MANAGEMENT OF CANCER PATIENT

Other doctors (consultant)

Patient

Doctor

Cytopathologist

Radiologist Laboratory

diagnosis and treatment patient depend on one clinician only

MANAGEMENT OF CANCER PATIENT

Patient

Medical Team (teamwork) Standard Facility Standard Protocol Medical Record

Better Communication Unity of work rhythm Minimal mistake Maximal patient service

Oncology aspect Patients & family aspect

Outcome & Side Effect Monitoring

Oncology Aspect

Diagnose:- pathology :* morphologic class : adenoCa ? * histologic grade * pattern of invasion - tumor biology ? : Her2Neu, CD20, p53, Bcl2 proliferation indeces Diagnose: Staging Medical Status: Risk group - Anamnesa (co-morbid) - Physic, Laboratory, ECG - Performance status (Karnosfky-ECOG)

Patients & family Aspect

Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemotherapy - informed consent

Outcome & Side Effect Monitoring

Outcome

Side Effect

Survival Objective & Subjective Outcome

Diagnose & management

 Mechanism chemotherapy in cellular level Reduction of tumor after Chemotherapy Rational , patient financial ?

( influence on the response to chemotherapy )

1.Tumor cell proliferation

Doubling Time

Check point controle mechanism Cell Cycle mechanism

Target of Actions of drugs ( Phase specificity ? / Non phase ?) Mechanisme of Actions

2.Tumor cell Apoptosis

Mitochondrial pathway (Bcl2 family,p53) Death receptor pathway (Fas-FasL, caspase family of protein)

5 FU
Phleomycin

Bleomycin Cyclophosphamide
Actinomycin

Vinblastine Vincristine Colchicine Griseofulvin

0,5-1h
Differentiation Hydrocortisone Chalones

0.5-1h G2 M
2-10h

Purin antagonis

Hydroxy urea

Actinomycin D
Cyclophosphamide

G1

6-20h 18-30h

Mytomycin
6-Marcaptopurine 6-Thioguanine

Doxorubicin

5 Fudr .5FU, Ara C. Mitomycin,Doxorubicin Thioguanine

5 Fudr ara C 6-Hydroxyurea

Alkylating agent Antimetabolic Mitotic inhibitor, Antibiotic

5 FU METHOTREXATE

Number of Tumor cell

No response
1012 (1kg)

Early recurrence

Late recurrence

109 (1 g)

Tumor detectable (clinically)

106 (1 mg) Tumor invisible (Remission) 103

Long-term Remission Not palpable

(1 g)

Immune resistance of host (humoral&cellular)

Induction

Consolidation

Maintenance

Cure

Tepat indikasi : kemoterapi tepat dipilih berdasar titik tangkap kerjanya berdasar patogenesis kanker sehingga dapat tercapai tujuan : 1.kuratif 2.mencapai bebas penyakit (DFI) yang lebih lama 3.neoadjuvant (mengecilkan volume tumor preoperasidown staging) 4.mempertahankan atau meningkatkan quality of life (terapi paliatif)

Tepat jenis obat : sebaiknya lebih spesifik, selektif, mempunyai Response rate tinggi, established, dan dapat dijangkau oleh penderita Tepat dosis obat : sesuai Maximum Tolerated Dose ( Risk group )

Tepat cara pemberian obat : oral, IV, bolus, infusion dsb yang penting : penderita nyaman , tidak takut dan dengan kesadaran sendiri ingin melanjutkan kemoterapi
Tepat monitoring efek obat : - penilaian hasil / respons terapi - kemampuan hidup (quality of life) dan - efek samping obat

CANCER OUTCOME of TREATMENT

1.Objective Response Evaluation 2.Subjective Response Evaluation (3). Survival

OBJECTIVE RESPONSE EVALUATIONS

1. TUMOR SIZE : - Complete remission (CR) - Partial remission (PR) - No Changes (Stable Disease = St D) - Progressive Disease (PD) 2. Marker Tumour : - CEA, CA15-3, MCA Breast Ca - CEA, CA19-9 Pancreas Ca, Colorectal Ca - HCG Chorio Ca - PSA Prostat Ca 3. Objective-Qualitative : - Change of Clinical sign : Brain Ca-neurology sign

SUBJECTIVE RESPONSE EVALUATION

Performance status : Karnofsky / ECOG
Palliative
CURATIVE : caution of safety of side effects

SIDE EFFECT MONITORING

DIAGNOSE of Side Effect
PHARMACOLOGY When Side effect become: NADIR point (degree of SE) Onset of SE, Specificity of organ target

MANAGEMENT of Side Effect

Anticipation & Prevention Dose related side effect monitoring Early treatment of side effect

PROFILE EPISODE of FEBRIL NEUTROPENI

11

nadir

16

21

26

Chemotherapy day

Chemotherapy day

FEBRILE NEUTROPENIA
CRITERIA :
NEUTROPENIA : absolute count of neutrophill in circulating blood < 2000 cells/mm3 FEVER : body temperature > 38.50C in 3 x measurement per 24 hours

DEGREE OF NEUTROPENIA

Mild : 2000 1000 cells/mm3 Moderate : 1000 500 cells/mm3 Severe : < 500 cells/mm3

TREATMENT of FEBRIL NEUTROPENI

Empiric antibacterial

nadir
Empiric antibacterial G-CSF Sterile room

Chemotherapy day

Chemotherapy day

1. Onset of SE : - Immediately ( < 1 Hour post Chemotx) Anaphylaxsis - early (1- 48 hours ) Nausea-Vomiting profuse - delayed (2 days -2 months ) leucopenia - Late (after 2 months ) myopathy, neuropathy 2.Organ Target : CNS, Cardiovascular, Respiratory, Gastroentestinal System

3.Level/degree of SE (IUCC,WHO, ECOG) : - grade 0-2 : tolerable ( safety enough ) - grade 3 (severe) : must be alert (Yellow light), need treatment - grade 4 (life threatening) : Hazard, early and adequate treatment

RESUME :

Better Communication Unity of work rhythm Minimal mistake Maximal patient service

RESUME :

Oncology aspect Diagnose:- pathology - biology cell type ? Diagnose: Staging

Patients & family aspect

Medical Status: Risk group

Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemtherapy - informed consent

Outcome & Side Effect Monitoring Survival Objective & Subjective Outcome Side Effect : Diagnose & management