PowerPoint Slides English Text Brazilian Portuguese Translation Supportive Management of Cancer-related Symptoms VideoTranscript

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1 PowerPoint Slides English Text Brazilian Portuguese Translation Cancer-related Symptoms VideoTranscript Gerenciamento de Apoio nos Sintomas Relacionados ao Câncer Transcrição do vídeo Professional Oncology Education Cancer-related Symptoms Time: 20:43 Cynthia Abarado, DNP, RN, GNP-BC Advanced Practice Nurse Genitourinary Medical Oncology The University of Texas MD Anderson Cancer Center Hello, my name is Cynthia Abarado. I am an Advanced Practice Nurse at the Department of Genitourinary Medical Oncology here at the MD Anderson Cancer Center. Educação Profissional em Oncologia Gerenciamento de Apoio nos Sintomas Relacionados ao Câncer Duração: 20:43 Cynthia Abarado, DNP, RN, GNP-BC Enfermeira Especializada em Clínica Geral Oncologia Médica Geniturinária MD Anderson Cancer Center Universidade do Texas Olá, eu sou Cynthia Abarado. Sou enfermeira especializada em clínica geral e trabalho aqui, no Departamento de Oncologia Médica Geniturinária do MD Anderson Cancer Center. Cynthia Abarado, DNP, RN, GNP-BC Advanced Practice Nurse Genitourinary Medical Oncology 1

2 Objectives Upon completion of this lesson, participants will be able to: Identify common disease-related symptoms Assess patients for the presence and severity of these symptoms Provide appropriate therapeutic interventions to address these issues I am going to talk to you about supportive management of cancer-related symptoms today. The objectives of this presentation are to identify common disease-related symptoms, assess patients for the presence and severity of these symptoms, and provide appropriate therapeutic interventions to address these issues. Hoje falarei sobre gerenciamento de apoio nos sintomas relacionados ao câncer. Os objetivos desta apresentação são: identificar sintomas comuns relacionados à doença, avaliar pacientes para a presença e gravidade desses sintomas e oferecer intervenções terapêuticas adequadas para solucionar esses problemas. Cancer Pain Pain is one of the most common symptoms associated with cancer Defined as a sensory and emotional experience associated with an actual or potential tissue damage or described in terms of such damage One of the most common cancer-related symptoms is cancer pain. Pain is one of the most common symptoms associated with cancer. The prevalence of pain among patients with cancer varies approximately at 50%, increasing to 75% to 86% with advanced cancer. Pain is defined as a sensory and emotional experience associated with an actual or potential tissue damage described in terms of such damage. Um dos sintomas mais comuns relacionados ao câncer é a dor oncológica. A dor é um dos sintomas mais comuns associados ao câncer. A prevalência da dor nos pacientes com câncer varia aproximadamente de 50%, aumentando para 75% a 86% com cânceres avançados. A dor é definida como a experiência sensorial e emocional associada ao dano tecidual real ou potencial [ou] descrito nos termos de tal dano. International Association for the Study of Pain, Subcommittee on Taxonomy. Pain (S1):226 Cohen MZ et al. J Pain Symptom Manage (6):519 2

3 Classification of Pain Nociceptive pain Results from injury to somatic and visceral structures with the resulting activation of nociceptors Described as sharp, well-localized, throbbing or pressure-like (somatic); more diffused, aching and cramping (visceral) Neuropathic pain Result of an injury to the peripheral or central nervous system Described as sharp, shooting or burning pain The two major classification of pain are nociceptive pain and neuropathic pain. Nociceptive pain is described as a result from injury to somatic and visceral structures with the resulting activation of nociceptors. It is often described as sharp, well localized, throbbing or pressure-like, more diffuse, aching and cramping sensation. Neuropathic pain, on the other hand, is the result of an injury to the peripheral or central nervous system described as sharp, shooting, or burning pain. A dor é classificada em dois tipos principais: dor nociceptiva e dor neuropática. A dor nociceptiva é descrita como o resultado de lesões em estruturas somáticas e viscerais com a consequente ativação de nociceptores. É descrita frequentemente como uma sensação aguda, bem localizada, pulsante ou tipo pressão, mais difusa, constante e tipo cólica. Por outro lado, a dor neuropática é o resultado de uma lesão do sistema nervoso periférico ou central descrita como uma dor aguda e penetrante ou ardência. Pain Assessment Pain should be assessed at the initial contact with the patient Comprehensive pain assessment: History of pain Pain intensity Location Aggravating factors Alleviating measures Breakthrough Response to therapy How it affects his functioning Pain assessment should be started or initiated at the initial contact with the patient. It is recommended to perform a comprehensive pain assessment, which includes taking a history of pain, reviewing symptoms related to pain intensity, location, aggravating factors, alleviating measures, and breakthrough pain. It is also important to assess the response to therapy and how it affects the functioning or lifestyle of an individual. A avaliação da dor deve ser iniciada durante a primeira consulta do paciente. Recomenda-se realizar uma avaliação abrangente da dor, incluindo anamnese da dor, revisão dos sintomas relacionados à intensidade da dor, localização, fatores agravantes, medidas de alívio e dor incidental ("breakthrough pain"). Também é importante avaliar a resposta à terapia e seu efeito sobre a funcionalidade ou estilo de vida da pessoa. 3

