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The advanced cancer patient. Stephan Tanneberger Euro-Arab School of Oncology (EASO). Cairo 11/2011. Cancer mortality by age groups Bologna a nd Provinz. Percentage of Patients knowing their diagnosis of cancer Italy 1985 - 2001.

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The advanced cancer patient

Stephan TannebergerEuro-Arab School of Oncology (EASO)

Cairo 11/2011

Centro Elaborazione Dati


Cancer mortality by age groups bologna a nd provinz
Cancer mortality by age groupsBologna and Provinz

Centro Elaborazione Dati


Percentage of patients knowing their diagnosis of cancer italy 1985 2001
Percentage of Patients knowing their diagnosis of cancerItaly 1985 - 2001

Centro Elaborazione Dati


What patients want to have if the end of life is coming closer?

1. Control of symptoms 100%

2. To be close to family/friends 80%

3. To be at home 70%

4. Dignity 50%

5. No diagnostical/therapeutical procedures

without improving quality of life 40%

6. More decent communication 40%

7. Euthanasia 07%

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Incidence of non-controlled symptoms in two groups of advanced cancer patients living in Italy or India.

ANT Bologna CANSUPPORT New Delhi

(250 patients) (334 patients)

Pain 36% 88%

Anorexia 37% 61%

Dyspnoe27% 34%

Fatigue 22% 82%

Nausea/vomiting 12% 47%

Centro Elaborazione Dati

Centro Elaborazione Dati


Cancer pain pan european level of patients view on prevalence and relief breivick et al 2009
Cancer Pain: pan-european level of patients view on prevalence and relief (Breivick et al 2009)

Centro Elaborazione Dati

Stephan Tanneberger ottobre 2009


Relief of cancer pain in the world
Relief of cancer pain in the world prevalence and relief (Breivick et al 2009)

  • An analysis of 12 surveys covering nearly 2600 patients

  • in developed countries suggests that more than 50%

  • of patients suffer unrelieved pain.The reasons are,

  • obstacles in the implementation of palliative care

  • lack of recognition by health workers of the fact that

  • established methods exist for the relief of almost all pain

  • legal and other constraints on the medical use of

  • analgetic drugs notable morphin.

  • The available data show that the percentage of unrelieved

  • cancer pain in developing countriesis still much higher.

Centro Elaborazione Dati


The haemoglobin level of prevalence and relief (Breivick et al 2009)

advanced cancer patients

Nr. Pats. Characteristics CT/ Haemoglobin Author post-CT <WHO <8 g/dl

105 advanced cancer ? 68% - Dunn

147 advanced cancer ? 56% 15% Munch

41 389 advanced cancer mixed 50% 15% ANT

310 advanced cancer no CT 10% ANT

15 000 all types mixed 39% - ECAS

694 all types mixed 35% - Seshadri

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Anaemia : Confusion with Definitions prevalence and relief (Breivick et al 2009)

for the Pharmaceutical industry

12 -12.5 g/dl haemoglobin

for Health Authorities

ca. 10.5 g/dl haemoglobin

for transfusion experts/oncologists

ca. 8g/dl haemoglobin

M.Mitterer 2008

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Where patients are dying in the industrialized world
Where patients are dying in the industrialized world prevalence and relief (Breivick et al 2009)

Countries with home care

Countries without home care

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Dignity of life prevalence and relief (Breivick et al 2009)

means social security and peace of mind.

A free and personal decision of the patient

about the circumstances of his terminal life

is of fundamental importance

We call this

EUBIOSIA,

good life until the end

the opposite to euthanasia

Pannuti F, Tanneberger S 1993

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+ prevalence and relief (Breivick et al 2009)

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- prevalence and relief (Breivick et al 2009)

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What about dignity of life for majority prevalence and relief (Breivick et al 2009)

of dying cancer patients in Egypt, Iran,

Sudan 2010 ( Expert analysis)

  • Dignity of life is not guaranteed

  • The reasons are:

  • - financial problems

  • - structural problems

  • - educational problems

  • - medical problem

  • - nursing problems

  • A major problem is lack of awarness,

  • knowledge and culture regarding

  • palliative care

Centro Elaborazione Dati


Sometimes emotions open the door to prevalence and relief (Breivick et al 2009)

diagnostical and therapeutical procedures

without improving quality of life

What emotions have cancer patients?

initial advanced

to fight 52.3% 53.1%

anxiety 21.3% 17.9%

fatalism 20.8% 19.9%

weakness 04.4% 07.6%

ignorance 01.2% 01.5%

Centro Elaborazione Dati


Last minute cancer chemotherapy prevalence and relief (Breivick et al 2009)

2003 -2005 (793 evaluated patients)

