No two people experience cancer in quite the same way, and the differences aren’t just physical. How cancer affects you depends on many factors in your life, from your general health to your natural support systems, coping habits and even where you live. Any cancer treatment plan involves certain clinical protocols and timelines, but within that framework, care teams in Alberta find ways to accommodate individual needs, capabilities and preferences.
Educating Patients In Breast Cancer Care Planning
Dr. Karen King is a medical oncologist at Edmonton’s Cross Cancer Institute. She treats patients with breast cancer, but, like all cancers, it’s a condition that defies easy categorization.
“No two patients have the same disease,” King says.
For that reason, King believes it’s a care team’s responsibility not just to deliver clinical treatments, but to make recommendations, educate patients and try to communicate as clearly as possible the benefits and risks of any therapy — from the earliest stages. That way, patients can make informed, confident decisions specific to their personal situations.
“Patients need to understand what they’re getting into so they can consent to it. They need to understand their disease,” King says.
The education process begins after a positive biopsy result, which happens long before a patient meets King at the Cross Cancer Institute, for example. Following the positive biopsy, the patient enters the first phase of breast cancer care, a series of diagnostic tests that, in most cases, lead up to a lumpectomy or mastectomy.
To navigate all these appointments, the patient is referred to Alberta Health Services’ Comprehensive Breast Care Program, a centralized network of services in Alberta that helps patients find the information they need to create a care plan. The purpose of the program is not to tell patients what they must do, but to help them understand the available services and options and support them through this phase.
When this diagnostic/surgical phase is complete, many patients require radiation, endocrine therapy and/or chemotherapy. At this point, they leave the Comprehensive Breast Care Program and enter a new decision-making process, with the advice of a triage nurse, and the guidance of a multi-disciplinary team of practitioners (usually a medical oncologist like King, a radiation oncologist and a nurse practitioner, as well as input from the patient’s surgeon and pathologists). This team — called the Northern Alberta Breast Cancer Program at the Cross where King works (it’s southern counterpart is the Southern Alberta Breast Cancer Program) — considers all the factors that may affect outcomes for the individual, including age, general health, tumour pathology, family history, genetic profile and even cosmetic outcome (i.e., whether a patient wants a breast reconstruction or not). They also look for relevant clinical trial opportunities that might be a fit for the patient.
Based on patient needs, the team may suggest modified treatment plans that accommodate personal challenges. For example, a patient who can’t access chemotherapy easily can be connected with a community cancer care program closer to home.
King says the medical team never wants to compromise patient care, but they must consider the big picture: sometimes a patient’s health is best served not by insisting on a particular treatment, but by removing barriers that could prevent that patient from showing up for treatment.
No matter what the experts determine, the patient is in control. A patient can opt out of any treatment at any time, even if doing so puts her health at risk. The important thing is that it’s an informed decision.
“We always tell patients, you’re the boss. You make the decisions,” King says.
Keeping The Big Picture In Mind When Delivering Radiation Therapy
Radiation therapy targets cancer cells directly, while sparing healthy tissue. It is a hyper-localized treatment, but that doesn’t mean radiation therapy teams don’t consider a patient’s big picture. Fiona Lochray, associate manager of radiation therapy at Calgary’s Tom Baker Cancer Centre, says her team never forgets that patients are whole people. “Our focus is totally about the patient and what’s best for them,” she says.
Making sure radiation is targeted precisely is a highly individual process. After the type of tumour is confirmed, the patient’s next step is to go through a CT simulator, which determines the radiation plan for treatment. To ensure precision, each patient also receives a miniature CT scan (called a cone beam CT) before each treatment, and small adjustments are made to ensure the patient is correctly positioned for treatment.
There are other factors to consider, too, which have to do with a patient’s ability to tolerate radiation therapy. Treatments take 15 minutes or more and may be delivered daily for up to six weeks. Can the patient stay completely still for as long as the procedure takes, or will they need to be immobilized? Can they show up for all their treatments? How’s their general health? Are they in pain? Are they mobile? Are they losing weight during the course of treatment? Only after these questions are answered can the individualized treatment plan be created.
Accessibility is also a factor, because each treatment must be performed in a designated clinic. Patients who have trouble getting to appointments may be referred to Wheels of Hope, a volunteer driver program for cancer patients. The Foothills Medical Centre Hostel in Calgary and Outpatient Residence near Edmonton’s Cross Cancer Institute offer temporary housing for patients undergoing cancer treatment, and radiation clinics in Calgary and Edmonton are open 7:30 a.m. to 6 p.m. so patients can come outside of their regular schedules.
Meanwhile, a project to improve access to radiation therapy province-wide is nearly complete. The Radiation Therapy Corridor, a north-south network of radiation clinics in Alberta, will bring 92 per cent of residents within 100 kilometres of a radiation therapy clinic. Grande Prairie’s new regional hospital and cancer care centre is scheduled to open in 2019, joining Lethbridge’s Jack Ady Cancer Centre and Red Deer’s Central Alberta Cancer Centre to complete the corridor.
Letting The Patient Lead With Psychosocial Supports
Psychosocial services, which address the emotional, social, practical and spiritual impact of cancer on individuals and families, are an important part of a multi-disciplinary treatment plan.
“A cancer diagnosis affects more than your physical health,” says Dr. Laura Labelle, a Calgary-based clinical psychologist and south supportive care lead with CancerControl Alberta. Diagnosis, treatment, recovery and survivorship affect mental, emotional, practical and spiritual well-being, and it’s different for every patient.
Unlike medical treatments, which tend to be delivered on a schedule and in a specific order, psychosocial supports include a range of cancer-specific services and resources from which patients can pick and choose. The network is made up of psychosocial support clinicians who specialize in cancer care, for example social workers, psychologists, psychiatrists and spiritual care providers. Depending on their needs and with the guidance of their medical providers, who may provide information, suggestions and referrals, patients can receive psychosocial services as an individual, couple, family or with other patients in a supportive group environment.
“When patients are connected to psychosocial services, what they’re offered may relate to where they are in their cancer experience and tailored to their unique needs,” Labelle says. For example, a newly diagnosed patient may be overwhelmed by practical concerns like finances, taking time off work and managing caregiving responsibilities, while a post-treatment survivor may experience complex feelings about their identity and fears about recurrence. Once they’re engaged with psychosocial supports, a patient will be involved in ongoing conversations about how they’re doing and what they may need to add or change to their support structure.
Labelle is working closely with Dr. Jill Turner, her counterpart in Edmonton, on a province-wide approach to psychosocial services that will ensure timely access to psychosocial care as close to home as possible, with the same quality of care for all Albertans living with cancer. With the support of the Alberta Cancer Foundation, they’ve introduced programs that address specific needs, including cancer patient navigators for adolescents and young adults, and sexual health services.
“Emotional well-being and physical well-being are connected,” Labelle says. “Patients are often better able to manage their symptoms and side-effects if they’re taking care of their whole person.”
Personalized medicine goes gene deep
In cancer treatment, “personalized medicine” has a deeper meaning: it describes an approach to the disease that takes into account a patient’s genetic makeup, as well as the genetic makeup of a specific tumour. Sometimes called precision medicine, this genetic approach to cancer care helps clinicians to plan treatments — particularly drug therapies — that are more precisely targeted than ever before. It can also help to predict who is most likely to develop cancer, while making early detection easier and preventing recurrence after treatment.