Lung Cancer.pdf

98 Y. De Jesus and G.L. Walsh
KEY PRACTICE POINTS
• The purpose of using clinical practice guidelines and clinical pathways is to
enhance, manage, and evaluate patient care while measuring and maintaining
appropriate outcomes using a cost-effective approach.
• A clinical practice guideline is a framework for treating a specific disease
entity and includes all treatment modalities supported by the medical literature,
current practice standards, and expert opinion. Guidelines are often
presented in the form of flowcharts.
• Clinical pathways are detailed, step-by-step descriptions of the various treatment
options that form a practice guideline.
• Guidelines and pathways serve as valuable teaching tools that help residents
and fellows learn best practices for patient care.
• The use of structured pathways can help trainees deliver optimal patient care
with minimal unnecessary laboratory and radiographic testing.
• Use of structured pathways permits analysis of differences in patient outcomes
and costs between physicians.
• Analysis of deviations from clinical pathways can indicate where pathways
need to be changed.
Following the CT scan, patients will undergo a nuclear imaging staging
procedure to determine whether distant metastases are present. If the
findings are negative for distant metastases, patients will be referred directly
to surgery, where biopsy and surgical treatment will be done at the
same time after some form of exercise testing that will most likely differ
from our present, static spirometric testing. Larger tumors that are still isolated
to the chest will be treated with neoadjuvant chemotherapy prior to
surgery. Patients with positive findings on nuclear screening will be referred
to medical oncologists and may undergo chemotherapy, but probably
with agents less toxic than those in use today.
Surgical pathways will be far simpler. The anesthetic agents will be better
tolerated. Techniques will be developed for better postoperative pain
control. Tissue sealants will be developed that will minimize the problem
of postoperative air leaks that are often responsible for a prolonged hospital
stay after pulmonary resection. Chest tubes will be removed within 12
to 24 hours, and patients will be monitored in a hotel environment with
telemetry monitoring from a distance and with rehabilitation specialists
rather than nurses helping to minimize the risk of perioperative pneumonia.
Better oral analgesics will permit pain control without the ileus and
gastrointestinal side effects that presently delay many discharges. Surveillance
will continue with high-speed CT scanners, but the need for followup
patient visits to the clinic will be minimized.