Things you need to know
An occasional series providing specialty-specific advice for hospitalists from experts in the field.
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Cancer patients can be some of the most complicated and high-stakes patients who come into a hospitalist’s care.
The issues faced by such patients are three-pronged: Besides the effects of the cancer itself, these often elderly patients also grapple with the side effects of treatment and other medical issues.
The Hospitalist sought tips for caring for hospitalized cancer patients from a half-dozen experts in hematology and oncology. Here are the 10 most common pieces of advice they had for hospitalists caring for cancer patients.
1 Know the History
This includes the subtleties of the patient history, which can be quite involved, says Fadlo R. Khuri, MD, FACP, deputy director of the Winship Cancer Institute of Emory University and chair of hematology and medical oncology at the Emory University School of Medicine in Atlanta.
“Part of that history may be obtained from the patient and the patient’s family, but if the treatment has been evolving over time, you need to get in touch with the treating physician or at least have access to the records of the patient’s treatment,” he says. “The arsenal of drugs that we use against cancer has expanded dramatically and in different directions. Now we have tremendous technological innovations with very focused radiation or very refined surgery, and not just novel chemotherapy but also targeted therapies that can target a specific Achilles heel of cancer.”
Basically, it is important for hospitalists to know exactly “what you are dealing with.”
“That’s a lot of information that the hospitalist needs to know. Whom do I contact? Whom do I need to access, not just on the web, but in person, to understand what this patient is going through?” he adds.
With many patients, time is of the essence. This is part of the reason why it’s so important to get a complete history and full picture of a patient’s treatment right away, Dr. Khuri says.
“The patient with cancer often presents in worse shape than patients with other diseases,” he says. “Therefore, with patients with cancer or patients with other really life-threatening illness, you generally have less time to figure out what is going on.”
2 Communication Is Paramount
“The reason that communication is important is to convey the right message to the patient,” says Suresh Ramalingam, MD, professor and director of medical oncology and the lung cancer program at the Emory School of Medicine. “An oncologist who’s been following a patient for a year and a half…I would think has some insight that he or she can provide the hospitalist to manage the acute illness that the patient is admitted with.
“The other thing is many times a patient comes in the hospital and the first question they have is, ‘Does this mean my cancer is getting worse? What is the next option for me? And am I going to die right away?’ And they’re going to ask this question of whomever they see first. Having the oncologist’s thoughts on the patient’s overall status of cancer is important to address such issues.”
Dr. Ramalingam says that a situation that used to occur, but is now less frequent, is frantic calls from a patient in a hospital bed saying, “The hospitalist just walked in, and he said I’m going to die in three weeks. You never told me about that.”
When that happens, “we have to go back and talk to the patient and reassure the patient that that’s not the case,” Dr. Ramalingam says.
3 Treating Cancer Is More Than Treating Cancer
At the MD Anderson Cancer Center in Houston, where a pilot hospitalist program that began six years ago has grown into a permanent part of the center, treatment comes from all angles, not just medical, says Josiah Halm, MD, MS, FACP, FHM, CMQ, and Sahitya Gadiraju, DO, assistant professors of general internal medicine at the center.
“I think the biggest thing is to understand that a cancer patient is very complex and there’s much more than the physical component,” says Dr. Gadiraju, one of nine hospitalists at MD Anderson. “There’s an emotional component. There’s a mental component. There’s the family that’s involved.
“One of the biggest things that we do is not just support the patient physically and medically but also emotionally and mentally. And we provide very good family support working as part of an interdisciplinary team.”
4 Know the Baseline
Dr. Khuri says hospitalists should start by seeking answers to some simple questions.
“What kind of situation were they in when they began to deteriorate? Was this patient walking, talking, healthy, eating, working? And is this an acute deterioration, or is this a gradual deterioration?” he says.
The hospitalist caring for a patient with an acute decline might play a major role in the outcome.
“Some of these acute, precipitating events may be treatable, and the hospitalist may be—forgive my language—Johnny-on-the-spot—and may be able to make a major difference in turning that patient around,” he says.
