Terapi Suportif dan Paliatif pada Pasien Kanker Terapi Paliatif Terapi Suportif dan Paliatif pada Pasien Kanker Djumhana Atmakusuma Divisi Hematologi – Oncologi Medik Departemen Ilmu Penyakit Dalam Universitas Indonesia

Tujuan Manajemen Kanker Bentuk Pengobatan Kanker

Tujuan Manajemen Kanker Prevensi kanker : = prevensi primer = prevensi sekunder Deteksi awal kanker (prevensi tersier) Pengobatan kanker : - Kuratif/penyembuhan - Paliatif (terapi keluhan akibat komplikasi kanker) - “End of life” or “hospice” care (prediksi bertahan hidup < 6 bulan)

Bentuk Pengobatan Kanker Modalitas Utama Terapi Suportif - Pembedahan - Radiasi - Kemoterapi  Terapi sistemik kanker dgn obat anti kanker Untuk mendukung keberhasilan modalitas utama pengobatan: - yg bertujuan kuratif - yg bertujuan paliatif - yg bertujuan “end of life” / “hospice” care

Terapi Suportif pd Manajemen Kanker Kemoterapi paliatif, Radiasi paliatif Pembedahan paliatif Modalitas Utama: Pembedahan Radiasi Terapi Sistemik Tujuan pengobatan kanker tercapai: kuratif: sembuh / disease free survival > paliatif: keluhan komplikasi kanker (-)/ <<<< “end of life” or hospice management (prediksi bertahan hidup < 6 months) Terapi SUPORTIF PALLIATIVE CARE !!! PALLIATIVE CARE !!!

Nyeri dan simptom lain yang mengganggu Antisipasi, prevensi & mengurangi penderitaan, dan mensuport quality of life (QOL) pasien dan keluarga , tanpa memandang stadium kanker dan kebutuhan pengobatan lainnya untuk kanker

SUPPORTIVE TREATMENT Infections: Prevention and treatment (bacterial, fungal, viral infections) Febrile neutropenia Fatigue due to Anemia Bleeding and coagulation problems Nausea and vomiting Mucositis Diarrhea Anorexia and Cachexia Pain Bone metastasis Neurological complications Dermatological complications

SUPPORTIVE TREATMENT Obstructive syndromes (Gastrointestinal tract, urinary tract, respiratory obstruction, neurological obstruction, etc) Psychiatric / Psychological Problems Sexual Health and Functioning after Cancer Malignant effusion Oncology emergencies

Kemoterapi Sitotostatika Onkologi Bedah Pengobatan Kanker Modalitas Utama Terapi Suportif Pembedahan Kemoterapi Sitotostatika Radiasi Terapi Target Terapi Sistemik Terapi Hormon Onkologi Radiasi Terapi Biologik Onkologi Medik Onkologi Medik Lain lain

WHO common toxicity criteria of cytotoxic chemotherapy Grade 1 (slight toxicyties) to grade 4 (life threatening) Relatively common: acute or delayed toxicities Common acute toxicities: - myelosuppression (leukopenia, thrombocytopenia, anemia) - gastrointestinal effects (nausea, vomiting, etc) - mucous membrane ulceration - alopecia Leukopenia  Febrile neutropenia  Sepsis  septic shock Nausea vomiting  dehydration  Renal failure

Localized Breast Cancer ENT &Main modality of treatment HN O Surgery Radiation + Radiosensitizer Adjuvant Chemotherapy ENT &Main modality of treatment HN O = Cisplatin = Docetaxel + e.g. FAC regimeny Terapi Suportif Terapi Suportif Terapi Suportif

Terapi Suportif pada Kanker

Leukopenia >>> Trombopenia Anemia Myelosupresi Leukopenia >>> Trombopenia Anemia

Recommendation for grading of toxicity (WHO Criteria) Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 (life thre atening) Hb (g %) ≥ 11.0 >9.5 - 10.9 8.0 - 9.4 6.5 - 7.9 < 6.5 Leukocyte ≥ 4 3.0 – 3.9 2.0 – 2.9 1.0 – 1.9 < 1.0 (x1000/mm3) Granulocyte ≥ 2 1.5 – 1.9 1.0 – 1.4 0.5 – 0.9 < 0.5 Platelet ≥ 100 75 – 99 50 – 74 25 – 49 < 25

Leukopenia  Infeksi Bakteri  Sepsis  Septic shock  bisa FATAL Bakteri aerob Bakteri anaerob Jamur Virus

Muntah muntah hebat  dehidarsi  gagal ginjal akut  bisa fatal Mual dan Muntah: ESO anti kanker yang sering ditemukan, di samping leukopenia Muntah muntah hebat  dehidarsi  gagal ginjal akut  bisa fatal

WHO TOXICITY GRADING Grade 0 1 2 3 4 (life threatening) Nausea mlld moderate severe Vomiting mild moderate severe very severe 1 x 2 – 5 x 10 x > 10 x

Malnutrisi Nutrisi <<<  Kaheksia  Protein <<  Infeksi >>>

Nyeri 1111

Pain killer ? Cancer Pain !!! Specific procedure to relief cancer pain ?? Surgery ? Radiation ? Cytotoxic chemotherapy ? Targeted threapy ? Pain killer ? OR

WORLD HEALTH ORGANISATION NOCICEPTIVE STEP CARE APPROACH If pain is not relieved well, next ladder should be used Pain is treated right away Oxycodone Morphine Fentanyl Acetaminophen NSAIDs / COX2 Tramadol Step 2 Codeine Tramadol Acetaminophen NSAIDs / COX2 Tramadol Step 1 Acetaminophen NSAIDs / COX2 Light pain Moderate pain Severe pain ± CO-ANALGESICS 21 21 21