HOW TO REFER A CANCER PATIENTA PRACTICAL GUIDE ON WHAT TO DO IF “TUMOR IS THE RUMOR”

ACKNOWLEDGEMENTS

• I have had been involved in research and ad boards with many

pharmaceutical companies however declare that this talk does not involve

them and I therefore have no conflicts

• I have coordinated this talk with the Nova Scotia Cancer Care Program and

would like to thank them and praise them for working to fulfill their mission

statement “Led by compassion and driven by evidence, together we work to

alleviate the burden of cancer”

NSHA Cancer Care Program

Our vision: World class cancer care for generations

Our mission: Led by compassion and driven by evidence,

together we work to alleviate the burden of cancer

Prevention Screening DiagnosisTreatment &

Psychosocial

Support

EoL Care

Survivorship

Care

There is a role for Primary Care throughout the cancer trajectory

NSHA CCP: Clinical Services, Quality, Capacity Building, Cancer Registry and

Analytics

NSHA Cancer Care ProgramNSHA Cancer Care Program

Tertiary/Quaternary

Cancer Centers

Community Cancer

Clinics

*

www.nscancercare.ca

Photo credit: McCallum

PRACTICAL TIPS

• Consider patients preference, age, comorbidities and life expectancy when

determining extent of work up’

• Does the patient need further tests before referral ie biopsy, metastatic work

up, tumor markers, etc

• If you do not know what to do phone and ask

REFERRALS

• All Gyne onc and Heamatology consults are centrally triaged at the QEII

• Med Onc consults are triaged in Halifax or Sydney

• If you want a certain oncologist specify on the referral and tell the patient

they might have to wait longer and they may not treat that type of cancer

and you will someone else.

REFERRALS

• Required Information is almost always the final path report and all imaging. We triage by

tumor type and staging determines treatment.

• Use the Phone if need be.

• Urgent referrals mean something if we hear why ( worry is not unique enough to be

urgent)

• QEII referral Office 902-473-5140 or med onc/heam on call 902 473 2220

• Cape Bretton 902-567-7771

• Unfortunately we are full. Urgent consults may result in bumping. We do not have a wait list

because they cannot wait. We cannot see all patients locally or at certain times.

• Unattached patients are becoming a problem with followup.

HEAMATOLOGY CONSULTS 9024733910 (F)

• 4 categories C1-4

• Emergent Acute leukemia, severe “penia” plt<20.000 or HGB<60 or WBC<1,000

• Call and mark urgent need blood work and bone marrow if done

• Target to see 2 days Actual 1.8 days

• Urgent New lymphoma or non Hodgkin lymphoma

• Need tissue biopsy, blood work and bone marrow if available

• Target 14 days actual 11.5 days

• Semi-urgent Myeloma, CML, moderate anemia <80 or thrombocytopenia

<50,000

• Need blood work and bone marrow if available

• Target 42 days, actual 32.6 days

• Non urgent perioperative management of anticoagulation, CLL,

heamachromatosis, etc.

• Target 90 days A lot are not seen and advise given via phone

HEAMATOLOGY CONSULTS 9024733910 (F)

MEDICAL ONCOLOGY REFERRALS902 473 6079(F)

• All referrals need Pathology, staging ( imaging and bloodwork) and note

• Emergent (target 1 day) SVC syndrome from Small Cell Lung cancer.

Fax, write “emergency”, and call the Medical Oncologist on call

• Urgent ( target 7 days)Ewing’s Sarcoma (preoperative therapy),

Inflammatory breast cancer, metastatic testicular cancer, Osteosarcoma (

preoperative therapy), Small cell lung cancer, any urgent request with

explanation

MEDICAL ONCOLOGY REFERRALS902 473 6079(F)

• Semi urgent ( target 14 days) non urgent 1 and 2 (target 28 days and 42 days)

• Semi urgent are those cancers not already listed who we treat preoperatively like

gastric, esophageal, rectal, locally advanced pancreatic cancers, and Head and

Neck tumors. In the future more breast will be treated preoperatively and potentially

colon cancers.

• Also included are aggressive chemo sensitive cancers such as metastatic Ewings and

osteosarcomas or stage I testes.

