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癌 症病患常見問題 的處理

癌 症病患常見問題 的處理. 血液暨腫瘤科 R5 林煥超. Multidiscipline Treatment of Cancer. Clinical oncologist Surgeon Radiation oncologist Pathologist Radiologist. The Description of Cancer Patients. 1.The pattern of presenting symptoms and signs. 2.The evidence of diagnosis. 3.The disease extent.

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癌 症病患常見問題 的處理

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  1. 癌症病患常見問題的處理 血液暨腫瘤科 R5林煥超

  2. Multidiscipline Treatment of Cancer • Clinical oncologist • Surgeon • Radiation oncologist • Pathologist • Radiologist

  3. The Description of Cancer Patients 1.The pattern of presenting symptoms and signs. 2.The evidence of diagnosis. 3.The disease extent. 4.The treatment plan. 5.The effects and side effects of treatments. 6.The ongoing problems.

  4. Pathophysiology of Cancer • Local effects: 1. Tumor necrosis, infection, bleeding. 2. Tumor invasion of adjacent structure.

  5. Pathophysiology of Cancer • Remote effects: 1. Tumor production: hormones, growth factors, cytokines, other peptides. 2. Tumor-evoked production: a. Immune cells: antibodies, immune complex. b. Non-immune cells: other peptides.

  6. 如何給予化學治療藥物

  7. DNA synthesis Action sites of cytotoxic agents Antimetabolites Alkylating agents DNA DNA transcription DNA duplication Mitosis Intercalating agents Cellular level Spindle poisons

  8. 6-MERCAPTOPURINE 6-THIOGUANINE METHOTREXATE 5-FLUOROURACIL HYDROXYUREA CYTARABINE Action sites of cytotoxic agents PURINE SYNTHESIS PYRIMIDINE SYNTHESIS RIBONUCLEOTIDES DEOXYRIBONUCLEOTIDES ALKYLATING AGENTS ANTIBIOTICS DNA ETOPOSIDE RNA L-ASPARAGINASE VINCA ALKALOIDS TAXOIDS PROTEINS ENZYMES MICROTUBULES

  9. 化學治療可以 • 延長轉移患者的存活期 @ Primary chemotherapy • 減輕癌症引起的不適 @ Palliative chemotherapy • 增加手術或放射治療的療效 @ Neoadjuvant & adjuvant @ Concommitent radiosensitizer • 改善臨床的治療方式

  10. 化學藥物的給藥 • 靜脈注射: 大多數藥物 • 長期低劑量灌注 • 短期靜脈輸注 • 靜脈推注 • 口服藥物: VP-16, UFT, Xeloda, Hydroxyurea, 6-MP, 6-TG

  11. 化學藥物的給藥 • 局部化學治療 • 動脈內注射: 肝臟腫瘤 • 腹腔內注射: 卵巢癌, 腸胃道癌 • 肋膜腔/心包膜腔內注射: 癌性積液 • 脊髓腔內注射: 腦膜侵犯 • 腦室內注射: 腦膜侵犯 • 經皮給藥: 皮膚癌

  12. 化學藥物的靜脈給藥 • 依藥物,腫瘤的種類而有不同 • 不同的注射方式有不同的治療結果 • 不同的注射方式有不同的毒性反應 • Adriamycin, Epirubicin • 不同的注射方式有不同的殺死癌細胞的機制 • 5-FU

  13. 化學藥物給藥前應注意 • 確定病人姓名, 診斷及化療醫囑 • 包括藥名清楚, 劑量, 給藥方式及時間 • Mitoxantrone, Mitomycin-C • Fluorouracil, Fluconazole • Vincristine, Vinblastine

  14. 化學藥物給藥前 • 選定適當的注射位置 • 不可使用軟組織少又有重要構造的部位 • 手背, 腹股溝等部位 • 不可使用血液流通不佳的部位 • 不可使用關節部位 • 最佳位置為前臂手掌側 • Port-A 為最佳輸注管道 • 給藥前要確定靜脈管道通暢

  15. 化學藥物的給藥 • 給藥前再確定患者姓名, 藥物名稱, 劑量,給藥方式及灌注時間長短. • 依醫囑所述方式給藥, 包括給藥的順序, 若有困難應立即聯絡醫師. • Ara-C: push, subcutaneous, slow infusion, long term infusion. etc. • Cisplatin + Taxol. CDDP + MTX

  16. 化學藥物的給藥後 • 不同的藥物的給藥後注意事項根據其常見毒性反應可能不同 • 注意嚴重的立即性毒性反應 • Cisplatin: hydration & urine output • Adriamycin/ Epirubicin: heart failure • High dose Methotrexate: renal failure • Cyclophosphamide: hemorrhagic cystitis

