MANAGEMENT OF CANCER PATIENT

Patient

Medical Team (teamwork) Standard Facility Standard Protocol Medical Record

Better Communication Unity of work rhythm Minimal mistake Maximal patient service

MANAGEMENT OF CANCER PATIENT

Other doctors (consultant)

Patient

Doctor

Cytopathologist

Radiologist Laboratory

diagnose and treatment patient depend on one clinician only

The Relative Frequency of Head & Neck Carcinoma

Nasopharynx (1%)

Nasal sinuses (4%)

Oropharynx (10%)

Oral Cavity (55%)

Hypopharynx (5%)

Larynx (25%)

(Skeel RT,et.al 2000)

TERAPI DENGAN BAHAN KIMIA (HORMON/SITOSTATIKA) YANG DAPAT MENGHAMBAT PERTUMBUHAN SEL KANKER

1. 2. 3. 4.

Mencapai kesembuhan ( kuratif =CURE ) Mencapai masa bebas penyakit (DFI) yang lebih lama Memperbaiki kualitas hidup (SURVIVAL) Memperkecil masa tumor sebelum operasi (neoadjuvant) mempermudah operasi

ADJUVANT setelah operasi NEOADJUVANT sebelum radiasi atau operasi PRIORITAS UTAMA RADIOSENSITIZER sebelum atau bersamaan radiasi

KANKER KELENJAR (LIMFOMA MALIGNA)

KEMOTERAPI PRIORITAS UTAMA (tanpa harus operasi) KURATIF

PROBLEM PENANGANAN
Bedah : deformitas & fungsi kosmetik Radiasi : ES (xerostomia, mucositis/stomatitis, disfagi, nekrosis, infeksi) disfungsi Kemoterapi : ES (mucositis/stomatitis,infeksi)

PEMEILIHAN TERAPI HARUS MEMPERTIMBANGKAN KOMPLIKASI DARI SETIAP MODAL TERAPI

Oncology aspect Patients & family aspect

Outcome & Side Effect Monitoring

Oncology Aspect

Diagnose:- pathology :* morphologic class : adenoCa ? * histologic grade * pattern of invasion - tumor biology ? : CD20, Bcl2, p53 c-KIT(CD117), EGFR 1, Her2, EBV ?, IgA Diagnose: Clinical Staging Medical Status: Risk group - Anamnesa (co-morbid) - Physic, Laboratory, ECG, Radiology - Performance status (Karnosfky-ECOG)

 Mechanism chemotherapy in cellular level Reduction of tumor after Chemotherapy Rational , patient financial ?

( influence on the response to chemotherapy )

1.Tumor cell proliferation

Doubling Time

Check point controle mechanism Cell Cycle mechanism

Target of Actions of drugs ( Phase specificity ? / Non phase ?) Mechanisme of Actions

2.Tumor cell Apoptosis

Mitochondrial pathway (Bcl2 family,p53) Death receptor pathway (Fas-FasL, caspase family of protein)

5 FU
Phleomycin

Bleomycin Cyclophosphamide
Actinomycin

Vinblastine Vincristine Colchicine Griseofulvin

0,5-1h
Differentiation Hydrocortisone Chalones

0.5-1h G2 M
2-10h

Purin antagonis

Hydroxy urea

Actinomycin D
Cyclophosphamide

G1

6-20h 18-30h

Mytomycin
6-Marcaptopurine 6-Thioguanine

Doxorubicin

5 Fudr .5FU, Ara C. Mitomycin,Doxorubicin Thioguanine

5 Fudr ara C 6-Hydroxyurea

5 FU METHOTREXATE

Alkylating agent, Antimetabolic, Mitotic inhibitor, Antibiotic

Number of Tumor cell

No response
1012 (1kg)

Early recurrence

Late recurrence

109 (1 g)

Tumor detectable (clinically)

106 (1 mg) Tumor invisible (Remission) 103

Long-term Remission Not palpable

(1 g)

Immune resistance of host (humoral&cellular)

Induction

Consolidation

Maintenance

Cure

Patients & family Aspect

Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemotherapy - informed consent

Outcome & Side Effect Monitoring Aspect

Outcome

Side Effect

Survival Objective & Subjective Outcome

Diagnose & management

1. Onset of SE : - Immediately ( < 1 Hour post Chemotx) Anaphylaxsis - early (1- 48 hours ) Nausea-Vomiting profuse - delayed (2 days -2 months ) leucopenia - Late (after 2 months ) myopathy, neuropathy 2.Organ Target : CNS, Cardiovascular, Respiratory, Gastroentestinal System

3.Level/degree of SE (IUCC,WHO, ECOG) : - grade 0-2 : tolerable ( safety enough ) - grade 3 (severe) : must be alert (Yellow light), need treatment - grade 4 (life threatening) : Hazard, early and adequate treatment

