Panel 3: Creating a Responsive Health Care System for Patients With Advanced Rectal Cancer, Ms. Sherri Baker, Dr. Silvana Spadafora, Dr. Patrick Critchley
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Panel 3: Creating a Responsive Health Care System for Patients With Advanced Rectal Cancer, Ms. Sherri Baker, Dr. Silvana Spadafora, Dr. Patrick Critchley



Panel #3 from the 2013 Regional Oncology Conference.

Panel #3 from the 2013 Regional Oncology Conference.



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Panel 3: Creating a Responsive Health Care System for Patients With Advanced Rectal Cancer, Ms. Sherri Baker, Dr. Silvana Spadafora, Dr. Patrick Critchley Presentation Transcript

  • 1. Panel 3: Creating a Responsive Health Care System for Patients with Advanced Rectal Cancer Panelists: Sherri Baker NCFW BSW RSW Silvana Spadafora MD FRCP(C) Patrick Critchley MD CCFP FCFP
  • 2. Mr. TW: Case History 3 • Mr. TW completes therapy and is followed appropriately over the next 10 years • He presents with liver metastases and is referred to the cancer centre • His case is assessed for “HPB” rounds. He has pre-op chemo and metastasectomy • Over some time his disease slowly progresses. He enters the palliative phase
  • 3. The Role of the Aboriginal Patient Navigator Sherri Baker NCFW BSW RSW Aboriginal Patient Navigator Northeast Cancer Centre, HSN
  • 4. Role of Aboriginal Navigator • Support at clinical visits – Attending or speaking with attending physicians regarding patient status. • Communication with health care providers & make appropriate referrals to other services – i.e. hospice, health services in the patients community. • Language and cultural translation – Accessing services through the medicine lodge • Address the cultural and spiritual needs / travel / finance/ caregiver and family needs. – Assisting with accessing any NIHB, ODSP, elders or other community services both in Sudbury and their home community. • Other psychosocial needs – Counselling or supportive services
  • 5. Accessing services All people who self identify as First Nations, Métis & Inuit are in need of supportive services. Referral to services can come from an Internal source, Self and or a community referral. Patients must have a diagnosis of cancer and are ambulatory patients.
  • 6. Management of CRC Liver Metastases Silvana Spadafora MD FRCP(C) Medical Director Algoma District Cancer Program Regional Clinical and Quality Co-Lead for Systemic Treatment
  • 7. Role of Liver Metastasectomy CCO’s Program in Evidence Based Care: • Liver resection…offers the possibility of cure in stage IV disease limited to the liver. • Patients who have complete resection of the liver metastases have a 5 yr. survival rate of ~ 45% and a 10 yr. survival rate of 25% • Patient selection is very important and done through Multidisciplinary Case Conferences CCO PEBC Evidence-based Series 17-7: The role of liver resection in colorectal cancer metastases June 2012
  • 8. The pathway for a real patient 2008: • 77 yr. male with rectal bleeding → rectal lesion → staging negative, CEA 1.6. • Neoadjuvant chemo-radiotherapy → surgery → margins not identified, N2 • 6 months oral adjuvant → staging negative, CEA 0.8. • Appropriate CEA & imaging follow-up
  • 9. The pathway for a real patient 2010 • CEA 10; R lobe liver metastases on CT • Reviewed by Toronto Hepatobiliary Team • Metastasectomy performed in Toronto • No chemotherapy required • Post-op CEA 1.0 2013 • Age 83 and CEA remains 0.8-1.2
  • 10. Clinical Tools and Guidelines for Primary Care Patrick Critchley MD CCFP FCFP Regional Primary Care Lead: Northern Districts Northeast Cancer Centre, HSN
  • 11. Objectives • ESAS - Edmonton Symptom Assessment Scale • PPS - Palliative Performance Scale • Cancer Care Ontario Symptom Management Guidelines
  • 12. Primary Care Ideal position to provide and coordinate palliative care: – Long-established relationships with our patients – Use to dealing with co-morbidity and uncertainty – Trained to treat patients holistically
  • 13. Health Care Team • Expanding number of members • Changing and expanding roles • Working in multiple settings • Communication and use of a common language are key to success