  17. Mucositis Nausea/vomiting Diarrhea Cystitis Sterility Myalgia Neuropathy Side effects of chemotherapy Alopecia Pulmonary fibrosis Cardiotoxicity Local reaction Renal failure Myelosuppression Phlebitis

  18. INCREASED EFFICACY Aim of combination therapy SAFETY ACTIVITY Different mechanisms of action Compatible side effects Different mechanisms of resistance

  19. 會引起組織壞死的藥物 • Vinka alkaloids: Vincristine(Oncovin), Vinblastine, Vinorelbine(Navelbine) • Anthracyclines: Epirubicin, Idarubicin • Mitomycin-C, BCNU, DTIC • Taxoids, Topotecan • Mithramycin, Nitrogen Mustard • VP-16, Cisplatin • Fludarabine, Gemcitabine, Irinotecan

  20. 化學藥物外滲的處置 • 及早發現,立即停止輸注 • 局部冷敷 • Cold Compression for 30 min. Q6H • 抬高患處,減少水腫 • 治療可能之局部感染 • 保持壞死皮膚所形成的水泡的完整及消毒 • 開與止痛藥物,甚至morphine • 若有皮膚表面壞死, 請教整形外科共同評估,甚至需要植皮.

  21. Chemotherapy-associated Emesis

  22. Type of Treatment-related Emesis • 1.Acute-phase symptoms: Correlated with serotonin (5-HT) release from enterochromaffin cells. Emetic signals are propagated at local 5-HT3 receptors.

  23. Type of Treatment-related Emesis • 2.Delayed-phase symptoms: Not to be related to serotonin. Severity and duration often correlate with drug dosage. Nausea severity reportedly is similar during both phases.

  24. Type of Treatment-related Emesis • 3.Anticipatory emetic symptoms: An aversive conditioned response Develops after repeated antineoplastic treatments that are characterized by poor emetic control. Complete control throughout antineoplastic treatment remains the best preventive strategy.

  25. Antiemetic Options 1.Serotonin (5-HT3) receptor antagonists: Granisetron (Kytril)Ondansetron (Zofran) • More effective and safer to use then other types of antiemetics.

  26. Serotonin Antagonists Ondansetron, Granisetron. • 健保給付規定 1.骨髓移植患者接受高劑量化學治療時。 2.惡性腫瘤患者使用cisplatin劑量超過50mg/m2可預防性使用一日劑量。Delay vomiting每療程使用以不得超過五日為原則

  27. Serotonin Antagonists 3.惡性腫瘤患者使用中性致吐劑cisplatin劑量>30，< 50mg/m2可預防性使用一日劑量且發生嚴重延遲性嘔吐，使用dexamethasone及metoclopramide無效之病例，每療程使用以不得超過五日為原則。須檢附病歷摘要及使用dexamethasone及metoclopramide 無效之記錄。

  28. Serotonin Antagonists 4.接受腹部放射照射之癌症病人，得依下列規範使用ondansetron及granisetron： (1)total body or half body irradiation (2)pelvis or upper abdominal region of single irradiation dose> 6 Gy (3)腹部放射治療中產生嘔吐，經使用dexamethasone、metoclopramide或prochlorperazine等傳統止吐劑無效，仍發生嚴重嘔吐之患者。

  29. Antiemetic Options 2.Steroids:Acute-phase symptoms: effective against mildly to moderately symptoms. Delayed-phase symptoms: most active agents. Dexamethasone (2-20mg) & methylprednisolone + 5-HT3- and D2-receptor antagonists.

  30. Antiemetic Options 3.Metoclopramide: A weak competitive 5-HT3-receptor antagonist at high dosages. 4.Benzodiazepines: Lorazepam (Ativan). 5. Dopaminergic (D2)-receptor antagonists: Phenothiazines—Prochlorperazine. Butyrophenones—Haloperidol.

  31. Neutropenic Fever

  32. Neutropenic Fever • Fever: 1 oral temperature > 38.3oC. 2 oral temperatures > 38oC, an hour apart. • Neutropenia: ANC (Band + Neutrophil) < 500/mm3. ANC 500/mm3 ~ 1,000/mm3, with a predicted decline to < 500/mm3 within 48 hours.

  33. Neutropenic Fever In the absence of white cells: 1. Signs and symptoms of invasive infections may be absent. 2. Infections can invade and spread quickly. 3. Fever may be the only manifestation of a potentially life-threatening infection.

