Consultant physicians working with patients - Royal College of ...

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2 Specialties Medical oncologyMedical oncologyDr Johnathan Joffe MBBS MD FRCP Consultant medical oncologistDr Janine Mansi MBBS MD FRCP Consultant medical oncologistDr Dan Stark MB BChir PhD FRCP Workforce lead for SAC in Medical OncologyAlison Norton Administrator, Association of Cancer Physicians1 Description of the specialtyMedical oncologists are specialist physicians trained inthe investigation and care of patients with cancer. Theyare an integral part of the cancer multidisciplinary team(MDT), providing particular expertise to patientsthrough their knowledge of the systemic treatment ofcancer with hormonal treatment, conventionalcytotoxic chemotherapy and newer molecular-targetedtreatments. These treatments may be delivered withboth curative intent, particularly in early cancers, andpalliative intent to alleviate symptoms plus,increasingly, for prolonging life in more advancedcancers. Medical oncologists are especially trained tounderstand the biology of cancer and the pharmacologyof drugs. They are ideally prepared for the role ofmonitoring the efficacy and safety of current treatmentsandalsointhetestinganddevelopmentofnewmedicines. Medical oncologists have a central role in theconduct of clinical trials and are expected to enterpatients into nationally approved trials. Many have aremit to design and develop new treatment strategiesthrough translational research.Medical oncologists are tumour-site specialists focusingon two or three specific types of cancer. The specialtyhas a strong academic component, with many medicaloncologists having a higher degree and a highproportion with combined academic and NationalHealth Service (NHS) appointments. Increasinglymedical oncologists require skills in management andservice delivery to understand the complex issuesinvolved in introducing new treatments, commissioninghealthcare in relation to changing models of care andmonitoring standards through peer review.In addition to this specialist role, many medicaloncologists now have a defined role in the practice of‘acute oncology’, 1 a service designed to ensureappropriate and urgent management of complicationsof cancer and its treatment, and also the rapidassessment and diagnosis of patients presenting withsymptoms of previously undiagnosed malignancy.Medical oncologists are drivers of the current focus onprevention of cancer. It is recognised that many cancerscould be prevented by lifestyle changes. For somecancers, interventions (secondary prevention) mayafford opportunities to prevent development of thedisease.Who are the patients?One in three people in the UK will be diagnosed withcancer during their lifetime. This rate will increase asthe population grows proportionally older, which partlyexplains the increasing incidence and prevalence ofcancer year on year. Advances in the early detection ofcancer and major improvements in treatment haveresulted in a decrease in cancer mortality, with morepeople surviving cancer. Although many bigimprovements in survival have been in rarer cancersaffecting younger patients, new therapies for commoncancers are delivering similar advances in older people.This trend for improved survival will continue over thenext decade as still better methods of prevention,diagnosis and treatment are delivered.As well as caring for patients with active cancer, medicaloncologists are involved in monitoring and supportingcancer survivors.2 Organisation of the service and patternsof referralA typical serviceSince the government appointment of a national cancerdirector in England, cancer care in the UK has beenrevolutionised through a number of important strategicpublications, 2–4 each taking forward the developmentof the structure of cancer services.C○ Royal College of Physicians 2013 153
Consultant physicians working with patientsReferral of patients with suspected cancer is usuallyinitiated by the patient’s GP. In England, Wales andNorthern Ireland, waiting-time targets ensure that thetime from referral to diagnosis to first definitivetreatment is as short as possible. All suspected andproven cases of cancer are discussed within an MDT toagree an appropriate treatment. All MDTs require activeattendance and participation by cancer site-specialisedoncologists. More recently, further targets in Englandhave been set to improve the whole patient pathway,with all subsequent treatments to be given within 31days of the decision to treat.Locality-based and/or regional servicesMDT meetings take place within cancer units forcommon tumour types. Less common tumour types arecentralised within a cancer centre with a critical volumeof patients and staff to deliver the highest possiblestandard of care. The constitution is specific for eachtumour type as set out by improving outcomesguidance (IOG). 5 Until the reorganisation of the healthservice in April 2013, cancer units were each part of oneof 34 cancer networks, with each network serving apopulation of 1–3 million. Since this date the networkfunctions are being absorbed into the new strategicclinical networks that will serve larger populations andcover multiple specialist areas. Within each networkthere are tumour site-specific boards to ensure acoordinated approach for both the organisation ofservices and the equity of access for patients. There is anestablished national programme of peer review toensure that services are appropriate, effective and in linewith national guidance. There is increasing focus onnew models of care, eg centralising wherever necessaryto improve outcomes for complex treatment delivery.Inpatient care and acute oncologyPatients may be admitted acutely to almost anydepartment when they present with symptoms orcomplications of advanced disease or complicationsrelated to therapy. Recently the focus has moved on tothe safe and effective out-of-hours management ofpatients receiving chemotherapy and the care ofnon-elective patients admitted with cancer. 1 InEngland, the National Cancer Action Team (NCAT)introduced the new multidisciplinary specialty of ‘acuteoncology’, which addresses more effective diagnosticpathways for new patients presenting acutely withsymptoms of cancer, reducing unnecessaryinvestigations and length of stay. It also ensures thesafest management of complications of disease ortreatment, addressing the concerns of the NationalConfidential Enquiry into Patient Outcome and Death(NCEPOD), which investigated deaths within 30 days ofsystemic anticancer therapy. 63 Working with patients: patient-centredcareInteraction with patientsMedical oncologists work with patients and theirfamilies to provide a holistic approach to care thatrecognises their right to information, autonomy,support and guidance that are sensitive to their culturalbackground and appropriate to their knowledge andbeliefs. Medical oncologists are trained in advancedcommunication skills so that they can deliver bad newsin an empathic fashion, and discuss the risks andbenefits of complex and toxic treatments or, perhaps, noactive therapy at all. This may include difficultdiscussions of statistical risk of relapse or the benefits ofpalliative therapies that may be associated withsignificant toxicity.Very often, where new treatments keep patients wellwith advanced disease over long periods, medicaloncologists provide ongoing and continuous support topatients and their families over many years. In thesesituations, the cancer can be considered as a chronicdisease requiring repeated assessment and discussionrelating to ongoing management.Involving patients in decisions about theirtreatmentMedical oncologists’ communications skills arecomplemented by involvement, if necessary, ofappropriate interpreters and patient advocates. Thedecisions in oncology are often complex. Verbalinformation is always reinforced with written, audio orvideo material. Validated internet resources, such as thewebsites of Macmillan Cancer Support(www.macmillan.org.uk), the National CancerResearch Institute (NCRI) (www.ncri.org.uk)andCancer Research UK (www.cancerresearchuk.org), areprovided to interested patients.Medical oncologists contributed to and led many of theworkstreams of the English National ChemotherapyImplementation Group (NCIG), including those154 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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2 Specialties DermatologyDermatolog
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2 Specialties Gastroenterology and
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Consultant physicians working with patients - Royal College of ...

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