Palliative care in cancer patients

MARQUES, Angela ^[1]

MARQUES, Angela. Palliative care in cancer patients. Multidisciplinary Core scientific journal of knowledge. 03 year, Ed. 06, vol. 05, pp. 79-94, June 2018. ISSN:2448-0959

Summary

This is an exploratory study conducted in order to understand the total care and active patients whose disease is no longer responsive to curative treatment. The methodological approach was the narrative research, integrative and qualitative search electronic health Virtual Library-VHL in American Literature and databases of Caribbean Health Sciences-LILACS, Scientific Eletronic Library-SCIELO and International literature on health sciences – MEDLiINE. The data were constructed with necessary information concerning treatment and palliative care, it is concluded that the quality of life in palliative care has an impact on the lives of terminally ill individuals in cancer treatment.

Keyword: Drugs, palliative care.

Introduction

The therapeutic treatment along with the most appropriate palliative care will depend on the type of cancer, the extent of disease and the stage of life in which the patient lies. In the case of tumors that affect vital organs such as lungs, liver, pancreas, brain, kidneys, expectations of success are smaller, even more when the cancer presents metastases. During cancer treatment, the patient may present a range of signs and symptoms of emotional and physical order, in most cases, help determine the evolution of the disease. These feelings often cause a significant worsening in quality of life, well-being and in the response to the treatment of this patient.

The palliative care Treatment should gather the skills of a multidisciplinary team to help the patient adapt the life changes imposed by illness, and promote the reflection necessary to fight this life threatening condition for patients and their families.

For this work to be performed requires a minimum team, consisting of: a doctor, a nurse, a psychologist, a social worker and at least one professional in the area of rehabilitation (to be defined according to the need of the patient). All properly trained in the philosophy and practice of palliation.

The remedial action has to start already at the moment of diagnosis and the palliative care develops together with the therapies able to modify the course of the disease. Palliation WINS expression and importance to the patient as the modifier treatment of disease (in search of healing) lose your effectiveness. In the final stage of life, Hospice are compelling and linger in the period of mourning, individually.

The optimism over the control of diseases does not seem to be true, given the growing chronic disease that we have experienced, perhaps in much due to aging of the population. Aware of our limitations as health professionals, we need to stop thinking about the finiteness or chronic illness as a medical failure, since it is the relief of pain and suffering from one of the goals of health professionals.

1. What is cancer?

Cancer is the name given to a set of more than 100 diseases that have in common the disordered growth (malignant) cells that invade the tissues and organs and can spread (metastasize) to other parts of the body. Dividing quickly, these cells tend to be very aggressive and uncontrollable, determining the formation of tumors simply means a localized mass cells that multiply slowly and resemble your original fabric, rarely a risk of life.

• Tumors can be benign or malignant.
• Benign tumors are not cancerous. They can often be removed, and, in most cases, they don't come back. The cell in benign tumors do not spread to other parts of the body.
• Malignant tumors are cancerous. The cells in these tumors can invade nearby tissues and spread to other parts of the body. The spread of cancer from one body part to another is called metastasis.
• Some cancers do not form tumors. For example, leukemia is a cancer of the bone marrow and blood.

1.2 About the social history of cancer

Close your cancer story a strange paradox related to the fact that, as the medicine was expanding knowledge and developing increasingly powerful technologies against their harmful effects, the dread of populations in relation to it also If expanded. For a long time almost nothing was known about the disease, and the ability of doctors in null and avoid suffering and deaths he caused. However, the cancer was little understood in society, part of a large list of ills that impingiam suffering and death. His victims, there were only the agony and often caused by fear of social anathema your infectiousness. From the mid-20th century this situation started to turn. Promising treatments, still at the beginning of the century, began to improve, showing more effective, while the prevention by early diagnosis entered on the agenda for the medicine.

However, the greater awareness of the disease and the emergence of some hope in the treatment of affected also expanded their programs of the understanding of the extent of evil, of its many faces and the limited capacity of medicine to tame him, intensifying the fear of society, who went on to view cancer as the scourge of modernity.

1.3 cancer control in Brazil

In the first decades of the 20th century, the cancer was slowly becoming a focus of attention of various medical groups in the country. The interest of these professionals on the problem of cancer was due, in large part, to your contacts with the international literature on the topic and, especially, for his performances in international medical Congresses. The first efforts of systematised, as de Azevedo Sodré in 1904 and 1910, with Portugal in Olímpio different interpretations, but with the common goal to educate doctors about the dangers of Brazilian disease (Sodre, 1904; Portugal, 1910).

