PALLIATIVE CARE DELIVERY IN SOUTH TRINIDAD

Dr Dylan Narinesingh and TeamPresenters : Dr P.Sylvester and Dr N.Bhim

Inpatient setting

Assess and treat symptomatically Family meeting concerning options

for home care vs hospice care Home care not feasible referral to

Hospice Family advised to visit place to meet

health care providers at the Hospice Then patient is transported from SFGH

Hospice

Outpatient setting

Zometa

Intravenous bisphosphonate Indicated for Rx with metastatic bone

disease Multiple Myeloma

Prevents SRE and relieves bone pain Administered every 4 to 5 weeks

Zsuzsanna Nagy : Zoledronic acid (ZOMETA) : a significant improvement in the treatment of Bone metastases. Pathology and Oncology Research Vol 11, No 3, 2005.

Initial clinic visit for Zometa

Counselling side effects Calcium supplements Monthly blood tests to review prior to

administering (RFT’s and Ca2+) Informing physician on dental procedures

Severity of Bone pain Pain management according to the WHO

Analgesic ladder Palliative radiotherapy @ NRC

http://www.zometa.com/dosing-and-administration/dosing-for-solid-tumours-and-multiple myeloma/treat-every-3-to-4-weeks.jsp

Palliative Radiotherapy

Patients referred to be assessed at National Radiotherapy Centre on Tuesdays

Clinical mark-up planning Radiation dose of 8Gy x 1 Fraction or 20Gy

x 5 Fractions (administered to the area that gives the patient the most pain)

Chow E, Harris K, Fan G : Journal of Clinical Oncology, Vol 25, No 11 (April 10), 2007: pp. 1423-1436

Palliative Xeloda clinic

Indicated in Metastatic Colorectal Cancer 1

and Breast Cancer2

Initial visit Counseling patient on side effects and how to

manage them Blood test to review before prescribing ( CBC,

RFT, LFT) Vitamin B6 to be taken daily Patients seen every 3/52 Reassessment after 3 cycles1. http://www.xeloda.com/about/prescribed-for/mcrc2. Blum JL, Jones SE, Buzdar AU, et al. Multicenter phase II study of

capecitabine in paclitaxel-refractory metastatic breast cancer. J Clin Oncol. 1999;17(2):485-493.

District Health Facilities Princes Town / Couva / Siparia Providing best supportive care Team effort comprising Physicians,

Nurses and counselors Provide education and counseling of

Patient and relatives

Paliative Care clinic

Situated at SFGH outpatient Oncology Clinic every 2/52

Dr S. Chamely Palliative care physician

Patients receiving home care

Hospice care in South Trinidad Soon to be established at Petrotrin

Medical Centre

ZOMETA AUDIT

Overview

Audit period 10/7 (October 4th, 2011 to October 19th , 2011)

Inclusion Criteria Metastatic bone disease Duration of treatment with Zometa

>3mths

Total population approx. 100 patients

Demographics

Sample size 34 patients: 28 males and 6 females

Age Distribution:Age

Group<50 50-59 60-69 70-79 >80

No. of Patients

0 6 11 15 2

% 0 17.6 32.4 44.1 5.9

Primary site of cancer

•Prostate•Breast•Other

Breast15%

Prostate70%

Other 15%

ZOLEDRONIC ACID AUDIT DATA COLLECTION SHEET 

 Date:_____________                                                               Record No._____________ 

Name:__________________________________________________________________  

DOB (age):       /     /          _____yrs  

Gender:  M   F  

 Ethnicity:        Black      Asian       East Indian     Caucasian       Mixed_____________  

Address:________________________________________________________________________________________________

Cancer Type:   Breast      Prostate      Lung   Colon/Rectum    Kidney    Lymphoma (HL/NHL)         Malignant Melanoma      Brain    Head & Neck      Gastric      Esophagus 

Pancreatic          Liver          Cervix           Endometrial        Ovarian       CUP 

Other______________________________ 

Histology:________________________________________________________________________________

Date Diagnosed with Cancer:___________________________ 

Date Diagnosed with Bony Metastases:_________________________ 

 

Imaging Modality used for diagnosis:  X-rays   Bone Scan    MRI    CT 

Site of Bony Metastates:  Pelvis    Spine (Cervical   Thoracic   Lumbar    Sacral)   Rib Cage   Skull   Scapula   Clavicle   Femur   Humerus     Other____________________ 

 

Spinal Cord Compression (at time of diagnosis):   Y     N 

RT administered for SCC:    Y     N  

Bone Pains:   Y    N 

Site of Bone Pains: ___________________________________________  

RT administered for Bone Pain:   Y     N  

Receiving Palliative Chemotherapy/Hormonal Therapy:     Y       N  

Date Zoledronic Acid started:________________________________________________ 

Baseline Creatinine and Calcium levels:_______________________________________  

Duration of Treatment (months):_____________________________________________  

Date Zoledronic Acid Discontinued:__________________________________________  

Reason for discontinuation:       Renal Failure    Hypocalcaemia    Osteonecrosis of Jaw   Atypical Fracture            Other__________________ 

Did patient experience any adverse skeletal-related event (SRE) or hypercalcemia of malignancy (resulting in admission) whilst receiving Zoledronic Acid:    Y    N 

Specify:_________________________________________________________________ 

Dose Reduction of Zometa:    Y     N 

Reason for Dose Reduction:    Renal Impairment      Other_________________________ 

 

Objective Improvement in Quality of Life  

Compare Before and After Zoledronic Acid administered:  

Describe in patient’s (and/or caregiver’s) own words: _______________________________________________________________________

