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“Top Ten” Clinical Tips on Symptom Management for Patients with Advanced Cancer Dr. José Pereira Head Division of Palliative Care, University of Ottawa.

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Presentation on theme: "“Top Ten” Clinical Tips on Symptom Management for Patients with Advanced Cancer Dr. José Pereira Head Division of Palliative Care, University of Ottawa."— Presentation transcript:

1 “Top Ten” Clinical Tips on Symptom Management for Patients with Advanced Cancer Dr. José Pereira Head Division of Palliative Care, University of Ottawa Medical Chief, Palliative Care Service, Bruyère Continuing Care & The Ottawa Hospital Provincial Medical Lead for Palliative Care, Cancer Care Ontario Dr. Sandy Buchman Palliative Care Consultant, Temmy Latner Centre, Toronto & University of Toronto Quality & Primary Care Engagement Lead, Palliative Care Program, Cancer Care Ontario

2 Faculty/Presenter Disclosure  Faculty: Dr. José Pereira  Program: 51 st Annual Scientific Assembly  Relationship with commercial interests: –Grants/Research Support: Takeda (past) Education grant to conduct review of breakthrough pain –Speakers Bureau/honoraria: Nil to report –Consulting Fees: Nil to report –Other: Nil to report

3 Disclosure of Commercial Support  This program has NOT received financial support  This program has NOT received in-kind support (except for myself and my organization who have allowed me to be here to present on their time)  No potential for conflict(s) of interest to declare

4 Mitigating potential bias  Jose Pereira –Takeda: Product has very limited role & prohibitively expensive

5 Faculty/Presenter Disclosure  Faculty: Dr. Sandy Buchman  Program: 51 st Annual Scientific Assembly  Relationship with commercial interests: –Grants/Research Support: Nil to report –Speakers Bureau/honoraria: Nil to report –Consulting Fees: Nil to report –Other: Nil to report

6 Disclosure of Commercial Support  This program has NOT received financial support  This program has NOT received in-kind support (except for myself and my organization who have allowed me to be here to present on their time)  No potential for conflict(s) of interest to declare

7 Mitigating potential bias  Sandy Buchman –Nil to declare

8 Any burning questions??

9 1. Systematic Screening of Symptoms

10 Cancer patients experience many symptoms across the illness trajectory Symptom Intensity & Tumor Stage (Non-hematological cancers) N= 240 Median # of symptoms = 8 per patient No evidence of disease Local disease Regional disease Metastatic disease No. of symptoms9 (0-24)7 (0-17)6 (0-15)10 (0-25) Moderate to severe symptoms 4 (0-14)3 (0-12) 6 (0-20) Chang VT et al. Symptom and Quality of Life Survey of Medical Oncology Patients: A Role for Symptom Assessment. Cancer 2000;88:

11 Symptoms are under-reported by patients unless standardized questionnaire used White C, et al. ‘‘Now that You Mention it, Doctor... ’’:Symptom Reporting and the Need for Systematic Questioning in a Specialist Palliative Care Unit, J Pall Med 2009; 12(5):

12 Symptoms: Patient reporting versus systematic assessment  Total symptoms identified: 2,397 –Of these, only 14% (322) were volunteered Homsi J, et al. Symptom evaluation in palliative medicine: Patient report vs systematic assessment. Support Care Cancer 2006;14:444–453.

