This article addresses the misconception that patients with cancer should undergo a definitive “transition” to palliative care at some point in their trajectory, and instead proposes that a gradual shift should occur from primary palliative care provided by the oncologist to specialty palliative care when the need exists. The goal is to help practitioners identify which patients are in need of specialty palliative care, suggest when oncologists should consider making a referral, and offer a model for sharing the responsibilities of care once palliative care clinicians become involved. This model enhances the patient and family experience through improving symptom control and quality of life, and may even prolong survival. It also minimizes patients’ perception of abandonment at the end of life, while reducing the risk of physician burnout in practicing oncologists. Lastly, the misconceptions of oncologists are addressed regarding how patients and families will accept the idea of a palliative care consultation, and suggestions are offered for responding to patient and/or family resistance to referral when it arises.
Maxwell T. Vergo and Amelia M. Cullinan
Ariel Polish, Maxwell T. Vergo and Mark Agulnik
Neuroendocrine tumors (NETs) of unknown origin account for more than 10% of all NETs. Most of these tumors are poorly differentiated and, thus, very aggressive. Establishing the location of the primary tumor can be challenging. Workup of these NETs of unknown origin includes a thorough family history, immunohistochemistry, imaging, and OctreoScan. If the location of the primary malignancy is not determined, treatment is often initiated based on the grade and level of differentiation of the tumor, with well- and moderately differentiated tumors treated as carcinoid tumors, whereas poorly differentiated tumors are treated similarly to small cell tumors. Therapy is chosen based on symptoms and with the goal of debulking tumor when feasible and safe.
Maxwell T. Vergo and Al B. Benson III
The development of treatment decision strategies to guide the use of adjuvant chemotherapy in patients with stage II colon cancer continues to challenge many oncologists. Clearly, recurrence risk and prognosis for patients with stage II colon cancer can be variable, with subsets of patients with stage II disease at potentially higher risk than some with stage III. Adjuvant chemotherapy seems to produce a consistent relative risk reduction for recurrence across studies. Using clinical calculators to predict individual recurrence risk based on histopathologic and patient data allows this relative risk reduction to be translated into absolute benefit to the patient. In addition, gene expression assays in combination with these histopathologic data may further improve the accuracy of recurrence risk calculations and allow more accurate absolute benefit estimations. This absolute benefit should be discussed with the patient, taking into account the risk of morbidity from chemotherapy and individual preferences to arrive at a shared medical decision regarding adjuvant chemotherapy.