Presentazione sul tema: "Azienda Ospedaliera Sant’Andrea"— Transcript della presentazione:
1Azienda Ospedaliera Sant’Andrea Paolo MarchettiOncologia MedicaII Facoltà diMedicina e ChirurgiaSapienzaUniversità di RomaAzienda Ospedaliera Sant’AndreaRomaLa terapia di supporto
2Azienda Ospedaliera Sant’Andrea Paolo MarchettiOncologia MedicaII Facoltà diMedicina e ChirurgiaSapienzaUniversità di RomaAzienda Ospedaliera Sant’AndreaRomaLa simultaneous care!
3Oggi… La tutela della salute = prodotto L’assistenza sanitaria = servizioil malato = utentel’ospedale = aziendalo Stato, definisce, eroga, paga e controlla le prestazioni.ma è corretto definire la salute come un prodotto o servizio e la persona malata come cliente o utente?
4Significant unmet needs Significant unmet needs are those needs that patients identify as both important and unsatisfied.The range of unmet need, and the kinds of patients who are more likely to claim unmet need, should be carefully identified.K. Soothill et al., Supportive Care in Cancer, 2001
5Simultaneous care in oncology Unmet needs in cancer patients
6Significant unmet needs The NHS Cancer Plan  has highlighted the need to streamline cancer services ‘around the needs of the patient’ and to provide ‘the right professional support and care as well as the best treatments’.However, the real question is whether the overall needs of cancer patients are actually being met.K. Soothill et al., Supportive Care in Cancer, 2001
7Number of unmet needsK. Soothill et al., Supportive Care in Cancer, 2001
8Significant need and unmet need Top 18 items K. Soothill et al., Supportive Care in Cancer, 2001
10Ministero della Salute PIANO ONCOLOGICO NAZIONALE 2010/2012
11WHAT IS PERSONALIZED HEALTHCARE? Medical practices that are targeted to individuals based on their specific genetic code in order to provide a tailored approach.The goal of personalized health care is to improve health outcomes and the health care delivery system, as well as the quality of life of patients everywhere.
12Every Tumor is Unique! Mutations Are Random. Every tumor develops a unique antigenic fingerprint.10-8 per bp per cell division cycle on 6 x 109 bp = thousands to millions of unique mutations
13Every Patient is Unique! Problems Are Random. Every patient develops a unique individual fingerprint.thousands of unique problems!
14Leaving the era of the “median results”, but targeting … what? Patient:Genotype and polymorphisms:role of SNPs (CYP2D6)Tumor: refining the population targetProliferation gene Index (PGI): the best ?RE+/PG- population: does it mean something?EGFR: is or is not ?Triple negative BC: time for separating ?
15Tamoxifen activity is related to its metabolic pathway 80 variant alleles of cytocrome p450 2D6Alleles 3,4 5 6 account for 99% of the variantsCatalyzes metabolism of many common drugsInhibited by flouxetina and paroxetina, frequently used by women assuming tamoxifenTamoxifen metabolites have different anti-estrogenic power.
16Practical implication Very important remind: we deal not only with the tumor, but also with the hostSimilar observation with other anti-hormonal drugs (i.e. CYP19 and Letrozole, ASCO 2004)Confirmatory and prospective studies neededIn the meanwhile, pay attention to all drugs you administer in combination with TAM, particularly new antidepressantimplication in some type of drug resistance?
17Leaving the era of the “median results”, but targeting … what? Patient:Genotype and polymorphisms:role of SNPs (CYP2D6)Tumor: refining the population target
18Histologically they look like, but… Pt 39 yrs, pre-menopausalT 2.2 cm, N (-), G1ER (±)/PR(+), HER-2 (-)09/2000: QUARTFEC100 x LHRH-TamPt 47 yrs, pre-menopausalT 2.4 cm, N (-), G1ER (±)/PR(+), HER-2 (-)12/2003: QUARTFEC100 x LHRH-Tam10/2004: Metastatic disease09/2005: NEDTopoisomerase IIBy courtesy of S. Iacobelli, 2006
19Cancer BiologyDiversity of tumor subtypes: time for separating patients and treatments?Going inside to cancer biology can help clinicians?
