1. Palliative Chemotherapy Dr. Oscar S. Breathnach Consultant Medical Oncologist Palliative Care Multidisciplinary Study Day Beaumont Hospital Sept. 19 th, 2013

2. You have been diagnosed with CANCER ADVANCED CANCER

4. OUTCOME PATIENT [ mind- body-spirit ] FAMILY / FRIENDS MEDIA / INTERNET MEDICAL / NURSING STAFF Life Events Belief Systems Cultural Environment

5. Cancer, an age-related event in a population with Less Births / Prolonged Survival

8. When cure is not a reality Suspecting the cancer Suspicions confirmed Staging the cancer Advanced stage Opinion re chemotherapy Personal and family reactions Hope vs reality Chemotherapy

9. Objectives PERSON: Live longer Quality of Life Dignity STATE: Cost-effectiveness Standards of care MEDICAL STAFF: Maintain quality of life Minimise toxicity Prolong survival Progression-free survival Minimise disease- related toxicity Balance between all the various factors

10. Palliative Chemotherapy Other patients / families (the waiting room) Anti-cancer agents Support personnel: –oncologists, nurses, physios, OTs, dieticians, social workers, psycho-oncology, palliative care team, health care assistants, ward clerks, catering staff, cleaners, etc The Hospital building The Internet’s message of hope / options The Myths History / transmitted memories

11. 3 Lives -:- 3 Pathways Relatively asymptomatic Symptomatic, but reversible Profoundly symptomatic, non-reversible

12. Considerations re Treatment Performance Status Range of agents Therapeutic target Measuring benefit –Symptoms –Radiology –Function When to break / stop

13. Survival curve percentiles and their corresponding scenarios. Kiely B E et al. JCO 2011;29:456-463 ©2011 by American Society of Clinical Oncology

14. Selected Toxicities Erlotinib and Docetaxel (indirect retrospective contrast)

15. Emerging Targets: NSCLC, adenoca.

16. Metastatic: NSCLC, 1 st line Histology / Molecular profile –EML4-ALK mutation (7% of adenocarinoma) –EGFR mutation (17% of adenocarcinoma) –K-ras (22% of adenocarcinoma) StudyAgentsRRPFS (mos) LUX LUNG 3 Cisplat-Pem Afatinib 22% 56% 6.9 11.1 (13.6) IPASS Carbo-Pac Gefitinib 41% 71% 5.5 9.0 EURTAC Cis/Doc or Gem Erlotinib 15% 58% 5.2 9.7

17. Lux Lung 3: common mutations

18. Toxicity Profile Afatinib vs Cis/Pem Grade 3/4 Toxicity (%) Grade 3/4 Toxicity (%) Diarrhoea 14.40 Rash/acne 16.20 Stomatitis/mucositis 8.70.9 Paronychia 11.40 Nausea 0.93.6 Fatigue 1.312.6 Lux Lung 3

19. Ms. A.A Small cell Lives with partner, children abroad Nervous Extreme dyspnoea Haemoptysis

20. Nov. 13 th, 2012

21. Pre- and Post 4 cycles of chemotherapy

22. Post sequential chest radiation

23. 8 months post diagnosis 5 months post completion of chemotherapy

24. Ms. M.C. Breast lesion x 4yrs Single; no children Bleeding chest wall; increasing left arm pain, with decreasing sensation Deliberated over radiation and chemotherapy

25. Pre-Treatment

26. Progressive disease: Dx date +5 months

27. Further chemotherapy: Dx date +12 mths

28. Considerations The Person The Realistic outcomes Realistic optimism The person’s objectives Focus on Quality / Prolongation of life When not to treat Beyond treatment Those remaining

29. Choose Wisely