Primary care- top tips for - PowerPoint Presentation

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Primary care- top tips for managing cancer treatment complications

Lois Mulholland August 2020

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Regional oncology services

2 centres – NICC, NWCC3 units- UHD, CAH, AAH

24 hour helpline in each trust

AO team in each trust

AO Hub NICCWorking towards 7 day cover/ longer days

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Acute oncology

Subspecialty of oncologyTeams of consultant oncologists and CNSAdvisory (ie

do not bed hold)

Complications of cancer

Complications of treatmentNew diagnosis/ CUP

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History

Acute Oncology regional launch April 2016Microguide App launchedAO Clinical Reference Group established 2017

Peer review 2019 (external process against national standards)

Primary care colleagues requested at a glance version of AO guidelines

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Aims of guidelines

Early interventionEnhanced relationship/ communication between primary and secondary careIncreased confidence in managing common toxicities

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General considerations

“Tunnel vision”Is the problem related directly/indirectly to the cancer?Are they on treatment?

-

What kind

eg chemo/IO/TKI

-

Consider

timing

wrt

onset of

symptoms

Often simple changes make a big difference

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Toxicity grading- CTCAE

Grade 1 Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated.

Grade 2

Moderate; minimal, local or

noninvasive intervention indicated;

limiting age-appropriate instrumental ADL*.

Grade 3

Severe or medically significant but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated;

disabling; limiting self care ADL**.

Grade 4

Life-threatening consequences

; urgent intervention indicated.

Grade 5

Death

related to AE

.

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CTC examples

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Case 1

40 year old female T2 N1 breast caCycle 1 adjuvant FEC-D chemotherapyPhones for advice re nausea and vomiting post chemotherapy

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What do you need to know?

Timing related to chemotherapy- acute vs delayed emesisNo of episodes / 24 hours?Is she using anti emetics and able to keep them down?

Overall intake in last 24 hours?

Is she otherwise well?

Rule out other causes eg ill contacts, food poisoning

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Confirms she is D4 post chemo, was ok for the first 48 hours but now vomiting x 2 times in last 24 hours

Nauseated between vomits but managing fluids and light dietFeels otherwise well

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Steroids and 5 HT3 antagonists given as standard for

emetogenic regimes- pre med and 2 day supplyAs vomiting started

soon after

stopping

Ondansetron- restart for 2-3 days and reassessFurther call D6- vomiting has worsened. Now 6-8 times a day. Feels exhausted and mouth dry.

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Advise contact helpline for assessment as > 4 episodes/ day

If G1/2 N/V can try regular metoclopromide

Next cycle- can try extended steroids and 5HT3 or for severe emesis, commence syringe driver prior to chemotherapy

Overall 75-80% of patients have no more than short lived, mild nausea with modern anti emetics

Those with previous problems eg

travel sickness, pregnancy related emesis are more at risk

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Case 2

40 year old female T2 N1 breast caC4 adjuvant FEC-D chemotherapy

Nausea has been better controlled but she generally isn't feeling well today. Exhausted and

achey

. Much worse than first 3 cycles.

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What you need to know

Timing in relation to chemo- could she be neutropenic?Infective symptomsTemperature Diarrhoea

Again- rule out other causes. (

Covid

causing a lot of difficulties as a differential.)

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Points to note

FEC- D is a common regime used in node positive breast cancer ( 3 anthracycline then 3 Docetaxel)Docetaxel is awful!We also use GCSF

(Granulocyte-colony

stimulating factor) with this regime, given D2

Myalgia/pain very common with both drugs- may even require opiate analgesiaHigh rate of admission with FEC-D ( especially 1

st

cycle

Doce

)

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Management

Confirms- D4 post treatment, temp normalMay simply be myalgia secondary to chemo or bone pain secondary to GCSF Regular analgesia, fluids, rest, contact helpline if doesn’t settle

Phones 2 days later-more unwell ,feels shivery, temp 37.7

PHONE HELPLINE, NEEDS ASSESSMENT

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Management

Suspect NS if on chemo andTemp > 37.5 or < 36.0

Any

infective symptoms

DiarrhoeaAny SIRS ( temp, HR>90, RR>20) presume early sepsis

All patients given chemo info pack with thermometer and contact details, fridge magnet and emergency card

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Management

AdmitCultures- paired if line in situFBP, biochemistry, CRPSeptic screen

CXR

Standard of care for NS is 48 hours IV

Tazocin qds then reassess, can switch to orals and dc if low risk and clinical improvement

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Case 3

63 year old maleHx Colorectal Ca , resection 2017Presents with weight loss and nausea

CT shows liver metastases

Offered palliative chemotherapy with IMDG (Irinotecan)

Phones to speak to you as experiencing cramps and diarrhoea

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What you need to know

Timing related to treatmentWhat kind of treatment?Any other features eg

temp, vomiting

Any oral chemo?