20Targeting Dysregulated Pathways With Novel Agents
21Circulating Tumor Cells at First Follow-Up Predict Progression-Free Survival 100% 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 %<5 CTC (n=114), ~7.0 months≥5 CTC (n=49), ~2.1 monthsFirst follow-up (3-4 wk), n=163, Logrank p < 0.001Percent probability of progression-free survival~2.1 months~7.0 monthsSlide 4.30Ideally, we would like to not only predict progression-free survival at baseline but also be able to predict whether therapy affected this progression-free survival. To test whether this was viable, the Hayes group drew blood at various intervals throughout therapy. They found that at about one month after the initiation of new systemic therapy, patients with greater than five circulating tumor cells had a progression-free survival rate of 2.1 months, suggesting that their initial therapy was probably not going to work. However, participants with five or less circulating tumor cells had a progression-free survival rate of about seven months.Time from baseline (weeks)CTC = circulating tumor cellsCristofanilli M et al. N Engl J Med 2004;351(8):
23Challenges of cancer treatment The key goals of cancer treatment remain toCure patientsImprove overall survivalImprove quality of lifeIdentify novel targets and therapeuticsProvide more tailored, individualized treatment
25Leaving the era of the “median results”, but targeting … what? PatientTumorThe patient with a cancer!
26How Accurate Is Clinician Reporting of Chemotherapy Adverse Effects? 10038657765701730608060Percentage4020It is quite accurate, however, for nausea, vomiting, and diarrhea, which are expected after chemotherapy. By comparison, 77% of patients reporting dyspnea were not identified by the physician as having it. To understand some of this cardiotoxicity, more vigilance is needed toward the symptoms that could relate to it.FatiguePainDyspneaInsomniaAnorexiaNausea/VomitingDiarrheaConstipationPhysician identifiedPhysician missedJ Clin Oncol. 2004; 22:Slamon D. SABCS General Session I.
28ESMO takes a stand on supportive and palliative care Make alleviation of pain and other symptoms a high priorityMedical oncologist must be expert with the evaluation and management of pain and other symptomsCancer center should provide supportive and palliative care as part of the basic basket of services.Sottolineare i termini usati“takes a stand”“must be expert”(Ann Oncol 14: 1335, 2003)
29Bridging the Divide: Integrating Cancer-Directed Therapy and Palliative Care We must take symptom management a priority at diagnosis, throughout treatment, during periods without treatment, and finally, at the end of lifeWe need all of these effort and more to traverse the divide that now exists between palliative care and cancer-directed therapy.SottolineareTutte le fasi della malattiaUnire ciò che ora è divisoIntegrazione piuttosto che sequenzaContinuità piuttosto che separazione(JL Malin, JCO 22: 3438, 2004)
31FatigueAgreement and disagreement between patients and clinicians. E. Basch et al., Lancet Oncol 2006
32Survival According to the Underlying Cause of Cardiomyopathy 1.00Peripartum0.751%IdiopathicDue todoxorubicin therapyProportion of Patients Surviving0.50Due toischemic heart diseaseAs of 2002, the most common therapeutics associated with cardiomyopathy are the anthracyclines. They account for only approximately 1% of adult cardiomyopathy with a particularly adverse outcome of approximately 50% at 2 years.Due to infiltrative myocardial disease0.25Due to HIV infection0.0051015YearsFelker GM, et al. N Engl J Med. 2000;342:
3343. 7% of Medical Oncologists used multiple symptoms tools and 37 43.7% of Medical Oncologists used multiple symptoms tools and 37.9% used symptom specific tools;58.9% used some instrument to assess pain.More than a third of the respondents (35.5%) used patient-tailored protocols.No statistical differences were found regarding region of residency, availability of consultants in pain therapy and/or palliative care, colleagues with main interest on palliative care, and beds dedicated to palliative care.
