End of Life Care Dr Anant Sachdev GPSI Palliative Medicine

Learning objectives Urological Cancer symptoms in End of Life Identify those at risk from the following 2 serious clinical scenarios Understand treatment options Refer appropriately General principles

Symptoms Pain Malaise, Fatigue & Cachexia GI: Poor appetite, nausea Weight loss Bleeding Incontinence Delirium Spinal Cord Compression Hypercalcaemia

Malignant spinal cord compression First contact is usually primary health care team! Common Significant impact on QOL and survival Requires rapid decision making

Incidence Incidence  5% of all cancers in final 2 years  Presenting feature  ACUP, NHL, myeloma and lung  Decreases with age, but 90% are >50yrs  Depends on primary site  60% are lung, prostate or breast  NHL, Multiple myeloma and renal (5- 10%)  Colorectal, ACUP and sarcomas

Pathophysiology Vertebral body mass – anterior compression Vertebral body collapse Direct tumour growth through vertebral neural foramen (lymphoma) Metastases in epidural space (rare)

Clinical features Localisation 60-80% thoracic spine 15-30% lumbosacral <10% cervical 50% have more than 1 level

Clinical features Pain – early sign  Up to 95% for 8/52  localised then radicular  Worse when  recumbent  valsalva manoevre  Neck flexion/SLR Motor deficits – late sign  60-85% weakness at diagnosis  2/3 non ambulatory at diagnosis  Thoracic>lumbosacral

Clinical features Sensory deficits – late sign  40-90% at diagnosis  Sensory level 1-5 segments below lesion  Lhermitte’s sign Autonomic deficits – late sign  Urinary retention most common.  50% catheter dependent at diagnosis.  Unlikely to be an isolated sign.

Investigation Plain Xray  False negative 17% Bone scan  Back pain + negative bone scan & plain xray unlikely to have SCC CT Myelography MRI  Sensitivity 93%, specificity 97%  Diagnostic accuracy 95%  Multi level common therefore image entire spine

Spinal Cord Compression Treatment Corticosteroids  8mg BD (morning and lunchtime) and PPI cover  Random daily BMs Bed rest and pressure area care Bowel care RT (early as poss)  1# for pain mgt if no poss of recovery;  5# for treatment Surgery Early rehab

Treatment Corticosteroids  Reduce oedema  Inhibit inflammatory response  Stabilise vascular membranes  Delay onset of neurological dysfunction  Better ambulatory outcomes  ? Dose (16-100mg)  Only if neurological dysfunction

Recurrent Spinal Cord Compression 10% pt will develop local recurrence 25-50% pts surviving > 1 yr will experience local relapse. Mgt – surgery (may be inappropriate); Re- irradiation; supportive and palliative care

Spinal Cord Compression Prognosis Median survival is 3-6 months If ambulatory pre compression 8-10 months Non-ambulatory pre compression 2-4 months Primary tumour myeloma / lymphoma – 6-9 months Primary tumour lung – 2-3 months Almost all patients have recurrence within 3 years

Referral guidelines Immediate investigation (same day) ◦ New onset weakness +/- sensory symptoms +/- autonomic symptoms ◦ Prescribe steroid + PPI Urgent investigation ◦ Persistent severe back pain/nerve root pain without neurological symptoms if:  High risk group  Thoracic pain  Recumbent pain  Exacerbated by valsalva manoevre/Lhermitte’s sign No investigation ◦ Too frail for treatment ◦ Very short life expectancy (weeks) ◦ Already irradiated to tolerance or unfit for neurosurgery ◦ So disabled, cord compression will not effect overall mobility

Key points Common Poor outcome unless early diagnosis Pain is the key Subtle motor changes Neurological deficit is too late Be aware of:  High risk groups  Clinical features

Hypercalcaemia in Advanced Cancer The Commonest life-threatening metabolic emergency associated with advanced cancer A condition which is usually amenable to treatment If untreated distressing and fatal Always consider when there is deterioration for no clear cause

Definition?

Hypercalcaemia Defined as corrected plasma calcium >2.6mmol/l Significant symptoms usually develop above >3.0 Levels > 4.0 are fatal if untreated in a few days

Hypercalcaemia Incidence ◦ 10 – 20% of all cancer patients ◦ Up to 20% of patients develop hypercalcaemia without bone metastases ◦ Common cancers: bronchial, breast, myeloma, prostate ◦ Rare in gastric/colorectal cancer

Hypercalcaemia Cause / risk factors: ◦ Bone metastases ◦ PTHrP – secreting tumours e.g. Lung Cancer ◦ Dehydration, renal impairment ◦ Tamoxifen flare

Hypercalcaemia Pathogenesis: ◦ Increased bone resorption (osteolysis) and systemic release of humoral hypercalcaemic factors ◦ Calcium is released from bone, and in addition there is may be a decrease in excretion of urinary calcium Calcium release from bone by production of locally active substances produced by bone metastases: ◦ Parathyroid hormone related peptide, ◦ Ectopic parathyroid secretion ◦ Tumour mediated calcitriol production ◦ (Some may occur with or without bone mets.)

Anorexia Weight loss Nausea and vomiting Constipation / ileus General Dehydration Polydipsia Polyuria Pruritis Recognising Hypercalcaemia Neurological Fatigue Confusion Myopathy Seizures Psychosis Coma Cardiac Bradycardia Atrial arrhythmias Ventricular arrhythmias Cardiac asystole Death GI

Prognosis Indicates disseminated Disease Poor prognosis 80% die within 1 year Median survival is 3 to 4 months Hypercalcaemia likely to recur

Hypercalcaemia Treatment may not be necessary if: the patient is very near to death or there are no symptoms distressing the patient

Treatments of Hypercalcaemia All treatments involve the correction of serum calcium levels, which results in a marked decrease in symptoms  Rehydration  Bisphosphonates  Steroids

Treatments of Hypercalcaemia Rehydration:  Dehydration due to vomiting and polyuria, large volume will lower calcium levels, note fluid-overload!  2-3 L/day usually  Avoid concomitant use of diuretics, Vitamin A and D which promote hypercalcaemia

Treatments of Hypercalcaemia Steroids: ◦ Have been shown to inhibit osteoclast activity and calcium absorption from the gut in vitro ◦ Limited to haematological and Breast malignancies when oral prednisolone mg/day is usually effective

Treatments of Hypercalcaemia Bisphosphonates ◦ Reduce bone resorption by inhibiting osteoclast activity ◦ Highly effective ◦ But take 48 hours to be effective ◦ Mainstay of hypercalcaemia treatment ◦ Further benefit is that of reduction of bone pain due to metastases

Treatment Dehydration should be corrected with iv fluids Most common choices of drug IV: ◦ Zolendronic Acid: 4mg over 15 minutes ◦ Disodium Pamidronate: mg over 2-4 hours Effect seen after days Lasts 2-4 weeks, many patients have monthly infusions 20% patients with hypercalcaemia will be resistant to infusion therapy

General EOL principles to follow: Review patient regularly - holistically Get District nurses involved early, others eg Macmillan Inform Out of Hours, and practice team - & update! Ascertain PPOC Review symptoms and drugs Communicate well with patient, family and carers ◦ Explain management of crises, ◦ whom to contact, ◦ use of 999, ◦ possible pathway for illness and symptoms expected when deteriorates, ◦ ethical issues : nutrition, hydration, use of ab, oxygen, ◦ supportive measures available, financial help ◦ (DS1500) Consider Just-in-Case medication Consider DNACPR statement All of the above - Adopt the Liverpool Care Pathway for holistic management of the dying patient

Thank you Dr Anant Sachdev any Q any Q