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Bast RC Jr, Kufe DW, Pollock RE, et al., editors. Holland-Frei Cancer Medicine. 5th edition. Hamilton (ON): BC Decker; 2000.

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Holland-Frei Cancer Medicine. 5th edition.

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Chapter 72Principles of Multidisciplinary Management

, MD, , MD, , MD, , MD, , MD, PhD, and , MD.

The cancer patient, and society in general, would like to think that the entire team of doctors, nurses, and scientists are cooperatively involved in solving each cancer patient’s problems. Those who are ill have little recognition of turf battles, professional egos, personal animosities, or fads in medicine, but if they knew of their existence would have even less tolerance for them. Happily, oncologists of all disciplines and other health professionals who interact with them are human, not unemotional automatons. The energies invested in picayune and counterproductive activities are small compared with the constructive and positive activities of individuals who practice the full scope of their particular professions with pride and, if necessary, determination and are consistently seeking improved (not just new) approaches to cancer.

The keystone for building a successful interdisciplinary management team is humility, tolerance, adaptability, and appreciation that alternative approaches need to be considered. None of us is so skilled that he or she can be as expert in every discipline as a highly competent exponent of that particular specialty. No one is omniscient, however, despite many years of commitment to cancer hence, we are, and must be, interdependent.

It is important to work with individuals who are trustworthy and friendly. More failures of interdisciplinary management seem to occur because of personality conflicts than because of intellectual disagreements. In the heat of confrontational oratory, emotional preferences may win out over reasoned accord. Resorting to the literature should be a mechanism that sheds more light on a problem, not more heat. A selective literature survey can often be construed to support either side of an acrimonious dispute. Facts trump opinions.

In actual clinical practice, decisions are often implemented by the oncologist who is the first to encounter the patient. A better way is to work with trusted colleagues and consultants whose opinions, where appropriate, are solicited before the first irreversible step is taken. Arbitrary undisciplined actions can seldom be undone. A formal tumor conference (never really possible or necessary for every patient) serves the purpose of institutionalizing a forum for discussion, thereby diminishing the impact of bias and prior anecdotal experience. A conference serves the additional function of allowing oncologists of several disciplines to recognize individuals of other disciplines whose opinions and consultations appear to be the most learned and whose personalities are compatible. A tumor conference occasionally alters the primary oncologist’s opinions and plans and, thus, the therapeutic approach to a specific patient. The most important contribution of a conference, however, is the establishment of dialogue, which impacts on the future disposition of similar clinical problems. Managed-care programs undeniably intrude on this concept, however, with limitation of referrals to plan members and the pressure of economic constraints to spend less time with and on each patient.

A second oncology specialist of a different discipline, whose encounter with the patient occurs after the first oncologist has already changed the tumor and the patient, may rightly point out a better approach for the future. A medical oncologist or radiation oncologist can better know and eventually better treat a patient who has been seen before definitive surgical treatment rather than after. A surgical oncologist (and the patient) would be ill-treated if a patient were prepared for surgery by chemotherapy or radiation therapy without the surgeon’s examining the tumor and the patient beforehand. In diseases where radiotherapy and chemotherapy both play a role, joint planning is mandatory.

In the absence of absolute oncologic truths, there is much room for diverse opinions. Multi-disciplinary oncology implies that each discipline performs a complementary function. The best analogy is to a symphony: each instrument is played harmoniously on the same score, rather than all on the same note, or each to a different tune. And as in a symphony’s output of music, multi-disciplinary oncology requires belief in the probability that better care will result, thus validating the commitment in time.

The Primary Physician

No universal blood or urine tests exist that can diagnose asymptomatic cancer. Occasional patients may present abnormal protein patterns or marker alterations, but excepting the prostate-specific antigen (PSA) test, such tests are not sufficiently sensitive or specific to justify them as screening tests. Many cancers can be found in asymptomatic status by periodic careful physical examinations: cancers of the skin, subcutaneous tissues, oral cavity, thyroid, lymph nodes, breast, gynecologic tract, testes, anus, prostate, and rectum. Some asymptomatic cancers are announced by a simple laboratory test: leukocytosis, anemia, microscopic hematuria, occult fecal blood, cervical cytology, hyperglobulinemia, or elevated PSA. Regular mammography, systematic colonoscopy, and periodic chest radiography (or better still, computerized tomography [CT] of the chest) can also discover asymptomatic cancers. Asymptomatic cancers tend to be smaller than symptomatic ones, which often implies a better prognosis. Regrettably, diagnoses when cancers are asymptomatic are still uncommon in most sites.