4 Tools: Pain Assessment Using 0-10 numerical scale Pictorial scale Wong-Baker faces rating scale Physical examination Relevant laboratory and imaging studies Some of the pain assessment tools used for a comprehensive pain assessment are using the 0 to 10 numerical scale, which 0 is no pain and 10 is the worst pain. Also, some other tools include pictorial scale, the Wong-Baker FACES Rating Scale, of course, physical examination and review of relevant laboratory and imaging studies. Pain assessment in nonverbal patients could rather pose a challenge. It requires a multifaceted approach that combines direct observation, family-caregiver input, and evaluation of response to pain medications, or nonpharmacologic interventions. Some of the tools that can be used for the assessment of patients with dementia include review of discomfort in dementia protocol or checklist of non-verbal pain indicators. For patients, however, in intensive care and those who are intubated, some recommended assessment tools include behavioral pain scale, critical pain observation, and, of course, it is very important to take into consideration the cultural and linguistic assessments as part of the comprehensive pain assessment. Alguns dos métodos abrangentes de avaliação da dor utilizam uma escala numérica de 0 a 10, sendo que 0 significa "sem dor" e 10, "a pior dor". Além disso, outros métodos incluem uma escala pictórica, a Escala de Faces de Wong-Baker e, obviamente, o exame físico e a revisão de estudos de laboratório e de imagens pertinentes. A avaliação da dor em pacientes que não se comunicam verbalmente pode representar um desafio. Exige uma abordagem multifacetada que combina a observação direta, a contribuição do cuidador da família e a avaliação da resposta aos medicamentos contra a dor ou às intervenções não farmacológicas. Alguns dos métodos que podem ser utilizados na avaliação de pacientes com demência incluem o exame de malestar no protocolo de demência ou na lista de verificação de indicadores não verbais da dor. No entanto, há quem recomende, para pacientes submetidos a terapia intensiva ou intubados, empregar métodos de avaliação que incluam uma escala comportamental da dor, a observação crítica da dor e, claro está, é muito importante levar em consideração as avaliações culturais e linguísticas como parte da avaliação abrangente da dor. 4

5 Pain Assessment It is important to determine underlying cause of pain Consideration of oncologic emergencies: Impending fracture Brain metastases Epidural metastases Leptomeningeal metastases Pain related to infection Perforated viscus Pain assessment is important to determine the underlying cause of pain, so that you can tailor the strategy of pain interventions. Some considerations of oncologic emergencies as cause of pain are related to impending fractures, brain metastases, epidural metastases, leptomeningeal metastases, and pain related to infection or perforated viscus. A avaliação da dor é importante para determinarmos a causa subjacente e podermos ajustar a estratégia das intervenções contra a dor. Algumas considerações de emergências oncológicas como causas da dor estão relacionadas a fraturas iminentes, metástases cerebrais, epidurais e leptomeníngeas e dor associada à infecção ou perfuração de víscera oca. WHO Algorithm for Pain Management Most widely accepted algorithm for treatment of cancer pain was developed by the World Health Organization Three-step ladder The World Health Organization has a widely accepted algorithm for treatment of cancer pain known as the three-step ladder. A Organização Mundial de Saúde conta com um algoritmo amplamente aceito para o tratamento da dor oncológica conhecido como "dos três degraus''. 5

6 3 2 Strong opioid ± Non-opioid ± Adjuvant Weak opioid ± Non-opioid ± Adjuvant Freedom from Cancer Pain (± with or without) Pain Persisting or increasing The World Health Organization recommends nonopioid treatment for mild pain, an addition of a weak opioid plus an adjuvant treatment for pain that is increasing or persisting, and for moderate-to-severe pain, which would be on the third grade or third step, would require a strong opioid plus a non-opioid in addition to adjuvant interventions. A Organização Mundial de Saúde recomenda um tratamento não opiáceo para a dor leve, a inclusão de um opiáceo fraco mais um tratamento adjuvante para a dor que aumenta ou persiste e, para a dor de moderada a severa, a qual estaria no terceiro degrau, exigiria um opiáceo forte mais um não opiáceo, além das intervenções com adjuvantes. 1 Non-opioid ± Adjuvant Pain Persisting or increasing Pain WHO s Pain Ladder WHO has developed a three-step "ladder" for cancer pain relief Non-opioids (aspirin and paracetamol) Mild opioids (codeine) Consider adjuvants to relieve anxiety Drugs should be given by the clock, that is every 3-6 hours, rather than on demand Surgical interventions if pain is not relieved Some of the non-opioids recommended by the World Health Organization in their three-step ladder include aspirin and paracetamol. For mild opioids, they recommend codeine and to consider adjuvant interventions to relieve anxiety. It is also a recommendation to administer pain medications on a scheduled basis rather than on demand. For persistent pain, surgical interventions can be explored. A aspirina e o paracetamol são alguns dos não opiáceos recomendados pela Organização Mundial de Saúde nesse protocolo dos três degraus. Como opiáceos [para a dor] leve, recomendam a codeína e considerar intervenções com adjuvantes para aliviar a ansiedade. Recomenda-se, também, administrar analgésicos regularmente, em horário pré-estabelecido, e não quando o paciente pedir. Em casos de dor persistente, pode ser explorada [a possibilidade] de intervenções cirúrgicas. 6

