Palliative and supportive
treatment
A.Gonda
Motto
 There is a limit to cure but no limit to care
Statistics
 World: 7.0 Million
 Hungary: 33.457
(The need for palliation in the group of the
patients is about 70 %)
What is palliative medicine?
 Palliative medicine is a treatment form where the
psycho-social and physical well-being should be
considered
 PC is not organ-specific
Goal of palliation
Diagnosis
Active treatment
Palliation
Death
Active treatment and palliation is reciprocal.
The philosophy of palliation
 Main goal: QoL
 Holistic treatment forms which mind the patient
itself
 Treating family members
 Accepting patient’s mind
Definition
 Palliation: Not the cause itself but symptoms are
treated/altered (painkilling, rehydration,
constipation etc.) Life expectancy is unimportant
 Supportation: treatment of the symptoms caused by
anticancer treatment (hyperemesis, leukopenia,
anaemia etc.) are treated
Palliation cont.
The two fundamental outcomes of any cancer therapy
are prolongation of survival, and quality of life
One of the challenges of palliation is that we do not
expect to achive cure, nor necessarily complete
resoluion of all cancer-associated symptoms
The attitude of our health-care
 It is focusing on the disease instead of the patient
 Somatic symptoms are minded first of all
 Psycho-social issues are depressed
 Communication is insufficient
Special aspects of palliative care
 PC does not necessarily end with the death of the
patient
 Some surviving relatives may need support during
bereavement period
 Those patients whose disease has been controlled
need sometimes psycho-social support.
Site of organisations
 Hospital-Hospice
 Home care
 Day clinic
The role of the oncologist in palliation
 Organizing infrastructures for the patient and for the
family
 Collaboration with other disciplines (surgery, radio-
therapy, pain-killing, communications etc.)
Members of PC group
 Physician
 Nurse
 Gymnastics
 Chaplain
 Psychologist
 Volunteer
 Social-worker
 Dietetics
Symptoms in cancer patients
 Pain 84%
 Dyspnoe 47%
 Nausea 51%
 Insomnia 51%
 Depression 38%
 Apetite loss 51%
 Constipation 47%
Pain
 It is pain and the unknown that people most fear in
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advanced cancer
The word of pain is bound up with the word „cancer”
Pain increases with the duration of illness (although
one out of four patients do not experiance significant
pain.
Globally at least 4 million people suffer from cancer
pain
It is necessary to accurately assess pain
Mechanisms of cancer pain
 1, nociceptive pain
 pain arising from somatic soft tissue
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(The tumor margins are often tender and hypersensitive, mediated
by tumour products and host prostaglandines
Compression of the host tissues
Bone pain
Visceral pain
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Caused by smooth muscle spasm or direct tumor infiltration with
an inflammatory response
The characteristics of nociceptive pain
 Pain that is difficult for the patient to localize
 It can be intense, episodic and associated with other
autonomic effects such as sweating, pallor, and
nausea
Mechanisms of cancer pain cont.
 Neuropathic pain
 Nerve compression and infiltration by tumour will initially
produce aching pain referred in the distribution of that nerve
 it may be associated with numbness or motor weakness
 It has qualities of burning, shooting, or stabbing and may have
sudden crescendo episodes with no apparent precipitating
cause
 Often does not respond well to opioid analgesics
 It is difficult to manage
Other aspects of pain
 1, Physical causes of pain
 Primary site of malignancy
 Metastatic sites
 2, Emotional, psychological and social causes of pain
 Anxiety
 Stress (diagnosis, treatment etc.)
 Cancer pain should be considered as being influenced by
many factors rather than only by the patient’s physical
status. These influences can lower the threshold for pain
Assessment of pain
 The detailed history
 The longer the patient has experienced pain, the more time is
required to unravel the true cause of that pain
 Measurement of pain
 there is no overall acceptable way of measuring pain
 Measuring of pain from one day to the next is a way of
establishing whether treatment is effective
 Visual analogue scales ( grade the pain from 1-10)
 Diagrams of facial expressions (children)
Special problems relating to pain
 They may arise when the patient experiences severe,
unexpected pain
 Panick attack, patient can be frightened or extremly
anxious
 Background:
 Bone fracture, spinal cord compression, respiratory distress,
intestinal obstruction, cardiac problems
Management of cancer pain
 1,Sysemic medication
 2,Radiotherapy
 3, Chemotherapy
 4, Surgery
 5,Embolisation
 6,Ganglion blockade
 7, psychotherapy
The steps of pain relief
strong opioids  non-opioids
III. step
 adjuvant medication
persistant pain
II. step
light opioids + non-opioid
 adjuvant medicines
persistant pain
I. step
non-opioids
 adjuvant medicines
Medications in cancer pain management
 Non-opioids
 Light opioids
paracetamol, metamizol, acetylsalycilsav,
 Strong opioids
morfin, fentanyl, hydromorphon,
oxycodon, methadon
 adjuvants
 antidepressants (TCA)
 antiepileptics
 neuroleptics
 anxiolytics
 steroids
codein, dihydrocodein, tramadol,
amitriptylin, imipramin, clomipramin
carbamazepin, valproát, gabapentin,
pregabalin, clonazepam
haloperidol, chlorpromazin,
levomepromazin
alprazolam, diazepam, hydroxyzin
dexamethason, methylprednisolon
Opioids
OPIOIDOK
(MORFINSZERŰ HATÁSÚ GY ÓGY SZEREK )
GY ENGE
OPIOIDOK
(TRAMADOL, CODEIN)
Hatás
ERŐS OPIOIDOK
(MORFIN, FENTANY L, METHADON)
Hatás
Dózis
Dózis
Light opioids
 codein
 dihydrocodein retard
 tramadol
 Side effects:
 constipation
 nausea
 vertigo
Strong opioids I.
