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M. Turner

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    ED 12 - Caring for the Lung Cancer Patient (ID 12)

    • Event: WCLC 2015
    • Type: Education Session
    • Track: Nursing and Allied Professionals
    • Presentations: 6
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      ED12.01 - Management of Paraneoplastic Syndrome (ID 1818)

      14:15 - 15:45  |  Author(s): J. White

      • Abstract
      • Presentation

      Abstract:
      Paraneoplastic Syndromes (PNS) are a group of clinical disorders that are associated with malignant diseases that are not directly related to the physical effects of the primary tumour (Spiro 2007). The mechanisms by which PNS occur is not fully understood (Dalmau 2014) but is related to the production of polypeptide hormones or cytokines by the cancer itself or an immune response to the cancer. PNS may occur in 10% of patients with lung cancer and with the type of cancer influencing the nature of syndrome (Kanaji 2014). A wide variety of PNS have been associated with lung cancer with the most common syndromes being endocrine and neurological syndromes. This paper will only address these two groups of syndromes. Paraneoplastic Endocrine Syndromes include: Inappropriate Antidiuretic Hormone Secretion: hyponatremia is seen in 30-70% of patients with lung cancer with only 1-5% having symptoms and mostly associated with small cell lung cancer (SCLC); symptoms include confusion, seizure, reduced consciousness and coma (Spiro 2007). Hypercalcaemia: the incidence ranges from 2-12% in lung cancer; symptoms include nausea, vomiting, abdominal pain, constipation, polyuria, thirst, dehydration, confusion and irritability (Spiro 2007). Cushing Syndrome: production of adrenocorticotropic hormone(ACTH) is the most common explanation with approximately 50% being neuroendocrine lung cancers with 36%-46% carcinoid tumours and 8%-20% SCLC of cases; symptoms include weakness, muscle wasting, drowsiness, confusion, psychosis, oedema, hypokalaemia alkalosis and hyperglycaemia. hypertrophic osteoarthropathy (HOA) and finger clubbing: 90% cases in lung cancer Prevalence of 5-15% in lung cancer most common with squamous cell and adenocarcinoma. occurs due to proliferation of connective tissue beneath the nail bed with HOA causing distal expansion of the long bones; The Paraneoplastic Neurological Syndromes most commonly displayed are peripheral neuropathies and include Lambert-Eaton Myasthenic Syndrome, necrotizing myelopathy, cerebral encephalopathy, visual loss and visceral neuropathy. Symptoms include muscle weakness, cognitive and personality changes, ataxia, cranial nerve deficits or numbness. Classical and Non-Classical Symptoms have been defined (Graus 2004 Table 1) to aid in diagnosis. These syndromes are often associated with the presence of anti-Hu antibodies which are produced together with antigen-specific T lymphocytes and attack parts of the nervous system (Pelosof 2010). This syndrome is detected in 80% of cases before cancer is diagnosed (Honnorat 2007) and upto 20 per cent of those with SCLC have detectable antibodies although this syndrome will not necessarily develop (Darnell 2003). There is a reported 4-5% incidence in SCLC. Diagnostic Pathway Patients with lung cancer usually present with multiple symptoms with a time delay between symptom recognition and the ultimate diagnosis of lung cancer. The presence of a PNS may not necessarily preclude treatment with a curative intent which may help in the improvement of symptoms. Pathways of care commence with clinical evaluation, CT scan, blood screen and rapid evaluation for the next diagnostic test. It is at this point where a PNS may become apparent and can aid in the diagnosis of lung cancer. Where there are concerning symptoms for Paraneoplastic Neurological Syndrome and there is difficulty in identifying the underlying cancer: antibody screening can be considered but require considered interpretation as patients without cancer can harbour paraneoplastic antibodies, variation in the consistency of the presence of antibodies can be associated with different syndromes and the absence of antibodies may not exclude a syndrome; PET may identify neurological syndrome activity; electrophysiology may confirm the syndrome but are not always associated with cancer; MRI can assist in the diagnosis of limbic encephalitis as atrophy can be detected. Treatment As symptoms often present prior to the confirmed diagnosis it is important to treat the signs and symptoms of: Hypercalcaemia with: an increase in fluid intake; Bisphosphonates. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) with: fluid restriction; chemotherapy (effective in 80% of SCLC cases); Demeclocycline; Vasopressin receptor antagonists (Conivaptan, Tolvaptan). direct inhibition of cortisol secretion to reduce circulating glucocorticoids (eg Ketoconazole); Octreotide (blocking the release of ACTH); bilateral adrenalectomy. Cushing syndrome by: Once the diagnosis of lung cancer has been established the optimal treatment for any PNS is to treat the disease. There is no randomised control trial data for treatment for PNS on which to base practice (Giometto 2012) but there is evidence that the anti-cancer treatments (surgery, radiotherapy, chemotherapy, biological therapies, immunotherapies, immunomodulation and immunosuppression including glucocorticoids) may be beneficial. One of the challenges is that irreversible neuronal damage may have already happened by the time the diagnosis has been established. Supportive Care The symptoms of PNS can have a major impact on the patient’s quality of life and on individual care requirements. It is recommended that a Health Needs Assessment (DoH 2011) is undertaken when symptoms first present, prior to starting any intervention and at the end of treatment. This assessment should take into account the patient’s physical, psychological, social, spiritual and practical needs and will enable interventions to be put in place to maximise the quality of daily life. When symptoms present the psychological and physical impact can be devastating as immobility, discomfort, cognitive dysfunction and loss of the ability to self-care can affect the patient and care providers. In the UK the role of the Lung Cancer Nurse Specialist (RCLCF 2014) is ideally placed to address these concerns not only when the diagnosis is first made but throughout treatment and beyond by providing psychological support and symptom management, home care coordination and referrals to other health professional such as Physiotherapists and Occupational Therapists. Once primary treatment has taken place the ongoing monitoring of response to treatment is required together with a comparison of presenting symptoms. Patients should know what to do if these reoccur and how they should access their clinical team. Conclusion The management of PNS is complex and in the absence of randomised trials there is available guidance to help with the management of Paraneoplastic Syndromes. The individual care of each patient should be tailored to the diagnosis, symptoms and holistic needs. References Dalmau J, Rosenfeld M (2014) Overview of paraneoplastic syndromes of the nervous system (Accessed 20[th] June 2015) http://www.uptodate.com/contents/overview-of-paraneoplastic-syndromes-of-the-nervous-system#subscribeMessage Darnell R, Posner J (2003) Paraneoplastic syndromes involving the nervous system. NEJM 349(16):1543-54. Department of Health (2011) Improving Outcomes: A strategy for Cancer. DoH Giometto B, Vitaliani R, Lindeck-Pozza E et al (2012) Treatment for Paraneoplastic Neuropathies. Cochrane Library (Assessed 30[th] June 2015) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007625.pub2/abstract Graus F, Delattre J, Antoine J et al (2004) Recommended diagnostic criteria for paraneoplastic neurological syndromes. Journal of Neurology, Neurosurgery and Psychiatry 75(8):1135-40 Honnorat J, Antoine, JC (2007) Paraneoplastic neurological syndromes Orphanet Journal of Rare Diseases 2.22 Kanaji N, Watanabe N, Kita N et al (2014) Paraneoplastic syndromes associated with lung cancer. World Journal of Clinical Oncology, 5(3), 197-223 Pelosof L, Gerber D (2010) Paraneoplastic syndromes: an approach to diagnosis and treatment. Mayo Clinic Proceedings 85:838–854. Roy Castle Lung Cancer Foundation (2013) Understanding the Value of Lung Cancer Nurse Specialists. RCLCF Spiro S, Gould M, Colice G (2007) Initial evaluation of the patient with lung cancer: symptoms, signs, laboratory tests, and paraneoplastic syndromes: ACCP evidenced-based clinical practice guidelines (2nd edition) Chest. 132:149S–160S. Figure 1



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      ED12.02 - Addressing the Nutritional Needs of the Lung Cancer Patient (ID 1819)

      14:15 - 15:45  |  Author(s): M. Culligan

      • Abstract
      • Presentation

      Abstract not provided

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      ED12.03 - Navigating Care for the Lung Cancer Patient (ID 1820)

