Editor:  Grace Leo

Contributors:  Sarah Sutherland, Sanjeev Kumar, Erin Moth, Aaron Tan

Reviewed:  Jennifer Lim

 

In a hurry? Make sure you know:

  • If the patient has been informed they have cancer
  • The patient’s diagnosis, stage, previous treatment and specialist involvement and functional status
  • Details and reports of tissue diagnosis

 

What history should JMOs know/collect?

  • Has the patient been informed they have cancer? 
    • The oncology team is usually happy to inform them but they need to know beforehand so that the matter can be handled respectfully and sympathetically
    • Given our culturally and linguistically diverse population, it is also helpful to know if the patient (or their family) WISH to know the diagnosis
  • When the patient was diagnosed
  • What type of cancer the patient has, stage of disease and if metastatic, sites
  • Significant comorbidities
  • Symptoms from their cancer (particularly if any of these have changed)
    • Dyspnoea
    • Pain
    • Weight loss
  • Regarding previous treatment and care:
    • Whether the patient is known to or has seen an oncologist before 
      • Include the patient’s past notes or letters in the notes
    • What treatment is the patient on?
      • Be as specific as you can – cytotoxic chemotherapy is very different to immunotherapy or targeted therapy, and all of these are different to radiotherapy
    • The details and date of last treatment is important. It is also helpful to note how successful treatment has been and if there are any important side effects that the patient suffers from
    • What the goals of care are
      • Active treatment or palliative/symptom control
    • The patient’s baseline health and independence as this will influence treatment options

 

What examinations and investigations should JMOs perform/order?

  • If the patient is being treated:
    • Check for mucositis, blood results:
      • WCC and differentials
      • Hb, platelets
      • EUC and Calcium levels
  • Imaging – available staging scans (if a previous diagnosis, any changes or is the disease stable?)
  • Tissue biopsy/histology results/tumour markers
  • Correspondence from any known oncologists
  • Assess the ECOG performance status

 

GRADE ECOG PERFORMANCE STATUS

0

Fully active, able to carry on all pre-disease performance without restriction

1

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2

Ambulatory and capable of all selfcare but unable to carry out any work activities; up and about more than 50% of waking hours

3

Capable of only limited selfcare; confined to bed or chair more than 50% of waking hours

4

Completely disabled; cannot carry on any selfcare; totally confined to bed or chair

5

Dead

*Oken M, Creech R, Tormey D, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5:649-655.

 

What additional information would impress you?

  • The urgency of the consult – if the patient can be seen in a clinic or if they require an inpatient review.
    • Please don’t apologise if it is indeed urgent –  we will see and transfer a new diagnosis of small cell lung cancer with superior vena cava obstruction as soon as possible!
  • Specific chemotherapy regimen (including how many cycles, up to what number cycle)
  • Previous complications of therapy (e.g. febrile neutropaenia)
  • Family expectations and support 
    • It is good to know who they are living with, who would like to be present when we review the patient and what their expectations are (often this is what drives the urgency of a review)
  • Proactive involvement of palliative care if the patient is symptomatic
  • Asking if patients out of area would prefer treatment at the base hospital or closer to home – we are happy to meet the patients, introduce the idea of medical oncology and facilitate a referral if that is required

 

What are common mistakes/omissions made by JMOs?

  • Calling medical oncology for lymphomas and leukaemias. Call haematology instead
  • Calling for a consult prior to a confirmed tissue diagnosis
  • Creating an expectation for the patient and their family that chemotherapy will be started emergently as an inpatient. Exceptions are germ cell tumour and small cell lung cancer

 

Helpful resources

As a junior doctor, informing patients about a new diagnosis of malignancy should usually be performed by the registrar or consultant. However, there may be times where you may be required to deliver bad news to patients.

Here are some useful resources to assist with this:

St Emlyn’s Podcast on Breaking Bad News (in the ED)

SPIKES protocol