Oral intake/ signs of dehydrationRule out other causes

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Management G 1-2 chemo induced

Loperamide 4mg then 2mg after every loose stool thereafter to max 8/day

No need for stool sample first

Increase fluids

Monitor temp and stool frequency/ consistencyHold anti cancer drugsUnresolved after 12 hours/ max

loperamide

- urgent assessment

If low risk- add codeine, high risk admit

12 hours diarrhoea free- stop treatment

G 3-4 - admit

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Case 4

54 year old femaleRecent surgery for CRCGiven high risk features, on C2 adjuvant chemotherapy with Capecitabine

(oral 5FU)

Attends for BP check but mentions mouth is sore

Had some issues C1 but seems worse this time

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What you need to know

Type of treatment and timing? Neutropenic or on steroids- risk of candidaAny xrt

to Head and Neck region?

Any discrete ulcers?

Any pain on swallowing / oesophagitis?Can they eat and drink?

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Case 4- MUCOSITIS

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Mucositis- mouthcare

Biotene or similar regularlySaline MW

Avoid chlorhexidine- can impair mucosal regrowth

Regular analgesia

eg paracetamolPractical advice

eg

avoid hot temps/ spicy food

Check for oral candida- use nystatin or fluconazole

G3/4 likely to require hospitalisation for fluids and symptom control

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Management

Ulcers- Bonjela, Hydrocortisone buccal tabletsOesophagitis

-

we use sucralfate and

oxetacaine , PPIConsider concurrent viral infection – aciclovir

as indicated

Soft paraffin/

diprobase

t

o lips

Tea tree mouthwashes

Vit

C dispersible tablet if tongue very coated

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Case 5

54 year old femaleRecent surgery for CRCC3 adjuvant chemotherapy with Capecitabine

(oral 5FU

)

Mouth seems better but hands and feet very painful , hacks around nails.

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Case 5- PPE

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Management of PPE

Also called hand foot syndromeSeen with TKI, liposomal doxrubicin,

capecitabine

Interrupt anti cancer treatment

Topical emollients regularlyTopical emollient with high urea content

Dermatology advice

EGFR inhibitors have separate algorithm- topical steroids, antibiotics, oral steroids

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The dyspnoeic patient

74 year old femalePresented with haematuriaCT urogram

showed mass left lung base

PET- widespread disease- bone, adrenal

metsPath – adenocarcinoma of lung, PDL1 95%PS 1

Decision to treat with

P

embrolizumab

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The Dyspnoeic patient

C1 20/4/20C2 deferred due to UTIC2 D8 admitted with pyrexia and deliriumCovid

swab –

ve

CRP 77.5FBP normalCXR felt to be in keeping with

Covid

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Pre immunotherapy

On admission

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T

reated as CovidAntibiotics, oxygenConcern re underlying pneumonitis

C/o Dexamethasone

Responded to intervention and d/c 4 weeks later on reducing steroids

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Readmitted 9 days later with dyspnoea and cough

Treated as pneumonitis secondary to immunotherapyC/o methylpred

, developed steroid induced diabetes

Slow reduction of oral

pred, dropping by 10mg/weekStable since dc

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Summary

Can be difficult to distinguish complications of treatment from complications of cancerPlease use helpline if any concerns

Covid

has added another level of complexity

Immunotherapy complications can occur up to a year after the last doseUseful guideline is “

are symptoms interfering with normal function?

”

If in doubt- hold oral SACT

AO services across all trusts who are happy to signpost/ advise

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Guidelines

Guidelines can be downloaded from the GPNI or NICaN websitewww.gpni.co.uk

www.nican.hscni.net

Full version available via

microguide app (NICaN)

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Questions?