      14:15 - 15:45  |  Author(s): V. Beattie

      • Abstract
      • Presentation
      • Slides

      Abstract:
      There were 35,371 deaths from Lung cancer in the United Kingdom in 2012 and it remains the leading cause of United Kingdom cancer deaths (Cancer Research UK 2014). Many patients can carry a high burden of symptoms, so the nature and scale of the disease can present significant challenges for the patients, their carer’s and for those who care for them within the National Health Service. As health care professionals we have a responsibility to provide an excellent service including communication and support of the highest standard. Lung Cancer Nurse Specialists (LCNS) are involved across all stages of the patient journey and have a distinctive role in communicating information and enabling patients with lung cancer to take an inclusive role in decisions around their care. They are mostly known as the patient’s keyworker, although the identified keyworker may change throughout the pathway according to the patient’s needs. Effective face to face communication along with regular telephone contact between the LCNS and the patient and carers can aid the development and implementation of individualised care plans. The LCNS should be available at all stages to complement care and facilitate best practice, responsible for the provision of information to patients and their families in a timely manner, within a supportive environment (NICE 2011). With an average annual new caseload of 122 patients per LCNS (UKLCC, 2012) there can be an overstrain on the level of support provided by the LCNS which can lead to inequity of access and inconsistent support (Leary et al, 2008). Yet consistent specialist support and advice are essential as individuals care needs and treatment options can be complex. With this in mind we have restructured the lung cancer service at Aintree Hospitalwith the development of a support worker role. Implementation of the role is competency led and training needs structured around specific pathways (Brummell et al, 2014). With correct delegation, such as being an access point for patients and health care professionals, the support worker can release the LCNS to enable a more effective use of LCNS skills, improving patient experience. United Kingdom Lung Cancer Coalition (UKLCC, 2012) recommends that all lung cancer patients should be able to access LCNS support and advocacy when they need it throughout their whole journey to support their holistic needs. Holistic care is total patient care that considers the physical, psychological, social, economic and spiritual needs of the person with his or her response to illness. Holistic Needs Assessment (HNA) helps form a base on which to navigate care needs of the individual. It provides a framework to discuss individuals concerns and how they are feeling, to identify and understand individual needs, enable care that is personalised, sign post to appropriate agencies, and enables patients to access, identify, appraise and interpret information. HNA should be performed at or near diagnosis and at the end of treatment and whenever health and social needs change. Indeed, work undertaken by Tod et al (2013) ‘Opening Doors to treatment’ explored the impact of LCNS’s on access to anti-cancer treatment. The report demonstrated why and how the LCNS has an impact in accessing treatment, with the communication and coordination aspects of the LCNS role being essential in realising the impact in increasing treatment access. This paper sets out to demonstrate as to why the LCNS in the UK is pivotal to navigating the care of the lung cancer patient. Brummell S, Tod A, Guerin M, Beattie V et al (2014) An evaluation of the role of the support workers in lung cancer. Cancer Nursing Practice. 14, 1, 22-27. Cancer Research UK (2014) Lung Cancer Statistics. [Online ]http:// cancerresearchuk.org/health-professional/cancerstatistics-by-cancer-type/lung-cancer/mortality [Accessed June 30 2015] Leary A, Bell N, Darlison L et al (2008) An analysis of lung cancer clinical nurse specialist workload and value. Cancer Nursing Practice. 7, 10, 29-33. National Institute of Clinical Excellence (NICE) (2011) Diagnosis and treatment of Lung Cancer. Department of Health. London. UK Lung Cancer Coalition (2012) The Dream MDT for Lung Cancer: Delivering High Quality Lung Cancer Care and Outcomes

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      ED12.04 - The Role of the Occupational Therapist in the Care of Lung Cancer Patients (ID 1821)