7 Pain Management - General Principles Appropriate dose Determine appropriate oral and parenteral dose equivalents of opioids based on single dose data Maintenance opioid therapy Use for continuous pain Once 24-hour opioid requirement is stable, change to extended release preparations Continue short-acting opioid for breakthrough pain Give pain medication on regular schedule with supplemental doses for breakthrough pain NCCN Clinical Practice Guidelines TM Pain Management Quantification of pain intensity Performance of a formal pain assessment Reassessment of pain intensity to measure effectiveness of present treatment Psychosocial support Patient education Some of the other general principles in pain management include appropriate dosing of analgesics, determining appropriate oral and parenteral dose equivalence of opioids based on single dose data. For maintenance of opioid therapy, it is important to use opioid for management of continuous pain. Once the 24-hour opioid requirement is established, it is recommended to change to extended-release preparations. However, for a breakthrough pain, it is recommended to continue short-acting opioids. It is important to give pain medication, as I mentioned, on a scheduled basis with supplemental doses for breakthrough pain. The NCCN Clinical Practice Guidelines TM highlight quantification of pain intensity throughout the continuum of pain management, performance of a formal pain assessment, and re-assessment of pain intensity to measure effectiveness of present treatment. And, in addition, support the patient psychosocially and provide patient education. A dosagem adequada de analgésicos, a determinação adequada da equivalência da dose oral e parenteral de opiáceos com base em dados de doses únicas são outros princípios gerais no controle da dor. Para a manutenção da terapia, o uso de opiáceos é importante para o controle da dor contínua. Depois de estabelecer a dose de opiáceos por dia, recomenda-se passar para formulações de liberação prolongada. Contudo, para a dor incidental, recomenda-se continuar com opiáceos com ação de curta duração. É importante administrar os analgésicos, como mencionei, em horários regulares com doses suplementares para dores incidentais. As NCCN Clinical Practice Guidelines TM destacam a quantificação da intensidade da dor por meio de um continuum do controle da dor, desempenho da avaliação formal da dor e reavaliação da intensidade da dor para medir a eficácia do tratamento atual. Além disso, dar apoio psicossocial e proporcionar educação ao paciente. NCCN Guidelines TM, 2007, 7

8 Management: Opioid Side-effects effects Nausea-make antiemetics available Sedation-assess for safety and dose adjustment if sedation worsens Opioid-induced constipation Preventive bowel regimen Adequate fluid and dietary intake Stimulate laxative + stool softener (senna + docusate 2 po daily) Reassess for severity and other causes of constipation Titrate laxative as needed Some of the side effects of pain management, such as opioids, could result to nausea, sedation, opioidinduced constipation, some respiration depression, and also some cognitive impairment. For nausea, it is very important to make antiemetics available. For a possibility of sedation, it is important to assess the patient on a continuous basis for safety and dose adjustment if sedation worsens. For opioid-induced constipation, it is recommended to proactively manage the patient with bowel regimens, such as adequate fluid and dietary intake as well as laxatives and stool softeners. One of the highlights of the 2010 NCCN Guidelines TM is to rule out obstruction or bowel obstruction in patients who have persistent constipation. It is important to reassess the severity and other causes of constipation, which can lead to bowel obstruction. And as part of the bowel regimen, it is important to titrate laxatives as needed. Alguns dos efeitos colaterais do controle da dor, como com os opiáceos, podem ser náusea, sedação, constipação induzida por opiáceos, um pouco de depressão respiratória e de comprometimento cognitivo. É muito importante dispor de antieméticos em casos de diarreia. Para a possibilidade de sedação, é importante avaliar o paciente continuamente quanto à segurança e ajuste de dose, caso a sedação piore. Em episódios de constipação induzidos por opiáceos, recomendase controlar pró-ativamente o paciente com regimes para o intestino, como consumo adequado de líquidos e alimentos, bem como [uso de] laxantes e emulsificantes fecais. Um dos destaques das 2010 NCCN Guidelines TM é descartar obstruções ou obstruções intestinais em pacientes que sofrem constipação persistente. É importante reavaliar a gravidade e outras causas da constipação, pois podem resultar em obstrução intestinal. E, como parte do regime para o intestino, é importante fazer a titulação dos laxantes, conforme a necessidade. 8

