an oncology patient’s journey… a PA’s perspective

1. 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

2. 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

3. 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

4. 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.

5. Characteristics of cancer • Uncontrolled growth of the cells in the human body • Ability of these cells to migrate from the original site and spread to distant site • Cancer is not a single disease

6. But what goes through a patient’s mind?

7. 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?

8. A Day in Life of Maitry

9. 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

10. 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

11. 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

12. 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

14. 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?

15. Existing cancer care pathway

16. Prevention

17. 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

18. Ontario Cervical Screening Program: • Women who are or have been sexually active have a Pap test every 3 years starting at age 21

19. 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

21. 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

22. Skin Cancer: • No current screening guidelines for general healthy population • High risk individuals: yearly physical exam

23. Lung Cancer:

24. 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?

27. Role of ER and GIM

29. 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

30. 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

40. How was Susan treated? Radiation:

41. Chemotherapy: Cisplatin interferes with cell division by mitosis  damaged DNA elicits DNA repair mechanisms  activation of apoptosis when repair proves impossible

42. 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

43. Hoarseness, laryngitis • Tooth decay • Earache, tinnitus • Trismus • Fatigue Radiation Side Effects: • Skin irritation • Oral mucositis • Oral thrush • Xerostomia • Taste changes • Esophagitis • Anorexia

44. About cancer diagnosis, ongoing treatment, and responsibilities Psychosocial: About not being able to go through with the treatment and not being disease free About not being available for her family members

45. Medications: • Mucositis Mouthwash • Morphine liquid • Fluconazole • Flamazine 1% How did we help Susan? G-tube: • Other: • Skin Care

46. Even after treatment ended… Ongoing side-effects • Thick oral secretions • Neck edema • Decreased hearing • Oral thrush • Psychosocial • Difficulty transitioning back to work • Depression • Ongoing guilt

47. Ongoing monitoring

48. Palliative Care and End-of-life • Multidisciplinary approach • Provide patients with relief from their symptoms, pain, physical and mental stress