Oncology Supportive Care Sec.1 PDF

Oncology Supportive Care Sec.1 Table of contents 01 Introduction 04 Leucopenia (Febrile Neutropenia) 02 Side effects of cancer 05 Thrombocytopenia & anticancer 03 CIBMS:- 06 Anemia Part.I...

Oncology Supportive Care Sec.1 Table of contents 01 Introduction 04 Leucopenia (Febrile Neutropenia) 02 Side effects of cancer 05 Thrombocytopenia & anticancer 03 CIBMS:- 06 Anemia Part.I Hematological Side Effects:- 01 Intro Supportive Care Managing the various side effects -- including physical, emotional, social, and financial effects -- of cancer is called "palliative and supportive care." It is an important part of a person's overall cancer care. You can receive palliative and supportive care at any age and for any type and stage of cancer. It can be given at any time during cancer treatment. Research shows that palliative and supportive care can improve the quality of your life. It can also help you feel more satisfied with the cancer treatment you receive.  02 Side Effects of cancer & anticancer Side effects of cancer & anticancer:- CIBMS:-Hematological Side Effects:- 1) Leucopenia (Febrile Neutropenia). 2) Thrombocytopenia. 3) Anemia. Nausea & Vomiting. Infertility. Hair Fall. Cancer Pain.  03 Chemotherapy induced bone marrow suppression (CIBMS). Chemotherapy induced bone marrow suppression (CIBMS):-  03 Febrile Neutropenia White blood cells = leukocytes (leucocytes) Cells of the immune system defending the body against both disease and foreign materials. WBC = Usual range of 4.8–10.8 × 100 cells/mm3 with a circulating life span of 6–12 hours. Decreased WBC = leucopenia or granulocytopenia. Six different and diverse types of leukocytes exist. White blood cells are classified as granulocytes & agranulocytes. There are three types of granulocytes: neutrophils, basophils & eosinophils. There are three types of agranulocytes: lymphocytes, monocytes & macrophages. Neutrophils The most abundant type of white blood cells. Form an essential part of the immune system. Because they have the fastest turnover, the effect of cytotoxic chemotherapy is greatest compared with platelets & RBCs. They are subdivided into segmented (segs) & banded (bands) neutrophils. ANC (Absolute Neutrophile Count) calculation:- ANC = (%Segs + %Bands) * WBCs “cells/ml”. Normal ANC >1500 cells/mm3 (1500 – 7700 cells/mm3). Pattern of ANC following chemotherapy administration:- NADIR:- is the lowest value to which ANC falls after cytotoxic chemotherapy. Usually occurs 10–14 days after chemotherapy administration, with counts usually recovering by 3–4 weeks after chemotherapy ANC NADIR No.of days following chemotherapy administration Febrile Neutropenia Neutropenia:- is an ANC of 500 cells/mm3 or less OR a count of less than 1000 cells/mm3, with a predicted decrease to less than 500 cells/mm3 during the next 48 hours. Febrile neutropenia:- is neutropenia and a single oral temperature of 101°F or more OR a temperature of 100.4°F or more for at least 1 hour. Neutropenic patients are at an elevated risk of developing serious and life-threatening infections. The usual signs and symptoms of infection (e.g., abscess, pus, infiltrates on chest radiograph) are absent, with fever often being the only indicator. In addition, cultures are typically negative. Notes:- The decreased WBC count below 4800 cells/mm3 “leucopenia” is associated with increased risk of life-threatening infections, the risk is high if ANC is less than 500 cells/mm3 & it is greatest when ANC is less than 100 cells/mm3. To receive chemotherapy, in general, a patient should have a WBC greater than 3000 cells/mm3 or an ANC greater than 1000 cells/mm3 and a platelet count of 100,000 cells/mm3 or more. Management Neutropenia but not febrile:- no treatment is recommended. Febrile neutropenia:- Febrile neutropenia that is considered to carry a low risk of complications may be treated with either oral or parenteral antibiotics in an outpatient or inpatient setting. Patients with high-risk febrile neutropenia (i.e., patients who do not have low-risk characteristics) should receive parenteral antibiotics in the hospital. Management Characteristics of low-risk febrile neutropenia include the following: ANC of 100 cells/mm3or more. Normal chest radiograph. Normal renal and hepatic function. Severe neutropenia (100 cells/mm3 or less) for less than 7 days and resolution expected in less than 10 days. No parenteral access site or catheter site infection. Early evidence of bone marrow recovery, malignancy in remission, Peak oral temperature of less than 102°F. No comorbid complications (e.g., shock, hypoxia, pneumonia, other deep organ infection, vomiting, diarrhea). Colony Stimulating Factors (CSFs) CSFs improve both the production and the function of their target cells. Examples:- Granulocyte colony-stimulating factor (G-CSF): Filgrastim (Neupogen®). Pegylated granulocyte colony-stimulating factor (G-CSF): Pegfilgrastim (Neulasta®). GM-CSF, Sargramostim (Leukine®). CSFs Pegfilgrastim, the long-acting agent. The choice of filgrastim or pegfilgrastim should be based on the expected duration of neutropenia and the specific anticancer regimen. Studies have shown that G-CSF and GM-CSF reduce the incidence, magnitude, and duration of neutropenia after chemotherapy and bone marrow transplantation.. CSFs Adverse effects: bone pain (most common) and fever. Contraindicated: BM diseases & malignancies. The CSF should be initiated between 24-72 hours after the administration of chemotherapy. Treatment should be continued until the post nadir ANC is more than 2000-5000 cells/mm3. If treatment is discontinued before ANC nadir is reached, ANC will decrease by about 50%. CSFs CSF use is restricted for patients who are neutropenic, febrile and having a risk factor for complications:- 1) ANC less than 100/mm3. 2) sepsis syndrome 3) Pneumonia. 4) Hypotension. 5) Multi-organ dysfunction. 6) Invasive fungal infection. Note:- CSFs may be used in addition to antibiotics to treat neutropenia in patients with these risk factors. CSFs Management of febrile neutropenia involves either dose reduction in the next cycle of chemotherapy or supporting with a colony stimulating factor (CSF). The potential curability of the disease influences what action will be taken during the next cycle of chemotherapy, either dosage reduction of myelosuppressive chemotherapy (palliative intent) or support with a CSF (curative intent). CSFs Secondary CSF Administration: If chemotherapy administration has been delayed or the dosage reduced because of prolonged neutropenia, then CSF use can be considered for subsequent chemotherapy cycles; administering CSF in this setting is considered secondary prophylaxis. Dosage reduction: Dose reduction of chemotherapy should be considered the first option (i.e., instead of a CSF) after an episode of neutropenia in patients being treated with the intent to palliate (i.e., not a curative intent). CSFs CSFs are recommended for primary prophylaxis with chemotherapy regimens associated with a 20% or greater risk of febrile neutropenia.  04 Thrombocytopenia Thrombocytopenia Normal range of platelet count is 140,000 – 440,000 cells/mm3. Thrombocytopenia is when platelet count drops below 100,000 cells/mm3. However, the risk of bleeding is not substantially increased until the platelet count is 20,000 or less. Management 1. Platelet Transfusion:- Many institutions do not transfuse platelet until the patient becomes symptomatic (ecchymosis, hemoptysis or hematemesis). Other institution will transfuse when the platelet count is 10,000 cells/mm3 or less, even in the absence of bleeding. Caution should be used in patients receiving antiplatelet therapy, monitor closely and consider interventions as clinically needed. Management 2. Oprelvekin (interleukin-11):- Drug stimulates BM to increase production of platelets only. Drug is available in 5-mg vials as a powder, which must be reconstituted with 1 ml of sterile water and injected within 3 hours of reconstitution. Common adverse events associated with oprelvekin include edema, SOB, tachycardia and conjunctival redness. Management 2. Oprelvekin (interleukin-11):- Rules of administration: Daily subcutaneous injection, beginning 6-24 hours after completion of myelosuppressive chemotherapy. Treatment is continued until post-nadir platelet count of 50.000 cells/mm3 or greater is achieved. Dosing beyond 21 days is not recommended, and oprelvekin must be discontinued at least 2 days before (the next cycle) of chemotherapy.  05 Anemia & Fatigue Anemia & Fatigue Normal RBCs counts in the range of 4.6-6.2 * 106 cells/mm3with a circulating life span of 120 days. Anemia defined as a reduction of RBC mass, number of RBCs, and Hgb concentration of RBCs (less than 13 g/dL in men or 12 g/dL in women). Signs and symptoms of anemia include weakness and fatigue, irritability, tachycardia and palpitations, shortness of breath, chest pain, pale appearance, dizziness & decreased mental acuity. Fatigue is estimated to affect 60%–80% of all patients with cancer. Fatigue can be assessed with a numeric rating scale, 0 = no fatigue and 10 = worst fatigue Causes of fatigue & Anemia Fatigue Causes:- ✓ Unmanaged pain or other symptoms can increase fatigue. ✓ Other mechanisms of fatigue (e.g., cytokines) are independent of hemoglobin concentration. ✓ Anemia also worsens fatigue. Anemia Causes:- ✓ Decreased RBC production because of anticancer therapy. ✓ Decreased endogenous erythropoietin production or decreased responsiveness to endogenous erythropoietin. ✓ Decreased body stores of vit.B12, iron, or folic acid. ✓ Blood loss Types of anemia There are several types of anemia, including microcytic (iron deficiency anemia), macrocytic/ megaloblastic anemia (vitamin B12 deficiency, folic acid deficiency), anemia of chronic disease (including chemotherapy-induced anemia). Thank YOU! Any question????