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Stephan Tanneberger Euro-Arab School of Oncology (EASO)

The advanced cancer patient. Stephan Tanneberger Euro-Arab School of Oncology (EASO). Cairo 11/2011. Cancer mortality by age groups Bologna a nd Provinz. Percentage of Patients knowing their diagnosis of cancer Italy 1985 - 2001.

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Stephan Tanneberger Euro-Arab School of Oncology (EASO)

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  1. The advanced cancer patient Stephan TannebergerEuro-Arab School of Oncology (EASO) Cairo 11/2011 Centro Elaborazione Dati

  2. Cancer mortality by age groupsBologna and Provinz Centro Elaborazione Dati

  3. Percentage of Patients knowing their diagnosis of cancerItaly 1985 - 2001 Centro Elaborazione Dati

  4. What patients want to have if the end of life is coming closer? 1. Control of symptoms 100% 2. To be close to family/friends 80% 3. To be at home 70% 4. Dignity 50% 5. No diagnostical/therapeutical procedures without improving quality of life 40% 6. More decent communication 40% 7. Euthanasia 07% Centro Elaborazione Dati

  5. Incidence of non-controlled symptoms in two groups of advanced cancer patients living in Italy or India. ANT Bologna CANSUPPORT New Delhi (250 patients) (334 patients) Pain 36% 88% Anorexia 37% 61% Dyspnoe27% 34% Fatigue 22% 82% Nausea/vomiting 12% 47% Centro Elaborazione Dati Centro Elaborazione Dati

  6. Cancer Pain: pan-european level of patients view on prevalence and relief (Breivick et al 2009) Centro Elaborazione Dati Stephan Tanneberger ottobre 2009

  7. Relief of cancer pain in the world • An analysis of 12 surveys covering nearly 2600 patients • in developed countries suggests that more than 50% • of patients suffer unrelieved pain.The reasons are, • obstacles in the implementation of palliative care • lack of recognition by health workers of the fact that • established methods exist for the relief of almost all pain • legal and other constraints on the medical use of • analgetic drugs notable morphin. • The available data show that the percentage of unrelieved • cancer pain in developing countriesis still much higher. Centro Elaborazione Dati

  8. The haemoglobin level of advanced cancer patients Nr. Pats. Characteristics CT/ Haemoglobin Author post-CT <WHO <8 g/dl 105 advanced cancer ? 68% - Dunn 147 advanced cancer ? 56% 15% Munch 41 389 advanced cancer mixed 50% 15% ANT 310 advanced cancer no CT 10% ANT 15 000 all types mixed 39% - ECAS 694 all types mixed 35% - Seshadri Centro Elaborazione Dati

  9. Anaemia : Confusion with Definitions for the Pharmaceutical industry 12 -12.5 g/dl haemoglobin for Health Authorities ca. 10.5 g/dl haemoglobin for transfusion experts/oncologists ca. 8g/dl haemoglobin M.Mitterer 2008 Centro Elaborazione Dati

  10. Where patients are dying in the industrialized world Countries with home care Countries without home care Centro Elaborazione Dati

  11. Dignity of life means social security and peace of mind. A free and personal decision of the patient about the circumstances of his terminal life is of fundamental importance We call this EUBIOSIA, good life until the end the opposite to euthanasia Pannuti F, Tanneberger S 1993 Centro Elaborazione Dati

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  14. What about dignity of life for majority of dying cancer patients in Egypt, Iran, Sudan 2010 ( Expert analysis) • Dignity of life is not guaranteed • The reasons are: • - financial problems • - structural problems • - educational problems • - medical problem • - nursing problems • A major problem is lack of awarness, • knowledge and culture regarding • palliative care Centro Elaborazione Dati

  15. Sometimes emotions open the door to diagnostical and therapeutical procedures without improving quality of life What emotions have cancer patients? initial advanced to fight 52.3% 53.1% anxiety 21.3% 17.9% fatalism 20.8% 19.9% weakness 04.4% 07.6% ignorance 01.2% 01.5% Centro Elaborazione Dati

  16. Last minute cancer chemotherapy 2003 -2005 (793 evaluated patients) Tumor Mean distance Number patients (days) last CT receiving CT within and death (range) last 3 months of life ------------------------------------------------------------------------ Lung & Pleura46.0 (1-530)41 (40.6%) Colon-Rectum75.5 (8-1305)17 (16.8%) Breast80.5 (24-1227) 04 (04.0 %) other 78.0 (1-1913)39 (39.0 %) all71.0 (1-1913)101 (22.7%) Martoni A, Tanneberger S, Mutri V Tumori 2007 Centro Elaborazione Dati