      14:15 - 15:45  |  Author(s): K. White

      • Abstract
      • Presentation
      • Slides

      Abstract:
      Occupational therapists are integral members of the lung cancer multidisciplinary team, working with lung cancer patients in the inpatient hospital setting, hospital outpatient clinics and in the community. The focus of the occupational therapist is on enabling an individual’s participation in chosen everyday activities (Morgan DD and White KM, 2012). For people living with metastatic lung cancer, this focus is on enabling continued participation in the face of functional decline and increasing symptom burden. This focus can also encompass rehabilitation for people who have undergone curative treatment for their lung cancer, with the aim of facilitating a return to previous chosen and meaningful roles. Occupational therapists can assist people living with lung cancer prioritise their goals while managing the side effects of treatment. They also have a vital role in assisting the person living with lung cancer as their function changes with progressive disease. People living with lung cancer experience high symptom burden, which can include refractory breathlessness, fatigue and pain (Yang P et al., 2012). There is a growing body of evidence for occupational therapy interventions for people living with cancer to assist with symptom management and many of these interventions are applicable for people living with lung cancer (Morgan DD and White KM, 2012). Interventions utilised by occupational therapists when working with people living with lung cancer include task analysis, task modification, equipment prescription, priority setting and relaxation therapy. The occupational therapist is in a unique position to facilitate mastery of non-pharmacological interventions to assist in the management of refractory breathlessness and fatigue. It is important to teach techniques early in the lung cancer trajectory, to ensure mastery prior to the escalation of symptoms. This assists with preventing decreasing function and supports the engagement of the individual in valued activities (White KM, 2013). Occupational therapy management of breathlessness has been extensively researched in chronic lung conditions. The work of Migliore Norweg et al (Migliore Norweg A et al., 2005)focuses on interventions targeting improvement in everyday function for people living with COPD through mastery of breathing techniques and task modification. These interventions focus on managing breathlessness during activities that provoke breathlessness. Participation in pulmonary rehabilitation programmes is an established form of care for people with chronic lung disease. There is now a growing interest in the role of pulmonary rehabilitation to optimise function pre and post surgery for lung cancer (Pasqua F et al., 2013), as well as the role of exercise generally for people living with lung cancer (Bade BC et al., 2015, Lin Y et al., 2014, Cheville AL et al., 2012). The use of rehabilitation programmes for people living with cancer are being reported more frequently in the literature, and the occupational therapist is identified as a key team member (Silver JK and Gilchrist LS, 2011). Energy conservation techniques are useful in managing both fatigue and breathlessness. The occupational therapist completes a detailed assessment, including task analysis of how the person completes their everyday activities. This then informs interventions which can include behaviour and task modification, relaxation techniques, biofeedback, prescription of adaptive techniques and environmental modifications (White, 2013). Those living with advanced lung cancer may not have the time, energy or function to achieve full mastery of fatigue and breathlessness management techniques. Using adaptive equipment can be an effective and immediate way of improving function and assisting with symptom management for people living with advanced lung cancer. Conclusion Occupational therapy interventions aim to improve and optimise a person’s participation in everyday activities (World Federation of Occupational Therapy, 2010). Internationally, there are few occupational therapists that specialise in the field of lung cancer. This has led to a paucity of evidence and research into occupational therapy interventions that may benefit people living with lung cancer. Many interventions utilised by occupational therapists have a research base in non-malignant conditions and nursing literature. It is critical that occupational therapists build on this evidence and continue to research the efficacy of interventions used to optimise function for people living with lung cancer. The focus of occupational therapy interventions for people living with lung cancer is on enabling continued participation in valued and chosen activities in the face of functional decline and increasing symptom burden. References BADE BC, THOMAS DD, SCOTT JB & SILVESTRI GA 2015. Increasing physical activity and exercise in lung cancer: reviewing safety, benefits, and application. Journal of Thoracic Oncology, 10, 861-871. CHEVILLE AL, DOSE AM, BASFORD JR & RHUDY LM 2012. Insights into the reluctance of the patients with late-stage cancer to adopt exercise as a means to reduce their symptoms and improve their function. Journal of Pain and Symptom Management, 44, 84-94. LIN Y, LIU MF, TZENG J & LIN C 2014. Effects of walking on quality of life among lung cancer patients. Cancer Nursing, Epub ahead of print. MIGLIORE NORWEG A, WHITESON J, MALGADY R, MOLA A & REY M 2005. The effectiveness of differenct combinations od pulmonary rehabilitation on program components: A randomized controlled trial. Chest, 128, 663-672. MORGAN DD & WHITE KM 2012. Occuptional therapy interventions for breathlessness at the end of life. Current Opinion in Supportive and Palliatve Care, 6, 138-142. PASQUA F, GERANEO K, NARDI I, LOCOCO F & CESARIO A 2013. Pulmonary rehabilitation in lung cancer. Monaldi Archives for Chest Diseases, 79, 73-80. SILVER JK & GILCHRIST LS 2011. Cancer rehabilitation with a focus on evidence-based outpatient physical and occupational therapy interventions. American Journal of Physical Medicine and Rehabilitation, 90, S5-S15. WHITE KM 2013. Occupational therapy interventions for people living with advanced lung cancer. Lung Cancer Management, 2, 121-127. WORLD FEDERATION OF OCCUPATIONAL THERAPY 2010. Definitions of occupational therapy from member organisations. World Federation of Occupational Therapy. YANG P, CHEVILLE A, WAMPFLER JA, GARCES YI, JATOI A, CLARK MM, CASSIVI SD, MIDTHUN DE, MARKS RS, AUBRY M, OKUNO SH, WILLIAMS BA, NICHOLS FC, TRASTEK VF, SUGIMURA H, SARNA L, ALLEN MS, DESCHAMPS C & SLOAN JA 2012. Quality of life and symptom burden among long-term lung cancer survivors. Journal of Thoracic Oncology, 7, 64-70.

