TAMPA, Florida-The best plan
of care for an elderly cancer patient
may not be one developed in isolation
but rather in consultation with nurses,
nurse practitioners, dietitians, social
workers, and pharmacists, according
to Julie Meyer, MPH, ARNP, OCN.
"With the team approach, we are
able to help patients compromised by
chemotherapy move through that
whole cancer-treatment trajectory,
from being cancer victims to being
cancer survivors," said Ms. Meyer, senior
oncology nurse practitioner at
the H. Lee Moffitt Cancer Center,
University of South Florida, Tampa.
Ms. Meyer described the Center's
multidisciplinary elderly cancer care
program, which draws on the expertise
of several team members to complement
the treatment plan outlined
by the medical oncologist.
A standard plan of care developed
by a medical oncologist might focus
solely on anticancer therapy.
By contrast, the multidisciplinary
approach may draw upon the expertise
of other professionals to identify
risk factors and potential complications.
Team members work together
to promote patient independence,
nutrition, education, and emotional
To illustrate the difference betweenthe standard and team-focused care
plans, Meyer described the case of a
75-year-old woman with unresectable
pancreatic carcinoma. Upon presentation,
the woman complained of fatigue,
abdominal pain, and a lack of
Under the standard oncology plan
of care, this patient may have received
a less-sedating antiemetic, an increased
pain-patch dosage, and an
appetite stimulant, in addition to a
recommendation for weekly gemcitabine (Gemzar) chemotherapy, Ms.
However, the Moffitt multidisciplinary
team uncovered several issues
that would have remained unaddressed
by the standard care plan.
The first step was to use a simple
12-question screening assessment instrument
based on recommendations
by the National Comprehensive Cancer
Network (NCCN). "When we are
looking at doing an assessment, it
doesn't have to be a very laborious
screening process in order to get somegood
answers," Ms. Meyer explained.
During screening, the woman reported
weight loss, memory difficulties,
and a "blue" mood. She required
assistance with meal preparation and
transportation, and rated quality of
life as poor (3/10).
With the Moffitt approach, specific
team members consult on an asneeded
basis to address specific patient
problems. In this case, a joint
assessment by a social worker, a nutritionist,
and a nurse identified additional
factors affecting the patient, including
constipation, poor hydration,
and acute-stage grieving because of
recent spousal loss.
As a result of the team assessment,
interventions added to the care plan
included prescription for a stool softener;
a short acting opioid for breakthrough
pain; a recommended diet of
nutrient-dense foods with an increase
in fluids; information about support
groups and coping with grief; education
about chemotherapy side effects;
and exercises for increasing physical
Ms. Meyer and her colleagues hope
that, by screening for risk factors and
by prompt intervention, they can minimize
a downward "illness trajectory,"moving from decreased functional status
to decreased survival.
Team identification of grief, in particular,
may have helped to preserve
function in this 75-year-old patient
with pancreatic cancer.
"It seems once you add that emotional
component, everything you are
experiencing physically is magnified,"
Meyer explained. "When a patient
begins to have a decrease in functional
status, it puts a tremendous burden ondisthe
caregivers, in this case of the
75-year-old woman, her two children;
she could quickly become at risk
for falls, lose her independence,
and become at risk for decreased survival."