 morfin
Morphinum HCL inj
 Sevredol
 M-Eslon caps
 MST Continus
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 hydromorphon
 Palladone SR
 Jurnista
Strong opioids II.
 Fentanyl
 Durogesic
 Fentanyl Hexal
 Matrifen
 Dolforin
 Fentanyl inj.
 methadon
 Depridol tbl
 oxycodon
 Oxycontin inj.
 buprenorphin
 Transtec
Opioids effectivity
Name
Relative effectivity
tramadol
codein
dihydrocodein
MORFIN
oxycodon
hydromorphon
buprenorphin
fentanyl
1/10
1/10
1/6
1
2
7,5
70
70-100
Opioid substitution and rotation
 If an opioid causes unacceptable adverse effects, or if
the opioid has been used for sometime, and there is
no apparent benefit from increasing the dose, it is
appropriate to change or substitute that opioid for
another. (opioid rotation)
Nutritional care
 When we are ill and our appetite may be poor, food
and drink can be a source of conflict and take on a
greater importance
 Giving patients the feeling that they can help with
their own well-being through what they eat and
drink is important
Cachexia
 A characteristic feature of advanced malignacy is
cachexia
 It presents the clinical picture of
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weight loss
anorexia
weakness
 It leads to progressive loss of mobility, mental apathy
and shortened survival
 Paraneoplastic manifestation which is the result of a
host responce to the presence of tumor
Symptoms of tumour induced cachexia
 BMI decrease
 Asthenia
 Anorexia
 Decreased sensitivity to CT and RT
 Decreased effectiveness of any anticancer treatment
Metabolic characteristics of cachexia
 Negative energy balance
 While reduced intake is very important, the
underlying program lies in the profound changes
seen in protein, lipid and carbohydrate metablism as
a result of cancer.
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Increased protein syntesis in the liver (acute phase proteins)
Fat stores are progressively depleted
Tumor-derived lipolytic factor may be partly responsible for fat
breakdown
Anaerobic glycolysis in tumor tissue produces lactic acid
Increased gluconeogenesis in the liver
Reduced insulin response
Other factors in cancer malnutrition
 Dysphagia
 Gastrointestinal obstruction
 Nausea
 Vomiting
 Mucositis
 Enteritis
Treatment of tumour induced cachexia
 Steroid
 Megestrol acetate
 NSAID
 Thalidomide
 Canabinoids
Loss of 30 % of body weight could be fatal
Nausea and vomiting
 Affecting 40-70% of patients
 It can be very distressing
 It may be difficult to control
 Nausea
 Associated with autonomic symptoms (cold sweats,
pallor, salivation, tachycardia,)
 Often more unpleasant than vomiting
Features of vomiting
 Concomitant nausea
 Nature of vomit
 Timing of vomit
 Abdominal distension
 Constipation
 Urinary symptoms
 Headache on waking
 Dyspepsia
Simple „non-drug” measures
 Avoidance of food smells or unpleasant odors
 Relaxation
 Acupressure
 Acupuncture
Causes of vomiting
 Gastrointestinal
 Upper: sore tongue, candidal infection, difficulty
expectorating, oesophagitis, carcinoma of the oesophagus
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Mid: peptic ulcer, gastritis, carcinoma of the stomach,
pancreas tumor, gall bladder disease, bowel obstruction
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Lower: constipation, bowel obstruction
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Hepatic disease
Causes of vomiting cont.
