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Palliative and supportive care in lung cancer,[object Object],Dr. Răzvan Curcă,[object Object],Emergency County Hospital Alba Iulia, Romania,[object Object]
Palliative care (PC),[object Object],Seeks to manage the symptoms of advanced and terminal illness,[object Object],Views people as a whole individual rather than a disease process to be treated,[object Object],Delivers holistic care through multidisciplinary team working,[object Object],MORE ON THIS SUBJECT ON SUNDAY AT 8:30 A.M.,[object Object]
Model of palliative cancer care,[object Object]
Main physical problems in advancedlung cancer patients,[object Object],Pain,[object Object],Dyspnea,[object Object],Local airway symptomes: cough, hemoptysis, and postobstructive pneumonia,[object Object],Brain metastases,[object Object],Palliative emergencies- spinal cord compression, superior vena cava syndrome, hypercalcemia,[object Object],Silvestri GA, et. Al: Caring for the Dying Patient With Lung Cancer, Chest, September 2002, 122:1028-1036,[object Object]
Comprehensive assesment in PC&SC,[object Object]
Ideal therapy in advanced lung cancer,[object Object],Improve overall survival,[object Object],Improve quality of life,[object Object],No or minimal toxicity,[object Object],Nearly all of the recommendations in this guideline are based on clinical trials that demonstrate improvements in OS using chemotherapy, with improvement (or lack of detriment) in QOL.,[object Object],Azzoli, CG, Baker S, Jr, Temin, S, et al. ASCO Clinical Practice Guideline update on chemotherapy for stage IV NSCLC. JClinOncol 2009; 27:6251.,[object Object]
Early Palliative Care for Patients withMetastatic Non–Small-Cell Lung Cancer,[object Object],Temel JS, Greer JA, Gallagher E, Admane S, Pirl WF, Jackson VA, Dahlin C, Muzikansky A, Jacobsen J, Lynch TJ,[object Object]
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
Study objectives,[object Object],Primary objective: Change from baseline to 12 weeks in the score on the Trial Outcome Index (TOI), which is the sum of the scores on the lung cancer subscale (LCS) for 7 cardinal symptomes and the physical well-being and functional well-being subscales of the FACT-L QoL scale.,[object Object],Secondary objectives:,[object Object],Mood change from baseline to 12 weeks in the score on Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire 9 (PHQ- 9),[object Object],Percentage of patients receiving aggressive end-of-life care (chemotherapy within 14 days before death, no hospice care, or admission to hospice 3 days or less before death),[object Object],Overall survival,[object Object]
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
There was no difference in the use of antidepressant agents! ,[object Object]
Effects on end-of-life care,[object Object], Fewer patients in the PC vs. the standard care group received aggressive end-of-life care.,[object Object],Aggressive End of Life Care,[object Object],Standard Care 			54%  p = .05,[object Object],Standard Care + PC		33%,[object Object]
Less aggressive end-of-life care,[object Object],More resuscitation directives in advance (54% vs. 33%, p = 0.05).,[object Object],Early referral to hospice (median duration of hospice care, 11 vs. 4 days, P = 0.09),[object Object],Fewer chemotherapy within 14 days before death,[object Object],BUT less aggressive end-of-life care did not adversely affect survival!,[object Object]
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
Study Limitations,[object Object],[object Object]
1 Center (MassGenH)
Relatively Non-Diverse Population
Some patients in the non-Palliative Care group received ‘Palliative Therapies’ (but this eventually reduced the magnitude of the observed benefit!),[object Object]
NEJM Speaker’s Editorial“Palliative Care — A Shifting Paradigm”,[object Object],Well designed, well-executed study with clinically relevant end points.,[object Object],Early palliative medicine referral improved survival with almost 3 months along with better QOL.,[object Object],Same survival advantage as palliative platinum-based chemotherapy.,[object Object],This study is an example of research that shifts a long-held paradigm that PC is the alternative to life-prolonging or curative care — “what we do when there is nothing more that we can do”— rather than as a simultaneously delivered adjunct to disease-focused treatment.,[object Object],Kelley AS, Meier DE. Palliative Care — A Shifting Paradigm. NEJM 2010; 363:781-782. ,[object Object]
Early PC in advanced lung cancer,[object Object],,[object Object],,[object Object],,[object Object],Improved overall survival,[object Object],Improved quality of life,[object Object],No toxicity,[object Object],IN ADDITION TO STANDARD CHEMOTHERAPY!,[object Object]