9 Management: Opioid Side-effects effects Respiratory depression use reversing agents cautiously; rule out other causes of neurologic status if not responsive within 10 minutes after naloxone Delirium assess for other causes of delirium, consider changing the opioid, consider haloperidol, mg po every 4-6 hours or neuroleptic agents Motor and cognitive impairment monitor during analgesic administration and titration For other opioid side effects such as respiratory depression, it is important to rule out other causes of neurologic status if the patient does not respond to naloxone or Narcan within 10 minutes, also to assess other underlying symptoms of delirium. Addition of Haldol 0.5 to 2 mg every 4 to 6 hours or other neuroleptic agents can also help. Other side effects such as motor and cognitive impairment would require some titration and adjustments of the analgesic administration. Para outros efeitos colaterais causados por opiáceos, como depressão respiratória, é importante descartar as causas do estado neurológico se o paciente não responder a naloxona ou Narcan dentro de 10 minutos, além de avaliar outros sintomas subjacentes de delírio. Acrescentar 0,5 a 2 mg de Haldol cada 4 a 6 horas, ou outros agentes neurolépticos, também pode ser útil. Outros efeitos colaterais, como comprometimento motor e cognitivo exigiriam titulação e ajustes na administração dos analgésicos. Specific Pain Problems Pain associated with inflammation Trial of NSAIDS or glucocorticoids Bone pain without oncology emergency NSAIDS and titrate analgesic Consider radiation or nerve block For diffuse bone pain consider trial of bisphosphonates, hormonal or chemotherapy for responsive tumors Nerve compression Trial of glucocorticoids Neuropathic pain Trial of antidepressants, anticonvulsants or topical agents Other specific pain problems, which can compound the whole cancer pain syndrome, would be specific to pain associated with inflammation, bone pain without oncologic emergency, and nerve compression, as well as neuropathic pain. For pain associated with inflammation, a trial of glucocorticoids or NSAIDs are recommended. For bone pain without oncologic emergency, treatment of NSAIDs and other titration of analgesics as well as consideration of radiation or nerve block are also recommended. For diffuse pain that may be responsive to bisphosphonates, hormone, and chemotherapy are also recommended for consideration. And for nerve compression, trial of glucocorticoids is also recommended. Other neuropathic pain could respond to trial of antidepressants, anticonvulsants as well as topical agents. Outros problemas específicos relacionados à dor, que podem conformar toda a síndrome da dor oncológica, seriam específicos da dor associada à inflamação, dor óssea sem emergência oncológica e compressão neural, além de dor neuropática. Para a dor associada à inflamação, recomenda-se experimentar com glicocorticoides ou AINEs. Para a dor óssea sem emergência oncológica, também é recomendado o tratamento com AINEs ou outra titulação com analgésicos, bem como considerar irradiação ou bloqueio neural. Para a dor difusa que pode responder a bifosfonatos, também é recomendado considerar o uso de hormônios e quimioterapia. E no caso de compressão neural, também recomenda-se experimentar com glicocorticoides. Outra dor neuropática poderia responder a tentativas com antidepressivos, anticonvulsivantes, bem como agentes tópicos. 9

10 Pain Consult Complex pain syndromes Pain unrelieved by routine management Consideration of nerve block It is also recommended that pain consultation should be sought if a patient s pain is persisting, for complex pain syndromes, as well as for those that are unrelieved by routine management, and for possible consideration of a surgical intervention or a nerve block. Outra recomendação é que o paciente busque uma consulta para a dor quando ela for persistente, constituir um grupo complexo de síndromes álgicas, bem como para aqueles que ainda não obtiveram alívio pelo tratamento habitual e em possíveis considerações de intervenções cirúrgicas ou quando de bloqueio neural. Psychosocial Support and Patient Education Provide emotional support Assist accessing treatment as needed Educate patient and family that pain management is a team effort Teach coping skills on pain relief, redirect focus on optimizing quality of life Provide patient and family education, emphasize the goal of pain management, provide medication list and side-effects, provide a contact number in case of problems Along with these interventions, psychosocial support and patient education are critical in the comprehensive pain management. It is important to provide emotional support to the patient and to the family; assist them and make sure that the treatment is accessible; providing education to patient and family that pain management is a team effort. Also teaching them coping skills on pain relief and redirecting focus on optimizing quality of life are some of the psychosocial support needs that can help with their coping and having pain. Emphasize the goal of pain management and providing medication lists and side effects of patient medications. Also providing a contact number in case of problems can also alleviate and help patients cope with pain management. Paralelamente a estas intervenções, o apoio psicossocial e educação ao paciente são essenciais no controle abrangente da dor. É importante dar apoio emocional ao paciente e à família, ajudá-los e confirmar se têm acesso ao tratamento, oferecer educação ao paciente e à família quanto ao controle da dor ser um trabalho de equipe. Além disso, ensinar-lhes formas de lidar com a dor e seu alívio e redirecionar a atenção em otimizar a qualidade de vida são algumas das necessidades de apoio psicossocial que podem ser úteis quando [o paciente] tem de enfrentar e lidar com a dor. Por ênfase no objetivo do controle da dor e informar o paciente sobre diversos medicamentos e seus efeitos colaterais. Fornecer um número para contato em caso de haver problemas também pode aliviar e facilitar o esforço do paciente em lidar com o controle da dor. 10