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      ED12.05 - Overcoming the Challenges of Getting Patients Through Chemo and XRT (ID 1822)

      14:15 - 15:45  |  Author(s): W. Uyterlinde

      • Abstract
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      Abstract:
      Due to toxicity during chemoradiation, patients are at risk for discontinuation of treatment and might not benefit optimally from this treatment.Small intervention trials are a possible tool to reduce toxicity within limited time. Toxicity and discontinuation of treatment were scored in 188 NSCLC patients treated with concurrent chemoradiotherapy. Literature based small intervention studies were performed for the reduction of toxicity Severe toxicity was seen in 33% of the patients; discontinuation of treatment in 20%. Esophagitis, gastro-intestinal toxicity and renal impairment were the most prominent toxicities. Intervention studies led to a reduction of nausea, weight loss, nephro toxicity and dysphagia CCRT for NSCLC is the treatment of choice at the cost of severe toxicity. Small intervention studies have shown to be benificial in reducing severe toxicity, enabling patients to accomplish CCRT en thus benifit optimal from this treatment.

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      ED12.06 - Importance of Exercise in Lung Cancer Treatment (ID 1823)

      14:15 - 15:45  |  Author(s): C. Michaels

      • Abstract
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      Abstract:
      Lung cancer survivors may suffer difficulty breathing, coughing, fatigue, anxiety, depression, insomnia and pain. Lung cancer survivors often experience a reduced quality of life. The good news is that quality of life can be improved with exercise and it should be considered for every patient. Exercise reduces the risk of lung cancer and is associated with reduced mortality. Exercise also lessens adverse symptoms and may improve quality of life, by enhancing physical and social function and lessening fatigue. The following are three of the more recent studies that have examined the benefits of exercise for lung cancer patients: 1. A 2012 study from Denmark looked at 25 patients with stage III/IV non-small cell cancer, and four patients with extensive disease small cell lung cancer. They participated in a 6-week supervised structured exercise and relaxation-training program. The researchers found that of the 23 patients, who completed the program, the majority adhered to the program and there were significant improvements in VO2 peak and 6-minute walking distance, as well as in muscle strength. The patients also reported a significant improvement in emotional well being. 2. In 2014, a larger study in Germany, included 40 patients with predominantly advanced NSCLC, who were receiving simultaneous or sequential radio chemotherapy or chemotherapy alone. The authors concluded, “ In this pilot study, endurance and strength capacity improved over time, indicating the rehabilitative importance of the applied intervention.” 3. In 2015, Dr. Gerard Silvestri, Dr. Brett Bade, David Thomas, and JoAnn Scott at the Medical University of South Carolina researched the benefit of physical activity and exercise for lung cancer patients. Their results were published in the Journal of Thoracic Oncology, June 2015. They found that physical activity should be considered as a therapeutic option for patients with lung cancer. They also concluded that exercise is safe, reduces symptoms, improves quality of life, increases exercise tolerance, and decreases length of hospitalization and post-surgery complications for lung cancer. Additionally, health care professionals should recommend exercise and encourage physical activity in patients at any stage of lung cancer. We can conclude from these studies and from my experience of working with this population that lung cancer survivors benefit from cancer exercise programs. These programs teach survivors how to exercise properly, and provide an exercise schedule. They can also provide a social and educational forum. Lung cancer patients may see even the idea of exercising as overwhelming, particularly if they suffer from shortness of breath, coughing or fatigue.The Medical University of South Carolina study found that patients with lung cancer want advice about physical activity from a cancer center physician before, during and following cancer therapy. The researchers also found that, when patients received this type of advice, there was a