1. SUPPORTIVE AND PALLIATIVE CARE Andrés Cervantes University Hospital Valencia SPAIN

6. CARE VS CURE IT IS NOT ALL VERSUS NOTHING CARE SHOULD BE PLANNED EARLY EVEN WHEN SYMPTOMS HAVE NOT APPEARED

7. DIFFERENCES BETWEEN TRADITIONAL ONCOLOGY AND PALLIATIVE MEDICINE ISSUES ONCOLOGY PALLIATIVE CARE AIMS CURE CARE ANAMNESIS GENERAL SYMPTOM ORIENTED PATHOCRONY ACUTE IT NEVER STOPS VS CHRONIC DECISIONS PHYSICAL PHYSICAL, SOCIAL EMOTIONAL SPIRITUAL DO NOT RESUCITATE ORDERS SOMETIMES ALLWAYS DIAGNOSTIC INSTRUMENTAL MINIMAL TEAM HEALTH INVOLVES PROFESSIONALS PATIENTS/FAMILY

9. MRS. X IS A 55 YEAR-OLD BUSSINESS EXECUTIVE WITH A PAST HISTORY OF RECENTLY DIAGNOSED BREAST CANCER EIGHTEEN MONTHS AGO SHE DISCOVERED A 2 CM RIGHT UPPER QUADRANT BREAST MASS SHE HAD A PARTIAL MASTECTOMY WITH AXILLARY DISECTION 3/10 AXILLARY NODES WERE INVOLVED WITH TUMOR ESTROGEN AND PROGESTERONE RECEPTORS +

10. Mrs X. HAS ENJOYED EXCELLENT HEALTH, EXCEPT FOR EPISODES OF CHRONIC LOW BACK PAIN, WITH OCCASIONAL FLARE-UPS OF A RIGHT-SIDED SCIATIC PAIN SYNDROME SHE BLAMES HER BACK PAIN ON THE 10 YEARS SHE SPENT AS A NURSE. SHE REMEMBERS AN ACUTE EPISODE OF BACK PAIN WHEN LIFTING A HEAVY PATIENT SHE IS LEADING WITH SUCCES A CATERING FIRM WITH ONE OF HER SONS SHE IS HAPPILY MARRIED WITH FOUR FULLY GROWN CHILDREN

11. AFTER BREAST SURGERY SHE HAS BEEN ON TAMOXIFEN DURING THE PAST TWO WEEKS SHE HAS DEVELOPPED STEADLY INCREASING PAIN IN THE CALF AND THE LATERAL ASPECT OF HER LEFT FOOT ONE OF HER DAUGHTERS, A PHYSICIAN, GAVE HER A COMBINATION OF ACETAMINOPHEN-CODEINE, WHICH ONLY SLIGTHLY ALLEVIATED THE PAIN Mrs. X THINKS THE ASSOCIATED CONSTIPATION HAS MADE THE PAIN WORSE SHE GOES TO HER DOCTOR FOR ADVICE

12. HOW YOU WILL ASSESS Mrs. X COMPLAINT?

15. HISTORY TAKING : WHILE PAIN IS SUBJECTIVE, IT CAN BE QUANTIFIED WITH SYMPTOMS RATING SCALES

16. QUANTIFICATION OF PAIN EDMONTON SYMPTOM ASSESSMENT SYSTEM DATE: no pain severe pain very active inactive no nausea severe nausea no depressed very depressed no anxiety severe anxiety no dizzy severe dizziness good appetite Sever anorexia Wellfare very uncofortable no air hunger severe dyspnea Assessed by:---------------

18. PHYSICAL EXAMINATION Mrs. X HAS SEVERAL FIRM, PAINLESS RED NODULES IN THE AREA OF THE OPERATIVE SCAR ON THE RIGHT CHEST WALL SHE GOT EXQUISITE PAIN WHEN YOU CARRY OUT GENTLE PERCUSSION OVER THE LOWER LUMBAR VERTEBRAE THE ANKLE JERK ON THE LEFT WAS ABSENT OCCASIONAL MUSCLE FASCICULATIONS ON THE LEFT CALF AREA STRAIGHT LEG-RAISING IS LIMITED BY PAIN ON THE LEFT AND THERE IS A PATCHY AREA OF HYPOAESTESIA IN THE LATERAL LEFT CALF