SIDE EFFECT MONITORING

DIAGNOSE of Side Effect
PHARMACOLOGY When Side effect become: NADIR point (degree of SE) Onset of SE, Specificity of organ target

MANAGEMENT of Side Effect

Anticipation & Prevention Dose related side effect monitoring Early treatment of side effect

PROFILE EPISODE of FEBRIL NEUTROPENI

SELAMA KEMOTERAPI

11

nadir

16

21

26

Chemotherapy day

Chemotherapy day

Hiperpigmentation (Fluorouracili )

Emetogenic potency of cytostatic drugs

Weak : mitomycin, mitoxantron, ifosfamid, 5 FU, bleomycin,etoposide,melphalan, gemcitabin Moderate : cyclophosphamide,anthracyclines,cytarabin,car boplatin,taxanes,irinotecan,topotecan Strong : cisplatin,dacarbazine,dactinomycin,any high dose therapy

Management Side Effect

1. ANTIDOTUM to specific agent : - Antidotum of MTX : Calcium leucovorin, Ca Lefofolinat - Cardiomyopathy prophylaxis Doxorubicin > 450 mg/m2 * Dexrazosane 10 mg Doxorubicin 1 mg 2. Dose modification : - Toxicity grade 3 and 4 : decrease dose 25% - 50% 3. Supportive Drugs : - Haemopoetic GF : G-CSF, GM-SF, IL-3, Epo - Component Blood transfuse - Selective antibiotic 4. Sterile Room technology

TREATMENT of FEBRIL NEUTROPENI

SELAMA KEMOTERAPI

Empiric antibacterial

nadir
Empiric antibacterial G-CSF Sterile room

Chemotherapy day

Chemotherapy day

CANCER OUTCOME of TREATMENT

1.Objective Response Evaluation 2.Subjective Response Evaluation (3). Survival

OBJECTIVE RESPONSE EVALUATIONS

1. TUMOR SIZE : - Complete remission (CR) - Partial remission (PR) - No Changes (Stable Disease = St D) - Progressive Disease (PD) 2. Marker Tumour : - CEA, CA15-3, MCA Breast Ca - CEA, CA19-9 Pancreas Ca, Colorectal Ca - HCG Chorio Ca - PSA Prostat Ca 3. Objective-Qualitative : - Change of Clinical sign : Brain Ca-neurology sign

Stage IV Nasopharyngeal Cancer: Change in Overall Survival, 1980-2000

Treatment RT without salvage

% 5-Year Survival <30

RT with salvage
Concurrent CT + RT Sequential CT RT RT CT CT + RT CT CT CT + RT
CT = chemotherapy , RT = radiotherapy

40
50-55 50-55 50-55 75 >90
(Muhyi Al-Sarraf,2002)

RINGKASAN :

Tepat indikasi : kemoterapi tepat dipilih berdasar titik tangkap kerjanya berdasar patogenesis kanker sehingga dapat tercapai tujuan : 1.kuratif 2.mencapai bebas penyakit (DFI) yang lebih lama 3.neoadjuvant (mengecilkan volume tumor preoperasidown staging) 4.mempertahankan atau meningkatkan quality of life (terapi paliatif)

Tepat jenis obat : sebaiknya lebih spesifik, selektif, mempunyai Response rate tinggi, established, dan dapat dijangkau oleh penderita Tepat dosis obat : sesuai Maximum Tolerated Dose ( Risk group )

Tepat cara pemberian obat : oral, IV, bolus, infusion dsb yang penting : penderita nyaman , tidak takut dan dengan kesadaran sendiri ingin melanjutkan kemoterapi
Tepat monitoring efek obat : - penilaian hasil / respons terapi - kemampuan hidup (quality of life) dan - efek samping obat

RESUME :

Better Communication Unity of work rhythm Minimal mistake Maximal patient service

RESUME :

Oncology aspect Diagnose:- pathology - biology cell type ? Diagnose: Staging

Patients & family aspect

Medical Status: Risk group

Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemtherapy - informed consent

Outcome & Side Effect Monitoring Survival Objective & Subjective Outcome Side Effect : Diagnose & management

TERIMA KASIH

Regimens of Chemotherapy
Regimen Methotrexate Regimen Bleomycin Cisplatin Carboplatin Doses RR 25-50% 15-25% 25% 25% 15% 25% 28-42% 40% ??
(Skeel RT,et.al 2000)

40-60 mg/m2/weekly Response 10-30 mg/m2/weekly 4-60 mg/m2/3 weeks 360-400 mg/m2/4 weeks divided in 3 daily 5 FU 500-750 mg/m2/d1-5/ 4 weeks Anthracyclines 50 mg/m2/3 weeks Ifosfamide 2 g/m2/3-4 weeks Taxan(P) 250 mg/m2/3 weeks Gemcitabine 1250 mg/m2/d1,8/3 weeks