Handbook of Advanced Cancer Care

Abstract

'My patients don't die, they just stop coming to outpatient clinics.' This tongue-in-cheek statement by a senior oncologist does reflect the cancer journey of many patients with advanced malignant disease. Patients with newly diagnosed cancer are commonly managed at a cancer centre or a specialist cancer unit, but when the disease progresses or the possibility of specific or appropriate anti-cancer therapy is exhausted, the task tends to be taken over by primary care, palliative care and community-based teams. Much of this care will be delivered not by physicians but by multiprofessional teams of nurses, physical therapists, social workers, pharmacists and other allied health professionals who have only limited knowledge of cancer and specialist palliative care. The Handbook of Advanced Cancer Care is written for such multidisciplinary teams. The book comes in three parts—general concepts of oncology, primary tumour management and cancer-related symptoms and syndromes. Most of the contributors are from North America, so the book has an inevitable slant. In the chapter 'Understanding Hospice' the authors have tried to discuss the principles of hospice care in general with reference to models outside the USA, but they deal primarily with the US hospice system. The chapter on ethics and decision-making at the end of life likewise concentrates on the ethical issues surrounding entry into the American hospice system. What a lost opportunity to address the numerous ethical issues that arise as one approaches the end of life, including withdrawal of food and fluids, resuscitation and advance directives. Although not all will admit to doing so, many patients with cancer will seek out some form of complementary or alternative medicine (CAM) at some stage during their disease trajectory. This may range from simple foot massage to high-dose vitamins and mind–body–spiritual interventions. Therefore, it is disappointing that the chapter dealing with this subject is so brief. Although resources for information about CAM are listed, more specific detail about the range of CAM might have been helpful to readers who deal with enquiries from patients. Modern standards of consent for treatment demand that patients are fully informed. Therefore, patients must be told about their cancer, their prognosis and the risks and benefits of any treatment. Many physicians still find this very difficult. In the excellent chapter on breaking bad news, Baile and Buckman discuss the necessity to take cultural beliefs into account when imparting bad news, and offer advice on how to do this with a set protocol. Another useful chapter concerns the role of surgery. At first glance, surgery within palliative care may seem incompatible with the caring non-interventional approach. A not uncommon scenario is that of a woman with far advanced ovarian cancer and bowel obstruction who may or may not benefit from surgery. Barry Feig points to those situations where aggressive surgery can lead to very worthwhile palliation, at the same time acknowledging that potential risks versus benefits are often hard to predict in the palliative setting. Similarly, there is a good overview of the place of radiotherapy, despite some controversial statements (for example the recommendation of radiotherapy for the palliation of liver metastases). Contributors were asked to adopt a readable writing style and to cite key references, reviews and websites at the end of each chapter rather than within the text. Some of the best and most readable chapters have adhered to this advice—for example those on breast cancer and malignant melanoma. It is a weakness of the book that not all conform to this style. Some chapters read as if they have been lifted straight from an oncology journal and will consequently be less useful for the target audience. The text is meant to be evidence-based. While the lack of direct referencing works in many of the primary tumour chapters where the evidence is well-known and transparent, this style works less well in the chapters dealing with symptom management. The evidence does not exist to support many of the interventions and practices commonly used in palliative care. Some of the sweeping statements in the third part of the book (for example on the justification for opioid rotation, in the chapter on pain management) should not be accepted as the last word on these subjects. Most common adult malignancies remain incurable, but with modern treatments and better supportive care, many patients are living longer with their disease. This book does fill a gap, in recognizing the information needs of the wide range of multidisciplinary health professionals caring for these patients.