Objective improvement in mobility: 

ECOG/Karnofsky/Lansky Performance Status Before Zoledronic Acid:______________ 

ECOG/Karnofsky/Lansky Performance Status After Zoledronic Acid:________________ 

Number of Doses/Cycles given before improvement noticed:_______________________ 

Objective improvement in bone pain (see NIPC rating scales): 

Numeric Rating Scale Before Zoledronic Acid: _________________________________ 

Verbal Pain Intensity Scale Before Zoledronic Acid:______________________________ 

Numeric Rating Scale After Zoledronic Acid: __________________________________ 

Verbal Pain Intensity Scale After Zoledronic Acid:_______________________________ 

Number of doses/cycles of Zoledronic Acid given before improvement noticed:________ 

KARNOFSKY PERFORMANCE STATUS SCALE DEFINITIONS RATING (%) CRITERIA

Able to carry on normal activity and to work; no special care needed.

  100   Normal no complaints; no evidence of disease.

90 Able to carry on normal activity; minor signs or symptoms of disease.

80 Normal activity with effort; some signs or symptoms of disease.

Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed.

70 Cares for self; unable to carry on normal activity or to do active work.

60 Requires occasional assistance, but is able to care for most of his personal needs.

50 Requires considerable assistance and frequent medical care.

Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.

40 Disabled; requires special care and assistance.

30 Severely disabled; hospital admission is indicated although death not imminent.

20 Very sick; hospital admission necessary; active supportive treatment necessary.

10 Moribund; fatal processes progressing rapidly.

0 Dead

ECOG PERFORMANCE STATUS

Grade ECOG

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours

3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours

4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

5 Dead

0–10 Numeric Pain Rating Scale

Duration of Treatment

<6mth 6-12mths 13-18mths 19-24mths >24mths0

2

4

6

8

10

12

No of patients

Dose reduction

44%

56%

Chart Title

Y N

Spinal Cord Compression

Y21%

N79%

Bone Pain

62%

38%

Y N

Improvement in pain scores

Yes No No pain

64.7%

23.5%

11.8%

Percentage of patients

Improvement in pain

Average no. of doses before decrease in pain noticed 2.5 doses

Average decrease in numeric pain rating: approximately 3.5pts

Improvement in mobility

Yes No

44.1%

55.9%

Percentage of patients

Improvement in mobility

Average no. of doses before change noticed: 2months

Average increase in performance status by ECOG Scale approximately 2pts

Average increase in performance status by Karnofsky Scale approximately 20pts

Skeletal Related Events

Nil adverse eventsSRE

DISCUSSION

What is Zometa?

Zometa (Zoledronic acid) belongs to a class of drugs known as bisphosphonates.

Zometa fights against skeletal destruction in advanced tumours and multiple myeloma

Mechanism of action

Mechanism of action

In addition to being a potent inhibitor of bone resorption, Zometa also possesses anticancer properties that could contribute to its overall efficacy in the treatment of metastatic bone disease

Zometa is administered as an IV infusion every 3-4 weeks in MM and advanced solid tumours

SRE

Skeletal Related events can shorten the survival in patients with advanced prostate and breast CA

Prostate CA

49% of patients with advanced prostate Ca and bone metastases will experience a SRE within the first 2yrs

Average time to first SRE is 10.7mths

Average frequency of SRE was approximately every 8 mths

Breast CA

68% of patients with advanced breast Ca and bone metastases will suffer a SRE within 2yrs

The average length of time to first time SRE was 7mths

The frequency of SREs occur approximately every 3mths

In view, of data collected in audit thus far.

At a cost of $2400.00TT per dose of Zometa vs an average $1100.00TT per hospital bed per night.

How cost effective is the use of Zometa in Palliative care in our setting?

References 1. Coleman RE. Metastatic bone disease: clinical features, pathophysiology and treatment

strategies. Cancer Treatment Rev. 2001;27:165-176. 2. Lipton A, Theriault RL, Hortobagyi GN, et al. Pamidronate prevents skeletal complications

and is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases: long term follow-up of two randomized, placebo-controlled trials. Cancer. 2000;88:1082-1090.

3. Saad F, Lipton A, Cook R, Chen Y-M, Smith M, Coleman R. Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer. 2007;110:1860-1867.

4. ZOMETA Summary of Product Characteristics. Novartis Pharma AG. 5. Andre F, Slimane K, Bachelot T, et al. Breast cancer with synchronous metastases: trends

in survival during a 14-year period. J Clin Oncol. 2004;22:3302-3308. 6. Rosen LS, Gordon D, Kaminski M, et al; Zoledronic Acid Breast Cancer and Multiple

Myeloma Study Group. Long-term efficacy and safety of zoledronic acid compared with pamidronate disodium in the treatment of skeletal complications in patients with advanced multiple myeloma or breast carcinoma: a randomized, double-blind, multicenter, comparative trial. Cancer. 2003;98:1735-1744.

7. Kohno N, Aogi K, Minami H, et al. Zoledronic acid significantly reduces skeletal complications compared with placebo in Japanese women with bone metastases from breast cancer: a randomized, placebo-controlled trial. J Clin Oncol. 2005;23:3314-3321.

8. Aapro M, Abrahamsson PA, Body JJ, et al. Guidance on the use of bisphosphonates in solid tumours: recommendations of an international expert panel. Ann Oncol. 2008;19:420-432.

9. Van Poznak CH, Temin S, Yee GC, et al. American Society of Clinical Oncology executive summary of the Clinical Practice Guideline update on the role of bone-modifying agents in metastatic breast cancer. J Clin Oncol. 2011;29:1221-1227.