11 Constipation Most common side-effect but not often discussed Almost 100% of cancer patients taking pain medications will have constipation Most common causes of constipation are inadequate fluid intake and opioids One of the other side effects of opioid or pain medications is constipation. Almost 100% of cancer patients taking pain medications will have constipation. And constipation affects everyone across the life span. It affects around 2% to 28% of the total population, which equals to around 63 million. So, it is very important to really assess the pain the side effects of pain in terms of constipation. And the role of constipation risk assessment really is a proactive approach in prevention of development of constipation. A constipação é um dos efeitos colaterais de opiáceos ou analgésicos. Quase 100% dos pacientes com câncer que recebem medicamentos apresentam constipação. E a constipação afeta a todos em qualquer idade. Afeta cerca de 2% a 28% de toda a população, que está ao redor de 63 milhões. Por isso, é verdadeiramente importante avaliar a dor, seus efeitos colaterais quanto à constipação. E, na verdade, a avaliação do risco de constipação é uma abordagem pró-ativa de prevenção contra a constipação. Constipation Risk Assessment Identify patients at risk for constipation using a constipation risk assessment tool (example: Constipation Risk Assessment Scale by Janice Richmond) Other constipation risk assessment tools Norgine Risk Assessment The Eton Scale It is important to identify patients at risk for constipation using some systematic constipation risk assessment scale. And one of this constipation risk assessment scale is by Janice Richmond. Some other constipation risk assessment tools are Norgine Risk Assessment and the Eton Scale Assessment. É importante identificar pacientes em risco de constipação utilizando escalas sistemáticas de avaliação de risco de constipação. Uma dessas escalas é a de Janice Richmond. Outros métodos de avaliação do risco de constipação são o de Norgine e a escala de Eton. Richmond JP, Wright ME. Clin Eff Nurs (1-2):37 11

12 Nutritional Strategies for Managing Constipation Increased dietary fiber and fluid intake Encourage oral fluids at least 8-10 glasses of fluids daily Recommend mobility and adequate exercise Limit gas-forming foods and beverages Recommend bulking agents and/or stool softeners, if appropriate Laxatives essential for opioid induced constipation There are a lot of preventive or nutritional strategies that can be implemented or developed by healthcare providers in managing constipation. And some of these are increasing dietary fiber and fluid intake, encourage oral fluids, at least 8 to 10 glasses of fluids a day, recommending mobility and adequate exercises, recommending bulking agents and/or stool softeners if appropriate, and also using laxatives that are essential for opioid-induced constipation, and, of course, limiting gas-forming foods and beverages. Existem muitas estratégias preventivas ou nutricionais que podem ser implementadas ou desenvolvidas pelos profissionais de saúde no controle da constipação. E algumas delas são: aumentar a ingestão de fibra alimentar e de líquidos, motivar o consumo de líquidos via oral de, no mínimo, 8 a 10 copos por dia, recomendar mobilidade e exercícios adequados, agentes volumosos e/ou emulsificantes fecais, se pertinente, e usar laxantes essenciais na constipação induzida por opiáceos e, obviamente, limitar alimentos e bebidas que produzam gases. Cancer-related related Fatigue Distressing persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning The other cancer-related symptom that I am going to talk about is cancer-related fatigue. Fatigue is defined as a distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. O outro sintoma relacionado ao câncer do qual falarei é a fadiga. A fadiga é definida como uma sensação de cansaço ou exaustão estressante, persistente e subjetiva relacionada ao câncer ou ao tratamento antineoplásico que não é proporcional às atividades recentes e interfere com a funcionalidade usual. NCCN, 2007, 12

13 Cancer-related related Fatigue Incidence: Affects % of cancer patients Prevalence: 75% among patients with metastatic disease Patients perceive fatigue as the most distressing symptom associated with cancer and cancer treatments It is prevalent among 75% of patients with metastatic disease and affects 70% to 100% of cancer patients. Patients perceive fatigue as the most distressing symptom associated with cancer and cancer treatments. É prevalente em 75% dos pacientes com doença metastática e afeta de 70% a 100% dos pacientes com câncer. Os pacientes percebem a fadiga como o sintoma mais estressante associado ao câncer e aos tratamentos antineoplásicos. Pathophysiology: Cancer-related related Fatigue Exact explanation of physiology is unknown Multi-factorial explanations Stress/stress response model Neurophysiologic model involving the brain and the spinal cord Endogenous tumor necrosis factor Multidimensional fatigue framework The exact cause or pathophysiology of cancerrelated fatigue is rather unexplained or unknown, but a lot of factors come into play. And some of these are stress, which is the basis of the stress/stress response model, the neurophysiologic model involving the brain and the spinal cord. And some endogenous tumor necrosis factor. But the most common explanation that is in the literature is the multi-dimensional fatigue framework. A causa exata ou a fisiopatologia da fadiga relacionada ao câncer é desconhecida ou não totalmente explicada, mas nela participam muitos fatores. Alguns deles são o estresse, que é a base do modelo baseado no estresse ou na resposta ao estresse, e o modelo neurofisiológico, que inclui o cérebro e a medula espinhal e alguns fatores endógenos de necrose tumoral. Porém, a explicação mais frequente na literatura é o quadro multidimensional da fadiga. 13