Until reliable diagnostic blood tests for visceral cancers are invented, probably tumor by tumor, history remains the most important diagnostic tool. Most cancers are discovered when the patient no longer has other simple explanations and remedies for a new significant symptom and finally seeks medical attention. Most such symptoms of cancer are readily confused with symptoms of common benign diseases. By attentive consideration of every minor symptom, a good primary doctor must sift out the symptom that could be one of cancer from that which is not likely to be. It is the constellation of symptoms, their duration, and associated findings that lead the alert physician to consider cancer. Cough, dyspepsia, anorexia, hoarseness, constipation, diarrhea, menorrhagia, weight loss, fever, fatigue, or pain, any one of which persists for 2 weeks and cannot be explained, requires consideration of cancer in the differential diagnosis. Other possible causes may exist and lead to other diagnoses, but cancer that is not thought of at this time is always diagnosed too late. It is the physician’s job to be suspicious and to exclude the diagnosis of cancer, rather than being complacent, and finally arriving at the diagnosis of cancer only when the patient’s complaints are severe and unambiguous. Suspicion is a virtue when looking for cancer. Cancer symptoms can be remittent; subcutaneous masses and nodes can even regress temporarily.

Pain at the outset is most often not constant and, when present, may be poorly localized or even migratory. Systemic dysfunction may be so mild as to be easily overlooked by the patient. Histories that are taken are more valuable than histories that are given.

On suspecting cancer, the primary physician is often able to order the appropriate tests for histologic or cytologic confirmation of that suspicion. It is at this point that the multi-disciplinary process should start. Studies that do not establish a diagnosis of cancer could be the wrong studies. Oncologic consultation might suggest other procedures of value. The primary physician often sends a patient to a surgeon for biopsy, which, when positive, may be followed by resection without further consultation. We believe that the proper time for discussion with representatives from the many disciplines who might eventually become involved is after a diagnosis is suspected or after it is proved but before the inauguration of definitive therapy. Psycho-oncologic consultation and formal rehabilitation may not be necessary for every patient but, when needed, should be arranged before the therapeutic program is initiated. Pathology consultation is always needed and is best obtained in person, at the pathologist’s double-headed microscope with the slide in view.

The surgeon, medical oncologist, and radiation oncologist should, in many cases, have protocols for therapy of common cancers. Where possible, these protocols should be part of designed studies that will accumulate sufficient numbers from which conclusions can be drawn. Sometimes this involves a single institution (or even a single practice); whenever possible, it should be part of institutional or national protocols designed to answer fundamental questions concerning the management of cancer. When multiple protocols exist, a consensus must be reached to prioritize the sequence in which they will be offered to patients. Where no protocol exists, agreement should be sought ahead of time that defines the procedures and the sequence for a particular patient. The family physician should be a full partner in all these decisions.

The family physician may also be a principal member of the serial follow-up of cancer patients, identifying any change from well-being that signals possible tumor activity and, thus, participation of an oncologist. He or she must also assess the possible familial risk and supervise the appropriate survey of family members in conjunction with the medical oncologist.

The Radiologist

Imaging specialties are essential in the diagnosis and staging of cancer. Every oncologist should review relevant imaging studies with the appropriate radiologist, sonographer, or nuclear medicine physician. A written report is mandatory but is much improved by the oncologist’s personal viewing of the images with the radiologist. Although it is commonplace to order standard menus (a CT or a magnetic resonance imaging [MRI] scan), a radiologist can suggest the best techniques for particular problems. Special CT scans with thinner slices can provide better definition of small lesions, or special MRI views (axial, coronal, sagittal, with or without gadolinium) may provide optimal visualization. Follow-up examinations using dynamic flow scanning, single photon emission computed tomography (SPECT), positron emission tomographic (PET) scanning, sonographic or CT-guided needle biopsy, and similar procedures always require the professional input of an imaging specialist.