13 Edmonton Symptom Assessment Scale (ESAS)

14 ISAAC II ESAS R Patient Self-Report Functional Status (ECOG) Additional questions Beginning process of tailoring kiosk to clinics & needs

15 Clinicians can fail to recognize 50-80% of patients concerns during consultation Significantly reduced symptom distress across a number of symptoms

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19 2. Useful Clinical Tools

20 The Palliative Performance Scale (PPS) 20 ECOG Palliative Performance Scale (PPS) %Ambulation Activity & Evidence of Disease Self-CareIntake Level of Consciousness 0100Full Normal activity No evidence of disease FullNormalFull 1 90Full Normal activity Evidence of disease FullNormalFull 80Full Normal activity with effort Evidence of disease Full Normal/ Reduced Full 2 70Reduced Unable to do normal work Evidence of disease Full Normal/ Reduced Full 60Reduced Unable to do house work Significant disease Occasional Assistance Normal/ Reduced Full or Confusion 3 50 Mainly Sit/Lie Unable to do any work Evidence of disease Considerable Assistance Normal/ Reduced Full or Confusion 40 Mainly in Bed As Above Mainly Assistance Normal/ Reduced Full or Drowsy or Confusion 4 30 Totally Bed Bound As AboveTotal CareReduced Full or Drowsy or Confusion 20As Above Total Care Minimal Sips Full or Drowsy or Confusion 10As Above Total CareMinimal/nilDrowsy or Coma Transitional Stable E-of-life

21 Palliative Alerts 21 For some patients the decline may be more gradual while for others it may be more precipitous Death Explore pt’s understanding of illness, discuss prognosis & goals of care. Encourage patient to see family physician regularly or find one. Advance care planning. Discuss code status Review treatment plan Advance care planning. Discuss code status Review treatment plan Ensure ESAS & PPS/ECOG done at each visit. Initiate home care Establish plans to deal with emergencies (e.g. pain crisis) DNR & Advanced directives Discuss preferred versus optimal place of death based on needs & circumstances ILLNESS TRAJECTORY IN PROGRESSIVE CANCER Consult Palliative Care Team as needed %

22 Prognosticating using the PPS in Cancer Patients Lau F, Downing M, et al. J Pain, PainSympt Manage. 2009;38(1)

23 End-of-lifeTransitioning

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25 Cancer Care Ontario Symptom Management Guidelines Mobile Smartphone App & Pocket Guides: https://www.cancercare.on.ca/toolbox/symptools/ Symptom screening tools

26 3. Palliative Care Earlier Than Later

27 Old model of Palliative Care

28 Palliative Care: Earlier in illness, not only at end-of-life

29 Palliative and End of Life Trajectories 29   

30 Palliative and End of Life Trajectories 30   

31 Palliative and End of Life Trajectories 31   

32 4. Selecting an analgesic: The WHO Ladder

33 Pain: A Multidimensional construct “I have pain”

34 34 Total Suffering Total Suffering/Pain Several domains merging Other symptoms Pain Spiritual & existential Cultural Social & financial Psychological

35 WHO Analgesic Ladder

36 Selecting between different opioids  Morphine remains first line strong opioid  Inter-individual variability between opioids  No large studies to demonstrate that one opioid is superior to another  Less constipation with fentanyl –Clinical significance?  Renal impairment –May still use morphine but reduce dose/prolong dosing intervals & monitor –Fentanyl & buprenorphine –Beware of methadone

37 37 Short-acting formulations for  Opioid-naïve patients  Pain crises Long-acting formulations  Reserve for stable situations  Add short-acting opioids for breakthrough pain Opioid Formulations

38 38 Opioid Neurotoxicity  Clinical Presentation –Myoclonus, hallucinations, cognitive impairment, delirium, severe somnolence, dysesthesia, allodynia  Mechanism unclear  Management strategies –Switching opioid (opioid rotation) –Decreasing opioid dose (if pain is well controlled) –Hydration

39 Adjuvants for neuropathic pain  1 st line –TCA, gabapentin, pregabalin –Start low & go slow –Trial of at least 5-7 days before increasing dose –Monitor for side effects –NNT=3-4  2 nd line –Pregabalin, corticosteroids  3 rd line –Ketamine, lidocaine

40 40 Adjuvants for Bone Pain  NSAIDs –Limited use in severe pain –Renal and gastro-intestinal side effects –Limitations of Cox-2 specific NSAIDs recently noted  Steroids –Useful in pain crises  Radiotherapy –75% to 85% response rate (decreased pain) –Few side effects with palliative therapy –Response within 1 to 2 weeks (maximum response up to 4 weeks later) –Duration of analgesia is several months

