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

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

The Role of the

Aboriginal Patient Navigator

Sherri Baker NCFW BSW RSW

Aboriginal Patient Navigator

Northeast Cancer Centre, HSN

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

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.

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

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

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

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

Clinical Tools and

Guidelines for Primary Care

Patrick Critchley MD CCFP FCFP

Regional Primary Care Lead: Northern Districts

Northeast Cancer Centre, HSN

Objectives

• ESAS - Edmonton Symptom Assessment

Scale

• PPS - Palliative Performance Scale

• Cancer Care Ontario Symptom

Management Guidelines

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

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

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

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

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

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

ESAS Benefits

• Common language between health care

providers

• Efficiency

• Monitoring benefits of treatment plan

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

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

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

PPS

• 70-100% - stable

• 40-60% - transitional

• 0-30% - end of life

PPS - uses

• Useful in determining prognosis in

advanced cancer

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)

So now what?

• I’ve had the patient complete the ESAS -

now what?

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)

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

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 non-

pharmacological and pharmacological

– DOES NOT REQUIRE WIFI TO FUNCTION

North East Oncology News

www.hsnsudbury.ca under Northeast Cancer Centre, Professional Resources and Networks, Primary Care Resources

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

Download your CCO-SMG

App today!

To Download, Search:

App Library CCO