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
 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
 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

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, 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)

EGFR is a receptor located at

the cell membrane

Activated by binding of specific

ligand (EGF, TGF)

EGFR will undergo dimerization

(homo or heterodimer), which
in turns activates Tyrosine
kinase
Epidermal Growth Factor Receptor (EGFR)
Tyrosine Kinase inhibitor
EGFR mutation incidence
 OPTIMAL: 1L Erlotinib vs chemotherapy in
EGFR Mut+ NSCLC

Chemo nave Erlotinib

Stage IIIB/IV NSCLC 150mg/day
EGFR activating Mut+
(exon 19 deletion or exon 21 R 1:1
L858R mutation)
ECOG PS 02 Gemcitabine (1,000mg/m2 d1,8) +
carboplatin (AUC5 d1)
(n=165) q3w, up to 4 cycles
Phase III, open-label, active-controlled
Primary endpoint Secondary endpoints Stratification factors
PFS OS Mutation type
ORR Histology
TTP Smoking status
DoR
HR QoL

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

OPTIMAL : PFS Result
OPTIMAL: PFS Results

Wang J, et al. Chicago Multidisciplinary Symposium in Thoracic Oncology 2010. Abstract 18.
 EURTAC: 1L Tarceva vs chemotherapy in
EGFR Mut+ NSCLC

Erlotinib
Chemo nave 150mg/day
Stage IIIB/IV NSCLC
EGFR exon 19 deletion or exon
21 L858R mutation R 1:1

ECOG PS 02
Platinum-based doublet
(n=173)
chemotherapy
q3wks x 4 cycles*
Phase III, open-label, active-controlled

Primary endpoint Secondary endpoints Stratification factors

PFS ORR Mutation type
OS ECOG PS
EGFR mutation analysis in serum
*Cisplatin 75mg/m2 d1 / docetaxel
75mg/m2 d1; cisplatin 75mg/m2 d1 /
gemcitabine 1,250mg/m2 d1,8;
carboplatin AUC6 d1 / docetaxel
75mg/m2 d1; carboplatin
AUC5 d1 / gemcitabine 1,000mg/m2 d1,8
Rosell R, et al. Lancet Oncol 2012;13:23946
 EURTAC : PFS Result
OPTIMAL: PFS Results

Wang J, et al. Chicago Multidisciplinary Symposium in Thoracic

Rosell R, Oncology
et al. Lancet Oncol2010. Abstract 18.
2012;13:23946
 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
Toth, US Pharm, 2009; 34(11):3-12
pain
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 *p<0.001
40
% Pasien

35 *
30
25
20 *
15 *
10 *
5
0
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
0.5 Oxycodon

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 200

per adjusted gram
in the population (USA)
150

100

Oxycodone 50
Morphine
Fentanyl 0
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
John Welsh, Palliative Medicine 2005; 19: 9/16
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)

. 150 ug/hr TTS

. Adjuvant Tx
- amitriptyline 50mg/d
- dexamethasone 4mg/d

. 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 Multi modality
Radioterapi
Targeted therapy
 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