Oncologists can request that the imaging specialist not give an interpretation directly to the patient. Thoughtless reporting of radiologic findings to patients before they are known by the responsible oncologist causes significant difficulty in management, not only for the oncologist but usually also for the patient. Information given out of context to an individual whose personality the radiologist has not fathomed provides none of the benefits that advocates of complete disclosure maintain. The contract lies between the oncologist and the imaging specialist. The radiologist is a consultant to the oncologist, not to the patient. The responsibility for the interpretation of findings to the patient, and for the support that often must go with it, rests on the oncologist.

The Pathologist

The pathologist is arguably an indispensable member of every interdisciplinary team. The function of the entire team is dependent on the proper diagnosis, and therefore pathology is a defining control. When a pathologist is not sure, it is not a disgrace. Other local pathologists can render opinions, and the Armed Forces Institute of Pathology and several prominent universities and cancer centers are justly famed for their consultations.

The ready access of the entire gastrointestinal tract to endoscopic inspection and biopsy, similar access to the genitalia in both sexes, the accessibility of the tracheobronchial tree to fiberoptic bronchoscopy, and safe intraoperative biopsies mean that preoperative or intraoperative pathologic confirmation of diagnosis should be available for nearly every tumor. Renal, testicular, and some lung masses are typically removed without first establishing histologic proof, on the basis of characteristic clinical studies and tumor-associated markers. This is justified by the desire to avoid tumor spillage that can occur during a biopsy procedure. For other diseases, radical surgery without preceding pathologic diagnosis is unnecessary and dangerous. Similarly, an inadequate surgical procedure performed because the nature of the pathologic process was not appreciated suggests insufficient or mistaken intraoperative consultation. Amputation of a breast or an extremity without pre- or intraoperative pathologic diagnosis constitutes malpractice. On the basis of his surgical judgment, a surgeon may conscientiously and competently sacrifice an adjacent dispensable normal organ, such as the spleen, kidney, adrenal, a segment of gut, diaphragm, bladder wall or vaginal wall which appears to be involved by cancer, without histologically establishing invasion. In other circumstances, the pathologist’s imprimatur is necessary to justify cancer therapies. The same restrictions apply to radiation therapy or chemotherapy, unless one stipulates and documents that the therapeutic procedure is intended prophylactically, for subclinical disease that may exist.

The pathologist is responsible for giving as definitive a description of the tumor as determined effort can guarantee: its extent, its relationship to surgical margins, and normal structures, and the involvement of lymph nodes, lymphatics, and blood vessels. Wherever possible, a specimen of fresh tissue should be maintained frozen, since, increasingly, new immunodiagnostic, molecular biologic and biochemical techniques allow classification of tumors for receptors, oncogenes, tumor suppressor genes, and antigens that may some day provide prognostic information of great value. In selected circumstances, fresh tissue can be utilized for assays that predict chemotherapeutic or immunotherapeutic sensitivity.

In addition to tissue preservation for more sophisticated studies, if needed, pathology now allows better classification of tumors. Immunopathology and cytochemistry should be able to distinguish among most anaplastic neoplasms by study of leukocyte common antigen, cytokeratin, vimentin, mucin, neuron-specific enolase, and S100 protein, whether the tumor is a lymphoma, squamous carcinoma, sarcoma, adenocarcinoma, neuroectodermal tumor, or melanoma, respectively, all of which in their anaplastic state may resemble one another in hematoxylin and eosin staining. If any suggestion exists that pathologic classification might be complex, a small fresh sample of representative neoplasm should be placed in glutaraldehyde fixative in the operating room for eventual electron microscopy. Today’s research classifications may well become tomorrow’s standard rubric and nomenclature. Oncologists should encourage the most discriminating description and classification of tumors, since new therapeutic considerations may prove to be applicable as discoveries are made.

When doubt exists concerning the nature of a neoplasm, additional opinions are always appropriate. Pathologic uncertainty is a shaky foundation on which to build therapeutic strategy.

