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Case history

image A 58-year-old woman with relapsed platinum-resistant high-grade serous carcinoma of the ovary was admitted with abdominal pain, distension and constipation. A CT scan showed multifocal small bowel obstruction from progressive peritoneal disease. At initial presentation she had International Federation of Gynecology and Obstetrics stage IIIC disease. She received surgery and adjuvant carboplatin and paclitaxel; after progression 8 months later she received another six cycles of carboplatin and paclitaxel, resulting in stable disease 6 weeks before admission. Her comorbidities included profound hearing loss since having meningitis as an infant. She lived with her husband, who was also deaf. She had chronic anxiety and worried about the impact of her disability on her treatment.

Options of chemotherapy and best supportive care were discussed through a British Sign Language (BSL) interpreter. Surgery to relieve bowel obstruction was not deemed feasible given diffuse serosal disease and multi-level small bowel obstruction. She wished to have chemotherapy, and commenced cisplatin and gemcitabine with parenteral nutritional support. Care was managed through a multidisciplinary team (MDT) comprising oncologists, palliative care specialists, specialist nurses, dietitians and a discharge planning team. A BSL interpreter was available every day to facilitate communication with the patient and her husband. Chemotherapy was withdrawn, as no clinical improvement was observed after two cycles of treatment. Following discussion with the patient and her family it was agreed she would go home and receive best supportive care. At the patient's request, a complex venting jejunostomy was fashioned to replace a nasogastric tube. Shortly afterwards, she developed intra-abdominal sepsis and died in hospital 9 weeks after admission.

What are the evidence base and rationale for this patient's treatment?

How did the patient's deafness affect her care?

How can communication in deaf cancer patients be optimized?

How do the principles of patient-centred care relate to this case?

What was the influence of integrated cancer care for this patient?

What are the evidence base and rationale for this patient's treatment?

Malignant bowel obstruction affects at least half of patients with ovarian cancer.1 Cases with this complication are complex and require multidisciplinary input from oncologists, surgeons, the palliative care team, psycho-oncologists and dietitians. The prognosis, however, remains poor. A recent study found that the median overall survival in patients from diagnosis of bowel obstruction was 88 days;2 therefore, management needs to be holistic and focused on balance in improving prognosis and symptom control with side effects of treatment.

The treatment of malignant bowel obstruction is largely best supportive care, focusing on symptom management and quality of life (QOL). In selected cases surgery and/or chemotherapy can be effective in managing symptoms, controlling disease and prolonging life.2-5 The evidence base supporting chemotherapy is limited from retrospective case series. In one study of patients with malignant bowel obstruction, outcomes were not determined by platinum sensitivity. A simple prognostication tool based on performance status and type of obstruction (single- or ...

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