The first step towards the incorporation of cancer as a public health problem, in the national policy agenda, occurred in health reform of 1920, which gave rise to the National Department of public health (DNSP). In the new institution, occupied space in The prophylaxis of leprosy and venereal diseases. However, the effort to bring the disease to the logic of public health actions failed to immediate results, with limited Inspetoriação in combating disease (Sanglard, 2008; Teixeira, 2009).

The medical knowledge of the time approached the cancer and leprosy in contagion, as most of the doctors stated that both diseases should have similar transmission forms, resulting in the need for greater monitoring of your incidence, as well as the formulation of actions that avoid the spread (Teixeira, 2009).

In the context of expansion of disease concerns, such innovations have fostered the involvement of the medical community with the illness and boosted discussions and plans of action articulated to contain the advance of cancer (Teixeira, Fonseca, 2007).

1.4 the main categories of cancer include:

• Carcinoma-cancer that begins in the skin or in tissues that line or cover internal organs. There are a number of subtypes of cancer, including adenocarcinoma, basal cell carcinoma, squamous cell carcinoma and transitional cell carcinoma.
• Sarcoma-cancer that begins the bone, cartilage, fat, muscle, blood vessels, or other connective tissue or support.
• Leukemia-cancer that begins in the tissue that forms the blood, such as the bone marrow and causes large numbers of abnormal blood cells to be produced and enter the blood.
• Lymphoma and myeloma-cancers that begin in the cells of the immune system.
• Central nervous system cancers-cancers that begin in the tissues of the brain and spinal cord.

1.5 what causes cancer?

The causes of cancer are varied and may be internal or external to the organism, being both interrelated. External causes are related to the environment and the habits and customs of a social and cultural environment. The internal causes are, for the most part, genetically predetermined, are linked to the body's ability to defend itself from external aggressions. These factors causes may interact in many ways, increasing the likelihood of malignant transformations in normal cells.

In all cases, 80% to 90% of cancer are associated with environmental factors. Some of them are well known: smoking can cause lung cancer, excessive exposure to the Sun can cause skin cancer, and some viruses can cause leukemia. Others are under study, as some components of the food we eat, and many are still completely unknown.

Aging brings changes in cells that increase your susceptibility to malignant transformation. This, added to the fact that the cells of the elderly have been exposed longer to the different risk factors for cancer, explains in part why the cancer being more frequent in these individuals. Environmental risk factors for cancer are called carcinogenic or carcinogens. These factors act by altering the genetic structure (DNA) of cells.

The emergence of cancer depends on the intensity and duration of export of the cells to cancer-causing agents. For example, the risk of a person developing lung cancer is directly proportional to the number of cigarettes smoked per day and the number of years she's been smoking.

1.6 common types of cancer

Bladder cancer, breast, colon and rectal cancer, endometrium, kidney (renal cell), leukemia, lung, melanoma, non-Hodgkin's finfoma, pancreas, prostate and thyroid.

2. History of palliative care.

Some historians point out that the remedial philosophy began in ancient times, with the first definitions of caregiving. In the middle ages, during the Crusades, it was common to find hospices (hostels, in Portuguese) in monasteries, which housed not only the sick and dying, but also hungry, women in labor, the poor, orphans and lepers. This form of hospitality was as the host protection features, the relief of suffering, but that the search for the cure.

2.1 current Scenario of Brazil

In Brazil, the palliative care-related activities still need to be adjusted in the form of law. Still in first place in Brazil an enormous ignorance and prejudice related to palliative care, especially among the measured, healthcare professionals, hospital managers and judiciary. Still confuse with euthanasia and palliative care there is a huge bias with respect to the use of opioids, such as morphine, for pain relief.

Yet there are few palliative care services in Brazil. Smaller still is the number of those who offer attention based on scientific criteria and quality. The vast majority of services still requires the deployment of standardized models of care to ensure effectiveness and quality. There is a gap in the training of doctors and health care professionals in palliative care, essential for the proper care, due to the absence of medical residency and a short supply of specialization courses and graduate quality. Even today, in Brazil, the degree in medicine doesn't teach the doctor how to deal as a terminal patient, how to recognize the symptoms and how to manage this situation in a way that is humane and active.

2.2 palliative care

For palliative care understands the care for patients with diseases whose treatment no longer responds to curative treatment. In this way, the central objective is the well-being of the patient. According to the World Health Organization (who) is "an approach that improves the quality of life of patients and families facing problems associated with life-threatening diseases, through the prevention and relief of suffering by means of early identification, assessment and treatment of pain and other problems, physical, psychosocial and spiritual "(who, 2009).

Considered eligible for palliative care the patient with chronic, progressive and evolutionary, with forecasting of life supposedly shortened to months or year. Some slow progression disease like Alzheimer's, some neurological syndromes and certain tumor types make the patient eligible for palliative care, despite the period of high dependency for the daily life activities involve prognosis of more than one year of life (M, 2008).

