Dr Dylan Narinesingh and Team Presenters : Dr P.Sylvester and Dr N.Bhim.
-
Upload
bartholomew-hunt -
Category
Documents
-
view
218 -
download
4
Transcript of Dr Dylan Narinesingh and Team Presenters : Dr P.Sylvester and Dr N.Bhim.
PALLIATIVE CARE DELIVERY IN SOUTH TRINIDAD
Dr Dylan Narinesingh and TeamPresenters : Dr P.Sylvester and Dr N.Bhim
Inpatient setting
Assess and treat symptomatically Family meeting concerning options
for home care vs hospice care Home care not feasible referral to
Hospice Family advised to visit place to meet
health care providers at the Hospice Then patient is transported from SFGH
Hospice
Outpatient setting
Zometa
Intravenous bisphosphonate Indicated for Rx with metastatic bone
disease Multiple Myeloma
Prevents SRE and relieves bone pain Administered every 4 to 5 weeks
Zsuzsanna Nagy : Zoledronic acid (ZOMETA) : a significant improvement in the treatment of Bone metastases. Pathology and Oncology Research Vol 11, No 3, 2005.
Initial clinic visit for Zometa
Counselling side effects Calcium supplements Monthly blood tests to review prior to
administering (RFT’s and Ca2+) Informing physician on dental procedures
Severity of Bone pain Pain management according to the WHO
Analgesic ladder Palliative radiotherapy @ NRC
http://www.zometa.com/dosing-and-administration/dosing-for-solid-tumours-and-multiple myeloma/treat-every-3-to-4-weeks.jsp
Palliative Radiotherapy
Patients referred to be assessed at National Radiotherapy Centre on Tuesdays
Clinical mark-up planning Radiation dose of 8Gy x 1 Fraction or 20Gy
x 5 Fractions (administered to the area that gives the patient the most pain)
Chow E, Harris K, Fan G : Journal of Clinical Oncology, Vol 25, No 11 (April 10), 2007: pp. 1423-1436
Palliative Xeloda clinic
Indicated in Metastatic Colorectal Cancer 1
and Breast Cancer2
Initial visit Counseling patient on side effects and how to
manage them Blood test to review before prescribing ( CBC,
RFT, LFT) Vitamin B6 to be taken daily Patients seen every 3/52 Reassessment after 3 cycles1. http://www.xeloda.com/about/prescribed-for/mcrc2. Blum JL, Jones SE, Buzdar AU, et al. Multicenter phase II study of
capecitabine in paclitaxel-refractory metastatic breast cancer. J Clin Oncol. 1999;17(2):485-493.
District Health Facilities Princes Town / Couva / Siparia Providing best supportive care Team effort comprising Physicians,
Nurses and counselors Provide education and counseling of
Patient and relatives
Paliative Care clinic
Situated at SFGH outpatient Oncology Clinic every 2/52
Dr S. Chamely Palliative care physician
Patients receiving home care
Hospice care in South Trinidad Soon to be established at Petrotrin
Medical Centre
ZOMETA AUDIT
Overview
Audit period 10/7 (October 4th, 2011 to October 19th , 2011)
Inclusion Criteria Metastatic bone disease Duration of treatment with Zometa
>3mths
Total population approx. 100 patients
Demographics
Sample size 34 patients: 28 males and 6 females
Age Distribution:Age
Group<50 50-59 60-69 70-79 >80
No. of Patients
0 6 11 15 2
% 0 17.6 32.4 44.1 5.9
Primary site of cancer
•Prostate•Breast•Other
Breast15%
Prostate70%
Other 15%
ZOLEDRONIC ACID AUDIT DATA COLLECTION SHEET
Date:_____________ Record No._____________
Name:__________________________________________________________________
DOB (age): / / _____yrs
Gender: M F
Ethnicity: Black Asian East Indian Caucasian Mixed_____________
Address:________________________________________________________________________________________________
Cancer Type: Breast Prostate Lung Colon/Rectum Kidney Lymphoma (HL/NHL) Malignant Melanoma Brain Head & Neck Gastric Esophagus
Pancreatic Liver Cervix Endometrial Ovarian CUP
Other______________________________
Histology:________________________________________________________________________________
Date Diagnosed with Cancer:___________________________
Date Diagnosed with Bony Metastases:_________________________
Imaging Modality used for diagnosis: X-rays Bone Scan MRI CT
Site of Bony Metastates: Pelvis Spine (Cervical Thoracic Lumbar Sacral) Rib Cage Skull Scapula Clavicle Femur Humerus Other____________________
Spinal Cord Compression (at time of diagnosis): Y N
RT administered for SCC: Y N
Bone Pains: Y N
Site of Bone Pains: ___________________________________________
RT administered for Bone Pain: Y N
Receiving Palliative Chemotherapy/Hormonal Therapy: Y N
Date Zoledronic Acid started:________________________________________________
Baseline Creatinine and Calcium levels:_______________________________________
Duration of Treatment (months):_____________________________________________
Date Zoledronic Acid Discontinued:__________________________________________
Reason for discontinuation: Renal Failure Hypocalcaemia Osteonecrosis of Jaw Atypical Fracture Other__________________
Did patient experience any adverse skeletal-related event (SRE) or hypercalcemia of malignancy (resulting in admission) whilst receiving Zoledronic Acid: Y N
Specify:_________________________________________________________________
Dose Reduction of Zometa: Y N
Reason for Dose Reduction: Renal Impairment Other_________________________
Objective Improvement in Quality of Life
Compare Before and After Zoledronic Acid administered:
Describe in patient’s (and/or caregiver’s) own words: _______________________________________________________________________
Objective improvement in mobility:
ECOG/Karnofsky/Lansky Performance Status Before Zoledronic Acid:______________
ECOG/Karnofsky/Lansky Performance Status After Zoledronic Acid:________________
Number of Doses/Cycles given before improvement noticed:_______________________
Objective improvement in bone pain (see NIPC rating scales):
Numeric Rating Scale Before Zoledronic Acid: _________________________________
Verbal Pain Intensity Scale Before Zoledronic Acid:______________________________
Numeric Rating Scale After Zoledronic Acid: __________________________________
Verbal Pain Intensity Scale After Zoledronic Acid:_______________________________
Number of doses/cycles of Zoledronic Acid given before improvement noticed:________
KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA
Able to carry on normal activity and to work; no special care needed.
