1. May 2-6 2011 FUND FORUM Breast Cancer Supportive Care

2. Symptoms and Prognosis Challenge of symptom management:Challenge of symptom management: – block toxicity without compromising efficacy

3. Supportive Care Toxicity Targets HematologicHematologic MyelosuppressionMyelosuppression GastrointestinalGastrointestinal Nausea/vomitingNausea/vomiting Constipation/diarrheaConstipation/diarrhea MucositisMucositis CardiovascularCardiovascular ThrombosisThrombosis CardiacCardiac NeurologicNeurologic Peripheral neuropathyPeripheral neuropathy CognitiveCognitive PulmonaryPulmonary RenalRenal CutaneousCutaneous AlopeciaAlopecia RashRash

4. Gastrointestinal: Nausea and Vomiting ChemotherapyChemotherapy Radiation therapy-especially brain, abdomen, pelvisRadiation therapy-especially brain, abdomen, pelvis Brain metsBrain mets Bowel obstructionBowel obstruction Electrolyte imbalanceElectrolyte imbalance Other medicationOther medication

5. Perception of Chemotherapy (1983) Nausea and vomiting are the two most feared toxicities of chemotherapy Coates, Eur J Cancer Clin Oncol 19:203, 1983

6. Nausea and Vomiting Physiologic processPhysiologic process –Body’s normal response to expel toxins Delayed NauseaDelayed Nausea –Occurs days after therapy with certain chemotherapy agents Anticipatory NauseaAnticipatory Nausea –occurs before treatment in patients who have previously vomited after chemotherapy

7. The best way to manage nausea and vomiting caused by cancer therapy is to prevent it.

8. Natural History of Delayed Nausea and Vomiting Kris, J Clin Oncol 3:1379, 1985 Hours after cisplatin Percent with nausea or vomiting

9. Expectation vs Reality Moderately Emetogenic Chemotherapy Grunberg, Cancer 100:2261, 2004 Percent of patients

10. Levels of Emetogenicity Modifying Factors AgeAge –Younger patients vomit more than older patients GenderGender –Women vomit more than men Alcohol historyAlcohol history –Patients with a history of heavy alcohol use vomit less than those without such a history Nausea/vomiting historyNausea/vomiting history –Patients with a history of morning sickness or motion sickness are more likely to vomit

11. Antiemetic Consensus Guidelines - 2008 Adapted from Koeller, Support Care Cancer 10:519, 2002 RiskAcuteDelayedHigh 3 drugs 2 drugs Moderate 3 drugs 1 drug Low Single Agent None MinimalNoneNone

12. Effect of Physician Education on Antiemetic Guideline Compliance ► Lecture by visiting expert No change in behavior ► Distribution of written guidelines Improved compliance x 2 months ► Direct feedback of patient experiences Improved compliance x 4+ months Mertens, J Clin Oncol 21:1373, 2003

13. Levels of Emetogenicity Highly Emetogenic Chemotherapy (HEC) (> 90%)Highly Emetogenic Chemotherapy (HEC) (> 90%) –Cisplatin –Mechlorethamine Moderately Emetogenic Chemotherapy (MEC) (30-90%)Moderately Emetogenic Chemotherapy (MEC) (30-90%) –Cyclophosphamide –Doxorubicin Low Emetogenic Chemotherapy (10-30%)Low Emetogenic Chemotherapy (10-30%) –Paclitaxel –5-Fluorouracil Minimally Emetogenic Chemotherapy (< 10%)Minimally Emetogenic Chemotherapy (< 10%) –Vincristine –Bleomycin

14. Highly emetogenic (>90%) DRUGS –AC –Cisplatin –Higher dose Cyclophosphamide TREATMENT 3 drugs Dolasetron (Anzemet; oral), granisetron (Kytril), ondansetron (Zofran), or palonosetron (Aloxi)Dolasetron (Anzemet; oral), granisetron (Kytril), ondansetron (Zofran), or palonosetron (Aloxi) Dexamethasone for one to three days Dexamethasone for one to three days Aprepitant (Emend) for three daysAprepitant (Emend) for three days

15. Moderately emetogenic: 30-90% DRUGS –Carboplatin –Cyclophosphamide –Doxoubicin –epirubicin TREATMENT two-drug combination –Dolasetron (Anzemet; oral form), granisetron (Kytril), ondansetron (Zofran), or palonosetron (Aloxi) –Dexamethasone, for one to three days

16. Low risk emetogenic-10- 30% DRUGS –Docetaxel –Paclitaxel –Methotrexate –5-fluoriuracil –Gemcitabine –Methotrexate –Topotecan –trastuzumab TREATMENT ONE drug –dexamethazone

17. Minimally emetogenic (less than 10%) DrugsVinorelbine Treatment –No treatment required unless the patient has previously experienced vomiting with this treatment.

18. With appropriate medications, nausea and vomiting can be prevented in nearly all patients undergoing cancer treatment.

19. NEUTROPENIA Fever (temperature of 38 C or higher)Fever (temperature of 38 C or higher) Chills or sweatingChills or sweating A sore throat or sores in the mouthA sore throat or sores in the mouth Any redness, swelling, or pain, especially around a cut, wound, or an intravenous (IV) catheter siteAny redness, swelling, or pain, especially around a cut, wound, or an intravenous (IV) catheter site Abdominal painAbdominal pain Diarrhea or sores around the anusDiarrhea or sores around the anus Pain or burning when urinating or frequent urinationPain or burning when urinating or frequent urination A cough or breathlessnessA cough or breathlessness Unusual vaginal discharge or itchingUnusual vaginal discharge or itching

20. PREVENT INFECTION Delay the next round of chemotherapy or recommend a lower dose.Delay the next round of chemotherapy or recommend a lower dose. Prophylactic antibioticsProphylactic antibiotics Neutropenic feverNeutropenic fever –Consider white blood growth factors during subsequent cycles of chemotherapy. –filgrastim (Neupogen), pegfilgrastim (Neulasta), or sargramostim (Leukine or Prokine).

21. Advice for Patients RESTREST AVOID CROWDSAVOID CROWDS AVOID People who are illAVOID People who are ill Do not share personal items- utensils, toothbrushesDo not share personal items- utensils, toothbrushes No Raw food; wash foods wellNo Raw food; wash foods well Good dental careGood dental care Keep clean, use skin lotion (avoid dry, cracked skin)Keep clean, use skin lotion (avoid dry, cracked skin) Use care with sharp objectsUse care with sharp objects WASH your handsWASH your hands Use gloves to garden and cleanUse gloves to garden and clean Do not handle animal wasteDo not handle animal waste

22. CANCER-RELATED FATIGUE Persistent sense of tiredness or exhaustionPersistent sense of tiredness or exhaustion Small effort, such as walking across a room, can seem like too muchSmall effort, such as walking across a room, can seem like too much Affects ability to work, be involved with their family, or socialize.Affects ability to work, be involved with their family, or socialize. May cause people to avoid or skip cancer treatmentsMay cause people to avoid or skip cancer treatments May even affect their desire to live.May even affect their desire to live.

23. Fatigue management Exercise regularlyExercise regularly Conserve energyConserve energy Manage other conditionsManage other conditions –Pain –Depression –Sleep disorders