5 Fight for DVT prophylaxis
When patients should be given prophylaxis for DVT, do not be deterred from doing so by the treating oncologist, says Efrén Manjarrez, MD, SFHM, assistant professor of medicine and interim chief of the division of hospital medicine and patient safety officer for the Sylvester Comprehensive Cancer Center at the University of Miami Miller School of Medicine. For patients undergoing chemotherapy, oncologists might be concerned about the potential for bleeding events, but it’s important to “get with the guidelines,” Dr. Manjarrez says.
“Oftentimes, hospitalists can be undermined by the oncologists that they’re managing their patients with,” he says. “Make sure that you stick to your guns and make sure that you’re strong about giving DVT prophylaxis to these patients, unless they truly meet exclusion criteria for that prophylaxis.
“Sometimes, hematologists or oncologists might actually cancel your order.”
6 ‘More Is Better’ for Genome Analysis
With a fine-needle biopsy, there might not be enough specimen left for molecular analysis, Dr. Ramalingam explains.
“The purpose of the biopsy is no longer just diagnostic; it has significant therapeutic implications. Therefore, getting as much tissue [as possible] during that initial diagnostic biopsy is very helpful, because we conduct detailed molecular studies on these specimens,” he says. “If you don’t get enough specimen in the first biopsy, but you just have enough to make a diagnosis of the type of cancer, then you have to resort to a second biopsy. So, more is better when it comes to tissue.”
7 Consider Pediatric Test Tubes for Pancytopenic Patients
Using smaller test tubes will lower the potential for anemia caused by frequent blood draws, Dr. Manjarrez says. Recent evidence suggests that hospital-acquired anemia prolongs hospital costs, length of stay, and mortality risk—all directly proportional to the level of anemia.1
“We’re causing [patients] to be more anemic with blood draws,” he says. “When you have cancer patients who get chemotherapy, their bone marrow is wiped out by the chemotherapy. So what happens is that you end up in the cycle where you have to keep transfusing these patients. The more blood draws that you get from them, the more we’re exacerbating it.”
8 Respect Your Turf, Their Turf
Dr. Manjarrez says the best way to ensure the hem-onc specialists respect the hospitalist’s turf, and vice versa, is to discuss the treatment parameters ahead of time.
“Try and negotiate comanagement deals with your hematologist-oncologist colleagues before you enter into comanagement relationships with them,” he says.
One particularly sticky situation is when a patient is admitted with the expectation that the hospitalist will be caring for acute issues like infection or cancer-related pain, but then the hospitalization is extended because the oncologist wants to start chemotherapy.
“That can be a problem,” he says. “Agree with your hematology-oncology colleagues what you’re going to do in advance, as much as you can.”
“Oftentimes, hospitalists can be undermined by the oncologists that they’re managing their patients with. Make sure that you stick to your guns and make sure that you’re strong about giving DVT prophylaxis to these patients, unless they truly meet exclusion criteria for that prophylaxis.”
—Efrén Manjarrez, MD, SFHM, assistant professor of medicine, interim chief, division of hospital medicine, patient safety officer, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine.
9 Be Cautious in Using Granulocyte Colony-Stimulating Factor (GCSF)
The medication is used to stimulate the body to produce more white blood cells, which sometimes is needed after chemotherapy. They are good for certain situations but should be handled with care, says Lowell Schnipper, MD, clinical director of the Beth Israel Deaconess Medical Center Cancer Center in Boston.
“Because it’s unnecessary and very expensive,” says Dr. Schnipper, who is chair of the American Society of Clinical Oncology’s Value of Care Task Force. “If this is a chemotherapy regimen that has a risk of fever and neutropenia in the context of the chemotherapy, [and] the odds of having that complication are 20% percent or higher with a chemotherapy regimen, we suggest using GCSF.”
If not, then GCSF should be avoided, he says.
Such decisions likely will fall to the treating oncologist, but Dr. Schnipper says it is a topic with which hospitalists should be familiar.
10 Rethink Imaging
“If you get a PET scan in the hospital and a patient is admitted for a different diagnosis, there’s a good likelihood that it’s not going to be reimbursed,” Dr. Ramalingam says.
Plus, he says, a scan done in the hospital could cloud the radiographic findings used to make decisions.
“For instance, for someone with pneumonia, the infiltrate might be difficult to differentiate from cancer,” he says.
Tom Collins is a freelance author in South Florida and longtime contributor to The Hospitalist.