Multidisciplinary Approach May OfferBetter Outcomes for Elderly With Cancer

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. Team-Focused Care 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 support. 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 appetite. 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(Drug information on gemcitabine) (Gemzar) chemotherapy, Ms. Meyer said. 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 strength. 'Illness Trajectory' 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."