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December 2002 CE.
This final article in a three-part series provides healthcare representatives with an understanding of the complications of cancer and cancer treatment, clinical research, and the cancer team.
Judy Chase, Pharm.D., Division of Pharmacy, University of Texas, M.D. Anderson Cancer Center, Houston, TX; John J. Kavanagh, M.D., chief professor, section of gynecologic medical oncology, department of clinical investigation, University of Texas, M.D. Anderson Cancer Center; and Patton B. Saul, M.D., medical director and director of gynecologic oncology, Lewis-Gale Cancer Center, Salem, VA, clinical associate professor of gynecology and gynecologic oncology, University of Virginia School of Medicine, Charlottesville, VA, served as consultants for this article for the Certified Medical Representatives Institute Inc.
* Describe some of the oncologic complications experienced by cancer patients.
* Describe some of the supportive therapy issues relevant to cancer patients.
* Describe the process and institutions underlying clinical research on cancer.
* Name and describe the roles of important cancer care providers.
* Describe the treatment settings available to cancer patients.
Many patients with cancer are living longer because of earlier detection and improved treatments. This prolonged survival time has also led to an increasing number of patients who experience cancer-related complications and an expansion of the care and treatment setting options.
This article begins with a discussion of the complications that can occur as a result of cancer or cancer treatment. It then summarizes current processes around clinical research and concludes with a discussion of cancer care management.
Most patients with cancer die of metastatic disease and related complications, which can occur at any time during the course of the disease. Management of an oncologic complication is influenced by many factors related to the patient's health status and the extent of the underlying disease. Some of the most common oncologic complications are:
* Disseminated intravascular coagulation, an alteration in the body's blood-clotting mechanism, resulting in accelerated coagulation, thrombosis and hemorrhage.
* Hypercalcemia, a metabolic condition that occurs when the serum calcium level rises above the normal level.
* Malignant pleural effusion, the abnormal accumulation of fluid in the pleural cavity, caused by a malignancy.
* Neoplastic cardiac tamponade, the compression of the cardiac muscle by pathologic fluid accumulation under pressure within the pericardial sac.
* Septic shock, a complex interaction of hemodynamic, humoral, cellular and metabolic abnormalities that results from the proliferation of Gram-negative bacteria and their toxins in the blood.
* Spinal cord compression, caused by a tumor in the epidural space that grows and pushes against the cord, compressing it.
* Superior vena cava syndrome, which results when the venous flow through this vessel is obstructed, resulting in impaired venous drainage and engorgement of the vessels from the head and upper body.
* Syndrome of inappropriate antidiuretic hormone, a condition of water imbalance in the body.
* Thrombosis, a blood clot within a blood vessel.
Cancer care supportive therapy issues
All the frequently used methods of cancer treatment – surgery, chemotherapy, radiation therapy and biotherapy – produce adverse effects that can impair a patient's physical, mental and social functioning.
Patients recovering from surgery and those undergoing chemotherapy, radiation therapy and biotherapy consistently report fatigue. Fatigue can be managed by identifying the contributing factors and treating them appropriately.
Nausea and vomiting are common adverse effects of chemotherapy and radiation therapy. The severity of these effects may cause patients to withdraw prematurely from a chemotherapy regimen. Various agents can be used to manage chemotherapy-induced emesis. Some patients may also benefit from relaxation and diversion therapy.
Cancer and its treatment may affect the nutritional status of the patient in a variety of ways, including interfering with the ability to chew and swallow, causing nausea and vomiting, and affecting nutrient absorption. Patients who are nutritionally depleted run the risk of weakening their immune system. The immune system works with cancer treatment to destroy tumor cells. Thus, maintaining adequate nutritional status and immune system function is a key consideration for supportive therapy. The extent of nutritional intervention depends on the cause of weight loss and the overall goals of the patient and healthcare team. Feeding by the oral route is always preferred, but enteral feeding (tube feeding) may be considered when there is a mechanical impairment to food ingestion.
