May 2-6 2011May 2-6 2011FUND FORUMFUND FORUM

Breast Cancer Supportive Care

Symptoms and PrognosisSymptoms and Prognosis

• Challenge of symptom Challenge of symptom management: management:

– block toxicity without block toxicity without compromising efficacycompromising efficacy

Supportive Care Toxicity TargetsSupportive Care Toxicity Targets

• HematologicHematologic• MyelosuppressionMyelosuppression

• GastrointestinalGastrointestinal• Nausea/vomitingNausea/vomiting

• Constipation/diarrheaConstipation/diarrhea

• MucositisMucositis

• CardiovascularCardiovascular• ThrombosisThrombosis

• CardiacCardiac

• Neurologic Neurologic • Peripheral neuropathyPeripheral neuropathy

• CognitiveCognitive

• PulmonaryPulmonary

• RenalRenal

• CutaneousCutaneous• AlopeciaAlopecia

• RashRash

Gastrointestinal: Nausea Gastrointestinal: Nausea and Vomitingand Vomiting

• ChemotherapyChemotherapy

• Radiation therapy-especially Radiation therapy-especially brain, abdomen, pelvisbrain, abdomen, pelvis

• Brain metsBrain mets

• Bowel obstructionBowel obstruction

• Electrolyte imbalanceElectrolyte imbalance

• Other medicationOther medication

Perception of Perception of Chemotherapy (1983)Chemotherapy (1983)

Nausea and vomiting are the two most Nausea and vomiting are the two most feared toxicities of chemotherapyfeared toxicities of chemotherapy

Coates, Eur J Cancer Clin Oncol 19:203, 1983Coates, Eur J Cancer Clin Oncol 19:203, 1983

Nausea and VomitingNausea and Vomiting• Physiologic processPhysiologic process

– Body’s normal response to expel Body’s normal response to expel toxinstoxins

• Delayed NauseaDelayed Nausea– Occurs days after therapy with Occurs days after therapy with

certain chemotherapy agentscertain chemotherapy agents

• Anticipatory NauseaAnticipatory Nausea– occurs before treatment in patients occurs before treatment in patients

who have previously vomited after who have previously vomited after chemotherapychemotherapy

The best way to manage The best way to manage nausea and vomiting caused nausea and vomiting caused

by cancer therapy is to by cancer therapy is to prevent it. prevent it.

Natural History of Delayed Natural History of Delayed Nausea and VomitingNausea and Vomiting

Kris, J Clin Oncol 3:1379, 1985

Hours after cisplatinHours after cisplatin

Percent with Percent with nausea or nausea or vomitingvomiting

Expectation vs Reality Expectation vs Reality Moderately Emetogenic ChemotherapyModerately Emetogenic Chemotherapy

Grunberg, Cancer 100:2261, 2004Grunberg, Cancer 100:2261, 2004

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Levels of Emetogenicity Modifying FactorsLevels of Emetogenicity Modifying Factors

• AgeAge

– Younger patients vomit more than Younger patients vomit more than older patientsolder patients

• GenderGender

– Women vomit more than menWomen vomit more than men

• Alcohol historyAlcohol history

– Patients with a history of heavy Patients with a history of heavy alcohol use vomit less than those alcohol use vomit less than those without such a historywithout such a history

• Nausea/vomiting historyNausea/vomiting history

– Patients with a history of morning Patients with a history of morning sickness or motion sickness are sickness or motion sickness are more likely to vomitmore likely to vomit

Antiemetic Consensus Antiemetic Consensus Guidelines - 2008Guidelines - 2008

Adapted from Koeller, Support Care Cancer 10:519, 2002Adapted from Koeller, Support Care Cancer 10:519, 2002

RiskRisk AcuteAcute DelayedDelayed

HighHigh 3 drugs3 drugs 2 drugs2 drugs

ModerateModerate 3 drugs3 drugs 1 drug1 drug

LowLow Single AgentSingle Agent NoneNone

MinimalMinimal NoneNone NoneNone

Effect of Physician Education on Effect of Physician Education on Antiemetic Guideline ComplianceAntiemetic Guideline Compliance

►Lecture by visiting expertLecture by visiting expert

No change in behaviorNo change in behavior

►Distribution of written guidelinesDistribution of written guidelines

Improved compliance x 2 monthsImproved compliance x 2 months

►Direct feedback of patient experiencesDirect feedback of patient experiences

Improved compliance x 4+ monthsImproved compliance x 4+ months

Mertens, J Clin Oncol 21:1373, 2003Mertens, J Clin Oncol 21:1373, 2003

Levels of EmetogenicityLevels of Emetogenicity

• Highly Emetogenic Chemotherapy (HEC) (> 90%)Highly Emetogenic Chemotherapy (HEC) (> 90%)

– CisplatinCisplatin

– MechlorethamineMechlorethamine

• Moderately Emetogenic Chemotherapy (MEC) (30-90%)Moderately Emetogenic Chemotherapy (MEC) (30-90%)– CyclophosphamideCyclophosphamide

– DoxorubicinDoxorubicin

• Low Emetogenic Chemotherapy (10-30%)Low Emetogenic Chemotherapy (10-30%)– PaclitaxelPaclitaxel