  • 14. Would you be surprised if your patient were to die in the next 6-12 months? – General Indicators of decline and increasing needs • change in performance status, co-morbidity, advanced disease, decreasing response to treatment, weight loss, etc. – Specific Clinical Indicators • Cancer - may see rapid or predictable decline • Organ failure - erratic decline • Frailty/dementia - gradual decline
  • 15. If the answer is “no I would not be surprised”…. – consider palliative care approach – involve appropriate resource/team members – initiate proactive management (less crisis management) – plan according to patient’s preferences – assess patient and family needs ongoing and regular basis – utilize tools for assessment and symptom management
  • 16. Tools • Edmonton Symptom Assessment Scale (ESAS) – Validated multidimensional symptom assessment tool – Self-rating using scale of 0 - 10 for severity of 9 common symptoms and one additional symptom described by the patient – Measures how the patient is feeling at the time of completing the scale
  • 17. ESAS - uses • Measure and document common symptoms in EOL • Provide a good overview of symptoms in individual patients • Highly effective in the recognition of unreported symptoms particularly when combined with further interviewing to obtain the details of the positive responses
  • 18. ESAS Benefits • Common language between health care providers • Efficiency • Monitoring benefits of treatment plan
  • 19. ESAS utilization in Primary Care • TPC Demonstration project 2004-2006 – Visiting home RNs collected ESAS at each visit – Sent in to CCAC office – Entered into patient chart – Team rounds - ESAS graphs for each patient was presented and reviewed at regular team meeting – Management and education plan was formulated
  • 20. ESAS utilization in Primary Care • Family Physician office • Patient completes the ESAS and responses are entered into a stamp by secretary or RN • Practice Solutions • Can graph the scale • Can track medications on the scale • Facilitates a efficiency in the office assessment and treatment plan
  • 21. Tools • Palliative Performance Scale (PPS) – Originally developed for hospice patients – Based on Karnofsky’s Performance Scale – Clinician rated on 0% - 100% scale – 0 - deceased – 100- fully functional
  • 22. PPS • 70-100% - stable • 40-60% - transitional • 0-30% - end of life
  • 23. PPS - uses • Useful in determining prognosis in advanced cancer
  • 24. PPS - Benefits • Common language • Prognosis: – prepare patient, family, team – facilitate discussions regarding care wishes and planning including - Will, POA, funeral – advocate for additional services (CCAC)
  • 25. So now what? • I’ve had the patient complete the ESAS now what?
  • 26. Care Care Ontario Website • CCO Toolbox Tab – Palliative Care Tools • PPS - tool and description (PDF) • Collaborative care plans linked to PPS score (PDF) – App Library • Symptom Management Guidelines (link to App store) • Drug Formulary (link to App store)
  • 27. Care Care Ontario Website • CCO Toolbox Tab – Symptom Management Tools • ESAS - description (PDF) • ESAS Tool - (languages) – Symptom Management Guides • 10 symptoms • Algorithms, Pocket Guides, Guide-to-practice (PDF, printable, downloadable), Videos
  • 28. CCO - Symptom Management Guide App • Pain, Dyspnea, Depression, Anxiety, Nausea and Vomiting, Delirium • App is an algorithm – Based on severity of patient’s identified symptom (ESAS) – Guide assessment – Assist with care planning including both nonpharmacological and pharmacological – DOES NOT REQUIRE WIFI TO FUNCTION
  • 29. North East Oncology News under Northeast Cancer Centre, Professional Resources and Networks, Primary Care Resources
  • 30. In conclusion • Consider: – asking the question “would I be surprised?” – utilizing the PPS and ESAS in your management plan for palliative patients – Exploring CCO Website for these tools and symptom management guidelines - proactive not during a crisis
  • 31. Download your CCO-SMG App today! To Download, Search: App Library CCO