MEDICAL ONCOLOGY REFERRALS902 473 6079(F)

• The non urgent categories are all others but the time lines are not always

clear in that adjuvant therapies are measured from time of OR not referral

arrival so a 8 week timing for adjuvant breast cancer is sometimes sent to us

at 6 weeks and we need to try to fit in in 2 weeks

• Currently my next new patient appointment is FEB 25th . We have a locum

Medical oncologist in town awaiting credentialing and nursing resources to

help. Work load statistics show every oncologists exceeds their target as a

group are 23% over their target

Medical Oncology Referrals

SURGICAL REFERRALS

• Gynecological oncology treat both with surgery and chemotherapy fax consult to 902 473

7765

• Head and Neck tumors refer to Otolaryngologist-Head and Neck surgery QEII

• Prostate cancer refer to Dr. Ricardo Rendon or Dr. Ross Mason

• Thyroid cancers refer to ENT or endocrine depending on local resources

• Sarcoma

• Bone and soft tissue refer to Dr, Mike Biddulph

• Retroperitoneal refer to Dr Carman Giacomantonio or Dr. Lucy Helyer, QEII

• Melanoma refer to Dermatology ,Plastics or Drs. Helyer and Giacomantonio

REFERRAL PATTERNS

• Children refer to IWK if 16 or under, if 16-18 depends on type of cancer

and patient

DIAGNOSTIC PATHWAYS- PANCREAS, LIVER

• Symptoms such as weight loss, fatigue, dull epigastric pain, early satiety,

steatorrhea, glucose intolerance, and jaundice

• Investigations Abdominal imaging including ERCP if required and blood work

including CA19-9 and CEA

• Refer to HPB Surgeons who will do workup and any referrals required

DIAGNOSTIC PATHWAYS- LUNG

• Symptoms – hemoptosis, stridor, new unexplained cough and dyspnea

• CXR if negative observe and repeat if still suspicious

• If positive refer to Thoracic surgery

DIAGNOSTIC PATHWAYS- ABDOMINAL MASS

• Mass found on pt suspicious for cancer and not liver lung or pancreas

• Blood work including tumor markers for germ cell tumor (AFP ,BHCG)

• Biopsy needed unless testicular or germ cell tumor

• Invasive radiology / surgery /others. ( ongoing discussion)

Onc Emergencies Guideline

• Bleeding in a Cancer Patient• Gastrointestinal bleeding, Hematuria, Hemoptysis and Vaginal bleeding

• Brain Metastases, Increased Intracranial Pressure and Seizures

• Disseminated Intravascular Coagulation

• Febrile Neutropenia (High Risk and Low Risk)

• Hyperviscosity Syndrome

• Immunotherapy Adverse Reactions (2019 edition)

• Malignancy Associated Hypercalcemia

• Malignant Airway Obstruction

• Malignant Epidural Spinal Cord Compression

• Superior Vena Cava Obstruction

• Syndrome of Inappropriate Antidiuretic Hormone Secretion

• Tumor Lysis Syndrome • Hyperuricemia, Hyperkalemia, Hyperphosphatemia and Hypocalcemia

• Venous Thromboembolism (2019 edition)

Alert Cards

• Instructions for Patient and Physician/ED Staff

• Fever Alert Card (Fever in a Patient Receiving ST)

• Recent audit shows we are not in adherence timelines for ED bloodwork and

antibiotics and treatment of low risk Febrile Neutropenia

• Immunotherapy Alert Card

• QEII Patient Line 902-473-6067 (MO) 902-473-6605

(Hem)

