1. Palliative Chemotherapy Jason R. Beckrow, DO Lighthouse Oncology

2. Objectives Objectives: – Understand the concept of treat with curative intent vs. palliative intent. – Discuss the therapeutic goals of palliative chemo – Discuss targeted and palliative drug for various malignancies.

3. Intentions of Treatment Palliative Curative

4. The Problem: Conventional Care Model Fight or Quit

5. What do we mean by Palliative Chemotherapy?

6. GeriPal: A geriatrics and Palliative Care Blog Is there anyone amongst the readership that can direct me to a list, a compendium of purely "palliative" chemotherapy regimens? You can't find a protocol because there is no such thing. Chemotherapy produces symptoms, usually more symptoms than it relieves….Annonymous

7. “I Already Do Palliative Care” anonymous oncologist

8. Patients Reported Oncology Teams Often Do Not: Consider psychosocial care as a part of their patients’ cancer care. Understand their psychosocial needs, know about resources, or refer when needed. President’s Cancer Panel 2003, 2004

9. Community Oncology Offices Cancer-Free Survival Managed Chronic or Intermittent Disease Treatment Failure Treatment with Intent to Cure Palliative Medicine Diagnosis and Staging Death Where majority of cancer care is given today Where fewest psychological and social services available IOM President’s Cancer Panel, 2003, 2004 Slide Courtesy of Jimmie Holland, MD Memorial Sloan Kettering Cancer Center

10. Conventional Care PresentationPresentationDeathDeath Anti-disease Therapy Bereavement Care 6m6m Hospice Care

11. Model of palliative cancer care. Ferris F D et al. JCO 2009;27:3052-3058 ©2009 by American Society of Clinical Oncology

12. The Relief of Suffering Physicians’ failure to understand the nature of suffering can result in medical intervention that (though technically adequate) not only fails to relieve suffering but becomes a source of suffering itself. Eric Cassel, 1982

13. The Goals of Palliative Chemotherapy Symptom Relief Attainment of Life Goals Portability Accessibility Cost efficiency Your thoughts….

14. Goals of Palliative Chemotherapy

15. Early Palliative Care Study Procedures Palliative Care Guidelines Illness understanding and education Inquire about illness and prognostic understanding Offer clarification regarding treatment goals Distress Management Symptom management Pain Pulmonary symptoms Fatigue and sleep disturbance Mood Gastrointestinal Decision-making Assess mode of decision-making Assist with treatment decision-making Coping with life-threatening illness Patient Family/family caregivers www.nationalconsensusproject.org

16. Prepared and Hopeful

17. Oken, MM et al. Am J Clin Oncol 1982 …Principles of Oncology GradeActivity 0Fully active, no restriction 1Symptoms, restricted in strenuous activity 2Ambulatory and capable of all self-care, no work activity. Up more than 50% of the day 3Limited self care, confined to bed or chair >50% of the day 4Completely disabled, unable to care for self, totally confined to bed or chair. 5Dead ECOG Performance Status

18. Conditions Breast Cancer Lung Cancer Prostate Cancer Multiple Myeloma Colo-rectal Lymphoma Brain Mets Bone Mets Hypercalcemia Chord Compression SVC Syndrome Hemoptysis

19. Common Non Cyto-toxic Cancer Meds Steroids Biphosphanates

20. Prostate Cancer Androgen Deprivation – LHRH agonists – Anti androgens Taxanes Crizotnib

21. Breast Cancer Hormonal Therapy – Tamoxifen – Aromatase Inhibitors Her-2 Receptivity – Trastuzamab – Lapatnib Cyto-toxics – Taxanes

22. Colon Cancer VEGF-Bevacizumab EGFR – Cetuximab – Pantiumumab Cyto-toxics – 5-FU – Capecitabin

23. Non Small Cell Lung Cancer Pemetrexed Taxanes Erlotnib Bevacizumab

24. Small Cell Lung Cancer Platinum Etoboside Topotecan-Salvage Whole Brain RT

25. Pancreatic Cancer Gemcitabine Erlotnib

26. Multiple Myeloma Lenalidomide Bortezomib Chlorambucil Pulse Decadron

27. Ovarian Cancer Platinum Taxane

28. Non Hodgkin Lymphoma Rituxamab-CD 20 + Cytoxan

29. Renal Cancer Sorafanib Sunitnib