  34. Neutropenic Fever • Bacteremia: 10% to 20% • Gram-positive bacteremia: 70% Coagulase-negative staphylococcus S. aureus. • Gram-negative bacteremia: 30% Escherichia coli, Klebsiella sp., Enterobacter sp., and rarely, Pseudomonas aeruginosa.

  35. Neutropenic Fever • Common sites of local infection: The respiratory tract. Sinuses. Skin, soft tissue. Venous catheter entry/exit sites. Urinary tract. Gastrointestinal tract: oral cavity, anus.

  36. Neutropenic Fever • Laboratory evaluation: CBC/DC, Platelet. Chemistries (hepatic and renal function). Blood cultures. U/A and U/C. CXR.   Any accessible sites of possible infection.

  37. IDSA 2002 Guidelines CID 2002; 730-51

  38. Vancomycin • In initial empirical therapy: 1. Clinically suspected serious catheter- related infections. 2. Known colonization with penicillin- and cephalosporin-resistant pneumococci or MRSA. 3. B/C gram-(+) bacteria before final identification and susceptibility testing. 4. Hypotension or other evidence of CV impairment.

  39. G-CSF • Filgrastim, Lenograstim. • 健保給付規定 (1)造血幹細胞骨髓移植 (2)血液惡性疾病接受靜注化學治療後 (3)先天性或循環性中性白血球低下症者 (當白血球數量少於1000/mm3，或中性白血 球(ANC)少於500/mm3)。

  40. G-CSF (4)其他惡性疾病患者在接受化學治療後，曾經發生白血球少於1000/mm3，或中性白血球(ANC)少於500/mm3者，在下一療程即可使用。 (5)重度再生不良性貧血病人嚴重感染時使用，惟不得作為此類病人之預防性使用。 (6)化學治療，併中性白血球小於100 /mm3癌症不受控制、肺炎、低血壓、多器官衰竭或侵犯性微菌感染等危機程度高之感染。 使用本品之患者應檢附治療記錄，其內容需包括診斷、白血球數量變化、所使用之化學治療藥物名稱、劑量及使用本品劑量，如白血球超過4000/mm3時或中性白血球超過2000/mm3時，應即停藥。

  41. 癌症疼痛Cancer Pain

  42. Pain 89% Fatigue 69% Weakness 66% Lack of energy 61% Dry mouth 57% Constipation 51% Dyspnea 50% Sleep Dis. 49% Depression 41% Cough 38% Nausea 36% Edema 28% Taste 28% Hoarseness 24% Anxiety 24% Vomiting 23% 晚期癌症患者常見症狀

  43. 癌症疼痛可由一些簡單的治療方式在90%的患者得到有效的處置Cancer pain can be managed effectively through relatively simple means in up to 90% of Patients.Unfortunately, pain associated with cancer is frequently undertreated.

  44. 疼痛評估的基本原則 • 相信病人的疼痛抱怨 • 仔細詢問癌症及疼痛相關病史 • 評估心理狀態、可請精神科協助 • 進行理學、神經學檢查 • 開立診斷方式：如 CT，bone scan，MRI • 開始治療疼痛以便利適當檢驗 • 重新評估治療的反應 • 再設計、討論進一步治療方式

  45. 治療的基本原則 • 1.Dose "by mouth" whenever possible. • 2. Around the clock (ATC): Basal analgesic administration should not be based on an "as needed" (prn) basis. • 3.Dose by the WHO three-step ladder.

  46. Co-analgesics Strong Opioids ± Non-OpioidsMorphine, Oxycodone,Hydromorphone, TTS-Fentanyl, Methadon , Step 3 Weak Opioids ± Non-OpioidsCodein, Dihydrocodein, Tramadol, Tilidin/Naloxon Step 2 Non-OpioidsIbuprofen, Diclofenac, „Cox 2“ Paracetamol, Metamizol, Flupirtin Step 1 WHO Analgesic Ladder

  47. Strong Opioids Relation 1 2 7.5 100 Duration 8 - 12 8 - 12 8 - 12 48 - 72 Morphine Oxycodone Hydromorphone Fentanyl-TTS

  48. Strong Opioids • Morphine 10mg IV, IM = 20mg SC = 30mg PO

  49. Morphine SR Dosage If pain continues: 2 x 30 mg A. 2 x 60 mg B. 3 x 30 mg never < 8 hrs 12 hrs 12 hrs 8 hrs Fentanyl-TTS Dosage If pain continues: Every 3. day Every 3. day Every 2. day 25 mg/h A. 50 mg/h B. 25 mg/h never < 2 days

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