14 Neurophysiologic Model of Fatigue Impairment of peripheral nervous system or its component can cause impaired peripheral nerve function in transmission to the neuromuscular junction, thereby affecting nerve fiber activation Impairment of the central component causes lack of motivation, impaired spinal cord transmission and malfunction of the brain cells in the hypothalamic region The neurophysiological model of fatigue explains fatigue as an impairment of peripheral nervous system or its component causing impaired peripheral nerve function in transmission to the neuromuscular junction thereby affecting nerve fiber activation. Also, it describes impairment of the central or component causing lack of motivation, impaired spinal cord transmission, and malfunction of the brain cells in the hypothalamic region. O modelo neurofisiológico explica a fadiga como um comprometimento do sistema nervoso periférico ou seu componente causa comprometimento da função neural periférica na transmissão da junção neuromuscular, portanto, afetando a ativação das fibras nervosas. Além disso, descreve o comprometimento da motivação central ou um componente que causa a falta de motivação, comprometimento da transmissão [dos impulsos] na medula espinhal e o mau funcionamento das células nervosas na região hipotalâmica. Role of Tumor Necrosis Factor Reduction in skeletal muscle protein stores resulting from endogenous TNF or from TNF administered as antineoplastic therapy resulting in muscle wasting The role of the tumor necrosis factor is described as a reduction in skeletal muscle protein stores resulting from endogenous tumor necrosis factor or from the TNF administered as an antineoplastic therapy resulting in muscle wasting. O papel do fator de necrose tumoral (FNT) é descrito como a redução do estoque de proteína músculo-esquelética, originada pelo fator endógeno de necrose tumoral ou do FNT administrado como terapia antineoplásica, causando perda de massa muscular. 14

15 Multidimensional Framework of Fatigue Interaction of various factors: Biochemical Treatment Accumulation of metabolites Changes in transmission Some of the interactions of different factors are included in the multi-dimensional framework of fatigue and these are biochemical factors, which could be in the treatment and affecting the accumulation of metabolites, changes in transmission. Algumas das interações entre diferentes fatores são incluídas no quadro multidimensional da fadiga e elas são fatores bioquímicos, que poderiam estar no tratamento e afetar o acúmulo de metabólitos [e] as alterações na transmissão. Multidimensional Framework of Fatigue Physiologic Changes in energy level, activity/rest, sleep/wake cycles Oxygenation Unique circadian rhythms Behavioral Psychological factor Life events Social factors Environmental Symptoms Some other factors involve physiologic factors such as oxygenation and alterations in energy level, activity, rest, sleep and wake cycles as well as behavioral. Some psychological factors can attribute to fatigue, such as life events, social factors, environmental factors and other specific symptoms. Outros fatores são fisiológicos, como a oxigenação e alterações no nível de energia, atividade, descanso, ciclos de sono e vigília, além dos comportamentais. Alguns fatores psicológicos podem atribuir à fadiga, como eventos da vida, fatores sociais, ambientais e outros sintomas específicos. 15

16 Contributing Factors to Fatigue Cancer treatment Sleep disturbances Anemia Excessive inactivity Medications Pulmonary impairment Cachexia/anorexia Neuromuscular dysfunction Metabolic disturbances Pain Hormone deficiency Infection Psychological distress Comorbidities Some of the contributing factors that are explained in different review of literature relate to cancer treatment, anemia, medications, cachexia, anorexia, metabolic disturbances, hormone deficiency, psychological distress, sleep disturbances, excessive inactivity, pulmonary impairment, neuromuscular dysfunction, pain, infection, and comorbidities. Alguns dos fatores explicados em diversas revisões de literatura relacionam-se a tratamentos antineoplásicos, anemia, medicamentos, caquexia, anorexia, distúrbios metabólicos, deficiência hormonal, estresse psicológico, distúrbios do sono, excesso de inatividade, comprometimento pulmonar, disfunção neuromuscular, dor, infecções e comorbidades. Cancer Therapies and Fatigue Chemotherapy Radiation therapy Biologic response modifiers Surgery Target therapies Disease state Combination of treatment modalities Some of the cancer therapies that could cause fatigue are chemotherapy, radiation therapy, some biologic response modifiers, even surgery, some target therapies, the disease state itself and combination of treatment modalities. Algumas das terapias antineoplásicas que poderiam causar fadiga são: quimioterapia, radioterapia, alguns modificadores da resposta biológica, mesmo cirurgias, terapias alvo, o próprio estado da doença e combinações de modalidades terapêuticas. 16

