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CONTROLLING DISTRESSING SYMPTOMS IN THE CANCER PATIENT – OLD STANDARDS AND NEW APROACHES

CONTROLLING DISTRESSING SYMPTOMS IN THE CANCER PATIENT – OLD STANDARDS AND NEW APROACHES. Thomas J. Keating, MD, MS MaineGeneral Medical Center Augusta, Maine. OBJECTIVES. Identify the underlying pathophysiologic factors contributing to pain and GI distress in the cancer patient.

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CONTROLLING DISTRESSING SYMPTOMS IN THE CANCER PATIENT – OLD STANDARDS AND NEW APROACHES

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  1. CONTROLLING DISTRESSING SYMPTOMS IN THE CANCER PATIENT – OLD STANDARDS AND NEW APROACHES Thomas J. Keating, MD, MS MaineGeneral Medical Center Augusta, Maine

  2. OBJECTIVES • Identify the underlying pathophysiologic factors contributing to pain and GI distress in the cancer patient. • Understand the rationale and the therapeutic mechanisms of selected new medications and interventions. • Integrate optimal symptom management in the comprehensive care of the patient with progressive cancer.

  3. CANCER-RELATED SYMPTOMS • Pain • Respiratory • Gastrointestinal • Constitutional • Psychiatric

  4. CANCER-RELATED SYMPTOMS • Pain • Respiratory • Gastrointestinal • Constitutional • Psychiatric

  5. PAIN IN THE CANCER PATIENT • Common • Somatic vs Visceral vs Neuropathic Pain • BONE METASTASES

  6. BONE METASTASES

  7. BONE METASTASES • Frequently seen in : Breast, Prostate, Lung, Renal, Melanoma and Multiple Myeloma • Blastic vs Lytic Mets • Pathophysiology of pain

  8. LYTIC BONE MET

  9. LYTIC BONE METS

  10. BLASTIC BONE METS

  11. ANALGESIC REGIMEN FOR BONE PAIN • Acetaminophen, NSAIDS • “Weak” opioids • “Strong” opioids • Corticosteroids

  12. External beam radiation therapy Intramedullary rod placement INTERVENTIONS FOR BONE PAIN DUE TO METS

  13. “NEWER” INTERVENTIONS FOR PAIN DUE TO BONE METS • Radiopharmaceuticals * Strontium-89 (Metastron) * Samarium-153 (Quadramet) • Kyphoplasty / Vertebroplasty

  14. GI ADVERSE EFFECTS OF CANCER AND ITS THERAPIES • Nausea / Vomiting • Constipation

  15. PATHOPHYSIOLOGY OF NAUSEA Chemical mediators of the nausea /vomiting pathway : • Dopamine • Histamine • Acetylchline • Serotonin

  16. THERAPEUTIC OPTIONS IN N/V • Dopamine anatagonists • Anti-histamines • Anti-cholinergics • Serotonin antagonists

  17. OTHER OPTIONS IN N/V • Prokinetic agents • Corticosteroids • Dronabinol • Anxiolytics

  18. CONSTIPATION Causes • Opioids !!! • Abdominal Carcinomatosis

  19. TREATMENT OF CONSTIPATION • Stimulants • Osmotics • Lubricants • Detergents • Large volume enemas

  20. NEW OPTION FOR OPIOID-INDUCED CONSTIPATION Methylnaltrexone Bromide (Relistor)

  21. Methylnaltrexate • Peripherally-acting mu receptor antagonist • Does not cross the blood-brain barrier • Indicated for “opioid-induced contipation in pts with advanced disease when response to laxative therapy has not been sufficient • Subcutaneous injection

  22. REFERENCES • Berger, A. et al. Principles and Practice of Palliative Care and Supportive Oncology, Lippincott Williams & Wilkins, Philadelphia. 2007. • Doyle D., et al. Oxford Textbook of Palliative Medicine. Oxford University Press, Oxford. 2003. • The EPEC Project – Education in Palliative and End-of-Life Care http://www.epec.net/EPEC/webpages/index.cfm

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