“  There’s not a place in the world where I’ve found people eager to die. ,[object Object],	If [palliative care] is marketed as end-of-life care, there is the same reluctance; ,[object Object],	if it’s marketed as a way to have a much better life and help you live longer, then it’s much 	more acceptable.”,[object Object],Dr. Frank Ferris,[object Object],Director, International Programs, San Diego Hospice & Palliative Care,[object Object]
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
Consequence: defining BSC,[object Object],BSC (best supportive care) is an old term (‘80s), but very familiar to many oncologists,[object Object],It is “politically correct term” used for “no chemo” in clinical trials with chemotherapy vs. no chemotherapy design,[object Object],What is the difference between BSC and SC ??,[object Object]
Why was BSC introduced?,[object Object],It’s easier to be accepted by the patients in order to be included in clinical trials with that specific design (“best” is supposed to be better than standard care).,[object Object],It could be more acceptable by ethics comitees and regulatory bodies.,[object Object]
BSC - implications,[object Object],Usually, the BSC arm is found to be inferior to the chemotherapy arm with respect to objective tumor response and survival.,[object Object],Possible conclusion: it’s always preferable to receive chemo than to be referred to PC!,[object Object]
BSC – future directions,[object Object],After Temel’s study it will be mandatory to define precisely all PC&SC interventions in clinical trials in order to prevent flaws in results.,[object Object],Integration of new assessment instruments frequently used in PC (eg. ESAS).,[object Object],Necessity for defining and implementing quality standards for PC&SC (defining Best).,[object Object]
BALKAN MCO 2011 - R. Curca - Palliative and supportive care in lung cancer
Killing the symptom without killing the patient,[object Object],Maybe the most challenging cases are advanced lung cancer pts. with severe dyspnea,[object Object],The main question: are opioids safe in this clinical setting?,[object Object]
Management of dyspnea in advancedlung cancer patients,[object Object]
Opioids in the therapy of dyspnea,[object Object],It sounds like “malpraxis” for many oncologists from Balkan countries, because of a restrictive legislation promoting opiophobia among many physicians,[object Object],Lack of proper PC&SC training during medical studies and residency induce also opiophobia (e.g. in Romania- no PC training in almoust all Medicine Universities, only a few months during residency, few PC specialists and trainers),[object Object],Regulatory barriers in access to opioids,[object Object]
European consumtion of morphine,[object Object]
Bureaucratic barriers in opioid access,[object Object],The countries with the most limited opioid formularies tended also to have the greatest number of regulatory barriers to accessibility. ,[object Object],Among the Western European countries, Turkey and Greece had more limited formularies and more accessibility barriers compared with the other countries.,[object Object],Among the East-European countries, there was much greater heterogeneity. Some countries like the Czech Republic, Croatia and Hungary had formulary availability and accessibility that was as good as most of the Western European countries.,[object Object],In contrast, several countries including Montenegro, Macedonia, Bosnia–Herzegovina, Albania and Ukraine had very restricted formularies and multiple barriers to accessibility.,[object Object],N. I. Cherny, J. Baselga et al. Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe: a report from the ESMO/EAPC Opioid Policy Initiative Ann Oncol 2010: 21(3): 615-626 ,[object Object]
Pivotal trials of opioids for dyspnea,[object Object],Bruera E, MacEachern T, Ripamonti C, et al. Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med 1993,[object Object],Mazzocato C, Buclin T, Rapin C-H. The effects of morphine on dyspnea and ventilatory function in elderly patients with advanced cancer: a randomized double-blind controlled trial. Ann Oncol 1999,[object Object],Allard P, Lamontagne C, Bernard P, et al. How effective are supplementary doses of opioids for dyspnea in terminally ill cancer patients? A randomized continuous sequential clinical trial. J Pain Symptom Manage 1999,[object Object]
Opioids in the therapy of dyspnea,[object Object],Studies show that appropriate doses of opioids do not cause respiratory depression.,[object Object],Caution is adviced for pts.:,[object Object],> 65 years,[object Object],During dose titration of the opioid,[object Object],With abnormal renal function,[object Object],With concomitant use of sedatives,[object Object],Close monitoring is very important.,[object Object]
Opioids in the therapy of dyspnea,[object Object],Thomas JR, von Gunten CF. Clinical management of dyspnoea. Lancet Oncol 2002;3(4):223-8. ,[object Object]

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