Role of Systemic Therapy in Palliation of Cancer Patient By: Prof. Ahmed M Abdel-Warith NCI - Cairo University

1. Role of Systemic Therapy in Palliation of Cancer Patient By: Prof. Ahmed M Abdel-Warith NCI - Cairo University Feb 2005

2. Systemic therapy In cancer Cure: 1- Germ C T Lymphomas Leukemia 2- Adjuvant Palliate 1-Metastatic Recurrent 2-Solid tumors

3. The concept of PALLIATION Guidelines For CTH use

4. Humans Etiology Pathology S &S Diseases

5. Humans Etiology Pathology Diagnosis + Therapy S &S Diseases

6. Goal Of Therapy Cure Palliate 1- TARGET OF THERAPY 2- NATURE OF DISEASE 3-stage

7. 1-THE TARGET OF THERAPY Therapy Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Etiology Pathology S &S Diseases

8. 1-THE TARGET OF THERAPY Renal stones Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Etiology: Allopurinol Pathology: Sx fore stone S &S: Colic

9. 1-THE TARGET OF THERAPY Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Etiology: Allopurinol Pathology: Sx fore stone IMPORTANCE S &S: Colic COMPLIMENTARY

10. Tumors Therapy Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Etiology Pathology S &S

11. Tumors Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Etiology: Target therapy Pathology: Mass removal Therapy S &S Colics DVT

12. Tumors Therapy Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Etiology IMPORTANCE Pathology S &S COMPLIMENTARY

13. 2-THE NATURE OF THE DISEASE Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Acute Therapy Chronic Disease + complication

14. 2-THE NATURE OF THE DISEASE Acute: Tonsilitis Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Chronic Disease diabetes

15. 2-THE NATURE OF THE DISEASE Cure Cure Cure Cure Cure Palliative Palliative Palliative Palliative Palliative Chronic Disease CANCER

16. 3- Stage The aim of cancer management varies according to the stage in which the patient presents. EARLY CURATIVE LATE PALLIATIVE

17. 3- Stage While all attempts should be entertained to cure cancer patients, in some cases oncologists should admit that the aim of therapy in certain stages is palliation.

18. When cancer patients reach this stage, it is the duty of the specialized cancer care facilities to provide the patients with the best palliative care to achieve the ultimate goal for end stage cancer patient namely “Die with Dignity”

19. MULTIDESIPLINARAY APPROACH “Die with Dignity” Sx RTH CTH PAIN NUTIRI -TION PHSYCH SOCIAL

20. Role of Systemic Therapy in Palliation of Cancer Patient

21. DRUGS CAN BE DANGEROUS Guidelines of using systemic therapy in palliative setting Patient Therapy Tumor

22. Guidelines of using systemic therapy in palliative setting Patient

23. Guidelines of using systemic therapy in palliative setting Patient 1-Performance status (PS) -PS is a global measure of patient’s wellbeing. -Evaluation of PS (Karnofsky, WHO, or ECOG) is the first step in determining whether or not we should proceed with active systemic therapy. -Patients with ECOG PS =4 are not candidate for systemic palliative therapy.

24. Guidelines of using systemic therapy in palliative setting Patient 2-Age: younger patients encourage physicians to try to use therapies with somewhat expected toxicities depending on the body reserve the young patient might retain. WHO IS DEFINED AS YOUNG?

25. Guidelines of using systemic therapy in palliative setting Patient 3-Gender: this might affect the choice of therapy according to the toxicity expected. Alopecia and amenorrhea are not preferred by females.

26. Guidelines of using systemic therapy in palliative setting Patient 4-Body functions evaluation: -Accepted levels of body functions is needed before initiating systemic therapy. -Simple evaluation of kidney, liver, and bone marrow function

27. Guidelines of using systemic therapy in palliative setting Patient 4-Body functions evaluation: It is not uncommon to find significant thrombocytopenia, kidney dysfunction or elevated liver enzymes in apparently healthy patient that makes some types of systemic therapy contraindicated.

28. Guidelines of using systemic therapy in palliative setting Patient 5-life expectancy: if the patient is going to receive an investigational therapy at least a three month life expectancy is asked before initiating the systemic therapy.

29. Guidelines of using systemic therapy in palliative setting Patient • 6-Social and personal factors: • Sometimes these factors are detrimental in • deciding initiating active systemic therapy • e.g.-does the patient have somebody to take • care of him in case of expected toxicity? • -does he have access to a near by • health facility in case of expected toxicity?

30. Guidelines of using systemic therapy in palliative setting Tumor

31. Guidelines of using systemic therapy in palliative setting Tumor - It is important to stress that the patient should have no curative option left. - Physicians should not be encouraged to send patients for palliative chemotherapy based on the patient’s wish not to have radical surgery because, for example, it will end with a colostomy or a mastectomy.

32. Guidelines of using systemic therapy in palliative setting Tumor 1-Tumor type: -This might determine the drugs to be used whether chemotherapy or hormonal therapy. - For example breast and prostate cancer can benefit from hormonal treatment while lymphomas and lung cancer can benefit from chemotherapy.

33. Guidelines of using systemic therapy in palliative setting Tumor 2-Tumor symptoms: -“You can not palliate an asymptomatic patient”. e.g. Melaoma with skin nodules. -The target symptoms for palliation should be related to the tumor to be able to be palliated by therapy directed to the malignancy. e.g. anal fissure in lung cancer patient

34. Guidelines of using systemic therapy in palliative setting Tumor 3-Evaluable disease: : The presences of evaluable or measurable disease give a chance for objective evaluation make the decision for continuing the therapy easier to be taken.

35. Guidelines of using systemic therapy in palliative setting Therapy

36. Guidelines of using systemic therapy in palliative setting Therapy 1-Route &schedule IV vs PO, monthly vs daily =/>15% 2-Efficacy 3-Toxicity Profile: Acute vs chronic

37. Summary & Conclusions

38. Therapy Cure Palliate 1- TARGET OF THERAPY Symptoms, Pathology Etiology 2- NATURE OF DISEASE Acute Chronic 3-stage Early Late

39. Guidelines of using systemic therapy in palliative setting Patient Therapy Tumor Ps, Age, Sex, Body Functions Stage, Type, Evaluable Route, toxicity, efficacy

40. THANK YOU There is no ideal tumor, ideal drug, or ideal patient. • There is collaboration and coordination to give the best circumstances for end stage cancer patients to: “Die with Dignity”