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Palliative Care Delivery in South Trinidad

Dr Dylan Narinesingh and Team Presenters : Dr P.Sylvester and Dr N.Bhim. Palliative Care Delivery in South Trinidad. Inpatient setting. Assess and treat symptomatically Family meeting concerning options for home care vs hospice care Home care not feasible  referral to Hospice

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Palliative Care Delivery in South Trinidad

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  1. Dr Dylan Narinesingh and Team Presenters : Dr P.Sylvester and Dr N.Bhim Palliative Care Delivery in South Trinidad

  2. 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

  3. Outpatient setting

  4. 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.

  5. 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

  6. 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

  7. 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 cycles 1. http://www.xeloda.com/about/prescribed-for/mcrc 2. Blum JL, Jones SE, Buzdar AU, et al. Multicenter phase II study of capecitabine in paclitaxel-refractory metastatic breast cancer. J ClinOncol. 1999;17(2):485-493.

  8. 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

  9. Paliative Care clinic • Situated at SFGH outpatient Oncology Clinic every 2/52 • Dr S. Chamely Palliative care physician • Patients receiving home care

  10. Hospice care in South Trinidad • Soon to be established at Petrotrin Medical Centre

  11. Zometa Audit

  12. 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

  13. Demographics • Sample size 34 patients: 28 males and 6 females • Age Distribution:

  14. Prostate Breast Other Primary site of cancer

  15. ZOLEDRONIC ACID AUDIT DATA COLLECTION SHEET

  16. 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  

  17. 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_________________________ 

  18. 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:________ 

  19. KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA

  20. ECOG PERFORMANCE STATUS

  21. 0–10 Numeric Pain Rating Scale

  22. Duration of Treatment

  23. Dose reduction

  24. Spinal Cord Compression

  25. Bone Pain

  26. Improvement in pain scores

  27. Improvement in pain • Average no. of doses before decrease in pain noticed 2.5 doses • Average decrease in numeric pain rating: approximately 3.5pts

  28. Improvement in mobility

  29. 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

  30. Skeletal Related Events

  31. Discussion

  32. 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

  33. Mechanism of action

  34. 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

  35. SRE • Skeletal Related events can shorten the survival in patients with advanced prostate and breast CA

  36. 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

  37. 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

  38. In view, of data collected in audit thus far. • At a cost of $2400.00TT per dose of Zometavs an average $1100.00TT per hospital bed per night. • How cost effective is the use of Zometa in Palliative care in our setting?

  39. 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 ClinOncol. 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 ClinOncol. 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 ClinOncol. 2011;29:1221-1227.

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