The Surgical Oncologist

The surgical oncologist is most often the first specialist to see a patient before other oncologic specialists. The primary physician most commonly pursues a diagnosis, and in circumstances where this requires biopsy, the surgeon is called. For decades, any surgeon was considered competent to exercise all surgical skills, including cancer surgery. Indeed, while most surgeons may be acceptably competent, the specialty of surgical oncology is increasingly becoming recognized. Surgical oncologists are clinical scientists with knowledge of and experience in cancer surgery that come from additional training, limitation of the scope of general surgical practice, familiarity with the biology and natural history of cancers, and the role of the other oncologic specialties in their diagnosis and management. Until surgical oncology becomes recognized by the proper accrediting agencies, other oncologists must exercise their judgment about the oncologic qualifications of their surgical confreres. Membership in the Society of Surgical Oncology, postgraduate training in a cancer institute or university program under a mentor known for cancer surgical expertise, concentration of surgical practice on cancer and related diseases, and publications are some of the appropriate criteria.

Since a general surgeon may perform the biopsy, a surgical oncologist is on rare occasions called upon to supersede the first surgeon on the case. Herein lies some of the problem, since the primary cancer operation is of utmost importance for proper staging and for achieving surgical cure. In this regard, biopsy of any mass should be considered only in the context of whether the operating surgeon will be the best choice for eventual definitive surgical therapy. Since a considerable portion of their activity deals with neoplasia, thoracic surgeons, urologic surgeons, and neurosurgeons must be chosen for their general expertise because there is not likely to be an oncologic subspecialty in the near future for those specific organ systems. On the other hand, gynecologic oncology, orthopedic oncology, otorhinolaryngologic oncology, and surgical oncology are well defined, and the general gynecologist, orthopedist, otorhinolaryngologist, or surgeon is unlikely to be as well qualified as the oncologist within the specialty.

Because the implications for a proven neoplasm, potentially resectable, entail many other considerations to optimize curability, the prudent surgical oncologist surveys the potential contributions of medical oncology, radiation oncology, and other specialties before proceeding with the operation.

Where appropriate and possible, patients should be entered into clinical investigative trials. There is so much that is unknown about cancer that investigative activities should still be of prime concern to all oncologists. In institutions where investigative programs are not employed, sober consideration of joining in this effort through a community oncology program or in alliance with some other active institution should be exercised.

In the absence of a structured protocol, joint assessment is appropriate to determine whether chemotherapy or radiotherapy prior to surgery may improve outcome. Most often, this entails direct consultation with the medical and/or radiation oncologist. An opportunity for the three specialties to see the patient in the native unaltered state is of great value for subsequent planning.

Confidence building makes for easy consultation over the years with colleagues who share mutual trust. The treatment of breast cancer, rectal cancer, head and neck cancer, lung cancer, and soft tissue sarcoma, for example, are most often best approached by multi-disciplinary components from all three specialties. Whereas specific diseases may be treated well by single-modality approaches, bi-disciplinary or tri-disciplinary opinion is usually advantageous.

Surgical oncologists must also be available for surgical aspects of management later in the course of disease. Venous access devices may be required, depending on the drugs to be used and the status of peripheral veins. End-staging laparoscopy or laparotomy, in many instances, may make more sense than earlier operation so that the medical oncologist may be certain that a complete clinical remission is pathologically confirmed, rather than waiting for a lymphoma or ovarian cancer to relapse. Intestinal obstruction in the course of cancer may require operative surgical management. A medical or radiation oncologist may discover a suspicious mass or infiltration that needs biopsy and pathologic assessment.

Palliative surgery is an area where medical and radiation oncologists often present problems to the surgeon in hopes of potential operative remedy. Debulking, diverting, and pain-relieving operations are all appropriate procedures in the proper circumstance.

Surgical oncologists also have legitimate interests in adjuvant chemotherapy and immunotherapy. For those willing to devote the time required for this undertaking, use of established drugs in adjuvant programs can be an improvement over surgical procedures alone. Indeed, the National Surgical Adjuvant Breast and Bowel Project (NSABP) has contributed significantly to our knowledge of adjuvant therapy for these diseases. Surgical oncologic investigators have also been among the pioneers of immunologic cancer research. The rarity of surgical oncologists in practice, however, ordinarily precludes these activities for surgeons, since so much of their time is ordinarily invested in pre- and postoperative care and in actual surgery. Medical oncologists must stand ready to assume primary responsibility for subsequent oncologic management. Orthopedic oncologists, otorhinolaryngologic oncologists, and neurosurgical oncologists ordinarily ally themselves with a medical oncologist with specialized interests and expertise in the treatment of neoplasms of their particular discipline.