  17. Complementary and alternative medicine (CAM) in the world: utilization and cost Country % user Market Cost for patients CAM billion/year billion/year ------------------------------------------------------------------------------- USA 34 % 13.7 10.3 Australia 49 % 0.9 0.4 Benelux 60 % + 15% UK 74 % + 15% China 2.4 Japan + 15% Germany 38% 3.3 ( -> 20) Centro Elaborazione Dati

  18. CAM in adult cancer patients in Turkey and Pakistan Country Nr. patients CAM user User characteristicsAuthor Turky 615 47.3% femal, high income, Tas et al. advanced stage, 2005 usage of multiple chemotherapy Pakistan 191 54.5% 36% before any Malik et al. conventional therapy 2000 Centro Elaborazione Dati

  19. Cancer patients at all stages are suffering physically and phsychologically. Therefore palliative care means both, physical and psychological care The basic element of psychological care is communication Centro Elaborazione Dati

  20. Communication : How? Patients want to speak but speaking is not all • Direct communication • voice • hands • eyes • cloths • environment • Indirect communication • Mass media/Internet • Health Insurance • Family/friends Centro Elaborazione Dati

  21. How physicians communicate the transition to palliative care (questionaire- based survey of bereaved family members of adult patients in Japan Patients families report they were very distressed 39% distressed 31% slightly distressed 20% not so distressed 6.6% not distressed 3.8% Communication methodes were rated as requiring much improvement 6.3% considerable improvement 13% some improvement 39% no improvement 42% Morita et al. 2004 Centro Elaborazione Dati

  22. Communication and religion This study (50 pts) suggests that spiritual wellbeing is an important component of the quality of life (Qol) of advanced cancer patients Kandasamy et al. Bangalore 2011 185 community-dwelling individuals with advanced illness reported that “having grown closer to church was associated with better Qol Solomon et al. New York 2010 Support of 343 terminal ill patient‘s spiritual needs by the medical teams was associated with better patient QoL near death Balboni et al. Boston 2010 Centro Elaborazione Dati

  23. Euthanasia Loss of dignity (50-60%) and pain 40-50%) are the main arguments for requests for euthansia. Both is avoidable. We consider euthanasia to be the expression of social and medical inability to realize a basic human right – a death in peace and dignity as the harmonious end of biological life Pannuti F, Tanneberger S, 1993 Centro Elaborazione Dati

  24. The advanced cancer patient: The dream of ANT Centro Elaborazione Dati

  25. Reserve Centro Elaborazione Dati

  26. Valutazione economica dell’assistenza sanitaria: analisi di costo-efficacia (CEA) e di costo-utilità (CUA) Criterio pragmatico: sono considerate costo-efficaci le strategie che portano al prolungamento di un anno di vita al costo di meno del doppio del prodotto interno lordo (GDP) pro capite (Marino 2008) Oxaliplatino+cetuximabper il tumore del colon in fase avanzata: 12 000-31.000 $. Prolungamento della sopravvivenza di un anno?? Centro Elaborazione Dati

  27. First-line chemotherapy in metastatic NSCLC Nr. pts Regime OR (%) PFS(m) OS(m) Author/Year 179 DDP + Etoposid 15 9.1 Belani 2005 190 CarboP+Paclitax 23 7.8 Belani 2005 422 Mitox/Iphos/DDP 42 1-year Survival 40% vs GEM/CarboP 41 1-year Survival 30% 334 GEM vs. 11 8.6 Sederholm 2005 CarboP + GEM 30 10.0 OxaliP+GEM 25 - 11.3 Bidoli 2007 140 DDP+IFO+GEM 9.7 Sculier 2007 141 GIP + Paclitaxel 11.9 Sculier 2007 145 DDP+Irinotecan 31 4.8 13.9 Ohe 2007 145 CarboP + Paclita 32 4.0 12.3Ohe 2007 146 DDP + GEM 30 3.5 14.0 Ohe 2007 145 DDP + Vinorelbine 33 3.4 11.4 Ohe 2007 297 DDP + Vinorelbine 4.0 7.5 Plessen 2007 Centro Elaborazione Dati

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