Problem Spesialis Bedah dalam kemoterapi untuk CCR Hendro Wartatmo Bagian Bedah RS Sardjito /FK UGM Yogyakarta
Pengertian / Terminologi: Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, or infusion, or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy, or biologic therapy. neoadjuvant therapy Treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery, is given. Examples of neoadjuvant therapy include chemotherapy, radiation therapy, and hormone therapy. It is a type of induction therapy.
adjuvant therapy Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, or biological therapy.
http://www.cancer.gov/publications/dictionaries/cancer-terms?cdrid=45800
Targeting therapi • Targeted therapy blocks the growth and spread of cancer by preventing cancer cells from dividing or destroying them directly. • While standard chemotherapy affects all cells in the body, targeted therapy directs drugs or other specially created substances (e.g., man-made immune system proteins) to attack cancer cells. The goal of targeted therapy is to interfere with specific molecules involved in tumor growth to block the growth and spread of the disease. • Because targeted therapy specifically seeks out cancer cells, it can avoid harm to healthy cells. In turn, targeted therapy may have fewer side effects than standard chemotherapy. http://www.cancercenter.com/colorectal-cancer/targeted-therapy/
Monoclonal antibody Monoclonal antibody therapy is a targeted drug therapy being used for colorectal cancer treatment • Bevacizumab (Avastin®) aims to prevent the growth of new blood vessels to tumors. This can help cut off a tumor’s blood supply, starving the tumor of the nutrients it needs to grow. • Cetuximab (Erbitux®) works by binding to a protein called the epidermal growth factor receptor, which exists on the surface of cells. This targeted cancer therapy helps block growth signals from reaching the inside of colorectal cancer cells, putting a stop to their division and growth. • Panitumumab (Vectibix®) also targets and binds to the epidermal growth factor receptor, preventing growth signals from reaching the inside of colorectal cancer cells. This stops their division and growth. http://www.cancercenter.com/colorectal-cancer/targeted-therapy/
Kasus 1 • Pria 29 th, datang ke RS dengan tanda klinis ileus obstruksi, setelah 4 hari sebelumnya dilakukan biopsi rektum dg hasil Adeno Ca deff. sedang. • RT : didapat tumor stinggi ujung jari, sirkuler, fixed. • Pada operasi didapat tumor setinggi pelvic floor, ukuran 7 cm, fixed. Dilakukan kolostomi diversi. • Pasca operrasi diberikan neo ajuvant kemoterapi dengan Capeox 6 siklus. • Selama pengobatan berat badan meningkat 56 kg ke BB sebelum sakit, 65 kg. CEA < 2 . Lab lain dbn.
• Setelah 6 siklus dilakukan evaluasi: – Tumor lebih mobile dp sebelumnya – MSCT: tumor mengecil
• Dilakukan re-laparatomi: – Reseksi dengan contour stapler, anastmosis end to end dengan stapler 33. – Komplikasi : infeksi superfisial pada dinding perut – PA : tepi irisan bebas tumor
• Follow up pasca re-laparatomi: – Berat badan naik 72 kg, CEA < 2 – Kolonoskopi 1 tahun kmd: tumor (-) – 4 bln setelah kolonoskopi: keadaan baik
Kasus 2 • Laki-laki 56 th dirawat di RS untuk operasi penutupan stoma. • RPS : – 8 bln sebelumnya telah dilakukan operasi Hartman a.i. obstruksi akibat keganasan kolon sigmod distal. – Pasca operasi penderita dikirim ke poliklnik onkologi untuk mendapatkan kemoterapi
• Pemeriksaan MSCT didapatkan tumor residif / residual yg besar ( ukuran > 10 cm ), CEA > 600, dan asites ringan disertai hipo albumineamia.
• Evaluasi ulang. – Selama kemoterapi CEA > 100, dan bertambah setelah siklus ke 5 – DPJP baru mengetahui program operasi Hartman setelah mendapat informasi dari pasien
• Re-laparatomi: – Tumor unresectable
Keterangan • Kasus A: – Seluruh proses ( diagnostik – tindakan bedah – neo ajuvant k – re-operasi – follow up / kolonoskopi ) melibatkan dokter bedah secara aktif
• Kasus B: – Setelah tindakan pembedahan, pasien tidak pernah berkomunikasi dg dokter bedah sampai setelah siklus ke 8, dimana pasien menyampaikan program pembedahan ulang.
Kondisi ideal • Team work • Diagnostik – Therapi – Follow up
Masalah Kemoterapi pada Kanker Kolorektal • Jumlah pasien yang tidak sebanding dengan Spesialis yang memiliki kewenangan: – Daftar antrian yang panjang – Waktu konsultasi terbatas – Rentan terjadinya under / over treatment
• Terputusnya komunikasi antara Operator ( Spesialis Bedah ): – Deteksi komplikasi bedah lambat ( ileus, residif, malnutrisi, infeksi luka operasi ) – Program pembedahan lanjutan tidak diketahui
Peraturan yg menyangkut kewenangan profesi utk melakukan kemoterapi • BPJS • Rumah sakit • Asuransi (?)
Usaha menambah SDM • Short course untuk SpPD • Untuk Spesialis Bedah ...? – Knowledge – Workshop / Training – Protokol
Ringkasan • Problem Spesialis Bedah dalam pelaksanaan kemoterapi utk CCR adalah dalam hal kewenangan. • Perlu ada pemikiran baru agar penanganan kemoterapi kanker kolorektal tetap melibatkan Spesialis Bedah dari awal sampai akhir agar dapat dilakukan penanganan yang komperhensif dan berkesinambungan.
Terima Kasih
