A 75-year-old woman presented to her GP with a 6 month history of weight loss and early satiety. She had previously been active at home and was the main carer for her husband who had advanced Parkinson's disease. The only past medical history of note was a non-ST elevation myocardial infarction, complicated by a transient episode of atrial fibrillation, 5 years previously. An echocardiogram at the time had shown a slightly decreased left ventricular ejection fraction (LVEF; 50%) but no valvular heart disease. She had no ongoing symptoms of angina and no signs or symptoms of significant heart failure.
Investigations, including gastro-oesophageal endoscopy and CT scan, showed a locally advanced gastric cancer with nodal disease but no distant metastases (T4N3M0). A biopsy confirmed adenocarcinoma with overexpression (3+ staining on immunohistochemistry) of human epidermal growth factor receptor 2 (HER2). Her estimated glomerular filtration rate (GFR) was slightly decreased at 75 ml/min. During her recent investigations there had been multiple problems with intravenous access (for blood sampling and contrast injection).
The patient's husband had regular geriatrician input, but he had had a number of falls at home, particularly at night, and had mild cognitive impairment. He mobilized unsteadily with a frame and his wife had adapted the home to single-level living. Her husband was completely dependent on her: she assisted him with all activities of daily living and helped him mobilize to the toilet three to four times every night, as his tremor precluded the use of urine bottles. He had a carer once daily for personal cares.
Through clinical history taking, the oncologist identified that her family were unable to assist with the care needs of her husband during a hospital admission or postoperative recovery. With the agreement of the patient and her husband, the oncologist asked their social worker to have an urgent discussion with the patient regarding what additional support could be offered during different treatment options. The oncologist provided the social worker with the likely timeframes for her treatment and the likely impact on her care-giving role. The social worker was able to offer an increase in the care package to bridge her husband's daytime needs but was unable to cover any night-time needs. The patient did not have the finances to cover the night-time needs privately. Respite placement was only available for a short period, and she felt this would be disorientating and would increase his likelihood of falls outside his own environment. Following discussion with her family, the oncology and surgical teams and the social worker, she decided against radical surgery, due to the effect of the recovery time and potential complications on her husband's care, particularly his needs at night.
Our patient underwent a full nutritional assessment prior to starting chemotherapy, including markers of nutritional status such as BMI and albumin levels. She commenced oral vitamin B supplements to prevent re-feeding syndrome. She also had a formal measurement of creatinine clearance prior to commencing cisplatin ...