100 Normal no complaints; no evidence of disease.
90 Able to carry on normal activity; minor signs or symptoms of disease.
80 Normal activity with effort; some signs or symptoms of disease.
Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.
70 Cares for self; unable to carry on normal activity or to do active work.
60 Requires occasional assistance, but is able to care for most of his personal needs.
50 Requires considerable assistance and frequent medical care.
Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.
40 Disabled; requires special care and assistance.
30 Severely disabled; hospital admission is indicated although death not imminent.
20 Very sick; hospital admission necessary; active supportive treatment necessary.
10 Moribund; fatal processes progressing rapidly.
0 Dead
ECOG PERFORMANCE STATUS
Grade ECOG
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead
0–10 Numeric Pain Rating Scale
Duration of Treatment
<6mth 6-12mths 13-18mths 19-24mths >24mths0
2
4
6
8
10
12
No of patients
Dose reduction
44%
56%
Chart Title
Y N
Spinal Cord Compression
Y21%
N79%
Bone Pain
62%
38%
Y N
Improvement in pain scores
Yes No No pain
64.7%
23.5%
11.8%
Percentage of patients
Improvement in pain
Average no. of doses before decrease in pain noticed 2.5 doses
Average decrease in numeric pain rating: approximately 3.5pts
Improvement in mobility
Yes No
44.1%
55.9%
Percentage of patients
Improvement in mobility
Average no. of doses before change noticed: 2months
Average increase in performance status by ECOG Scale approximately 2pts
Average increase in performance status by Karnofsky Scale approximately 20pts
Skeletal Related Events
Nil adverse eventsSRE
DISCUSSION
What is Zometa?
Zometa (Zoledronic acid) belongs to a class of drugs known as bisphosphonates.
Zometa fights against skeletal destruction in advanced tumours and multiple myeloma
Mechanism of action
Mechanism of action
In addition to being a potent inhibitor of bone resorption, Zometa also possesses anticancer properties that could contribute to its overall efficacy in the treatment of metastatic bone disease
Zometa is administered as an IV infusion every 3-4 weeks in MM and advanced solid tumours
SRE
Skeletal Related events can shorten the survival in patients with advanced prostate and breast CA
Prostate CA
49% of patients with advanced prostate Ca and bone metastases will experience a SRE within the first 2yrs
Average time to first SRE is 10.7mths
Average frequency of SRE was approximately every 8 mths
Breast CA
68% of patients with advanced breast Ca and bone metastases will suffer a SRE within 2yrs
The average length of time to first time SRE was 7mths
The frequency of SREs occur approximately every 3mths
In view, of data collected in audit thus far.
At a cost of $2400.00TT per dose of Zometa vs an average $1100.00TT per hospital bed per night.
How cost effective is the use of Zometa in Palliative care in our setting?
References 1. Coleman RE. Metastatic bone disease: clinical features, pathophysiology and treatment
strategies. Cancer Treatment Rev. 2001;27:165-176. 2. Lipton A, Theriault RL, Hortobagyi GN, et al. Pamidronate prevents skeletal complications
and is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases: long term follow-up of two randomized, placebo-controlled trials. Cancer. 2000;88:1082-1090.
3. Saad F, Lipton A, Cook R, Chen Y-M, Smith M, Coleman R. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer. 2007;110:1860-1867.
4. ZOMETA Summary of Product Characteristics. Novartis Pharma AG. 5. Andre F, Slimane K, Bachelot T, et al. Breast cancer with synchronous metastases: trends
in survival during a 14-year period. J Clin Oncol. 2004;22:3302-3308. 6. Rosen LS, Gordon D, Kaminski M, et al; Zoledronic Acid Breast Cancer and Multiple
Myeloma Study Group. Long-term efficacy and safety of zoledronic acid compared with pamidronate disodium in the treatment of skeletal complications in patients with advanced multiple myeloma or breast carcinoma: a randomized, double-blind, multicenter, comparative trial. Cancer. 2003;98:1735-1744.
7. Kohno N, Aogi K, Minami H, et al. Zoledronic acid significantly reduces skeletal complications compared with placebo in Japanese women with bone metastases from breast cancer: a randomized, placebo-controlled trial. J Clin Oncol. 2005;23:3314-3321.
8. Aapro M, Abrahamsson PA, Body JJ, et al. Guidance on the use of bisphosphonates in solid tumours: recommendations of an international expert panel. Ann Oncol. 2008;19:420-432.
9. Van Poznak CH, Temin S, Yee GC, et al. American Society of Clinical Oncology executive summary of the Clinical Practice Guideline update on the role of bone-modifying agents in metastatic breast cancer. J Clin Oncol. 2011;29:1221-1227.