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H. Bhanabhai



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    MS 09 - Worldwide Perspective/Review of Limitations, Resources, Programs and Accomplishments of Supportive Care and Palliative Care Multidisciplinary Teams, by Continent (ID 27)

    • Event: WCLC 2015
    • Type: Mini Symposium
    • Track: Palliative and Supportive Care
    • Presentations: 1
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      MS09.02 - Doctor's Perspective (ID 1882)

      14:30 - 14:40  |  Author(s): H. Bhanabhai

      • Abstract
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      Abstract:
      Lung cancer is the leading cause of cancer death in Canada, and is associated with the highest levels of distress among all cancers (Canadian Cancer Statistics 2012, Zabora J et al 2001). Over two-thirds of newly diagnosed lung cancer patients are over 65 years of age and have advanced-stage disease. Many of these patients experience malnutrition comprising a combination of starvation (inadequate nutrient intake), sarcopenia (loss of muscle mass associated with loss of strength and or function), and cachexia (presence of systemic inflammation/altered metabolism). These factors are also major determinants of frailty in elderly lung cancer patients (ELCP), and are associated with reduced cancer treatment tolerance and response (Vigano and Morais, 2015). The addition of palliative care consultation initiated in parallel to treatment for lung cancer has been shown to improve both overall lung cancer mortality and patient symptom burden during cancer treatments (Greer et al, 2013). However, there is a paucity of information regarding the peri-diagnostic, pre-treatment phase. Most often, the pre-treatment phase of lung cancer care is defined as a prolonged period (mean = 6 weeks) of fragmented care that is associated with high levels of symptom burden and psychological distress (Dekhuijzen et al, 2014; Iyer et al 2013). The supportive care needs of patients during this period are often inadequately addressed. Thus, the potential for personalized interventions to reduce frailty in ELCP by targeting malnutrition and symptom burden have been largely unexplored during this critical phase. The Rapid Investigation Clinic (RIC) at the McGill University Health Centre (MUHC) currently investigates and stages patients with suspected lung cancer. The clinic operates on a bi-weekly basis and includes dedicated pulmonologists with a particular expertise in lung cancer, a dedicated nurse clinician, and a palliative care consultant. Once staged, patients’findings are discussed at tumor board meetings and are evaluated at the multidisciplinary lung cancer clinic. The mean time from referral to lung cancer treatment is approximately 6 weeks. When patients are identified at the RIC as requiring supportive care they are referred to one of seven interdisciplinary clinic/programs available at the Cancer Care Mission of the MUHC (see figure below). Figure 1 For instance, if a patient presents primarily with signs and symptoms of cachexia or deconditioning, he/she is referred to the Cancer Rehabilitation Program (CRP) and Cachexia Clinic (CC) at the MUHC, which are fully integrated with the MUHC Nutrition and Performance Laboratory (MNUPAL, www.mnupal.mcgill.ca) . MNUPAL is a state-of-the-art facility devoted to nutritional and functional assessment for patients with advanced cancer.. The primary goals of these assessments are: a) to identify presence and severity of cachexia and/or sarcopenia, b) to address reversible causes for these syndromes, such as inadequate symptom control, nutritional and hormonal deficits (i.e. hypogonadism, hypothyroidism etc), and c) to identify personalized interventions (pharmacological, nutritional, and functional) that will be appropriate for patients’ conditions and wishes. The current research at MNUPAL is driving some of the future directions of specific and personalized care, especially in terms of the Cachexia Clinic and the stages of cancer cachexia that will ultimately provide more specific and personalized care for those who are in the various stages of cancer cachexia (Vigano et al, 2012). The CRP and CC teams include a palliative care physician, a nurse clinician, a physiotherapist, an occupational therapist and a