19. IN THIS CASE THE HISTORY REVEALS THAT: PAIN IS WORSE ON WALKING AND RELIEVED BY REST THE PATIENT IS OFTEN AWAKENED BY PAIN THE CALF AND FOOT PAIN IS DESCRIBED AS A DULL ACHE WITH A LANCINATING QUALITY PRECIPITATED BY WALKING SHE STATES THAT SHE HAS LOW-GRADE BACK PAIN, BUT SHE THINS IS QUITE DIFFERENT TO WHAT SHE EXPERIENCED BEFORE “ I GUESS LIFTING ALL THOSE PATIENTS IS COMING BACK TO HAUNT ME NOW, DOCTOR”

20. IN THIS CASE THE HISTORY REVEALS THAT: THE PATIENT RATES PAIN IN A PAIN SCALE AS 8/10 THE PAIN IS CONSTANT WHILE SHE IS AWAKE THE PATIENT IS UNDER SOME STRESS BECAUSE OF WORK ACTIVITIES, AND SHE BELIEVES THAT THIS MIGHT AFFECT HER PAIN

21. SUMMARY: BREAST CANCER 18 MONTHS AGO LOCAL SKIN RELAPSE SUSPECTED PAIN AND VERY SENSITIVE AREA UNDER LOW BACK PRESSURE DO NOT SUGGEST OSTEOPOROSIS OR DISC HERNIATION

22. TESTS TO DE DONE : BIOPSY OF A SKIN NODULE COMPLETE BLOOD COUNTS CALCIUM, LIVER AND KIDNEY FUNCTION ASSESSMENT CHEST X-RAY LUMBAR VERTEBRAE X-RAY BONE SCAN

23. BONE PAIN EPIDEMIOLOGY 60-85% OF PATIENTS WITH SOLID TUMORS ARE GOING TO PRESENT WITH BONE METASTASES THE MOST PREVALENT ARE BREAST, PROSTATE, LUNG, MULTIPLE MYELOMA, THYROID AND KIDNEY TUMORS REACH BONE BY HEMATOGENOUS SPREAD BONE METASTASES MAY BE LYTIC OR BLASTIC

24. BONE METASTASES COMPLICATIONS PAIN PATHOLOGIC FRACTURES LOSS OF FUNCTION DE FUNCIÓN: INMOVILITY BONE MARROW FAILURE: PANCYTOPENIA HYPERCALCEMIA CORD COMPRESION SYNDROME

25. HOW WILL YOU TREAT THE PAIN?

26. PRINCIPLES FOR TREATING CANCER PAIN BY THE WHO LADDER BY THE CLOK BY ORAL ROUTE PREVENTING TOXICITY: USE OF ADJUVANTS

27. PRINCIPLES FOR TREATING CANCER PAIN BY THE WHO LADDER 1. TO INITIATE WITH A NON-STEROIDAL ANTI-INFLAMATORY DRUGS OR ACETAMINOPHEN 2. IF PAIN PERSISTS, A MINOR OPIOID SUCH AS CODEIN SHOULD BE ADDED 3. MAJOR OPIOIDS SHOULD BE INITIATED IF MODERATE OR SEVERE PAIN IS NOT CONTROLLED

29. PRINCIPLES FOR TREATING CANCER PAIN BY MOUTH ANALGESICS SHOUL BE ALWAYS ADMINISTERED BY ORAL ROUTE, IF POSSIBLE IF IT IS NOT, DO CONSIDER TRANSDERMIC OR RECTAL ROUTES IF PARENTERAL ROUTE NEEDED, SUBCUTANEOUS ADMINISTRATION IS PREFERED TO INTRAMUSCULAR DO TREAT IN INDIVIDUAL BASES PAY ATENTION TO DETAILS