17 Signs and Symptoms of Fatigue Physical symptoms Psychological symptoms Cognitive changes Behavioral changes Functional status decline Some specific signs and symptoms of fatigue are broadly related to physical symptoms, psychological symptoms, cognitive changes, behavioral changes, as well as functional status decline. Alguns sinais e sintomas específicos de fadiga são amplamente relacionados a sintomas físicos e psicológicos, alterações cognitivas, bem como o declínio do estado funcional. Differential Diagnosis Underlying cardiopulmonary, renal, neurologic, endocrine, infectious, hematologic etiology Fluid/electrolyte imbalances Malnutrition Psychological distress It is very important to consider other differential diagnoses such as underlying cardiopulmonary, renal, neurologic, endocrine, infectious, and hematologic etiology that can cause fatigue. Some of these are fluid electrolyte imbalances as well, malnutrition, and psychological distress. É muito importante considerar outros diagnósticos diferenciais, como etiologias subjacentes do sistema cardiopulmonar, renal, neurológico e endócrino, bem como as infecciosas e hematológicas que possam causar fadiga. Alguns deles são o desequilíbrio eletrolítico, a desnutrição e o estresse psicológico. 17

18 Assessment of Fatigue Screen patients for fatigue as vital signs at regular intervals How would you rate your fatigue on a scale 0-10 over the past 7 days? None to mild 0-3; Moderate 4-6; Severe 7-10 The NCCN Guidelines TM recommends screening patients for fatigue as vital signs at regular intervals. Often they recommend asking the patient, How would you rate your fatigue on a scale 0 to 10 over the past 7 days? None to mild would be 0 to 3, moderate 4 to 6 and severe would be 7 to 10. As NCCN Guidelines TM recomendam o rastreamento para fadiga como sinal vital realizado regularmente em pacientes. Recomendam com frequência perguntar ao paciente: Como classificaria sua fadiga em uma escala de 0 a 10 nos últimos 7 dias? De nenhuma a leve seria de 0 a 3, moderada, de 4 a 6 e intensa, de 7 a 10. NCCN Guidelines TM, 2007, Assessment of Fatigue Complete primary evaluation Fatigue score 4-10 Focused history Review of systems Assessment of treatable contributing factors For those patients who have a fatigue score of 4 to 10, NCCN TM recommends a focused history, review of systems, and assessment of treatable contributing factors. Para os pacientes com grau de fadiga de 4 a 10, as NCCN TM recomendam uma anamnese focalizada, revisão de sistemas e avaliação de fatores predisponentes tratáveis. 18

19 Interventions Patients Experiencing Fatigue on Active Treatments Nonpharmacologic Activity enhancement Psychosocial interventions Attention restoring therapy Nutritional support Sleep therapy Family interaction Energy conservation Diversional Activities Education/Counseling Some of the other non-pharmacologic interventions or strategies that can help alleviate fatigue are activity enhancement, some psychosocial interventions in terms of support, attention restoring therapy, nutritional support, sleep therapy, family interaction, energy conservation, as well as diversional activities, and, of course, education and counseling. Outras intervenções ou estratégias não farmacológicas que podem aliviar a fadiga são: a intensificação das atividades, algumas intervenções psicossociais em termos de apoio, terapia para restituir a atenção, apoio nutricional, interação familiar, conservação de energia, bem como atividades recreativas e, obviamente, educação e aconselhamento. Interventions of Fatigue Pharmacologic Psychostimulants methylphenidate Anemia treatment Sleep medications Other interventions would of course include pharmacologic such as psychostimulants and most of the patients consider Ritalin or methylphenidate, treatment of anemia, and other sleep medications. E, claro, outras intervenções incluiriam o uso de fármacos, como psicoestimulantes, e a maioria dos pacientes considera a Ritalina ou metilfenidato, tratamento para anemia e outros soníferos. 19

20 Assessment Tools for Fatigue Brief Fatigue Inventory The Functional Assessment of Cancer Therapy-anemia The Functional Assessment of Cancer Therapy-fatigue Piper Fatigue Self-report Scale The Schwartz Cancer Fatigue Scale Fatigue Symptom Inventory The Profile of Mood States Fatigue/Inertia Subscale Lee s Visual Analogue Scale for Fatigue Cancer Fatigue Scale Brief Fatigue Inventory (BFI) Assessment Areas: Severity of fatigue and the impact of fatigue on daily functioning in the past 24 hours Method: Self-report, interview, or via an interactive voice response system (IVR) Time required: 5 minutes Scoring: A global fatigue score can be obtained by averaging all the items on the BFI There are also a lot of systematic assessment tools for fatigue and some of these are: Brief Fatigue Inventory; Functional Assessment of Cancer Therapy, such as specific for anemia; The Functional Assessment of Cancer Therapy, specific for fatigue; Piper Fatigue Self- Report Scale; Schwartz Cancer Fatigue Scale; Fatigue Symptom Inventory; the Profile of Mood States Fatigue or Inertia Subscale; and Lee s Visual Analog Scale for fatigue; as well as Cancer Fatigue Scale. One of the most common assessment tools is the Brief Fatigue Inventory. This is a tool that assesses the severity of fatigue and the impact of fatigue on daily functioning in the past 24 hours. It is a selfreport by interview or via an interactive voice response system and usually requires only 5 minutes. A global fatigue score can be obtained by averaging all the items in the Brief Fatigue Inventory Tool. E existem muitos métodos sistemáticos para avaliar a fadiga, dentre os quais estão: Inventário Breve da Fadiga, Avaliação Funcional da Terapia Antineoplásica, como as específicas para anemia e para fadiga, Escala Autoavaliativa de Fadiga de Piper, Escala da Fadiga Oncológica de Schwartz, Inventário dos Sintomas da Fadiga, Subescala da Fadiga ou Inércia do Perfil dos Estados de Humor e Escala Visual Analógica de Lee para fadiga, além da Escala da Fadiga Oncológica. Um dos instrumentos de avaliação mais utilizados é o Inventário Breve da Fadiga. Este instrumento avalia a intensidade da fadiga e seu impacto nas atividades diárias durante as últimas 24 horas. É um autorrelato realizado por entrevista ou por um sistema interativo de resposta verbal e, normalmente, só exige 5 minutos. O escore da fadiga global pode ser obtido calculando a média de todos os itens do Inventário Breve da Fadiga. 20

