Multidisciplinary Approach May OfferBetter Outcomes for Elderly With Cancer

TAMPA, Florida-The best planof care for an elderly cancer patientmay not be one developed in isolationbut rather in consultation with nurses,nurse practitioners, dietitians, socialworkers, and pharmacists, accordingto Julie Meyer, MPH, ARNP, OCN."With the team approach, we areable to help patients compromised bychemotherapy move through thatwhole cancer-treatment trajectory,from being cancer victims to beingcancer survivors," said Ms. Meyer, senioroncology nurse practitioner atthe H. Lee Moffitt Cancer Center,University of South Florida, Tampa.Team-Focused CareMs. Meyer described the Center'smultidisciplinary elderly cancer careprogram, which draws on the expertiseof several team members to complementthe treatment plan outlinedby the medical oncologist.A standard plan of care developedby a medical oncologist might focussolely on anticancer therapy.By contrast, the multidisciplinaryapproach may draw upon the expertiseof other professionals to identifyrisk factors and potential complications.Team members work togetherto promote patient independence,nutrition, education, and emotionalsupport.To illustrate the difference betweenthe standard and team-focused careplans, Meyer described the case of a75-year-old woman with unresectablepancreatic carcinoma. Upon presentation,the woman complained of fatigue,abdominal pain, and a lack ofappetite.Under the standard oncology planof care, this patient may have receiveda less-sedating antiemetic, an increasedpain-patch dosage, and anappetite stimulant, in addition to arecommendation for weekly gemcitabine (Gemzar) chemotherapy, Ms.Meyer said.However, the Moffitt multidisciplinaryteam uncovered several issuesthat would have remained unaddressedby the standard care plan.The first step was to use a simple12-question screening assessment instrumentbased on recommendationsby the National Comprehensive CancerNetwork (NCCN). "When we arelooking at doing an assessment, itdoesn't have to be a very laboriousscreening process in order to get somegoodanswers," Ms. Meyer explained.During screening, the woman reportedweight loss, memory difficulties,and a "blue" mood. She requiredassistance with meal preparation andtransportation, and rated quality oflife as poor (3/10).With the Moffitt approach, specificteam members consult on an asneededbasis to address specific patientproblems. In this case, a jointassessment by a social worker, a nutritionist,and a nurse identified additionalfactors affecting the patient, includingconstipation, poor hydration,and acute-stage grieving because ofrecent spousal loss.As a result of the team assessment,interventions added to the care planincluded prescription for a stool softener;a short acting opioid for breakthroughpain; a recommended diet ofnutrient-dense foods with an increasein fluids; information about supportgroups and coping with grief; educationabout chemotherapy side effects;and exercises for increasing physicalstrength.'Illness Trajectory'Ms. Meyer and her colleagues hopethat, by screening for risk factors andby prompt intervention, they can minimizea downward "illness trajectory,"moving from decreased functional statusto decreased survival.Team identification of grief, in particular,may have helped to preservefunction in this 75-year-old patientwith pancreatic cancer."It seems once you add that emotionalcomponent, everything you areexperiencing physically is magnified,"Meyer explained. "When a patientbegins to have a decrease in functionalstatus, it puts a tremendous burden ondisthecaregivers, in this case of the75-year-old woman, her two children;she could quickly become at riskfor falls, lose her independence,and become at risk for decreased survival."