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How to Mitigate the Long-Term Effects of Treatment. Steven D. Passik, Ph.D. Director, Symptom Management and Pharmacotherapy Lab Memorial Sloan Kettering Cancer Center Department of Psychiatry and Behavioral Sciences New York, NY. Cancer as a Disease Experience. Survival rates increasing
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How to Mitigate the Long-Term Effects of Treatment Steven D. Passik, Ph.D. Director, Symptom Management and Pharmacotherapy Lab Memorial Sloan Kettering Cancer Center Department of Psychiatry and Behavioral Sciences New York, NY
Cancer as a Disease Experience • Survival rates increasing • Cancer has largely transformed from an acute life threatening illness into a chronic illness • Focus naturally being placed on facilitating QOL American Cancer Society, 1997, Sarafino, 1994
Goals of People With Cancer • Old days • Get your affairs in order • Comfort • Say good-bye • Now-a-days • Continue work, life interests, hobbies • Maintain sense of self and identity • Continue to play important family roles
But… • People with Cancer are Highly Symptomatic • Average in-pt has 10 distressing symptoms • Average out-pt has 5 distressing symptoms with fatigue, GI upset and pain leading the way
The Relationship of Symptoms to Quality of Life • Chang and colleagues: • Direct linear relationship between the number of symptoms and patients’ reported quality of life • Symptom management is complex • How to get the most bang for the buck? • Does 10 symptoms mean 10 medicines? • Use of non-medical interventions • Is an intervention to treat one symptom helping or hurting
Women with MBCa Have Many Choices • Medical interventions • Psychological interventions • Alternative therapies • Exercise and physical therapeutic interventions
Pain Statistics • Cancer pain is common but not inevitable • Fatigue, GI upset, and psychosocial problems are often more prevalent, but pain is the #1 feared aspect of cancer for most patients • Rates of pain vary widely among disease sites: • 35% in lymphoma • 56% in breast cancer • 67% in head and neck cancer
Communicating About Pain • Communicate • Intensity • Location • What the pain feels like • What makes it worse • What helps
What Not to Fear • Addiction • Tolerance (using meds too soon, i.e., before “I really need them”) • Side effects • Good treatments exist for nausea, sedation and a ground breaking treatment will soon be available for constipation
Future Developments in Pain • Rapid onset opioids • Oxymorphone • “Smart” pills • Alvimopan
Depression: Background • Depressive spectrum: normal unhappiness, adjustment disorder, major depression • Diagnosis often complicated by somatic symptoms of cancer and its treatment • Psychotherapeutic, problem solving approaches have been well-validated • Growing body of research on antidepressants
Diagnosing Depression in Cancer Patients • Reliable Symptoms • Anhedonia • Persistent depressed mood • Unreliable Symptoms • Fatigue, insomnia, decreased libido, eating disturbances, situational emotional reactions
Antidepressant Selection • The art of treating depression pharmacologically • Minimization vs. Mobilization – match to symptom complex • The oncologist should learn to use 3 drugs alone or in combination: • “Clean” (one SSRI: fluoxetine, paroxetine, sertraline, venlafaxine) • “Dirty” (mirtazapine) • Stimulant (methlyphenidate) • If the patient fails to respond or has significant existential issues --- Refer to a psycho-oncologist
Alternative Treatments for Depression • Fish oil • Exercise • Yoga, meditation
Etiologies of Nausea and Vomiting in Oncology Patients • Chemical (chemotherapy-induced: acute and delayed; opioids) • Vestibular • CNS (increased intracranial pressure) • Visceral (direct disease-related sources, abdominal irradiation)
Potential of Olanzapine asAntiemetic Therapy • Literature indicates the need for activity at multiple receptor sites to control opioid-induced nausea and vomiting (which arises from visceral, vestibular, and CNS etiologies) • Olanzapine has activity at multiple receptor sites • Dopaminergic (D1, D2, D3, D4) • Serotonergic (5-HT2A, 5-HT2C, 5-HT6, 5-HT3) • Adrenergic (1) • Histaminergic (H1) • Muscarinic (m1, m2, m3, m4) • Minimal extrapyramidal side effects (EPS) (Passik, Lundberg, Kirsh, et al, JPSM, 2002)
Alternative Treatments • Relaxation • The sacrificial lamb approach • Wrist bands • Acupuncture
Cachexia and Nutritional Risk • Nutritional risk (ie, unwanted weight loss), including cachexia, is a common and distressing problem in advanced cancer, affecting up to 80% of patients (Bruera, 1993) • Negatively affects survival as well as quality of life (Delmore, 1993) • Etiologies: • abnormal gastrointestinal functioning • anorexia from nausea, anxiety, depression and cognitive dysfunction • metabolic abnormalities caused principally by cytokines (Keller, 1993)
Cachexia and Nutritional Risk • 4 main clinical manifestations of cachexia: • Anorexia • Chronic nausea • Asthenia • Change in body image • Pharmacologic treatment of cachexia is targeted principally at anorexia and chronic nausea (Bruera, 1993)
Pharmacological Approaches • The main pharmacologic approaches include: • Corticosteroids • Progestational agents (ie, megestrol acetate) • Cannabinoids (ie, dronabinol) • Antihistamines (ie, cyproheptadine) • Unique agents (ie, hydrazine sulfate) • Omega-3 fatty acids,EPA and docosahexaneoic acid (DHA) (n-3s) (Barber, et al, 2000; Hussey & Tisdale, 1999; Wigmore, et al, 2000) • Results of trials for cachexia have been mixed (Bruera, et al, 1985;Gold, 1975; Lener & Regelson, 1976; Silverstein, et al, 1989; Tayek, et al, 1987; Wadleigh, et al, 1990)
Ongoing and Future Work • Anabolic steroids • Protein shakes • Weight lifting with creatine • Olanzapine
Fatigue • Highly prevalent – effecting 2/3s of patients • Very disabling • Also makes the job of caregiving more stressful and exhausting for family
Fatigue – what works? • Exercise • Modifications in diet • Stimulant medications
Chemobrain • What really is chemobrain? • Subjective sense of slowed thinking, muddy thinking, lack of flexibility in cognitive processes • Poor concentration and secondarily, poor memory • What causes it? • Chemo? Hormones? Other meds?
Chemobrain – What works? • Stimulants • Meditation? • Anti-depressants? • Medications that increase red blood cell counts (ie epo)?
Insomnia • Highly prevalent symptom • 53% of people with cancer report difficulty sleeping • Breast cancer • Multiple problems can lead to poor sleep • Pain • Hot flashes • Worry
Insomnia • Multiple new sleep aids on the market • Eszopiclone • Remelteon • None evaluated in people with cancer • An oldie but a goodie • Trazadone (only hot flas med that is sedating and can be taken at bedtime)
Hot Flashes • Highly prevalent • Vary tremendously in frequency and intensity from patient to patient • Can be part of a viscious circle
Hot Flashes • Antidepressants work best • SNRIs (venlafaxine and possibly duloxetine) • SSRIs • Others? • Olanzapine (?) • Most of the herbal and supplement based treatments in effective • Loprinzi latest was negative trial of black cohosh
www.cancer.gov Follow links to PDQ Supportive Care
Conclusions • People with cancer are living longer • The focus is on quality of life in addition to quantity • People surviving cancer want to live normal lives • People with cancer have multiple symptoms • New treatments of various kinds are available and there is no need to suffer