greater likelihood that the patients would comply with an exercise program. Why exercise during and after treatment or surgery? Exercise is a safe and inexpensive cancer therapy that reduces symptoms and improves quality of life. It improves strength, endurance, pulmonary function and flexibility, decreases the side effects of treatment and post-operative complications. Inactivity in cancer patients is associated with poorer outcomes and can cause the heart and muscles to regress and become less efficient. Being physically active not only helps prevent lung cancer in the first place, but it appears to also improve survival and quality of life for those already diagnosed. How much and what type of exercise is needed? The goal is to be able to exercise every day with a total of 150 minutes a week, the same as a healthy person. Lung cancer survivors should progress slowly, set goals, and listen to their bodies. Exercises can be performed initially in small increments of 10 minutes at a time depending on the fatigue level. Aerobic exercise is a great way to improve fitness. It not only improves cardiac function, but also improves the oxygen capacity. Aerobic exercises include walking, dancing, or any activity that increase the heart rate. Participate in enjoyable low intensity activities. Low intensity exercise such as walking is a safe way to begin. Aerobic exercise can be performed at a time that is convenient and there is no need to belong to an expensive gym. You can start by walking around a room in the house and slowly increase the distance walked. This can be done several times a day. You can use a pedometer to measure your steps and to help you set and attain goals. When sedentary one loses strength and gets weaker. Try to add movement to your day. You can take the stairs, park far from your destination, dance or whatever you enjoy that involves movement. Lung cancer patients may also benefit from strength training because it can strengthen weakened muscles. Fatigue can lead to sedentary behavior. Muscle mass will decrease if you sit or lie in bed a lot. By getting stronger it may be possible to return to work and take care of activities of daily living. Strength training can help you to improve balance, posture and increase bone strength. Patients with shortness of breath due to their cancer should perform stretching exercises daily to increase lung capacity. These can help to keep chest muscles loose and encourage deep breathing. Stretching can also help improve posture. Sitting down all day at a desk or driving can cause rounded shoulders and kyphosis, which can decrease lung capacity. It is also good to exercise prior to surgery and treatments and for those who are not surgical candidates. Exercise before surgery has multiple benefits such as improved quality of life, pulmonary capacity, endurance and strength coupled with reduced fatigue and surgical complications. Fitness level before surgery may predict risks of surgical complications and pre-surgery fitness levels may also predict how long lung patients may live beyond traditional markers of longevity. Despite limited lung capacity, exercise can help patients with lung cancer improve their quality of life by reducing fatigue, adverse symptoms and depression, while improving muscle strength, flexibility and mood.

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    ED 05 - Case Presentations (3 Lung Cancer and 1 Mesothelioma) Discussed in Round Table Format (ID 5)

    • Event: WCLC 2015
    • Type: Education Session
    • Track: Nursing and Allied Professionals
    • Presentations: 1
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      ED05.06 - Nurse Practitioner (ID 1793)

      14:15 - 15:45  |  Author(s): M. Turner

      • Abstract

      Abstract:
      Multi-disciplinary care has become an essential part of medicine, especially in oncology. This care is not limited to the disciplines of medical, surgical and radiation oncology. We as providers must start, if we haven't already, expanding our thinking to involving other disciplines such as nutrition, social work, respiratory therapy, palliative care, physical therapy, psychiatry etc. Even though medicine is becoming more personalized with targeted therapies, we cannot allow this to narrow our focus of treating the patient as a whole. Our panel of experts from different disciplines will review and discuss lung cancer and mesothelioma cases highlighting the importance of a multi-disciplinary approach to patient care.