The Anesthesiologist

Few patients get to choose their anesthesiologist. Intraoperative management of a cancer patient is similar to that for any serious surgery. Since anesthesiologists often manage recovery rooms and even intensive care units, they get to interact with patients who are awake. Assurance of effective pain control in the immediate postoperative period is important to avoid any aggravation of anxiety and depression that may occur with the pain when first learning the significance of the operation and its findings. Patient-controlled epidural analgesia in the immediate postoperative period is the province of anesthesiology. Epidural block by continuous administration of narcotic and anesthetic solutions may also be indispensable for refractory pain in the course of metastatic cancer. Patient-controlled analgesia at other times for efficient pain control by intravenous narcotics is a technique of importance to all branches of oncology, however, and should not be considered a proprietary anesthesiologic exclusive.

The Medical Oncologist

The medical oncologist usually serves the traditional role of internist in the multi-disciplinary management of cancer. Whereas the surgical procedure, or even the radiotherapeutic treatment course is of short duration, the medical oncologist has continuing responsibility that may stretch over months or years of therapy, and decades of follow-up, depending on the neoplasm.

There is an understandable but regrettable tendency for every specialty that has interacted with a patient to schedule follow-up appointments, which may entail many more visits and much greater expense than is necessary or prudent. A combined modality follow-up clinic avoids this problem but may not be adaptable to most office practices. Each therapist is entitled to see the results of the particular treatment regimen that has been applied. The region of prior disease is only a portion of the patient’s overall health concerns, however. The search for remediable disease in regional as well as distant areas and a continuing assessment of the impact of the disease and its treatment on the patient as a whole are ordinarily considered medical tasks. A useful approach for medical oncologists is to send the findings at a follow-up visit, including laboratory and radiologic results, to the surgeon and radiation oncologist (or other appropriate specialist) so that what is going on is communicated to all. The medical oncologist is also most often the conduit to the patient for announcing program change, such as the appearance of metastases, the necessity of more therapy of whatever kind, and sometimes the shift to a palliative approach. The medical oncologist may also superintend the medical activities of the patient that are not addressed by the primary physician, together with general oncologic assessments that are of importance to the surgeon, radiation oncologist, and medical oncologist alike. When regional concerns arise that are in the purview of the other specialities, the medical oncologist should facilitate early real-time consultation. In circumstances where the patient has not received adjuvant therapy by a medical oncologist and is not undergoing treatment for metastatic disease, the involvement of a medical oncologist is left to the discretion of the primary physician and the other oncological specialists already engaged.

The medical oncologist should participate in the decisions concerning choice of therapy, as well as in the clinical staging which may determine operability. The medical oncologist should be responsible for evaluating the potential for induction (or primary, neoadjuvant) chemotherapy and for the choice of regimen for postoperative chemotherapeutic or immunotherapeutic management. Since our knowledge base is still incomplete, wherever possible, patients should enter research protocols. Data are emerging that emphasize the value of neoadjuvant (primary or induction) chemotherapy in the care of tumors classically considered first for regional surgical or radiotherapeutic approaches. Osteosarcoma and several pediatric tumors, stage III breast cancer, stage III-A non–small cell lung cancer and arguably some other cancers have benefited by chemotherapeutic impact on the presumptive micrometastases and on the primary tumor. Chemotherapeutic effect on the primary tumor serves as an in vivo bioassay of drug effect, allowing shift to a different regimen, if ineffectual. Complete pathologic regression of primary tumors has been associated with improved results for osteosarcoma, breast cancer, and head and neck cancer. Treatment of the primary neoplasm may be simplified, and lesions once considered inoperable are now potentially curable. This changing pardigm may increase the applicability of radiotherapy, surgery with intent to cure, chemotherapy, and some forms of immunotherapy.

