MAKING A TREATMENT PLAN

From information on the extent of disease and the prognosis and in conjunction with the patient's wishes, it is determined whether the treatment approach should be curative or palliative in intent. Cooperation among the various professionals involved in cancer treatment is of the utmost importance in treatment planning. For some cancers, chemotherapy or chemotherapy plus radiation therapy delivered before the use of definitive surgical treatment (so-called neoadjuvant therapy) may improve the outcome, as seems to be the case for locally advanced breast cancer and head and neck cancers. In certain settings in which combined modality therapy is intended, coordination among the medical oncologist, radiation oncologist, and surgeon is crucial to achieving optimal results. Sometimes the chemotherapy and radiation therapy need to be delivered sequentially, and other times concurrently. Surgical procedures may precede or follow other treatment approaches. It is best for the treatment plan either to follow a standard protocol precisely or else to be part of an ongoing clinical research protocol evaluating new treatments. Ad hoc modifications of standard protocols are likely to compromise treatment results.

The choice of treatment approaches was formerly dominated by the local culture in both the university and the practice settings. However, it is now possible to gain access electronically to standard treatment protocols and to every approved clinical research study in North America through a personal computer interface with the Internet.2

The skilled physician also has much to offer the patient for whom curative therapy is no longer an option. Often a combination of guilt and frustration over the inability to cure the patient and the pressure of a busy schedule greatly limit the time a physician spends with a patient who is receiving only palliative care. Resist these forces. In addition to the medicines administered to alleviate symptoms (see below), it is important to remember the comfort that is provided by holding the patient's hand, continuing regular examinations, and taking time to talk.

2 The National Cancer Institute maintains a database called PDQ (Physician Data Query) that is accessible on the Internet under the name CancerNet at wwwicic.nci.nih.gov/health.htm. Information can be obtained through a facsimile machine using CancerFax by dialing 301-402-5874. Patient information is also provided by the National Cancer Institute in at least three formats: on the Internet via CancerNet at wwwicic.nci.nih.gov/patient.htm, through the CancerFax number listed above, or by calling 1-800-4-CANCER. The quality control for the information provided through these services is rigorous.

MANAGEMENT OF DISEASE AND TREATMENT COMPLICATIONS

Because cancer therapies are toxic (Chaps. 70, 71), patient management involves addressing complications of both the disease and its treatment as well as the complex psychosocial problems associated with cancer. In the short term during a course of curative therapy, the patient's functional status may decline. Treatment-induced toxicity is less acceptable if the goal of therapy is palliation. The most common side effects of treatment are nausea and vomiting (see below), febrile neutropenia (Chap. 72), and myelosuppression (Chap. 70). Therapeutic tools are now available to minimize the acute toxicity of cancer treatment.

New symptoms developing in the course of cancer treatment should always be assumed to be reversible until proven otherwise. The fatalistic attribution of anorexia, weight loss, and jaundice to recurrent or progressive tumor could result in a patient dying from a reversible intercurrent cholecystitis. Intestinal obstruction may be due to reversible adhesions rather than progressive tumor. Systemic infections, sometimes with unusual pathogens, may be a consequence of the immunosuppression associated with cancer therapy. Some drugs used to treat cancer or its complications (e.g., nausea) may produce central nervous system symptoms that look like metastatic disease or may mimic paraneoplastic syndromes such as the syndrome of inappropriate antidiuretic hormone. A definitive diagnosis should be pursued and may even require a repeat biopsy.

A critical component of cancer management is assessing the response to treatment. In addition to a careful physical examination in which all sites of disease are physically measured and recorded in a flow chart by date, response assessment usually requires periodic repeating of imaging tests that were abnormal at the time of staging. If imaging tests have become normal, repeat biopsy of previously involved tissue is performed to document complete response by pathologic criteria. Biopsies are not usually required if there is macroscopic residual disease. A complete response is defined as disappearance of all evidence of disease, and a partial response as >50% reduction in the sum of the products of the perpendicular diameters of all measureable lesions. Progressive disease is defined as the appearance of any new lesion or an increase of >25% in the sum of the products of the perpendicular diameters of all measurable lesions. Tumor shrinkage or growth that does not meet any of these criteria is considered stable disease. Some sites of involvement (e.g., bone) or patterns of involvement (e.g., lymphangitic lung or diffuse pulmonary infiltrates) are considered unmeasurable. No response is complete without biopsy documentation of their resolution, but partial responses may exclude their assessment unless clear objective (though unmeasurable) progression has occurred.

Tumor markers may be useful in patient management in certain tumors. Response to therapy may be difficult to gauge with certainty. However, some tumors produce or elicit the production of markers that can be measured in the serum or urine and, in a particular patient, rising and falling levels of the marker are usually associated with increasing or decreasing tumor burden, respectively. Some clinically useful tumor markers are shown in Table 66-5. Tumor markers are not in themselves specific enough to permit a diagnosis of malignancy to be made, but once a malignancy has been diagnosed and shown to be associated with elevated levels of a tumor marker, the marker can be used to assess response to treatment.

The recognition and treatment of depression are important components of management. The incidence of depression in cancer patients is ~25% overall and may be greater in patients with greater debility. This diagnosis is likely in a patient with a depressed mood (dysphoria) and/or a loss of interest in pleasure (anhedonia) for at least 2 weeks. In addition, three or more of the following symptoms are usually present: appetite change, sleep problems, psychomotor retardation or agitation, fatigue, feelings of guilt or worthlessness, inability to concentrate, and suicidal ideation. Patients with these symptoms should receive therapy. Medical therapy with a serotonin reuptake inhibitor such as fluoxetine (10 to 20 mg/d), sertraline (50 to 150 mg/d), or paroxetine (10 to 20 mg/d) or a tricyclic antidepressant such as amitriptyline (50 to 100 mg/d) or desipramine (75 to 150 mg/d) should be tried, allowing 4 to 6 weeks for response. Effective therapy should be continued at least 6 months after resolution of symptoms. If therapy is unsuccessful, other classes of antidepressants may be used. In addition to medication, psychosocial interventions such as support groups, psychotherapy, and guided imagery may be of benefit.

Many patients opt for unproven or unsound approaches to treatment when it appears that conventional medicine is unlikely to be curative. Those seeking such alternatives are often well educated and may be early in the course of their disease. Unsound approaches are usually hawked on the basis of unsubstantiated anecdotes and not only cannot help the patient but may be harmful. Physicians should strive to keep communications open and nonjudgmental, so that patients are more likely to discuss with the physician what they are actually doing. The appearance of unexpected toxicity may be an indication that a supplemental therapy is being taken.3

3 Information about unsound methods may be obtained from the National Council Against Health Fraud, Box 1276, Loma Linda, CA 92354, or from the Center for Medical Consumers and Health Care Information, 237 Thompson Street, New York, NY 10012.