Transcript Giuliani_Patel_Patie.. - CAPA

AN ONCOLOGY PATIENT’S JOURNEY…
A
PA’S PERSPECTIVE
October 23, 2015
Maitry Patel, CCPA
Physician Assistant
Meredith Giuliani, MBBS, MEd, FRCPC
Staff Radiation Oncologist
Radiation Medicine Program
Princess Margaret Cancer Centre
Toronto, Ontario
Disclosures
• We have no potential conflicts with this presentation
• We have no relevant financial relationships to disclose
• We will discuss both generic and brand name medications
• We will not be discussing any off-label medications
Objectives
• Define cancer, both in medical and layman’s terms
• Explain the pathways for cancer management
• Bridge gap between specialty services and community
care, and explain oncology patient’s referral process from
primary care to hospital setting
• Explore the patient’s perspective
• Demonstrate the role of PAs in a patient’s cancer journey
• Review oncology patient’s survivorship and palliative goals
What is cancer?
• Oxford Dictionary definition of CANCER: A disease
caused by an uncontrolled division of abnormal
cells in a part of the body.
• Definition of ONCOLOGY: The study and treatment
of tumours.
Characteristics of cancer
1. Uncontrolled growth
of the cells in the
human body
2. Ability of these cells
to migrate from the
original site and
spread to distant site
3. Cancer is not a
single disease
But what goes through a patient’s mind?
Discussion
• What experiences have you had with
patients’ new diagnoses of malignancies?
• What kind of questions do they usually
have?
• What works when communicating with
these patients? What doesn’t?
A Day in Life of Maitry
Outpatient Clinical:
• New consults, follow-up, and on-treatment
patients [history and physical, assessment and
planning, breaking bad news, patient education,
and obtaining patient consent]
• Refer to specialty services
Inpatient Clinical:
• Monitor bloodwork; order and interpret imaging;
manage post-op complications
• Discharge summaries, daily rounds
Patient Education:
• Diagnosis, treatment modalities (surgery,
radiation, chemotherapy, or a combination of two
or more concurrently or in various orders)
• Survivorship post being disease-free
• Referral to palliative care/hospice
Preceptorship and Education:
• UofT and McMaster PA students and observers
• Medical students during their elective rotation
• Help orient new residents and fellows
Research:
• Recruit patients for ongoing clinical trials and
monitor patients currently enrolled in trials
• Serve as principal or co-investigator in identifying
new therapies or developing techniques that help
patients cope with the symptoms they experience
from cancer or cancer treatment
CME/Self-Study:
• Tumor boards, grand rounds, resident half-day
• Keep up-to-date with publications
Administrative:
• Call patients back regarding bloodwork and/or
imaging results
• Return patient and family calls, emails, etc. re:
queries and concerns
• Monthly PA Council meetings
Surgical:
• Mark and prep the patient, perform OR timeout
• First assist, in addition to skin closure/dressings
• Post-op orders, and handover to PACU nurses
Discussion
• What is your understanding of the existing
cancer care pathway in Ontario?
• What are your own experiences regarding
navigating your patients through this?
• What works well? What doesn’t work well?
Existing cancer care pathway
Prevention
Screening
Ontario Breast Screening Program:
• Age 50-74: mammogram every two years
• Age 30-69: referral for yearly mammogram
and breast MRI at OBSP screening for
Women at High Risk
Ontario Cervical Screening Program:
• Women who are or have been sexually
active have a Pap test every 3 years
starting at age 21
Colon Cancer Check:
• All individuals aged 50 to 74 years with no
family history of colorectal cancer should
be screened every two years with FOBT
• Individuals with first-degree relative with a
history of colorectal cancer: colonoscopy
beginning at age 50
Prostate Cancer:
• No current screening guidelines
• Avoid PSA testing in men with little to gain:
 Men 70 years of age and older
 Men with ≤ 10-15 year life expectancy
Skin Cancer:
• No current screening guidelines for general
healthy population
• High risk individuals: yearly physical exam
Lung Cancer:
Lung
Lung
Lung
cancers cancers cancers
detected detected detected
Scan 1
Scan 2
Scan 3
270
168
211
Lung
cancer
deaths
Total
deaths
427
1877
503
1998
CT
Total:
649
136
65
78
CXR
Total:
279
Lung cancer
deaths
avoided
1 for every
320 people
screened
Discussion
• About screening and prevention
• What are some setbacks in current
prevention and screening methods?
• What can we do to increase screening and
prevention rates in Ontario?
Role of ER and GIM
Let’s get to know Susan
• 48 year old ♀
• PMHx: gastric ulcers, multiple endoscopies
Meds: None on a regular basis || NKDA
• FHx: mother: gastric ca, father: colorectal ca,
brother: prostate ca, son: spinal muscular
atrophy, daughter: retinoblastoma
• SHx: Lifetime nonsmoker. Socially consumes
EtOH. Works in social services
How did she end up at PMH?
• Initial presentation: L throat discomfort
and ipsilateral ear discomfort
• GP Palpated enlarged Left tonsil but no
lymphadenopathy
• U/S: Large left neck mass
• Referral to local ENT surgeon  CT head
and neck
How was Susan treated?
Radiation:
Chemotherapy:
Cisplatin interferes
with cell division by
mitosis  damaged
DNA elicits DNA
repair mechanisms 
activation of
apoptosis when repair
proves impossible
Downhill during treatment
Chemotherapy side effects:
• Severe nausea and vomiting with blood-tinted emesis
• ER visit for dehydration, followed by CCAC and home
care over the weekend for IV hydration
• Declined IV hydration for 1 day  lightheadedness,
vagal episode, postural drop  Restart IV hydration
Radiation Side Effects:
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Skin irritation
Oral mucositis
Oral thrush
Xerostomia
Taste changes
Esophagitis
Anorexia
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Hoarseness, laryngitis
Tooth decay
Earache, tinnitus
Trismus
Fatigue
Psychosocial:
About cancer diagnosis,
ongoing treatment, and
responsibilities
About not being
able to go through
with the treatment
and not being
disease free
About not being
available for her
family members
How did we help Susan?
G-tube:
Medications:
• Mucositis Mouthwash
• Morphine liquid
• Fluconazole
• Flamazine 1%
Other:
• Skin Care
Even after treatment ended…
Ongoing side-effects
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Thick oral secretions
Neck edema
Decreased hearing
Oral thrush
Psychosocial
• Difficulty transitioning
back to work
• Depression
• Ongoing guilt
Ongoing
monitoring
Palliative Care and End-of-life
• Multidisciplinary approach
• Provide patients with relief from their symptoms,
pain, physical and mental stress
Discussion
• How can we make cancer care
coordination better?
• Thoughts about Susan’s care? How could
her journey have been better?
• What can we change?
• How do you envision cancer care in 2025?
Acknowledgments
Maitry Patel, Dr. Giuliani
[email protected]