The medical oncologist is most often the physician to reassure the patient when there is no evident cancer. Although the absence of tumor may be tumor in eclipse, the medical oncologist must keep the patient from dwelling incessantly and anxiously on imminent relapse. Reassurance should never involve a lie, just a reasoned basis for hope that relapse will not occur. Osler’s admonition to live life in day-tight packages is helpful.

The medical oncologist is the responsible physician when therapeutic options for disease control become progressively restricted as a cancer patient approaches death. Selective interventions by surgical or radiation oncologists or other specialists may be required. The overall responsibility for palliative care, pain control, psychosocial adaption, and coping with the actual aging process of the patient falls on the medical oncologist, however. A competent medical oncologist is expert at palliative care.

The Radiation Oncologist

Radiation oncology is the only medical specialty entirely devoted to the study of cancer. The radiation oncologist must, therefore, be in a position to make an overall oncologic evaluation, as well as specific recommendations for radiotherapy.

In the case of diseases where radiotherapy can sometimes cure, such as localized lymphomas, cancer of the tongue and oral cavity, cancer of the cervix, and cancer of the prostate, the radiation oncologist must have equal early access to the patient to set forth the possible indications for and accomplishments of radiation therapy for such tumors. Cordial interactive liaison with surgical and medical oncologists is crucial to allow this delineation of options before the patient is committed to and is changed by another treatment approach.

Controversy exists over the relative debilities and late toxicities of surgery and radiotherapy. Where equal curative potential exists, there is additional reason to assess the disruption of anatomy and the dysfunction that might occur from surgery or from radiotherapy. There is little consensus because single disciplines often champion their own approach. The major improvement in immediate reconstructive techniques has made surgery around the face much less disfiguring. Surgeons point out dry mouth and dysgeusia as late undesirable toxicities of radiation, while radiotherapists decry the organ loss, physiologic distortions, and cosmetic problems of surgery. Similar controversy attends vaginal dysfunction after radiation treatment for early carcinoma of the cervix, compared with total hysterectomy. In carcinomas of the bladder, the discordance is even greater because total cystectomy diminishes the quality of life, but American urologists question whether radiation therapy is ever equally effective, stage for stage. Although radiotherapy for T2 and T3 bladder cancers is reportedly highly effective in Europe, there has been little clinical investigation of this approach in the United States. Radical surgery for carcinoma of the prostate, with problems of capsular invasion, impotence, and incontinence, has not been directly compared with interstitial radiotherapy and teletherapy, which have complications of their own. A definitive comparison in early-stage prostate cancer is overdue, once there is consensus about which patients do not need immediate treatment at all.

For operable oral, pharyngeal, cervical, bladder, and prostate cancer, closer cooperation of the radiation oncologist and surgeon before decisions are finalized might, when therapy is equivalent stage for stage, provide for greater organ preservation and less dysfunction. The great problem, however, is to overcome the prejudice that the results will not be the same, with each specialty nearly equally persuaded and equally unpersuasive. Randomized clinical trials are sorely needed but may never be done because of the evolution of the combined-modality approaches.

In combined-modality approaches, chemotherapy is a major component, together with radiotherapy and surgery. Many reports indicate that chemotherapy induces major regressions when used as primary therapy for head and neck cancer, bladder cancer, breast cancer, pediatric sarcomas, and lymphomas. So, too, does hormonal therapy for prostate cancer. Primary chemotherapy, with its major theoretical advantage of decreasing the number of cells to be killed by radiation or to be removed by surgery is under active study. Until proven otherwise, radiation field sizes and surgical boundaries cannot be safely reduced below the original extent of the tumor, where residual cells may remain after chemotherapy. A major advantage of primary chemotherapy, in addition to decrease in primary tumor burden, is an early attack against undetected micrometastatic disease. Furthermore, when the tumor vasculature is intact, unimpaired by radiation angiopathy or surgical disruption, there is a greater chance of delivering a chemotherapeutically effective dose. Last, the regression of tumor seen in the primary neoplasm reinforces confidence in using the same chemotherapeutic regimen for presumed micrometastases during the adjuvant period. Indeed, when complete regression of tumor occurs, as demonstrated pathologically, outcomes are much improved in osteosarcoma and in breast cancer.

