Issue link: https://viewer.e-digitaledition.com/i/196089
++++++++++++++++++++++++++++++++ + +++ + SPECiAL SECTioN: CANCER +++ ++++++++++++++++++++++++++++++++ Leveraging a Comprehensive Multidisciplinary Cancer Care Plan by Charles a. kunos, mD, phD A 55-YEAr-oLd WomAN "Mrs. Edison" initially had two gynecolo g ic s y mpt om s: yellow-colored vaginal discharge and post-coital bleeding. Her medical review of systems was otherwise unremarkable — no headaches, swallowing problems, chest pains, breathing difficulties, nausea or changes in bowel and bladder habits. The next diagnostic step would be the sometimes-unsettling office pelvic examination with Papanicolaou test.1 If cancer is seen, what often follows is an uncoordinated battery of laboratory tests, imaging tests and referrals to specialists. Is there a better method? The light-bulb moment is that there is: a multidisciplinary team charged with writing an upfront comprehensive cancer care plan. A multidisciplinary cancer care plan is a structured approach to cancer-rendering functional limitations, medications, lifestyle changes and the possible surgical, radiation or chemotherapy treatments — realizing that all of these factors challenge the cancer patient's comfort with their normal daily routine.2 The plan also involves physical examination and radiographic findings that frame cancer stage, prognosis and long-term needs. Mrs. Edison knows cancer will impact her life. She thinks it is a short-term ailment. But that's where she is wrong. As a cancer survivor from the moment of her diagnosis, she must learn to appreciate that cancer, like diabetes or heart disease, is a chronic illness requiring timely surveillance and possible future intervention. Her plan leverages medical and service resources against a long-term cancer-related impact on her lifestyle. Her functional review of systems indicates that she works as a factory laborer, complaining of new shortness of breath when lifting materials on the job. She lives alone, cooks her own meals, attends to all activities of daily living and has a cheerful mood. She uses public transit and will need transportation assistance for cancer care appointments. She smokes 10 cigarettes and has done so for the past 33 years. She wants to quit. She has no difficulty managing her finances. 38 | Cleveland/Akron/Canton MD News NAmEd ■ mdNEWS.Com ■ NovEmBEr /dECEmBEr Her medication review discloses over-the-counter ibuprofen 200 mg taken as four tablets daily (800 mg) for pelvic pain rated an intensity of 4 out of 10 on a Likert scale.3 Her pelvic examination reveals an ulcerated 4 cm cervical cancer extending to the left uterosacral ligament. She had a hemoglobin of 11.8 g/dL. Her staging PET/CT scan finds disease confined to the uterine cervix. She has clinical stage IIB cervical cancer. A coordinated multidisciplinary cancer care plan can speak to a cancer-related problem list. It includes anticancer treatments, disease response surveillance, survivorship plan and pain management. She enrolled in an international clinical trial involving integrated chemotherapy administered by a gynecologic oncologist and radiation therapy overseen by a gynecologic radiation oncologist. Her multidisciplinary cancer care plan included smoking cessation counseling by her oncologists and nicotine replacement therapy aids if desired. The American Red Cross provided round-trip travel by van to cancer care appointments. Pain management involved stopping her ibuprofen (likely worsening the bleeding from her tumor) in exchange for oxycodone. A registered dietician provided nutrition counseling. Mrs. Edison returned to the office at three months posttherapy. Her bleeding symptoms had resolved on therapy and had not returned in the interval. Her PET/CT had resulted a therapeutic complete metabolic response without new metastatic disease. The important part was that she said, "I am a survivor after the team's help." When the light bulb goes on, a multidisciplinary cancer care plan intends holistic care for patient-centered gains in cancer survivorship. Dr. Charles A. Kunos is Medical Director of Radiation Oncology and Director of Brachytherapy/Radiosurgery at Summa Akron City Hospital. ■ references 1. Papanicolaou G. Atlas of exfoliative cytology. Boston Massachusetts Commonwealth Fund: University Press; 1954. 2. Kunos C, Ferris G, Waggoner S. Implementing chemoradiation treatment for patients with cervical cancer in a comprehensive cancer center community oncology practice. Commun Oncol 2010;7(10):446-450. 3. Likert R. A technique for the measurement of attitudes. Archives of Psychology 1932;22(140): 5-55.