2.3 the principles of palliative care are:

• Provide relief for pain and other stress symptoms such as fatigue, anorexia, Dyspnea and other oncological emergencies.
• Reaffirm life and death as natural processes.
• Integrate the spiritual, social and psychological aspects to the clinical aspect of patient care.
• Do not rush or postpone death.
• Offer a support system to help the family cope with the illness of the patient, in your own environment.
• Offer a support system to help patients live more actively the possible until your death.
• Use an interdisciplinary approach to access clinical and psychosocial needs of patients and their families, including counselling and bereavement support.

2.4 the points considered fundamental treatment are:

The unit includes the patient and your family.

The patient's symptoms should be routinely assessed and effectively managed through frequent consultations and active interventions.

Decisions related to assistance and medical treatment must be based on ethical principles.

Palliative care must be provided by an interdisciplinary team, instrumental in the evaluation of symptoms in all its dimensions, in the definition and conduct of pharmacological treatments and pharmacological, not essential to the control of all and any symptom.

Proper communication between health staff and relatives and patients is the basis for the clarification and favoring of treatment adherence and acceptance of the closeness of death.

Palliative care is organized into levels of complexity that add up to a full and active care. The General palliative care refer to approach the patient from diagnosis of disease progression, acting in all dimensions of symptoms that may present themselves. Palliative care are required specific to the patient in the last few weeks or the last six months of life, the moment becomes clear that the patient is in a State of decline. Every effort is made to stay as preserving of your self-care and around their loved ones. The end-of-life care refers, in General, the last days or last 72 hours of life. The recognition of this phase can be difficult, but it is extremely necessary for the planning of care and preparation of the patient and family for your loss and death. Even after the patient's death, the palliative care team should give attention to the process of death: how happened, what degree of comfort and that impacts brought to the family and interdisciplinary team. The post-mortem family assistance can and should begin with preventive interventions.

3. Cancer drugs

The area of Oncology is one of the more has excelled in health worldwide. The cancer drugs and support therapy account for much of the treatment of these patients at present. Understand the Pharmacology (pharmacokinetics and pharmacodynamics of conventional and innovative medicines), adverse reactions and the care of the handling and use of such medications is of great importance to the professional who acts or wish to act in this thread.

3.1 Main drugs used in cancer treatment

Antineoplastic agents more employed in the treatment of cancer include the Polyfunctional alkylating, antimetabolites, antibiotics antitumor, mitotic inhibitors and others. New drugs are being permanently isolated and applied experimentally in animal models before they are used in humans.

3.1.1 alkylating agents

Are able to override in another molecule a hydrogen atom by an alkyl radical. They bind to DNA in order to prevent the separation of the two strands of DNA in the double helix spiral, this phenomenon is essential for replication. The alkylating agents affect the cells in all phases of the cell cycle so nonspecific. Although effective as isolated agents for many forms of cancer, they rarely produce great clinical effect without combination with other agents-specific phase of the cell cycle. The main drugs employed in this category include nitrogen mustard, mustard phenyl-alanine, cyclophosphamide, the bussulfam, the nitrosureias, cisplatin and carboplatin analogue your, and ifosfamide.

3.1.2 Antimetabolites.

The antimetabolites affect cells by inhibiting the biosynthesis of the essential components of DNA and RNA. In this way, prevent the multiplication and normal function of the cell. This inhibition of biosynthesis can be directed the purines (as is the action of 6-Mercaptopurine quiet chemotherapy and 6-thioguanine), the production of timidínico acid (5-fluoruracyl and methotrexate) and the other steps of the synthesis of nucleic acids (cytosine-arabinosideo (C)). The Antimetabolites are particularly active against cells that lie in the synthesis phase of the cell cycle (S phase). The duration of life of tumor cells susceptible determines the destruction of these cells, which are prevented from entering mitosis by action of metabolic agents that act in the S phase. as can be inferred, the difference between the cell kinetics of each type of tumor can have considerable effect on clinic, both in the indication in the dosing schedule of these agents.

Are a group of substances with varied chemical structure which, although to interact with DNA and inhibit the synthesis of this protein or acid, not act specifically on a particular phase of the cell cycle. Despite performing such variation, have in common unsaturated rings that allow the incorporation of excess electrons and the consequent production of reactive free radicals. May submit another functional group that increaseth new mechanisms of action, such as alkylation (Mitomycin C), enzyme inhibition (actinomycin D and mitramicina) or inhibition and its analogues mitroxantona and epirrubicina). Like all chemotherapy, antibiotics Act on in normal cells as the evil. So also introduces undesirable side effects.

