Clinical Management
Patient Care Plans
Clinical management sets standards for clinical decision making and formulating patient care plans. Patient care plans are based on the histopathologic and/or molecular diagnosis identifying the type of cancer; the anatomic disease extent or stage; and the individual patient’s characteristics, such as age, comorbidities, and performance status. Determining the best clinical management for cancer patients involves defining the goals of care—cure, disease control, symptom control—recommending appropriate interventions, and setting out the optimal timeframes for instituting and completing treatment. The patient care plans vary from simple to complex, and may require a range of services.
Errors in clinical decisions can lead to increased morbidity and disability, increased costs, and even premature death. For example, a recent study reported that almost one-quarter of children with acute myeloid leukemia in El Salvador, Guatemala, and Honduras died from largely avertable treatment-related mortality (Gupta and others 2012).
Clinical Practice Guidelines
Clinical practice guidelines are developed to assist practitioners and patients in deciding on appropriate care for their circumstances (Hensher, Price, and Adomakoh 2006). Comprehensive cancer centers play a leadership role in developing and promoting treatment guidelines locally and nationally. Center clinicians and researchers work with professional organizations to develop guidelines for a wide range of scenarios. Some examples include the U.S. Preventive Services Task Force for screening guidelines and Cancer Care Ontario’s Program in Evidence-Based Care, which produces evidence-based guidance documents. Guidelines are not limited to therapeutic interventions and include indications for medical imaging and other diagnostic interventions and for symptom management. Nursing and other allied health professions develop guidelines to organize and direct care. Guidelines must be adapted for use in resource-constrained settings (Anderson and others 2008; Kerr and Midgley 2010).
Many clinical practice guidelines have been adopted and adapted for use in LMICs (Gralow and others 2012; Konduri and others 2012). Although the focus of most of these initiatives is broader than the comprehensive cancer centers, their impact has influenced the care of patients within centers. A well-known international example is the Breast Health Global Initiative, which has developed evidence-based, economically feasible, and culturally appropriate guidelines for breast health and cancer control in LMICs (chapter 3, this volume [Anderson and others 2015]; El Saghir and others 2011; Varughese and Richman 2010). The matrix guideline spans the spectrum of breast health care, from early detection to treatment and palliation, and considers the available resources at each stage (Sloan and Gelband 2007). Another example is the
United States–based National Comprehensive Cancer Network, which collaborates to produce international adaptations and translations of its guidelines that may include modifications based on local circumstances. Other examples include efforts in India to establish a wide range of guidelines adapted to local resource availability, and consensus group recommendations for imaging techniques for head and neck cancers in Singapore and South Asia, as developed by Wee and colleagues depending on resource availability (Wee and others 2009). Mexico has developed a series of Normas Officiales Mexicanas (Official Mexican Standards) that guide cancer services and finance.
Ref: Mary Gospodarowicz, Joann Trypuc, Anil D‘Cruz, Jamal Khader, Sherif Omar, and Felicia Knaul, Cancer Services and the Comprehensive Cancer Center, Mary Gospodarowicz, MD FRCPC FRCR (Hon), Princess Margaret Cancer Centre, University of Toronto