Thus far, our discussion of integrated care has focused on the coordination of physicians from multiple cancer-related specialties. One can broaden the definition of interdisciplinary treatment to include several other components of care. Ko reviewed the records of 301 cancer patients and 6,745 controls and found that oncology patients frequently had coexistent pulmonary and cardiac conditions, thus requiring the participation of primary care physicians, cardiologists, and pulmonologists in the process of treatment planning and delivery.119 A model of interdisciplinary care for hepatocellular carcinoma published by Van Cleave and colleagues includes (in addition to physicians) nurses, social workers, pharmacists, and a chaplain.120
To what extent do psychosocial and/or nutritional services alter outcomes in cancer care? Several clinical trials have tested the hypothesis that psychologic treatment can prolong survival in cancer patients.121-123 The results of these studies are contradictory, and no firm conclusions can be drawn. More uniform data suggest that this type of intervention can favorably affect quality of life.122,124-126 Arguably, relief of distress and enhancement of quality of life may be more appropriate metrics with which to evaluate the efficacy of psychosocial services for cancer patients than prolongation of survival.
Potential nutritional interventions range from oral to par-enteral and from cancer prevention to the support of patients with metastatic disease.126-128 Some investigators have found that oral intake of fish oil can reverse cancer anorexia and weight loss while others have observed no benefit.129,130 Although the use of parenteral nutrition for patients with end-stage cancer can prolong survival, the associated cost and adverse effect on quality of life add complexity to the decision to undertake this therapy.131
A detailed review of the data pertaining to psychologic and nutritional intervention in cancer care is beyond the scope of this manuscript (see Chapter 85). However, there exists a broad body of literature pertaining to these treatments with which physician members of the interdisciplinary team are unlikely to be familiar. Mental health professionals and nutritionists can bring this expertise to the interdisciplinary team.
A demonstration project entitled Safe Conduct has been implemented as a component of care for patients with advanced lung cancer at the Ireland Cancer Center at University Hospitals of Cleveland. For participating patients, in addition to physician services from several cancer-related specialties, the interdisciplinary team includes a spiritual counselor, a social worker, and a nurse practitioner. In addition to careful attention to pain and symptom control, this team addresses the spiritual, emotional, and logistic needs of participating patients throughout the continuum of care.
Project Safe Conduct's positive impact on patients and caregivers emerges in several areas, based on preliminary data comparing these patients to lung cancer patients receiving care at ICC 1 year before the introduction of the Safe Conduct Team (SCT) (Figure 14.2):
The number of hospice referrals increased from 13% to 80%. The hospice length of stay increased from an average of 10 days to 43 days. The hospital admission rate (number of hospitalizations per patient per year) was 3.20 before Project Safe Conduct and dropped to 1.05 for SCT patients. Unplanned hospitalizations and emergency room visits dropped from 6.3 per patient to 3.1.
TABLE 14.2. Models of interdisciplinary care.
Interdisciplinary clinic setup
Collaborative treatment planning
Prospective treatment planning conference
Virtual gastrointestinal (GI) clinic
Comprehensive GI clinic
Clinic visits not formally coordinated
Patients see multiple specialists during separate but coordinated visits
Patients meet with multiple specialists during a single clinic visit
Interdisciplinary treatment planning conference
Interdisciplinary treatment planning conference on separate day
GI specialists confer on treatment planning during clinic visit
Source: Courtesy of the Advisory Board Company.
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