

Type of Cancer Pain

Chronic Pain

Pain lasting for more

than 3 months.

More subjective and not

as easily described as

acute pain.

Chronic cancer pain often involves persistent

pain and breakthrough

pain

• Chronic cancer pain often involves persistent pain and breakthrough p a i n Toth, US

Toth, US Pharm, 2009; 34(11):3-12

Oral or Transdermal?

Oral or Transdermal?

Fentanyl has better profile of side effects compare to Oral Morphine

SR-morphine 15-30 mg/12h (n=641) Durogesic 25 mcg/h(n=1884) 50 45 40 35 30 25 20 15
SR-morphine 15-30 mg/12h (n=641)
Durogesic 25 mcg/h(n=1884)
50
45
40
35
30
25
20
15
10
5
0
% Pasien

dizziness

Nausea

Somnolence

Vomiting

Constipation

Clark AJ, et al. Curr Med Res Opin 2004;20:1419-28

Incidence of Abuse after Medical Use of Opioids

0.8 0.7 0.6 Oxycodon 0.5 0.4 0.3 Meperidine 0.2 Morphine 0.1 Fentanyl patch 0 1990
0.8
0.7
0.6
Oxycodon
0.5
0.4
0.3
Meperidine
0.2
Morphine
0.1
Fentanyl patch
0
1990
1991
1992
1993
1994
1995
1996

David E. Joranson, JAMA 2000.

Transdermal Fentanyl:

Low Addictive Potential

DAWN mentions

per adjusted gram in the population (USA)

OxycodoneDAWN mentions per adjusted gram in the population (USA) Morphine Fentanyl 200 150 100 50 0

Morphinementions per adjusted gram in the population (USA) Oxycodone Fentanyl 200 150 100 50 0 1997

Fentanylper adjusted gram in the population (USA) Oxycodone Morphine 200 150 100 50 0 1997 1998

200

150

100

50

0

1997 1998 1999 2000 2001
1997
1998
1999
2000
2001

Based on mentions as recorded in the Drug Abuse Warning Network database (Substance Abuse & Mental Health Service Administration), divided by grams per 100.000 populations (adjusted for equivalency)

Nowak S, et all. Pain Medicine 2004; 2: 59-65

Fentanyl patch May Be The 1st Choice:

Difficulty or pain when swallowing

Persistent nausea and/or vomiting

Gastrointestinal obstruction

Poor compliance with oral medications Tablet/morphine phobia

Unacceptable morphine side effects

Renal failure

Palliative Care Formulary (PCF) The Scottish Intercollegiate Guidelines Network (SIGN) Guidelines No 44

Fentanyl Transderm Patch: Easy to Use

Fentanyl Transderm Patch: Easy to Use
Fentanyl Transderm Patch: Easy to Use
Fentanyl Transderm Patch: Easy to Use

When is Fentanyl Transderm

Patch Appropriate?

Indicated for the management of chronic

pain that

cannot be managed by lesser means such as

acetaminophen-opioid

combinations, nonsteroidal analgesics, or prn dosing with short-acting opioids

requires continuous opioid administration

No ceiling dose for effective analgesia

(Durogesic ® PI, 2000)

Optimal Dose Fentanyl for Cancer Pain

62 yr man, Rectal cancer Home care hospice unit during last 3.5 months C.C ; severe anal pain(verbal pain scale 10/10)

3.5 months C.C ; severe anal pain(verbal pain scale 10/10 ) . 150 ug/hr TTS .

. 150 ug/hr TTS

. Adjuvant Tx

- amitriptyline 50mg/d

- dexamethasone 4mg/d

. Adjuvant Tx - amitriptyline 50mg/d - dexamethasone 4mg/d . Increased gradually to 1,000 ug/hr with

. Increased gradually to 1,000 ug/hr with good pain control (verbal pain scale 1-4 /10)

<Menahem S, et al. J Am Board Fam Pract 2004;17:388-390>

Summary

Tatalaksana berdasarkan:

Histologi

Stadium

Performance status

Komplikasi

Pengobatan:

Pembedahan

Kemoterapi

Radioterapi

Targeted therapy

– Komplikasi • Pengobatan: – Pembedahan – Kemoterapi – Radioterapi – Targeted therapy Multi modality

Multi modality

Penilaian terapi dengan RECIST

Targeted

therapy

(gefitinib,

erlotinib)

harus

berdasarkan status mutasi EGFR

Fentanyl transderm patch sangat baik untuk chronic cancer pain (moderate severe pain)

dg efek samping minimal

Semua modalitas pengobatan telah tersedia di BPJS dan Fornas