Fear of unremitting pain is one of the most common anxieties of patients with cancer. Yet, it has been estimated that up to 90% of all cancer-related pain can be relieved with appropriate management. Pharmacologic treatments include the nonopioids for mild to moderate pain and the opioids for moderate to severe pain. The accompanying figure shows the pharmacologic options for treating cancer pain. Nonpharmacologic approaches include noninvasive mechanical (physical) interventions, behavioral interventions and invasive techniques.
Patients with cancer may experience a breakdown of skin integrity. Treatment of skin complications may include antibiotics, antifungals and antivirals for infections. Surgical treatment of skin lesions may include incision and drainage, debridement, and skin grafting. Radiation therapy may be used to treat obstructions, and chemotherapy may treat the underlying disease for relief of pruritus.
Disruption of the mucous membranes may be caused by primary tumors of the head, neck, gastrointestinal tract, respiratory tract and genitourinary tract, as well as some forms of non-Hodgkin's lymphoma or leukemia. Chemotherapy and radiation therapy can also disrupt mucous membranes. Antibiotics, antifungals and antivirals are used to treat any resulting infections. Platelet transfusions and other agents may be used to stop bleeding from mucosal surfaces.
Complications associated with bone marrow suppression include increased susceptibility to infection, fatigue associated with anemia and increased risk of bleeding if platelet counts are low. Treatment of infection involves the immediate, empiric use of broad-spectrum, intravenous antibiotics. A diagnosis of anemia in an immunocompromised patient may warrant transfusion of red blood cells or the use of the drug epoetin. Platelet transfusions may be helpful in the case of bleeding.
Psychosocial issues. Anger, anxiety and depression are just a few of the psychosocial issues that the healthcare team must manage. Psychosocial oncology has become a distinct field of study and professional practice. More cancer treatments are available now, and many of them have greater success at prolonging life than previous options, but their use must be balanced against the quality of life desired by the patient and the adverse effects of aggressive therapy.
Patients with cancer are at much greater risk of having a negative body image because of radical surgical procedures or adverse effects of radiation therapy or chemotherapy. This can lead to feelings of unworthiness or inadequacy and cause the patient to avoid sexual activity with a partner even though it may be physically possible. Sexual counseling and a discussion of possible techniques can greatly improve quality of life for individual cancer patients and their partners.
When cure or control of disease is no longer possible, there is a shift to palliative care in what is often called the terminal phase of illness. During this phase, the patient and family must address a number of critical issues surrounding the type of care that will be provided.
The National Cancer Institute coordinates and funds much of the ongoing cancer research throughout the United States.
The drug development process. Development of anticancer drugs and treatment modalities is a significant part of clinical research. It involves the National Cancer Institute, the pharmaceutical industry and the healthcare community.
You may already be familiar with the drug development and approval process as it occurs within a pharmaceutical company. The NCI also has a division (the Investigational Drug Branch) that tests potential new compounds for efficacy against cancer. Each year, the NCI selects approximately 10,000 compounds to undergo further screening that will detect the compounds' degree of activity against both animal and human tumor cells. Only about 10 compounds out of the initial 10,000 compounds screened will be viewed as promising candidates for further development.
Most phases of development are the same for cancer drugs as for other drugs. However, unlike typical phase I studies that use healthy volunteers, cancer studies enroll patients already diagnosed with cancer and who may have received prior treatment with standard therapies. Phase I trials determine the maximum tolerated dose in humans, the most effective schedule of administration and a preliminary evaluation of the drug's safety, and establish the pharmacokinetic profile of the drug.
The cancer management team
The primary care or family physician has the greatest opportunity to make an early diagnosis of cancer. Many cancers can be found at the asymptomatic stage by a thorough, periodic physical examination and basic laboratory tests.
Imaging specialists are essential in the discovery and staging of cancer. Oncologists also review the imaging studies with the radiologist, the sonographer or a specialist in nuclear medicine. A pathologist may also be included in the initial diagnosis following a biopsy, and consultation prior to and following surgery for tumor removal or debulking. The responsibilities of the pathologist include characterizing the tumor according to its size, its relationship to surgical margins and normal structures, and the involvement of lymph nodes.