21 Brief Fatigue Inventory (BFI) (continued) Reliability: Cronbach's alpha reliability ranges from 0.82 to 0.97 psychometrically validated language versions Available in multiple languages English Chinese (simplified) German Japanese Korean It has a reliability of Cronbach's Alpha Reliability ranging from 0.82 to 0.97 and they have psychometrically validated tools in different language versions. O coeficiente alfa de Cronbach de confiabilidade desse instrumento varia de 0,82 a 0,97, e há disponibilidade de instrumentos validados psicometricamente em versões com diferentes idiomas. Cancer-related related Nutritional Issues Malnutrition in cancer is a common problem that plays a significant role in adverse outcomes, including mortality and morbidity The next topic would be a cancer-related symptom as it relates to the nutritional issues. Malnutrition in cancer is a common problem that plays a significant role in adverse outcomes including mortality and morbidity. O próximo assunto seria sobre sintomas relacionados ao câncer que têm a ver com a nutrição. A desnutrição no câncer é um problema comum e cumpre um papel significativo nos desfechos adversos, abrangendo a mortalidade e a morbidade. 21

22 Weight loss Best indicator for nutritional risk among cancer patients Weight loss of 5% or greater in 1 month or greater than 10% in 6 months is significant Prognostic indicator of survival, response to treatment and quality of life It is the best indicator for nutritional risk among cancer patients. Weight loss of 5% or greater in 1 month or greater than 10% in 6 months is significant. Weight loss is a prognostic indicator of survival and response to treatment, as well as quality of life. É o melhor indicador de risco nutricional nos pacientes com câncer. Uma perda de peso igual ou superior a 5% em 1 mês ou superior a 10% em 6 meses é significativa. A perda de peso é um indicador prognóstico de sobrevida e de resposta ao tratamento, bem como de qualidade de vida. Cancer-related related Nutritional Issues Weight loss Constipation Fatigue Diarrhea Nausea and vomiting Dry mouth (xerostomia) Taste alterations Loss of appetite Oral mucositis Cachexia Some of cancer-related nutritional status --- or nutritional issues rather are weight loss, fatigue, nausea and vomiting, taste alterations, oral mucositis, constipation, diarrhea, xerostomia or dry mouth, loss of appetite, and cachexia. Alguns dos estados... isto é, problemas nutricionais relacionados ao câncer são: emagrecimento, fadiga, náusea e vômito, alterações no paladar, mucosite oral, constipação, diarreia, xerostomia ou ressecamento da boca, perda do apetite e caquexia. 22

23 Nutritional Strategies for Managing Weight Loss Increase calorie and protein intake by eating favorite foods Encourage the addition of high-calorie and high protein food and snacks Physical activity to stimulate appetite Some strategies for managing weight loss include increasing calorie and protein intake by eating favorite foods, encourage patients addition of highcalorie and high-protein food and snacks, as well as physical activity to stimulate appetite. Algumas estratégias para controlar a perda de peso incluem o aumento da ingestão de calorias e proteínas ao ingerir alimentos preferidos, a motivação de incluir alimentos e lanches com alto teor energético e proteico, bem como atividades físicas para estimular o apetite. Conclusions Cancer patients frequently experience pain, malnutrition, and fatigue Constipation is also frequently encountered particularly for patients receiving a narcotic for pain control Assessment and treatment of these symptoms are important in improving the quality of life for cancer patients So, in conclusion, we have discussed cancerrelated symptoms as they relate to pain, malnutrition, and fatigue. Constipation is a frequently encountered problem especially for patients receiving narcotics for pain control. Assessment and treatment of these symptoms are important in improving the quality of life for cancer patients as well as improving patient outcomes. We would like to appreciate your feedback on this presentation and you can us. Thank you very much. Resumindo, discutimos os sintomas associados ao câncer, pois estão relacionados à dor, malnutrição e fadiga. A constipação é um problema bastante comum, especialmente em pacientes que recebem narcóticos para o controle da dor. A avaliação e o tratamento desses sintomas é importante para a melhoria da qualidade de vida e dos desfechos nos pacientes com câncer. Agradeceríamos a sua opinião sobre esta apresentação e que pode ser enviada por . Muito obrigada. 23