3.1.4 mitotic Inhibitors

Mitotic inhibitors can paralyze the mitosis in metaphase, due to your action on the protein tubulin, microtubules forming the spiral zone, by which migrate the chromosomes. In this way, the chromosomes during metaphase, are prevented from migrating, the interruption of cell division. This function has been useful in sync "when cells ¨ the inhibitors are combined with specific agents of the S phase of the cycle. Due to your specific mode of action, mitotic inhibitors must be associated with other agents for greater effectiveness of the chemotherapy. In this group of drugs included are alkaloids of vinca rosea (vincristine, vinblastine and vindesine) and derivatives of podofilotoxina (VP-16, etoposide; and the VM-26, teniposídeo).

3.1.5 other agents

Some drugs cannot be grouped in a certain class of pharmacological action. Among them, we highlight the Dacarbazine, indicated in the treatment of advanced melanoma, Sarcoma of soft tissues and lymphomas; the procarbazine, whose mechanism of action has not yet been completely explained, and which is used in the treatment of Hodgkin's disease; L-asparaginase, which hydrolyzes to L-asparagine and stops protein synthesis, used in the treatment of acute lymphocytic leukemia.

It is necessary to emphasize that the anticancer chemotherapy requires your duly trained professional complexity for your nomination and application. She must be employed and supervised by a specialist trained in the areas of medical and/or Pediatric Oncology and with physical conditions and appropriate materials for your administration. Clinical Oncologist must keep up to date with the constant launching on the market of new drugs for use in Oncology.

3.1.6 Action Mechanisms and classification of drugs antineoplásticas

Agents used in cancer treatment affect both normal cells as the neoplastic, but they result in greater damage to the malignant cells than those of normal tissues, due to the differences between the quantitative metabolic processes of these two cell populations. The cytotoxic aren't lethal neoplastic cells selectively. The different between the growth of neoplastic cells selectively. The differences between the growth of malignant cells and normal cells and small biochemical differences observed among them probably combine to produce specific effects.

DNA, the genetic material of all cells, acts as a girdle in the production of specific forms of RNA, ribosomal RNA and carrier messenger RNA and, thus, determines which enzyme will be synthesized by the cell. Enzymes are responsible for the majority of normal and neoplastic cell functions. Most of the drugs used in chemotherapy anticancer interferes somehow in this cellular mechanism, and a better understanding of normal cell cycle led to the clear definition of the mechanisms of action of most drugs.

3.1.7 classification of chemotherapy according to your performance on the cell cycle

Cycle-nonspecific – those who work in the cells that are in the proliferative cycle, such as nitrogen mustard.

Cycle-specific – only in cells that chemotherapy in proliferation, such as cyclophosphamide.

Specific phase-Those who work in certain phases of the cell cycle, such as methotrexate (S phase), the etoposideo (G2) and vincristine (M phase).

3.1.8 the multidisciplinary integrated approach

The medical specialists, responsible for the indication of surgery Oncology, chemotherapy and radiation are, respectively, the oncological surgeon, clinical oncologist and radiation therapy specialist.

However, the treatments imposed must be inserted into a multidisciplinary approach in other areas, such as social assistance and technical nursing, pharmacy, social work, nutrition, physical therapy, rehabilitation, dentistry, clinical psychology, Psychiatry and stomatherapy (ostomizados care), are necessarily involved.

Although each area has well established role, the multidisciplinary integrated approach is more effective than a succession of isolated interventions in the management of the patient.

Except for very limited disease surgery or premalignant lesions (such as the precursors of cervical cancer), the oncological treatment of high complexity (especially the cancer surgery, chemotherapy and radiotherapy) depends on support a tertiary level hospital structure, with greater technological density, specially prepared for:

Confirm diagnosis.
Perform the stay.
Promote the treatment, rehabilitation and palliative care, that can be arranged, on the network of health services in an integrated manner with the primary and secondary levels of attention.

Final considerations

The purpose of this article was to discuss about palliative care and cancer treatment, and these is always very individualized, it is important to note the needs and therapeutic possibilities of each patient. Can be curative or palliative intent (relief of symptoms with the aim of improving survival and quality of life).

The oncologist is specialized in clinical medical treatment of cancer, mainly for prescribing that each patient needs.

To do so, you need qualified human resources training in palliative care, since the technology used in this care are people, caregivers. When choosing care for patients at the end of life, the health team should have clear that care is more than cure. Right now, the health team can do more to ensure a death without pain, symptoms, controlled, the patient conscious and surrounded by people you love. I.e. not anticipate death nor prolong life, but ensure that if alive until the end with dignity.

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^[1] Nursing-Faculty Anhaguera de Ciências E Tecnologia in Brasília