For tumors that are regionally invasive beyond resectability in the pharynx, esophagus, pancreas, cervix, and prostate, radiation is usually employed as primary therapy, and sometimes after chemotherapy or hormone therapy. The dismal results often seen in these advanced tumors unfairly taints the potential contributions of radiation oncology in the treatment of less advanced tumors. Pilot efforts are needed to construct combined modality approaches for tumors that are regionally inoperable at first encounter but which might become resectable after chemotherapy and/or radiation therapy. On the basis of multiple biopsies showing no residual tumor, some might not require surgery at all. Creation of such regimens, with some success, would allow their transfer to less advanced problems in comparison with surgery.

Primary brain tumors are usually best treated by primary surgery followed by radiotherapy, often with chemotherapy. When surgery is unfeasible, new techniques of radiosurgery—delivering precisely localized radiation from several angles so as to spare normal brain—offer some promise.

Radiotherapy can cure localized and regionalized lymphomas of certain types. The advantages and disadvantages of combined modality therapy or of the use of chemotherapy alone are presented in detail for the specific diseases. There continues to be a clear indication for combined chemotherapy and radiotherapy in patients whose lymphomas are large and where certainty of tumor eradication by either modality alone is not assured. Radiotherapy may be a critical component in salvage regimens for relapsed leukemias and lymphomas, where maximal chemotherapy together with autologous or allogeneic stem-cell transplantation is undertaken.

For palliation and pain relief, radiation therapy is indispensable to the practice of oncology. Radiotherapy can usually offer relief from the pain of tumor infiltration in bone, regardless of tumor type. Although the extent of tumor regression (as a measure of radiosensitivity) varies, this may determine length of remission rather than initial pain relief.

The Gynecologic Oncologist

Gynecologic oncologists as a class may belong to the most integrated oncologic specialty. They are fully qualified to diagnose and treat neoplasia of the female genital organs by surgery and chemotherapy and to share in radiotherapeutic planning and execution to a considerable degree, particularly for brachytherapy. Highly skilled gynecologic oncologists are divided on whether gastrointestinal complications of ovarian or other cancers should be handled by surgical oncologists, general surgeons, or gynecologic oncologists. Much of this depends on local custom rather than expertise at performing lysis of adhesions or enteroenterostomies. The preoperative preparation for and execution of procedures that involve urinary tract manipulation are almost invariably conducted cooperatively with urologists.

Many medical oncologists treat gynecologic neoplasms with chemotherapy in investigational and clinical settings. This is true for adjuvant therapy as well as treatment of manifest clinical metastasis. In many academic institutions medical and gynecologic oncologists have collaborated in the study of the biology and treatment of gynecologic cancers. Local custom, the surgical obligations of gynecologic oncologists, and collaborative undertakings involving both specialties determine the allocation of work. Medical oncologists should be actively involved when a gynecologist without specific oncologic expertise or interest has undertaken to perform the surgery.

The Pediatric Oncologist

Pediatric oncologists generally maintain an independence from adult oncologic specialties. Radiotherapists and surgeons in major centers subspecialize in pediatric neoplasms. Some gynecologists and urologists have particular interests in pediatric diseases. Orthopedic oncologists devote much of their time to pediatric sarcomas, and thus there is no specialized subset for pediatric neoplasms. In major centers, pediatric counterparts to all the medical oncologic resources, such as pediatric neurologists, radiologists, and even pathologists, illustrate the specificity of pediatric oncologic information. Nearly every child in the United States can have access to programs of the newly consolidated Children’s Oncology Group. The dramatic progress in cancer therapeutics in children derives, in part, from the universal recognition that childhood cancer is a terrible tragedy, and that every effort must be made to derive all possible information from every case. This allows the child with cancer to benefit from all the information that has gone before and creates a new database for those who will come after.

