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Case history

image A 34-year-old woman with no previous medical history presented with a 6 month history of early satiety, increasing abdominal pain and vomiting. Initial gastroscopy and duodenal biopsies indicated mild reactive gastropathy. She was referred for a diagnostic laparoscopy due to ongoing symptoms and was diagnosed with a stenosing cancer arising at the pylorus and early part of the duodenum. Peritoneal metastases were evident at the point of diagnosis. Biopsies indicated adenocarcinoma. A gastrojejunostomy resolved the pain, vomiting and anorexia caused by the gastric outlet obstruction at presentation.

A referral to medical oncology was requested for consideration of palliative chemotherapy. At the point of diagnosis, the patient and her family requested information on targeted therapies, immunotherapy and intraperitoneal chemotherapies. Following referral there were in-depth discussions about the risks vs benefits of chemotherapy regimens in this setting. The family were keen for further information on potential clinical trials that were not available locally.

The patient's performance status (PS) was 1 at the point of diagnosis, in part due to her poor nutritional state, secondary to previous gastric outlet obstruction and ongoing difficulties with oral nutrition. Her presenting albumin level of 25 g/l continued its downward trend.

There were numerous discussions within the multidisciplinary team (MDT) and with the family regarding the role of parenteral nutrition in this setting. It was felt that a trial of total parenteral nutrition (TPN) prior to consideration of chemotherapy would potentially improve her nutritional state and therefore her PS before cytotoxic treatment. A repeat CT scan indicated a slow pace of change in the disease and clinically she was stable with no new symptoms of concern.

The patient indicated that feeling well and having an improved quality of life (QOL) were the most important immediate aims following diagnosis. She wished to delay palliative chemotherapy until after a family wedding. It was felt that this was a reasonable request and a decision was made to commence TPN in the interim period. Following 2 weeks of TPN a decision was made to proceed with a palliative chemotherapy regimen of oxaliplatin and fluorouracil. She received two cycles of oxaliplatin and bolus fluorouracil and had some improvement in bowel function and pain; however, her overall deterioration continued.

A decision was made not to give further chemotherapy and it was felt that she was unsuitable for review at the trials unit because of her PS 2-3. She was transferred to a hospice for symptom management and she died 6 months following her diagnosis.

What was the goal of cancer treatment for this patient?

What is the evidence base for her treatment options?

How did the patient's comorbidities affect cancer treatment decisions?

How does managing patient expectations change with the complexities of younger patients?

What is the role of TPN in the palliative care setting?

What was the goal of cancer treatment for this patient?

It was clear that treatment options were not curative in ...

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