41 41 Adjuvants for Bone Pain  Bisphosphonates –Reduction of skeletal events (good evidence) –Management of more acute pain with parenteral infusion (some controversy)  Calcitonin –Not effective

42 5. Managing Breakthrough Pain

43 Breakthrough Pain (BTP)  Transient exacerbation of pain on a background of well controlled baseline pain.  Variable in intensity, duration, frequency & cause  Types –Unpredictable –Predictable Incident Pain  “End-of-Dose” failure not BTP Treatment – Use a short acting opioid formulation – Use same opioid as background treatment if possible – Exceptions: Fentanyl patch – 10% of total daily dose – Then titrate breakthrough dose (5% to 20%)

44 Breakthrough pain  Breakthrough dose needs titration (5-20%) once baseline pain controlled  Role of new sublingual formulations of fentanyl very limited –Expensive –Patient must be on at least 60mg of oral morphine per day –Limited role

45 6. Management of Dyspnea

46 46 Is this patient short of breath?

47 47

48 48 Management Approach to Dyspnea Screen Identify and treat underlying causes if possible and if appropriate Treatment of symptom Communicate: Explain situation to patient and family and reassure + + Assess

49 49 Pharmacological Measures to Control Dyspnea?      

50 50 Pharmacological Measures to Control Dyspnea  Oxygen  Opioids  Adjuvant therapies

51 51 Non-Pharmacological Management  Use a fan  Position: lean forward, head up  Avoid exacerbating activities

52 7. Management of Nausea

53 53 Nausea & Vomiting: mechanisms Chemoreceptor Trigger Zone Neuro-transmitter: Dopamine, 5HT 3 Causes Drugs (chemotherapy, opioids, SSRIs) Toxins (infections, cytokines) Biochemical (hypercalcemia, uremia) Anti-emetic: 1 st line: Metoclopramide, domperidone 2 nd line: Haloperidol (small dose) 3 rd line: ondansetron Gastro-intestinal tract Neuro-transmitter: Dopamine, 5HT 3 Causes: Tumors & tumor bulk, Obstruction, ileus, constipation Anti-emetic: Same as CTZ Vestibular apparatus (rare) Neuro-transmitter: Histamine Causes: Motion sickness Anti-emetic: Antihistamine Vomiting Centre Transmitter: Ach, Dop Causes: co-ordinates vomiting reflex Anti-emetic: Same as CTZ Brain cortex(rare) Transmitter: GABA, Ach Causes: Anxiety, anticipatory nausea Anti-emetic: Anxiolytic

54 Selecting an anti-emetic  Depends on underlying mechanism  1 st line agents: –Usual (one of the following) Metoclopramide 10mg PO QID PO/Subcut Domperidone 10mg TID PO (max dose 30mg/day) –In case of bowel obstruction (one of the following) Haloperidol 0.5-1mg subcut BID Dimenhydrinate  2 nd line agents: Dexamethasone Ondansetron Methotrimeprazine Cannibinioids  If antidopamine agent: monitor for EPS & akitisea

55 8. The Management of Delirium in patients with advanced cancer

56 CLINICAL PRESENTATION Clinical Subtypes  Delirium presents in one of three forms. Hyperactive formHypoactive formMixed form Meagher D. Motor subtypes of delirium: Past, present and future. Int Rev Psychiatry 2009;21:59-73; Lawlor P et al. Occurrence, causes and outcomes of delirium in advanced cancer patients: a prospective study. Archives of Internal Medicine. 2000;160:

57 CAUSES OF DELIRIUM Causes per episode  Often multifactorial etiology per episode –On average, 3 causes per episode E.g. opioid neurotoxicity, dehydration and hypercalcemia  Consider several causes concurrently  Sometimes the causes are unclear or cannot be found  Urinary retention aggravates delirium  Consider underlying dementias in very elderly patients 57 Lawlor P, et al. Occurrence, causes and outcomes of delirium in advanced cancer patients. Archives of Internal Medicine. 2000;160: Bruera E et al. Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. Cancer 2009;115:

58 58 Common Causes of Delirium in Palliative Care  Drugs –Opioids –Anticholinergic drugs such as tricyclic antidepressants –Anticonvulsants –Benzodiazepines  Infections  Dehydration  Metabolic/Organ failure –Renal or liver failure, hypercalcemia, hyponatremia  Hypoxemia  Brain disease: metastases or primary brain tumors  BZP withdrawals (uncommon)  Full bladder (aggravates)

59 Overall management approach

60 Benzodiazepines  Appear to worsen delirium in palliative patients.  Generally avoided. Role of benzodiazepines in Palliative Care Breitbart W et al. Double- blind trial of haloperidol vs chlorpromzine vs lorazepam in palliative AIDS pts. J Am Psych 1996;153(2):

61 DELIRIUM Management Guidelines. Cancer Care Ontario 2010

62 Pharmacological management Symptom Management- 1 st line MildModerateSevere Haloperidol 0.5mg or 1mg po or subcut OD or BID PLUS Haloperidol 0.5mg or 1mg PO /subcut q1hr PRN Haloperidol 2mg or 2.5mg po or subcut BID to TID PLUS Haloperidol 2mg PO /subcut q1hr PRN OR Methotrimeprazine Single dose of midazolam 2.5mg to 5mg subcut stat PLUS Haloperidol 5mg subcut stat OR Methotrimeprazine Then titrate dose if initial dose ineffective (see “moderate” doses) Then titrate dose if initial dose ineffective Follow with haloperidol 2.5mg or 5mg q 30min PRN subcut (max of 10-15mg /day)

63 The Role of the Atypical versus Traditional Antipsychotic medications  Haloperidol remains 1 st line  Methotrimeprazine 2 nd line  Newer atypical antipsychotics reserved for: –Pts requiring longer term treatment –Pts with EPS on haloperidol –Olanzapine can be given SC

64 The Myth of the “PLEASANT CONFUSION”  54% of pts whose delirium resolved recalled the delirium experience.  78%: delirium as highly distressing  Patients with hypoactive delirium were just as prone to experiencing distressing delirium as those with hyperactive delirium. Breitbart W et al. The Delirium experience: Psychosomatics. 2002;43:

65 9. Depression at the End of Life

66 Diagnosing depression in palliative care context  What is the prevalence of a major depression in patients with advanced disease?

67 Diagnosing depression in palliative care context  What is the prevalence of a major depression in patients with advanced disease? –10-15% –25% in pancreas cancer  Challenge –Somatic symptoms non-specific Weight loss, fatigue  Pervasice Worthlessness, guilt, hopelessness, death wish

68 Management  Supportive Counseling in all  Pharmacological management in some (where ability function is affected) –Citalopram (sedating) –Venlafaxine (stimulating) –Mirtazapine (sedating, appetite stimulation) –Duloxetine (if requires adjuvant analgesic) –Methylphenidate (short onset of action)

69 10. Airway secretions

70 Airway “rattle” at end of life  Differentiate between upper and lower airway secretions.  Upper airway secretions: –If mild to moderate: Reposition & reassure family –If severe Reposition, reassure, anticholinergic Glycopyrrolate 0.4mg Subcut q2 hrs prn OR Scopolamine 0.4mg Subcut q 4 hrs prn  Lower airway secretions (Pulmonary edema) –Furosemide 20mg-40mg subcut stat

71 End of Life “Comfort measures” (last hrs/days)  Avoid blanket orders  No need to start “morphine drip” if there was no pain before  No need to start midazolam drip if there is no refractory symptom and palliative sedation is not required

72 QUESTIONS??


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