• QEII Oncologist On Call 902-473-2222

• Patient’s Oncologist during regular hours

Gynecologic Oncologists, QEII

Dr. Katharina Kieser, Division Chief

Dr. Jim Bentley

Dr. Lana Šačiragić

Dr. Stephanie Scott

Dr. Karla Willows

Hematologists

Dr. Sudeep Shivakumar, Division Chief, QEII

Dr. David Anderson, QEII

Dr. Mahmoud Elsawy, QEII

Dr. Louis Fernandez, QEII

Dr. Nicolas Forward, QEII

Dr. Christina Fraga, QEII

Dr. Wanda Hasegawa, QEII

Dr. Ormille Hayne, QEII

Dr. Mary Margaret Keating, QEII

Dr. Katherine Mac Innes, CBCC

Dr. K. Sue Robinson, QEII

Dr. Ismail Sharif, QEII

Dr. Darrell White, QEII

Dr. Daniel Rayson, Division Chief, QEII Breast, Neuroendocrine, Colorectal

Dr. Bruce Colwell, QEII Breast, Colorectal, Sarcoma

Dr. Arik Drucker, QEII Breast, Lung

Dr. Alwin Jeyakumar, QEII Breast, Colorectal

Dr. Kian Khodadad, CBCC All Sites

Dr. Nathan Lamond, QEII Colorectal, ENT

Dr. Robin MacFarlane, QEII Genitourinary, Melanoma

Dr. Mary MacNeil, QEII Lung, Neuro-Oncology

Dr. Ron MacCormick, CBCC All Sites

Dr. Jennifer Melvin, QEII Breast, Melanoma, Sarcoma

Dr. Julia Merryweather Breast, GI, Lung

Dr. Wojciech Morzycki, QEII Lung, Mesothelioma, Unknown Primary

Dr. Rajbil Pahil, CBCC All Sites

Dr. Ravi Ramjeesingh, QEII Breast, Hepatobiliary

Dr. Wassim Saliba, CBCC All Sites

Dr. Stephanie Snow, QEII Lung, Gastroesophageal, ENT

Dr. Lori Wood, QEII GU

Dr. Tallal Younis, QEII Breast

Medical Oncologists and tumor expertise

Name Site/s Treated

Dr. Jean Phillipe Pignol, Division Chief, QEII Breast

Dr. Mike Kucharczyk GI, Lung,

Dr. Kwamena Beecham, CBCC All Sites

Dr. Laura Best, QEII ENT, CNS, Skin

Dr. David Bowes, QEII Gyne, GU

Dr. Slawa Cwajna, QEII Breast, GI, Lung

Dr. Helmut Hollenhorst, QEII ENT, Lung

Dr. Ashraf Mahmoud-Ahmed, CBCC All Sites

Dr. Liam Mulroy, QEII CNS, Hematology, Lung

Dr. Maureen Nolan, QEII Breast, Sarcoma,

Dr Nik Patil, QEII GI, Gyn, GU

Dr. Mal Rajaraman, QEII ENT, Breast, Lung

Dr. Rob Rutledge, QEII Breast, GU, Paed CNS and Non-CNS

Dr. A. Sengupta, QEII ENT, Breast, Hematology, Lung

Dr. Sandra Wajstaub, CBCC All Sites except ENT

Dr. Derek Wilke, QEII GU, Hematology, ENT

Radiation Oncologists and tumor expertise

DRUG SHORTAGES

• Recently we have had a number of oncology drug shortages both IV and oral

• For IV drugs we have found alternatives or solutions so far for each shortage.

• The cancer care program has no jurisdiction in supplying or managing oral

drugs at this time. We feel however obligated to assist patients by trying to

organize a strategy for pharmacies. Tamoxifen is a recent example of a huge

amount of work that was done by the program that is unnoticed

NSCCP RESOURCES FOR PRIMARY CARE

• BC Cancer Drug Manual

• Oral systemic therapy Toolkit

• Immune Checkpoint Inhibitor Toolkit

NSCCP RESOURCES - SURVIVORSHIP

• Discharge templates to primary care Physicians from oncologist outlining surveillance

tests and schedules

• General Survivorship Care Plan

• Specific survivorship plans

• Breast

• Colon

• Thyroid

• Rectum

Patient Education Resources

• 80+ NSCCP Print Resources

• Videos

• Links to other reputable organizations

EDUCATIONAL OPPORTUNITIES

• Oncology Grand Rounds every thurs 1230 in person or Skype

• Provincial Cancer Network Meetings

• CME certified workshops

• Request an in-service on any Oncology topic

• Education contact meg.mccallum@nshealth.ca

QUESTIONS