30. CONSIDERING MRS X’S PAIN: IT IS A SEVERE PAIN, NOT IMPROVING AFTER CODEIN AND ACETAMINOPHEN (WHO LADDER STEP 2). TREATMENT SHOUL BE INITIATED WITH MORPHIN SULPHATE (WHO LADDER STEP 3) RAPID LIBERATION MORPHINE 10 MG EVERY 4 HOURS WITH A NIGHT DOSE OF 20 MG SHE HAS TO TAKE MORPHIN REGULARLY INDICATE THAT DOSE SHOUL BE ADJUSTED DEPENDING ON EFFICACY. IF PAIN REAPPEARS AT INTERVALS AN EXTRA DOSE SHOULD BE ADDED. ADJUVANTS: SALICYLATES OR IBUPROPHEN/

31. Mrs. X SAYS THAT SHE CAN NOT TAKE MORPHINE BECAUSE SHE IS ALLERGIC SHE TOOK MORPHINE SEVERAL YEARS AGO TO TREAT A POSTOPERAVTIVE PAIN AND SHE GOT NAUSEA AND VOMITING SHE DID NOT PRESENT WITH URTICARIA, LARINGEAL EDEMA, OR OTHER ANAPYLACTIC RELATED SYMPTOMS ALLERGY TO MORPHINE IS VERY EXCEPTIONAL AND OCCURS IN LESS THAN 1% OF PATIENTS Mrs. IS NOT ALLERGIC. SHE ONLY HAD COMMON COLLATERAL EFFECTS OF MORPHINE

32. WILL SHE GET NAUSEA AND VOMITING AGAIN WHEN SHE TAKES MORPHINE THIS TIME? MOST PROBABLY YES : ONE THIRD OF PATIENTS HAVING MORPHINE HAVE NAUSEA AND VOMITING BUT ... TOLERANCE DEVELOPS VERY RAPIDLY WITHIN A FEW DAYS PROPHYLACTIC ANTIEMETICS DURING THE FIRST WWEK OF THERAPY (METOCLOPRAMIDE 10 MG/6 HOURS) ARE RECOMMENDED TO AVOID THIS TOXICITY

33. WHAT OTHER TOXIC EFFECTS HAVE TO BE PREVENTED? CONSTIPATION SLEEPYNESS RESPIRATORY DEPRESSION CONFUSION

34. Mrs. X’S DAUGTHERS IS A RADIOLOGISTS. SHE IS WORRIED ON THE USE OF MORPHINE WOULD IT NOT BE POSIBLE TO CURE MY MOTHER WITH ANY SPECIFIC ANTITUMOR AGENT? I WOULD NOT LIKE TO SEE MY MOTHER SUFFERING, BUT I DON NOT WISH HER TO BECOME A MORPHINE ADDICT IF DISEASE PROGRESSES AND PAIN INCREASES, HOW ARE WE GOING TO CONTROL PAIN IN SUCH A DIFFICULT PERIOD? TOLERANCE, PHYSICAL DEPENDENCE, ADDICTION

35. TOLERANCE THIS IS THE GRADUAL DEVELOPMENT OF RESISTANCE TO THE EFFECTS OF A DRUG SUCH THAT MORE DRUG IS NEEDED TO PROVIDE THE SAME EFFECT TOLERANCE DEVELOPS TO BOTH BENEFITIAL AND ADVERSE EFFECTS OF OPIOIDS AT APPROXIMATELY THE SAME RATE EXCEPTING: RAPID TOLERANCE FOR: NAUSEA AND VOMITING SLOW TOLERANCE FOR : CONSTIPATION SLOW TOLERANCE FOR ORAL ADMINISTRATION RAPID TOLERANCE IF PARENTERAL ADMINISTRATION

36. PHYSICAL DEPENDENCE THIS IS CAUSED BY PHYSIOLOGIC ADAPTATION OF TISSUES TO THE EFFECT OF A DRUG IT HAS TO BE DIFFERENTIATED FROM ADICTION IT IS FREQUENT IT IS NOT DIFICULT TO LOWER DOWN OR TO SUPRESS MORPHINE IN PATIENTS WITHOUT PAIN REDUCE MORPHINE DOSE BY 25% AND SUPPRESS IN 7-14 DAYS

37. ADDICTION THIS IS A DISEASE STATE CHARACTERIZED BY COMPULSIVE REPETITIVE DRUG USE, WITH LOSS OF CONTROL AND CONTINUED DRUG SEEKING, DESPITE SEVERE ADVERSE CONSEQUENCES IS VERY EXCEPTIONAL WITH MORPHINE (<1:1000) PSEUDOADICTION IF PAIN IS NOT WELL CONTROLLED