 Chemical
 Drugs (opioids digoxin, antibiotics)
 Biochemical: uraemia, hypercalcaemia,
 Treatments: radiotherapy, chemotherapy
 Tumor toxins
 Infection
 Cerebral
 Anxiety
 Taste, smell
 Cerebral tumor
 Raised intracranial pressure
 Vestibular
 Vertigo, motion, acoustic neuroma
Receptors and their main blocking agents
 D2
 Phenothiazines,
 Haloperidol,
 Metclopramide
 Domperidone
 5-HT3
 Ondansetron
 Granisetron
 Tropisetron
 Metoclopramide (weak)
The antiemetic ladder
 Step 1:
 Try a single agent according to the possible cause of vomiting
 Step 2:
 If it is partially effective, increase the dose to maximum,
optimizing the dose every 24 hours, If it is necessary change
the drug
 Step 3
 If there is no effect, add together two drugs that act on
different receptor sites
 Step 4:
 If there is no effect, use a less specific antiemetic
(ondansetron), or adjuvant drugs like steroids
Constipation
 Over half of all palliative care patients complain of
constipation
 „straining to pass hard stool”
Common causes of constipation
 Patient
 Poor diet or low fluid intake
 Lack of exercise
 Immobility-paraplegia
 Depression
 Gastrointestinal tract
 Tumor, causing partial obstruction, stricture, adhesions and
decreased motility
Common causes of constipation
 Metabolic
 Hypercalcaemia
 Hypothyroidism
 Hypokalaemia
 Drugs
 Opioids
 Tricyclic antidepreassants
 Antacides
 Phenotiazines
 Chemotherapy-some types
Diagnosis
 Patient’s history
 Examination of the abdomen
 Abdominal X-ray
 Rectal examination
Treatment of constipation
 Softeners
 Oral agents: lactulose, magnesium hydroxide, fibre
 Stimulants
 Oral: senna, bisacodyl
 Rectal: glycerine suppositories, phosphate enemas
 Stimulants+softener combinations
 Prevention is better than cure !
Diarrhoea
 Frequent passage of loose stools
 Common causes
 Colonic tumor, carcinoid tumor
 Chemotherapy, radiotherapy, antibiotics, NSAIDs
 Infection, diverticulitis
 Constipation (false diarrhoea)
Treatment of diarrhoea
 Removal of predisposing factors
 Loperamide
 octreotid
The symptoms of coming death
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Extreme weakness
Patient is unable to move
Fluid ad food uptake is refused
Sleepiness
Loss of concentration
Confusion
Talking to „dead relatives”
irritation
Increasing pain
What to do and what not to do
 Try to avoid every unnecessary intervention
 Loving care
 hygienic care
 Reduce the number of medications
Medicines in the last hours
 1, parenteral morfin (morfin pump, or sc. inj)
 2, parenteral antiemetics (metoclopramid,
haloperidol)
 3, furosemid im. or iv.
 4, atropin sc. or iv.
Complementary therapies in palliative care
 Part of the holistic approach
 Recognize that the mind, body and spirit are all
connected
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Massage
Aromatherapy
Reflexology
Relaxation
Guided imagery
Visualization
Meditation
Music
Hypnotherapy
Supportation
 Treatment of symptoms that caused by
anticancer treatment (hyperemesis,
leukopenia, anaemia etc.)
Where and how to support?
 Improving WBC with using colony stimulants
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(GMCSF, GCSF)
Transfusions-erythropoetins
Thrombopoetins
Antibiotics
Wound healing
Aphtosis, mucositis
Nausea, vomiting
CSF
 GCSF: Neupogen, Neulasta
 WBC count will be enhanced in 2-3 days
 Should be delivered if WBC is less than 200/ul
 Cease it if WBC is more than 1500/ul
 Advantage : shorter improves WBC count than Leucomax
 Disadvantage: No influence on PLT count and RBC count
CSF
 Could be delivered preventively, but !
 1. Chemotherapy 2. CSF on day 2.
 Dosage. 5ug/kg/day
 Antibiotics in a preventive way ?
Erythropoetins
 Causes of anaemia : bleeding, haemolysis, decrease
of EPO – level
 Treatment forms : transfusions vs EPO
 EPO binds to receptor like IL-2, GCSF and other
cytokines
Erythropoetins
 There are 2 preparations, ie. alfa and beta
 S.c. and iv. forms – both effective
 Initial dosage : 100 U/kg or 5000 U / day or 40.000
U / week
 Indications : cancer related anaemia , CT induced
anaemia,
 Adverse effects : Blood pressure elevations, seizures
Thrombopoetins
 2 forms : in clinical trials
 Increases the size and number of megakaryocytes,
stimulates nucleic polyploidy, upregulates platelet
markers
 Dosing : not yet defined
 Indication : thrombopenia, bone narrow transplant
 Adverse events: few side effects, cardiorespiratory
disease?
Nausea and vomiting
 Variations :
 Acut emesis – in the first 24 hour of treatment
 Delayed emesis – between 2-7 days of treatment
 Anticipatory vomiting – before treatment – reflexogen activitiy
 Treatment forms : HT3 blockers, steroids,
anxiolytics, psychomimetics
During palliation
 Do not overtreat the patient!
 Holistic treatment is necessary
 Improve the quality of life
 Do not prolong suffering
 Help the family members