nutritionist. If patients present primarily with cancer related pain, they are referred to the Cancer Pain Clinic, whereas patients who have advanced disease and are no longer receiving treatment with a curative intent may be referred to the Palliative Care Clinic. Access to physiotherapy, occupational and nutritional services is available for all clinics which do not include these specialties in their teams.Patients assessed with psychosocial distress from all clinics are referred to the psychosocial oncology program and/or social services. CanSupport services (i.e. reimbursements for parking, transportation etc.) are also available upon request. Screening assessments for both malnutrition and symptom distress are available at the RIC. At the present time, there is ongoing research for using these screening to systematically identify frail elderly cancer patients prior to cancer treatment initiation. There is also a need to objectively determine if interventions targeted to decrease malnutrition and symptom burden will diminish frailty, may improve patient psychological and physiologic “readiness” for what are often aggressive treatments (chemotherapy, radiotherapy or surgery). There is a convincing body of research evidence including case reports (Carli et al., 2012, Carli et al., 2014), pilot studies (Li et al., 2013), and randomized clinical trials (Gillis et al., 2014) that supports geriatric patient engagement in multi-modal, cancer pre-habilitation programs designed to improve physical (physiological) and psychological (anxiety and depression) outcomes during a perioperative time period. We are therefore investigating ways to enhance access to supportive care services for elderly lung cancer patients, which include: Standardized screening for malnutrition and symptom burden. Standardized approaches to symptom control, psychological distress, as well as nutritional and functional problems Identification of specific therapeutic targets and interventions to reduce frailty Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012. Carli F, Brown R, Kennepohl S. Prehabilitation to enhance postoperative recovery for an octogenarian following robotic-assisted hysterectomy with endometrial cancer. Can J Anaesth. 2012 Aug;59(8):779-84. doi: 10.1007/s12630-012-9734-4. Epub 2012 May 26. Carli F, Awasthi R, Gillis C, Kassouf W Optimizing a frail elderly patient for radical cystectomy with a prehabilitation program. Can Urol Assoc J. 2014 Nov;8(11-12):E884-7. doi: 10.5489/cuaj.2025. Dahele, M., R. J. Skipworth, L. Wall, A. Voss, T. Preston and K. C. Fearon (2007). "Objective physical activity and self-reported quality of life in patients receiving palliative chemotherapy." J Pain Symptom Manage 33(6): 676-685. Dekhuijzen PN, Prins JB. Distress in suspected lung cancer patients following rapid and standard diagnostic programs: a prospective observational study. Psycho-oncology. 2014 Sep 9. doi: 10.1002/pon.3660. [Epub ahead of print] Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS, Carli F. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014 Nov;121(5):937-47. doi: 10.1097/ALN.0000000000000393. Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer.CA Cancer J Clin. 2013 Sep;63(5):349-63. doi: 10.3322/caac.21192. Epub 2013 Jul 15. Iyer S, Roughley A, Rider A, Taylor-Stokes G. The symptom burden of non-small cell lung cancer in the USA: a real-world cross-sectional study Support Care Cancer. 2014 Jan;22(1):181-7. doi: 10.1007/s00520-013-1959-4. Epub 2013 Sep 12. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, Kaneva P, Augustin B, Wongyingsinn M, Gamsa A, Kim do J, Vassiliou MC, Feldman LS. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc. 2013 Apr;27(4):1072-82. doi: 10.1007/s00464-012-2560-5. Epub 2012 Oct 9. Vigano A, Morais JA. The elderly patient with cancer: a holistic view. Nutrition. Published on line January 8, 2015. http://dx.doi.org/10.1016/j.nut.2015.01.001 Vigano A, Del Fabbro E, Bruera E, Borod M. The cachexia clinic: from staging to managing nutritional and functional problems in advancer cancer patients. Critical Reviews in Oncogenesis 2012 17(3), 293–304 Zabora J, Brintzenhofeszoc K, Curbow B, Hooker C and Piantadosi S. The prevalence of psychological distress by cancer site. Psycho-oncology 10 : 19–28 (2001)



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