An 82-year-old man presented to his GP with rectal bleeding and weight loss of 2 st over 6 months. He admitted to having increased fatigue and had become housebound. He lived alone and struggled to complete activities of daily living (ADL) such as cooking and cleaning. He had a past medical history of hypertension for which he took ramipril 5 mg and bendroflumethiazide 2.5 mg daily. On examination, he appeared thin, dishevelled and had palpable hepatomegaly. From the history and examination, it was clear that his performance status (PS) had deteriorated from a baseline of 1 to 2 over a period of just 3 months.
He agreed to a referral for a Comprehensive Geriatric Assessment (CGA) along with initial investigations. Flexible sigmoidoscopy and biopsy revealed a proximal rectal adenocarcinoma. A CT scan of the chest, abdomen and pelvis, and an MRI scan of the pelvis, confirmed this diagnosis and demonstrated liver metastases.
His case was discussed at the colorectal cancer multidisciplinary team (MDT) meeting, and his disease was staged T3N1M1. The patient was provided with a clinical nurse specialist to act as a key worker across the whole care pathway. A clinical nurse specialist is the first point of contact for cancer patients and acts as a coordinator between the patient and different medical specialties.1 An appointment was given to see an oncologist to discuss palliative systemic treatment options and suitability for palliative radiotherapy to the rectal primary. It was felt that initial surgery and local therapy for the metastases would not be appropriate due to his PS and the distribution of the metastatic disease. In addition, a referral was made to the community palliative care team.
Role of the CGA
What systemic treatments are available for this patient?
What are the potential toxicities of treatment?
Local treatment for liver metastases
Why is it important to identify and manage functional impairment?
Colorectal cancer is one of the commonest cancers in the UK: around 40,000 new cases are diagnosed each year.2 One of the main risk factors for developing colorectal cancer is age: almost 75% of new cases diagnosed are in those aged over 65 years.2 This presents clinicians with a unique set of challenges. For example, clinic appointments may take longer if the patient has impaired hearing, vision or cognition. Likewise, physical disabilities or frailties, problems with transport, and a lack of carers, friends or nearby family members can make attendance at clinic a significant challenge.
In the CGA clinic it became apparent that since the patient lost his wife 3 years earlier, he had found it difficult to cope with ADL. Cooking and other household chores had been taken care of by his wife and he had struggled to adapt. His hot water supply and washing machine were broken and he had not been able to negotiate ...