The Psycho-oncologist

The mind is the only organ system that is affected in every patient with cancer. Nonetheless, all patients do not need formal psychiatric help. Because general psychiatrists often lack full understanding of the organic aspects of cancers and the therapeutic procedures that are commonly employed, their effectiveness in dealing with these real-life problems is lessened. Psycho-oncologists have, by dint of special education and experience, a better foundation from which to undertake supervision of those patients too difficult for oncologists of other disciplines to manage. Psycho-oncologists implement much of their influence by interaction with staff rather than patients. “Sensitivity training” has been trivialized by its use in describing lesser activities. Helping train oncologists to deal sensitively and gently with their own patients is a continuing task for psycho-oncologists. It is important for oncologists to recognize the fact that a patient’s cancer is usually the greatest challenge that he or she has ever faced. Staring into the abyss, often for the first time, requires more equanimity and fortitude than many patients can muster. There are better and worse ways to communicate bad news to a patient. Training can make a difference. Teaching doctors how to handle their own inadequacies, how to tolerate their own frustrations and failures, and how to convey a humanitarian dimension to the grim reality of many cancer treatments is one of psycho-oncology’s best offerings. Not all medicine comes in a bottle.

The Rehabilitation Specialist

Rehabilitation specialists provide patients with the opportunity for self-reliance. Cutting the bonds of dependency can be the best of all remedies. Whether in speech, ambulation, ostomy care, physical appearance, occupational rehabilitation, or sexual expression, oncologists must maintain the goal that patients should lead pain-free lives with minimal, if any, deficits in normal function. Early and vigorous rehabilitation efforts can make life more worth living. Oncologists could and should consult rehabilitation medicine specialists earlier and more often.

The Nurse Oncologist

An oncology nurse has become one of the indispensable specialists. An oncologist’s nightmare is to have a complex cancer patient admitted to a general service floor. The unique medications, procedures, and tests for oncology patients are themselves adequate justification for the specialty of oncology nursing. Oncology nurses have a greater than ordinary understanding of cancer pain and a perception of the psychologic stresses that cancer patients suffer. These two precious insights allow a much more aggressive advocacy for pain control and a humanistic and realistic support of patients and families during their crises. Oncology nurses in ambulatory settings become telephone specialists in patient management, to the great advantage and comfort of cancer patients—and to the great advantage and security of oncologists.

Nurse oncologists have become the prime movers in home care, rendering active therapy or supervision of palliative measures. As this movement gains momentum, it is probable that home hospice care will become more desirable, more common, and more economical.

The Oncology Pharmacist

The very nature of oncologic drugs imparts a special responsibility for their appropriate and safe use. The special postgraduate training of an oncology pharmacist and the conscientious practice of his or her profession significantly benefit every cancer patient. Knowledge of appropriate doses, pharmacokinetics, incompatibilities, special administration procedures, acute and cumulative toxic manifestations, alternative drugs and routes of administration, and avoidance of personal exposure are all attributes that are brought to the multi-disciplinary team by an oncology pharmacist. Meticulous record keeping in computerized files are an indispensible back-up for the clinical chart. Any installation treating several patients each day can ill afford not to have a specialized oncology pharmacist.

Other Support Personnel

A few additional people are crucial in the oncologic approach to advanced cancer at home. A social worker familiar with the great stresses of cancer on every member of the family is a treasured asset. The complexities in social, insurance, economic, and service spheres can be greatly simplified by the compassionate and professional interest of an oncology social worker. Additional community resources, such as the American Cancer Society, Cancer Care, veteran patient support groups, Meals on Wheels, companion visits, and home health-care aides, which are often critical factors, may seem to be effortlessly mobilized by a social worker.

For those who have been guided by religious tenets and who have practiced their religion, the clergy can be extremely helpful and religious practice a strengthening act. Death-bed conversions seem to be uncommon, however. For those who have not made religion a significant portion of their lives, visits of the clergy or allusions to afterlife provide little comfort.

The principal support throughout the cancer experience comes from a loving family. All else may pale in comparison to the radiant affection of a spouse or another close family member. The loved one who recognizes that all the good that can be done must be done, rather than be left undone, will create the palpable substance of love for the patient. In addition to the benefit for the patient, such behavior creates comforting memories for the doer, and the satisfaction that in the ultimate crisis, he or she was steadfast.

© 2000, BC Decker Inc.
Bookshelf ID: NBK20769

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