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Patient Doctor
Other doctors (consultant)
Cytopathologist
Radiologist
Laboratory
MANAGEMENT OF CANCER PATIENT
diagnosis and treatment patient depend on one clinician only
Medical Team (teamwork) Standard Facility Standard Protocol
Medical Record
Patient
Better Communication Unity of work rhythm
Minimal mistakeMaximal patient service
MANAGEMENT OF CANCER PATIENT
Oncology aspect
Patients & family aspect
Outcome & Side Effect Monitoring
Oncology Aspect
Diagnose:- pathology :* morphologic class : adenoCa ? * histologic grade * pattern of invasion - tumor biology ? : Her2Neu, CD20, p53, Bcl2 proliferation indeces
Diagnose: Staging
Medical Status: Risk group - Anamnesa (co-morbid) - Physic, Laboratory, ECG - Performance status (Karnosfky-ECOG)
Patients & family Aspect
Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemotherapy - informed consent
Outcome & Side Effect Monitoring
SurvivalObjective & Subjective Outcome
Diagnose & management
Outcome Side Effect
Mechanism chemotherapy in cellular level Reduction of tumor after Chemotherapy Rational , patient financial ?
Cell Cycle mechanism
Doubling Time
Check point controle mechanism
Target of Actions of drugs( Phase specificity ? / Non phase ?)
2.Tumor cell Apoptosis
Mechanisme of Actions
Mitochondrial pathway (Bcl2 family,p53)
Death receptor pathway (Fas-FasL, caspase family of protein)
1.Tumor cell proliferation
( influence on the response to chemotherapy )
MG2
G1S
Bleomycin
5 Fudrara C6-Hydroxyurea5 FUMETHOTREXATE
6-Thioguanine
6-Marcaptopurine
Mytomycin
Actinomycin D
Hydrocortisone Chalones
5 FUVinblastineVincristineColchicineGriseofulvin
Differentiation
Phleomycin
Cyclophosphamide
Purin antagonisHydroxy urea
Actinomycin
Cyclophosphamide
5 Fudr .5FU, Ara C. Mitomycin,Doxorubicin Thioguanine
18-30h6-20h
0,5-1h0.5-1h
2-10h
Doxorubicin
Alkylating agent AntimetabolicMitotic inhibitor, Antibiotic
No response Early recurrence Late recurrence
Tumor detectable(clinically)
Long-term Remission Not palpable
Immune resistanceof host(humoral&cellular)
Induction Consolidation Maintenance Cure
1012
109
106
103
(1kg)
(1 g)
(1 mg)
Number ofTumor cell
Tumor invisible(Remission)
(1 úg)
Tepat indikasi : kemoterapi tepat dipilih berdasar titik tangkap kerjanya berdasar patogenesis kanker sehingga dapat tercapai tujuan : 1.kuratif 2.mencapai bebas penyakit (DFI) yang lebih lama 3.neoadjuvant (mengecilkan volume tumor preoperasi- down staging) 4.mempertahankan atau meningkatkan quality of life (terapi paliatif)
Tepat cara pemberian obat : oral, IV, bolus, infusion dsb yang penting : penderita nyaman , tidak takut dan dengan kesadaran sendiri ingin melanjutkan kemoterapi Tepat monitoring efek obat : - penilaian hasil / respons terapi - kemampuan hidup (quality of life) dan - efek samping obat
Tepat jenis obat : sebaiknya lebih spesifik, selektif, mem- punyai Response rate tinggi, established, dan dapat dijangkau oleh penderita
Tepat dosis obat : sesuai Maximum Tolerated Dose ( Risk group )
1.Objective Response Evaluation2.Subjective Response Evaluation(3). Survival
CANCER OUTCOME of TREATMENT
OBJECTIVE RESPONSE EVALUATIONS
1. TUMOR SIZE : - Complete remission (CR) - Partial remission (PR) - No Changes (Stable Disease = St D) - Progressive Disease (PD)2. Marker Tumour : - CEA, CA15-3, MCA Breast Ca - CEA, CA19-9 Pancreas Ca, Colorectal Ca - HCG Chorio Ca - PSA Prostat Ca
3. Objective-Qualitative : - Change of Clinical sign : Brain Ca-neurology sign
SUBJECTIVE RESPONSE EVALUATION
Performance status : Karnofsky / ECOG
Palliative
CURATIVE : caution of safety of side effects
DIAGNOSE of Side Effect
PHARMACOLOGYWhen Side effect become: NADIR point (degree of SE)Onset of SE, Specificity of organ target
MANAGEMENT of Side EffectAnticipation & PreventionDose related side effect monitoringEarly treatment of side effect
SIDE EFFECT MONITORING
PROFILE EPISODE of FEBRIL NEUTROPENI
Chemotherapy day
Chemotherapy day
nadir1 6 11 16 21 26
FEBRILE NEUTROPENIACRITERIA :• NEUTROPENIA :
absolute count of neutrophill in circulating blood < 2000 cells/mm3
• FEVER :
body temperature > 38.50C in 3 x measurement per 24 hours
DEGREE OF NEUTROPENIA
• Mild : 2000 – 1000 cells/mm3• Moderate : 1000 – 500 cells/mm3• Severe : < 500 cells/mm3
TREATMENT of FEBRIL NEUTROPENI
Empiric antibacterial
Empiric antibacterial
Chemotherapy day
Chemotherapy day
nadir
G-CSFSterile room
1. Onset of SE : - Immediately ( < 1 Hour post Chemotx) Anaphylaxsis - early (1- 48 hours ) Nausea-Vomiting profuse - delayed (2 days -2 months ) leucopenia - Late (after 2 months ) myopathy, neuropathy
2.Organ Target : CNS, Cardiovascular, Respiratory, Gastroentestinal System
3.Level/degree of SE (IUCC,WHO, ECOG) : - grade 0-2 : tolerable ( safety enough ) - grade 3 (severe) : must be alert (Yellow light), need treatment ± - grade 4 (life threatening) : Hazard, early and adequate treatment
RESUME :
Better Communication Unity of work rhythmMinimal mistakeMaximal patient service
Oncology aspect Patients & family aspect
Outcome & Side Effect Monitoring
Diagnose:- pathology - biology cell type ?
Diagnose: Staging
Medical Status: Risk group
Information about : - indication chemotherapy - regimen & cycle of Chx - Side effect of drug - living with chemtherapy - informed consent
SurvivalObjective & Subjective Outcome Side Effect : Diagnose & management
RESUME :