Tumor Mean distance Number patients (days) last CT receiving CT within

and death (range) last 3 months of life

------------------------------------------------------------------------

Lung & Pleura46.0 (1-530)41 (40.6%)

Colon-Rectum75.5 (8-1305)17 (16.8%)

Breast80.5 (24-1227) 04 (04.0 %)

other 78.0 (1-1913)39 (39.0 %)

all71.0 (1-1913)101 (22.7%)

Martoni A, Tanneberger S, Mutri V Tumori 2007

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Complementary and alternative medicine (CAM) in the world: utilization and cost

Country % user Market Cost for patients

CAM billion/year billion/year

-------------------------------------------------------------------------------

USA 34 % 13.7 10.3

Australia 49 % 0.9 0.4

Benelux 60 % + 15%

UK 74 % + 15%

China 2.4

Japan + 15%

Germany 38% 3.3 ( -> 20)

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CAM in adult cancer patients in utilization and cost

Turkey and Pakistan

Country Nr. patients CAM user User characteristicsAuthor

Turky 615 47.3% femal, high income, Tas et al.

advanced stage, 2005

usage of multiple

chemotherapy

Pakistan 191 54.5% 36% before any Malik et al.

conventional therapy 2000

Centro Elaborazione Dati


Cancer patients at all stages are suffering utilization and cost

physically and phsychologically.

Therefore palliative care means

both, physical and psychological care

The basic element of psychological care is communication

Centro Elaborazione Dati


Communication how
Communication : How? utilization and cost

Patients want to speak but speaking is not all

  • Direct communication

  • voice

  • hands

  • eyes

  • cloths

  • environment

  • Indirect communication

  • Mass media/Internet

  • Health Insurance

  • Family/friends

Centro Elaborazione Dati


How physicians communicate the utilization and cost

transition to palliative care (questionaire-

based survey of bereaved family members of

adult patients in Japan

Patients families report they were

very distressed 39%

distressed 31%

slightly distressed 20%

not so distressed 6.6%

not distressed 3.8%

Communication methodes were rated as requiring

much improvement 6.3%

considerable improvement 13%

some improvement 39%

no improvement 42%

Morita et al. 2004

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Communication and religion utilization and cost

This study (50 pts) suggests that spiritual wellbeing is an

important component of the quality of life (Qol) of advanced

cancer patients Kandasamy et al. Bangalore 2011

185 community-dwelling individuals with advanced illness

reported that “having grown closer to church was associated with better Qol Solomon et al. New York 2010

Support of 343 terminal ill patient‘s spiritual needs by the medical teams was associated with better patient QoL near death Balboni et al. Boston 2010

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Euthanasia utilization and cost

Loss of dignity (50-60%) and pain 40-50%)

are the main arguments for requests for euthansia.

Both is avoidable. We consider euthanasia to be

the expression of social and medical inability to realize a basic human right – a death in peace

and dignity as the harmonious end of biological life

Pannuti F, Tanneberger S, 1993

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The advanced cancer patient: utilization and cost

The dream of ANT

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Reserve
Reserve utilization and cost

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Valutazione economica dell’assistenza sanitaria: analisi di costo-efficacia (CEA) e di costo-utilità (CUA)

Criterio pragmatico: sono considerate costo-efficaci le strategie che portano al prolungamento di un anno di vita al costo di meno del doppio del prodotto interno lordo (GDP) pro capite (Marino 2008)

Oxaliplatino+cetuximabper il tumore del colon in fase avanzata:

12 000-31.000 $. Prolungamento della sopravvivenza di un anno??

Centro Elaborazione Dati


First line chemotherapy in metastatic nsclc
First-line chemotherapy in di costo-efficacia (CEA) e di costo-utilità (CUA)metastatic NSCLC

Nr. pts Regime OR (%) PFS(m) OS(m) Author/Year

179 DDP + Etoposid 15 9.1 Belani 2005

190 CarboP+Paclitax 23 7.8 Belani 2005

422 Mitox/Iphos/DDP 42 1-year Survival 40%

vs GEM/CarboP 41 1-year Survival 30%

334 GEM vs. 11 8.6 Sederholm 2005

CarboP + GEM 30 10.0

OxaliP+GEM 25 - 11.3 Bidoli 2007

140 DDP+IFO+GEM 9.7 Sculier 2007

141 GIP + Paclitaxel 11.9 Sculier 2007

145 DDP+Irinotecan 31 4.8 13.9 Ohe 2007

145 CarboP + Paclita 32 4.0 12.3Ohe 2007

146 DDP + GEM 30 3.5 14.0 Ohe 2007

145 DDP + Vinorelbine 33 3.4 11.4 Ohe 2007

297 DDP + Vinorelbine 4.0 7.5 Plessen 2007

Centro Elaborazione Dati


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