37Prevalence of BTcPThe prevalence of BTcP may differ due to the stage of the cancer and the methodology of the different studies, but it remains an important problem in cancer patients who are already receiving treatment for their pain.Up to 95% of patients with cancer suffer from BTcP.Zeppetella G, Ribeiro MD. Pharmacotherapy of cancer-related episodic pain. Expert Opin Pharmacother 2003
39Nutrition assessmentWeight loss at the time of diagnosis has been associated with decreased survival and reduced response to treatment.Dewys WD, Am J Med, 1980Treatment of nutrition-related symptoms reverse weight loss in in 50-88% of cancer patients.Ottery FD, Proc Am Soc Clin Oncol, 1998Assessment with Patient-Generated Subjective Global Assessment (PG-SGA), anthropometric and laboratory data or Bioelectrical Impedance Analysis (BIA– unavailable in most ambulatory settings)Sungurtekin H, Nutrition, 2004Lukaski HC, Ann N Y Acad Sci, 1999
40Cancer rehabilitation is the process that assists the cancer patients to obtain maximal physical, social, psychological and vocational functioning within the limits created by the disease and its treatment
41Optimization of physical functioning Vocational counselling The rehabilitation approach to cancer treatment originates with National Cancer Act (NCA) of 1971In 1972, the NCI sponsored the National Cancer Rehabilitation Planning Conference and developed training programs and research projects to identify 4 objectives in cancer rehabilitation:Psychosocial supportOptimization of physical functioningVocational counsellingOptimization of social functioning
42why do women fear breast cancer more than any other health risk? One out of two women in the United States will die from heart disease or stroke.Women also believe ovarian cancer is their biggest "cancer" threat when it is actually lung cancer that kills 70,000 women a year.
43The risk was perceived three times higher than it actually was. Breast Cancer Risk:Perception vs Reality Nearly 90% of Women Overestimate Breast Cancer RiskWhen asked to estimate the average lifetime chance of developing breast cancer, nine out of 10 women overestimated the risk.The risk was perceived three times higher than it actually was.P. Ubel et al., Patient Education and Counseling, 2005
44Breast Cancer Risk:Perception vs Reality Nearly 90% of Women Overestimate Breast Cancer Risk Estimating RiskRoughly one in eight women will eventually develop breast cancer. In other words, a woman has a 13% chance of developing breast cancer at some point during her life.Numbers don't give context: asking the patients to estimate their own risk can help put the actual risk in perspective.We shouldn't just throw numbers at patients without giving them some context for those numbers!P. Ubel et al., Patient Education and Counseling, 2005
46Comprendere ilPaziente! Quanto è grave la sua malattia?Quanto è curabile la sua malattia?
47The risk perception attitude (RPA) framework Four attitudinal groups based on their perceptions of risk and beliefs of personal efficacy.Responsive (high risk, high efficacy)Avoidance (high risk, low efficacy)Proactive (low risk, high efficacy)Indifference (low risk, low efficacy)These groups differ from each other in their self-protective motivations and behaviors.
48Comunicare in oncologia Cosa? Il tipo di trattamentoGli effetti collateraliLe risposte atteseLa prognosi
49… ma anche I risultati delle rivalutazioni clinico-strumentali Assenza di tumore o non evidenza di ripresa di malattia?Angoscia per i prossimi controlli o falsa tranquillità per i successivi 6/12 mesi?
50… ma anche Variazioni nel tipo di farmaco usato Paziente asintomatica, senza progressione di malattia, preoccupata di eventuali nuovi effetti collaterali.Paziente sintomatica, preoccupata che il cambio di farmaco sia dovuto ad un fallimento della precedente terapia
51Caso clinicoPaziente di 70 anni, operata per un ca della mammella da 2 anni, in trattamento adiuvante (precauzionale) con tamoxifen.Sulla base dei risultati con gli IA, deve sostituire il tamoxifen con un IA.La Paziente non ha avuto alcun effetto collaterale con il tamoxifen.Informata dei possibili effetti collaterali degli IA, è spaventata.Rinuncerà ai benefici della nuova terapia?