The surgical oncologist is likely to see a patient before the other oncology specialists. When a primary care physician or internist requires a biopsy to make a definitive diagnosis of cancer, a surgeon is usually consulted. Surgical oncologists also perform palliative surgery, such as debulking, diverting and pain-relieving operations.
The medical oncologist usually serves the traditional role of internist in the multidisciplinary management of cancer. The medical oncologist has continuing responsibility for the patient that may involve months or years of therapy and decades of follow-up, depending on the type of cancer. The medical oncologist may superintend the medical activities of the patient that are not addressed by a family physician or internist, together with oncologic assessment. If radiation is a part of the patient's therapy, a radiation oncologist will be on the care team. The radiation oncologist must be in a position to make an overall oncologic evaluation, as well as specific recommendations for radiotherapy. Other specialists may be involved, depending on the patient and the type of cancer. For example, children are often treated by pediatric oncologists.
The cancer treatment setting
In the past, the hospital was the primary setting for healthcare administered to patients with cancer. With the growth of managed care and an increased emphasis on providing more efficient healthcare, alternatives to hospital care are being increasingly utilized. These alternatives include extended care, home care and hospice care.
Some examples of extended care facilities are subacute care facilities, adult foster or sheltered care facilities, residential care facilities, and adult day care facilities. These facilities provide various levels of care and medical support, depending on patient and family needs.
The growing popularity of home healthcare has resulted in the growth of community-based support services and home healthcare businesses to help families care for the patient at home. Traditional home care services generally provide skilled nursing care; patient and family education; rehabilitative services, such as physical, occupational, and speech and language therapies; social work intervention; and home health aide support.
Another option for cancer patients is hospice care. The goal of hospice is to provide high-quality, comprehensive care for patients with a life expectancy of six months or less. Hospice care is provided by an interdisciplinary team of healthcare professionals and volunteers to address the physical, psychological and spiritual needs of the patient and family members. The hospice concept allows patients a measure of control over their care, particularly when all other treatment options have been exhausted. The setting for hospice care is usually in the home, with hospitalization only during a medical crisis or impending death.
Financial costs of cancer
The National Institutes of Health estimates that the overall annual cost for cancer is $156.7 billion. Many people need financial assistance to pay for cancer care. Even people who do have health insurance often have difficulty obtaining adequate reimbursement for cancer care.
Cancer treatment in the last decade has become very complex because of experimental trials in areas such as bone marrow transplantation, genetic engineering, colony-stimulating factor therapy and biologic response modifier therapy. Some insurance companies have denied patients reimbursement for these therapies, as well as unlabeled indications of chemotherapy, calling them "experimental use." One of the challenges in healthcare today is to integrate cutting-edge cancer care with the emphasis on efficiency and optimal management that is the hallmark of the managed care industry.
* Oncologic complications include disseminated intravascular coagulation, hypercalcemia, malignant pleural effusion, neoplastic cardiac tamponade, neutropenic infection, spinal cord compression, superior vena cava syndrome, syndrome of inappropriate antidiuretic hormone secretion and thrombosis.
• These complications carry a significant risk of death and must be treated immediately.
* Supportive therapy issues include fatigue, nutrition, pain, breakdown of protective mechanisms, psychosocial issues, sexual function and terminal care.
* The National Cancer Institute coordinates and funds much of the ongoing cancer research throughout the United States.
* The cancer care team consists of many different specialists.
• Primary care physicians, imaging specialists and pathologists may be especially important in diagnosis and staging of cancer.
• Surgical, medical and radiation oncologists plan and perform the patient treatment.
• Other specialists are involved, depending on specific patient needs, throughout the progression of disease.
* Care for cancer patients may occur in several different treatment settings outside of the hospital, including extended care facilities, home care and hospice care.
* Due to the complexity of available treatments for cancer patients, including experimental and off-label therapies, some physicians and patients are having difficulty obtaining reimbursement for certain types of care.
© 2002 The Certified Medical Representatives Institute Inc., Roanoke, VA 24018. All rights reserved. No part of this article may be reproduced by any method or in any form without written permission from the CMR Institute. Reprints of this article are available from the CMR Institute. Request Continuing Education article OM-3.