38. WHAT TYPE OF COMORBIDITIES WILL INCREASE THE RISK OF TOXIC EFFECTS? KIDNEY FUNCTION SHOULD BE ASSESSED IN CASE OF RENAL FAILURE, URINARY ELIMINATION OF ACTIVE METABOLITES OF MORPHINE IS DECREASED AND TOXICITY MAY BE INCREASE ELIMINATION OF MORPHINE CAN ONLY BE AFFECTED IF VERY SEVERE LIVER FAILURE IS OCCURRING

39. WHY SHOULD BE ASSOCIATE ANOTHER ANALGESIC DRUG TO MORPHINE? THE ASSOCIATION OF SALYCILATES OR NONSTEROIDAL ANTINFLAMATORY DRUGS IS USEFUL FOR TREATING BONE PAIN CAUSED BY BONE METASTASES OR SOFT-TISSUE INFILTRATION DUE TO TUMOR. TOXICITY CAUSED BY THOSE AGENTS SHOULD BE ALSO CONSIDERED: DECREASED GLOMERULAR FLOW RATE GASTRODUODENAL ULCERS BLEEDING DO NOT USE TWO ANTINIFLAMMATORY AGENTS AT THE SAME TIME AND EVOID ITS ASSOCIATION WITH CORTICOIDS

40. WHY DID WE CHOOSE IBUPROFEN? IT IS SAFE AND CHEAP THERE IS NOT AN ANTI-INFLAMMATORY DRUG BETTER THAN OTHER INDIVIDUAL VARIATIONS IN RESPONSE ARE FREQUENT IF IBUPROFEN IS NOT USEFUL, NAPROXEN OR DICLOFENAC MAY BE USED

41. Mrs. X AND HER DAUGHTER DO NOT WISH TO BE A PASSIVE RECIPIENT OF TREATMENT. IT IS IMPORTANT TO STABLISH A GOOD RELATION WITH PATIENTS AND FAMILIES PATIENT AND FAMILY EDUCATION IS IMPORTANT TO CONTROL PAIN WRITTEN TREATMENT PLANS ARE TO BE GIVEN

42. PSYCOLOGICAL INTERVENTIONS PAIN IS A SENSORY EXPERIENCE WHICH IS ACCENTUATED WHEN PATIENTS ARE ANXIOUS OR DEPRESSED TO ALLEVIATE PSYCOLOGICAL STRESS MAY BE IMPORTANT PSYCOLOGICAL INTERVENTIONS SHOULD BE OFFERED EARLY IN THE COURSE OF ILLNESS AND MAINTAINED THROUGHOUT THE FULL TRAJECTORY.

43. TEN DAYS AFTER MRS X CAME TO SEE THE RESULTS OF THE TESTS THE SKIN BIOPSY SHOWED A METASTASIS DUE TO BREAST CANCER WITH ER AND PgR NEGATIVE BONE SCAN: MULTIPLE HYPERCAPTATION IN SEVERAL AREAS, PARTICULARLY IN BACK BONE MULTIPLE LYTIC AND BLASTIC LESIONS OVER THE LOWER LUMBAR SPINE AND PELVIS IN RADIOGRAPHS. CBC, RENAL AND LIVER TESTS NORMAL CHEST-X-RAY WITHOUT LUNG METASTASES

44. Mrs. X PRESENTS A GOOD CONTROL OF PAIN : 2-3/10 WHEN WALKING AND 0/10 AT REST SHE IS NOT SUFFERING FROM TOXIC EFFECTS SHE TAKES 10 MG OF MORPHINE EVERY 4 HOURS DELAYED ORAL MORPHINE 30 MG EVERY 12 HOURS WAS RECOMMENDED THERAPEUTIC PLAN: MEDICAL ONCOLOGY

45. THERAPEUTIC PLAN : MEDICAL ONCOLOGY USE DE BIPHOSPHONATES IHNIBITORS OF BONE REABSORPTION (ZOLEDRONATE) LUMBAR VERTEBRAE: RADIOTHERAPY WITH ANALGESIC INTENTION CHEMOTHERAPY