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Gastric/GEJ Cancers: Challenges in Multimodality Care

Insights From: David Ilson, MD PhD, Memorial Sloan Kettering Cancer Center; Minaxi Jhawer, MD, Englewood Hospital and Medical Center
Published: Thursday, Jul 12, 2018



Transcript: 

Minaxi Jhawer, MD: Although multidisciplinary care is much appreciated by the patient and physicians alike, it’s very time-consuming. If you were to see some patients in half a day and you dedicated that half a day to multidisciplinary care, in essence you’ll probably be seeing 4 or 5 patients: maybe initially, maybe in the long term. What tends to happen is not only do you see the patient, you also see them with one of your colleagues or partners, a surgical colleague or a radiation colleague. You go back, review the case, and come up with a plan, and then you come back and discuss that with the patient. In real community practice, that would be 2 visits; but in a multidisciplinary clinic, that’s all encompassed in 1 visit. It needs to be well structured to give you time to take care of these patients on that particular day. It also needs infrastructure in terms of scheduling. You’re really tying 2 or 3 busy physicians together in 1 spot to see the patient in that 1 room, and that needs good coordination, whether it’s the front desk schedulers or your medical assistants all working together and scheduling these things. So there’s always cross talk in communication to make it smoother and better. I think the main thing is time, as you would imagine, and the capability and infrastructure and support from the hospital or the institution you work at, the community center, to be able to give you that support to carry out this level of care.

Patients with locally advanced gastric or GE [gastroesophageal] junction cancer tend to be very sick with a multitude of symptoms. The most common symptoms that you need to address tend to be pain, nausea, vomiting, obstruction, and ascites. What we try to strive for at our institution is to have the pain and the palliative team join us up front when a patient is diagnosed with locally advanced or metastatic cancer. They team up and work with us to address some of these symptoms and goals. All along, there’s a multidisciplinary approach because when patients have nausea, vomiting, or obstruction, you sometimes need a surgeon to create a gastrostomy or a tube to drain the obstruction or insert a J-tube [jejunostomy] or feeding tube to help them with nutritional needs. A nutritionist will help us in supporting the patient and their family in managing nutritional needs at home. Occasionally, the tumors get obstructed, and you can put in a stent, an endoluminal stent put in by the gastroenterologist, and for a short span of time, that could also work. So the decision of whether you put in a J-tube or a stent to palliate the symptoms of obstruction depends on the prognosis of the patient and on the expertise at the institution. All of that plays into the pathway as to how you take the next steps with these patients.

Other symptoms, such as pain, are addressed very well when you have a pain and palliative physician following the patient with you. The way we’ve devised it is that pain and palliative physicians come with us in the morning when we do inpatient rounds, so they’re well aware of some of the sicker patients they’re going to see. They set up appointments in the outpatient setting so that these patients can then continue to be followed. We do have a coordinator in the office who’s actual, full job tends to be to coordinate these visits so that when a patient is seen by us in the medical oncology office, the palliative doctor knows to come in and see them as well. The patient who’s already sick and in need of pain and palliative services does not have to go to another office. So that limits unnecessary visits and improves their quality of life significantly.

At our institution, we’ve been fortunate to have a Medicare-initiated program called MCCM [Medicare Care Choices Model]. It’s a Medicare choice program open in 180 centers that is really akin to hospice care, the difference being that we all know as treating physicians when you have hospice care, you really can’t give chemotherapy and radiation and actively take care of your patients. But what the MCCM has devised is that you can get hospice services for your patients and their family, but you don’t have to stop giving active treatment. Your goal is still symptom management, your goal is still palliation, but you do it alongside this team while giving chemotherapy and palliative radiation, supporting them, and watching them through their office visits but giving them that extra hospice nurse or care at home to improve their quality of life.

Transcript Edited for Clarity 
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Transcript: 

Minaxi Jhawer, MD: Although multidisciplinary care is much appreciated by the patient and physicians alike, it’s very time-consuming. If you were to see some patients in half a day and you dedicated that half a day to multidisciplinary care, in essence you’ll probably be seeing 4 or 5 patients: maybe initially, maybe in the long term. What tends to happen is not only do you see the patient, you also see them with one of your colleagues or partners, a surgical colleague or a radiation colleague. You go back, review the case, and come up with a plan, and then you come back and discuss that with the patient. In real community practice, that would be 2 visits; but in a multidisciplinary clinic, that’s all encompassed in 1 visit. It needs to be well structured to give you time to take care of these patients on that particular day. It also needs infrastructure in terms of scheduling. You’re really tying 2 or 3 busy physicians together in 1 spot to see the patient in that 1 room, and that needs good coordination, whether it’s the front desk schedulers or your medical assistants all working together and scheduling these things. So there’s always cross talk in communication to make it smoother and better. I think the main thing is time, as you would imagine, and the capability and infrastructure and support from the hospital or the institution you work at, the community center, to be able to give you that support to carry out this level of care.

Patients with locally advanced gastric or GE [gastroesophageal] junction cancer tend to be very sick with a multitude of symptoms. The most common symptoms that you need to address tend to be pain, nausea, vomiting, obstruction, and ascites. What we try to strive for at our institution is to have the pain and the palliative team join us up front when a patient is diagnosed with locally advanced or metastatic cancer. They team up and work with us to address some of these symptoms and goals. All along, there’s a multidisciplinary approach because when patients have nausea, vomiting, or obstruction, you sometimes need a surgeon to create a gastrostomy or a tube to drain the obstruction or insert a J-tube [jejunostomy] or feeding tube to help them with nutritional needs. A nutritionist will help us in supporting the patient and their family in managing nutritional needs at home. Occasionally, the tumors get obstructed, and you can put in a stent, an endoluminal stent put in by the gastroenterologist, and for a short span of time, that could also work. So the decision of whether you put in a J-tube or a stent to palliate the symptoms of obstruction depends on the prognosis of the patient and on the expertise at the institution. All of that plays into the pathway as to how you take the next steps with these patients.

Other symptoms, such as pain, are addressed very well when you have a pain and palliative physician following the patient with you. The way we’ve devised it is that pain and palliative physicians come with us in the morning when we do inpatient rounds, so they’re well aware of some of the sicker patients they’re going to see. They set up appointments in the outpatient setting so that these patients can then continue to be followed. We do have a coordinator in the office who’s actual, full job tends to be to coordinate these visits so that when a patient is seen by us in the medical oncology office, the palliative doctor knows to come in and see them as well. The patient who’s already sick and in need of pain and palliative services does not have to go to another office. So that limits unnecessary visits and improves their quality of life significantly.

At our institution, we’ve been fortunate to have a Medicare-initiated program called MCCM [Medicare Care Choices Model]. It’s a Medicare choice program open in 180 centers that is really akin to hospice care, the difference being that we all know as treating physicians when you have hospice care, you really can’t give chemotherapy and radiation and actively take care of your patients. But what the MCCM has devised is that you can get hospice services for your patients and their family, but you don’t have to stop giving active treatment. Your goal is still symptom management, your goal is still palliation, but you do it alongside this team while giving chemotherapy and palliative radiation, supporting them, and watching them through their office visits but giving them that extra hospice nurse or care at home to improve their quality of life.

Transcript Edited for Clarity 
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