– 5-Fluorouracil5-Fluorouracil

• Minimally Emetogenic Chemotherapy (< 10%)Minimally Emetogenic Chemotherapy (< 10%)– VincristineVincristine

– BleomycinBleomycin

Highly emetogenic Highly emetogenic (>90%)(>90%)

DRUGSDRUGS– ACAC

– CisplatinCisplatin

– Higher dose Higher dose CyclophosphamideCyclophosphamide

TREATMENTTREATMENT

3 drugs3 drugs• Dolasetron (Dolasetron (Anzemet; Anzemet;

oraloral), granisetron ), granisetron (Kytril),(Kytril), ondansetron ondansetron (Zofran),(Zofran), or or palonosetron (palonosetron (Aloxi)Aloxi)

• Dexamethasone for one Dexamethasone for one to three daysto three days

• Aprepitant (Aprepitant (EmendEmend) for ) for three daysthree days

Moderately emetogenic: Moderately emetogenic: 30-90%30-90%

DRUGSDRUGS– CarboplatinCarboplatin

– CyclophosphamideCyclophosphamide

– DoxoubicinDoxoubicin

– epirubicinepirubicin

TREATMENTTREATMENTtwo-drug combinationtwo-drug combination

– Dolasetron (Dolasetron (Anzemet; Anzemet; oral formoral form), granisetron ), granisetron ((KytrilKytril), ondansetron ), ondansetron ((ZofranZofran), or ), or palonosetron (palonosetron (AloxiAloxi))

– Dexamethasone, for one Dexamethasone, for one to three daysto three days

Low risk emetogenic-10-Low risk emetogenic-10-30%30%

DRUGSDRUGS– DocetaxelDocetaxel

– PaclitaxelPaclitaxel

– MethotrexateMethotrexate

– 5-fluoriuracil5-fluoriuracil

– GemcitabineGemcitabine

– MethotrexateMethotrexate

– TopotecanTopotecan

– trastuzumabtrastuzumab

TREATMENTTREATMENTONE drugONE drug

– dexamethazonedexamethazone

Minimally emetogenic Minimally emetogenic (less than 10%)(less than 10%)

DrugsDrugs

VinorelbineVinorelbine

TreatmentTreatment– No treatment No treatment

required unless the required unless the patient has patient has previously previously experienced experienced vomiting with this vomiting with this treatment.treatment.

With appropriate medications, With appropriate medications, nausea and vomiting can be nausea and vomiting can be

prevented in nearly all patients prevented in nearly all patients undergoing cancer treatment.undergoing cancer treatment.

NEUTROPENIANEUTROPENIA

• Fever (temperature of 38 Fever (temperature of 38 C or higher)C or higher)

• Chills or sweatingChills or sweating

• A sore throat or sores in A sore throat or sores in the mouththe mouth

• Any redness, swelling, or Any redness, swelling, or pain, especially around a pain, especially around a cut, wound, or an cut, wound, or an intravenous (IV) catheter intravenous (IV) catheter sitesite

• Abdominal painAbdominal pain

• Diarrhea or sores around Diarrhea or sores around the anusthe anus

• Pain or burning when Pain or burning when urinating or frequent urinating or frequent urinationurination

• A cough or breathlessnessA cough or breathlessness

• Unusual vaginal discharge Unusual vaginal discharge or itchingor itching

PREVENT INFECTIONPREVENT INFECTION

• Delay the next round of chemotherapy or Delay the next round of chemotherapy or recommend a lower dose. recommend a lower dose.

• Prophylactic antibioticsProphylactic antibiotics

• Neutropenic feverNeutropenic fever

– Consider white blood growth factors during Consider white blood growth factors during subsequent cycles of chemotherapy. subsequent cycles of chemotherapy.

– filgrastim (Neupogen), pegfilgrastim filgrastim (Neupogen), pegfilgrastim (Neulasta), or sargramostim (Leukine or (Neulasta), or sargramostim (Leukine or Prokine). Prokine).

Advice for PatientsAdvice for Patients

• RESTREST

• AVOID CROWDSAVOID CROWDS

• AVOID People AVOID People who are illwho are ill

• Do not share Do not share personal items-personal items-utensils, utensils, toothbrushestoothbrushes

• No Raw food; No Raw food; wash foods wellwash foods well

• Good dental careGood dental care

• Keep clean, use Keep clean, use skin lotion (avoid skin lotion (avoid dry, cracked skin)dry, cracked skin)

• Use care with Use care with sharp objectssharp objects

• WASH your WASH your handshands

• Use gloves to Use gloves to garden and cleangarden and clean

• Do not handle Do not handle animal wasteanimal waste

CANCER-RELATED FATIGUECANCER-RELATED FATIGUE

• Persistent sense of tiredness or Persistent sense of tiredness or exhaustion exhaustion

• Small effort, such as walking across Small effort, such as walking across a room, can seem like too mucha room, can seem like too much

• Affects ability to work, be involved Affects ability to work, be involved with their family, or socialize. with their family, or socialize.

• May cause people to avoid or skip May cause people to avoid or skip cancer treatments cancer treatments

• May even affect their desire toMay even affect their desire to live.live.

Fatigue managementFatigue management

• Exercise regularlyExercise regularly

• Conserve energyConserve energy

• Manage other conditionsManage other conditions

–PainPain

–DepressionDepression

–Sleep disordersSleep disorders