52l’informazione sulla diagnosi di tumore secondo le risposte dei caregiver Al paziente è stato detto che aveva un tumore?%(95% CI)SI37(34-40)NO, ma lo sapevano29(27-32)NO e non lo sapevano26(24-29)NO, non so se sapevano7(6-10)M. Costantini et al., Ann Oncol, 2006
53l’informazione sulla diagnosi di tumore secondo le risposte dei caregiver Quando la prognosi è diventata sfavorevole, è stato comunicato al paziente?%(95% CI)SI13(10-15)NO, ma lo sapevano50(46-54)NO e non lo sapevano27(24-30)NO, non so se sapevano10(8-14)M. Costantini et al., Ann Oncol, 2006
54ricevono più informazione l’informazione sulla diagnosi di tumore secondo le risposte dei caregiverchi sono i pazienti chericevono più informazioneresidenti nel nord Italiapiù giovanicon titolo di studio elevatocon tumori testa-collo o mammariocon aspettativa di vita lunga alla diagnosiM. Costantini et al., Ann Oncol, 2006
55Il punto di vista dei pazienti Il punto di vista dell’opinione pubblicaM. Costantini, 2008
56% di pazienti oncologici a cui è stata comunicata la diagnosi di tumore nei diversi studi italiani dal 1985 al 2005!M. Costantini, 2008
57Comunicare in oncologia Quando? Al momento della prima visita, delineando tutte le varie possibilità terapeutiche in funzione dei possibili risultati?In maniera continuativa, durante le diverse fasi dela evoluzione clinica della malattia?
58Comunicare in oncologia A chi? Ogni tipo di comunicazione deve essere attuata tenendo ben presente la persona malata, nella sua complessità ed interezza, valutando le sue specifiche caratteristiche umane, i suoi problemi e le sue preoccupazioni familiari, le sue incertezze e le sue paure sociali, insieme alle caratteristiche cliniche della neoplasia.
59Caso clinico Paziente di 41 anni, importante dirigente di industria. Viene operata per una carcinoma della mammella ad alto rischio e deveessere sottoposta a chemioterapia e ad ormonoterapia per 5 anni.… ma aveva deciso di avere dei figli con il suo nuovo compagno!
60A chi?La familiarità e la predisposizione genetica.
61Caso clinicoDonna di 36 anni, 3 figlie, M5 e O3, viene operata per un carcinoma ovarico.Paura per le figlie.Interessi conflittuali con i familiari.
62Comunicare in oncologia Come? Numeri, percentuali, numeri…Facile, poco coinvolgente, apparentemente molto tecnico.Ma le percentuali si riferiscono a popolazioni e non al singolo paziente che sied di fronte a noi!
63La comunicazione in oncologia La comunicazione in oncologia. Necessità clinica o inutile complicazione assistenziale?
64Study of unmet needs in symptomatic veterans with advanced cancer The total number of unmet needs was predictive of QOL.Shirley S. Hwang et al., 2004
65End of life issues and spiritual histories Patients facing end-of-life issues have spiritual concerns that may have an impact on their medical decision-making.Conclusion:Spiritual concerns of many patients facing end-of-life decisions are not being addressed.King DE e al (2003) End of life issues and spiritual histories South medical Journal 96:
66Religious struggle as a predictor of mortality among medically ill elderly patients. Although church attendance has been associated with a reduced risk of mortality, no study has examined the impact of religious struggle with an illness on mortality.Certain forms of religiousness may increase the risk of death.Elderly ill men and women who experience a religious struggle with their illness appear to be at increased risk of death, even after controlling for baseline health, mental health status, and demographic factors.Pargament Kl e al (2001) Religious struggle as a predictor of mortality among medically ill elderly patients. Archives Internal Medicine. 161:
67Breast cancer in the family Children's perceptions of their mother's cancer and its initial treatment .
69Cancer survivors with unmet needs were more likely to use complementary and alternative medicine. Despite advancements in cancer care, cancer survivors continue to experience a substantial level of physical and emotional unmet needs.Cancer survivors who experienced unmet needs within the existing cancer treatment and support system were more likely to use CAM to help with cancer problems.JJ Mao et al., J Cancer Surviv. 2008