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Case history

image A 79-year-old woman had a 2 week history of rectal bleeding. Her past medical history included hypertension, osteoarthritis, type 2 diabetes and myocardial infarction. Clinically she was assessed as having Eastern Cooperative Oncology Group performance status 1 at baseline. Investigations showed a non-obstructing, non-bleeding lesion of the sigmoid colon, with bilobar liver metastases and a pulmonary embolus. Biopsies confirmed a RAS-mutant moderately differentiated adenocarcinoma. Blood tests revealed iron deficiency anaemia (Hb 102 g/l). Dalteparin was started for the pulmonary embolus, and the patient's case was discussed by the hepatobiliary multidisciplinary team (MDT), who recommended primary chemotherapy.

At the initial oncology appointment, the oncologist recommended fluorouracil (5-FU)/oxaliplatin chemotherapy. A screening Comprehensive Geriatric Assessment revealed a history of falls, which prompted an urgent referral to the falls clinic. The review identified two recent falls due to multifactorial causes:

  • Postural hypotension attributed to antihypertensive drugs.

  • Grade 2 peripheral neuropathy (touch and pinprick) attributable to diabetes and vitamin B12 deficiency.

  • Poor strength, especially in the proximal lower limbs, and poor balance.

In light of the peripheral neuropathy, the oncologist changed the chemotherapy to full-dose 5-FU/irinotecan. A dose reduction was required at cycle 4 due to grade 2 anaemia and fatigue. The patient completed 12 cycles of doublet chemotherapy, with stable disease on an outcome CT. The hepatobiliary MDT recommended a two-stage (bowel, then liver) operation. Radiofrequency liver ablation was not an option, given the tumour location. Following discussion of the options, the patient declined surgery and was therefore put on surveillance.

What is the goal of cancer treatment for this patient?

What could be done to reduce her risk of falls as she undergoes cancer treatment?

What is the evidence base for her treatment options?

How did her comorbidities affect the cancer treatment decisions?

How can falls be identified and managed in cancer services?

What is the goal of cancer treatment for this patient?

It is important to be clear about the long-term goal of therapy at the outset, carefully considering the priorities and goals of the patient. In this case there were two options: a potentially curative approach involving intensive chemotherapy and multiple operations, or a palliative approach that would involve less intensive chemotherapy. Clear discussion of these options with the patient at the outset might have avoided the apparent mismatch between the priorities and goals of the doctors and those of the patient.

What could be done to reduce her risk of falls as she undergoes cancer treatment?

The management of comorbidities should always be reviewed at the time of starting cancer treatment: long-standing medical conditions might have changed; pharmacology might have altered; and the cost-benefit balance of preventive medications might have shifted.1

In this patient, antihypertensives were discontinued and her GP was asked to monitor her BP. Vitamin B12 level should be checked, and supplemented if necessary, in patients with falls ...

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