A look at the big picture
It’s 7.50am on a Friday at the Southern General Hospital in Glasgow and the meeting room on the fifth floor of the neurology block is already busy with about 20 people pouring themselves coffee and tea and helping themselves to the odd Danish pastry.
But it’s not the free breakfast they have come for – although the caffeine will help them remain alert over the next two hours as they review and discuss treatment plans of new patients that have been diagnosed with oral cancer.
They are members of the hospital’s Oral Cancer Maxillofacial/Head & Neck Multi-Disciplinary Team (MDT), which consists of representatives from a dozen different clinical and healthcare specialist departments.
As the room is plunged into darkness and the projector lights up the screen, the next two hours are spent listening to individual patient cases, reviewing their CT scans and discussing treatment plans and post-surgery requirements.
CT scans flicker back and forward on the screen showing the three dimensional layers of cancer growth eating away at flesh and bone. While the surgeons describe the extent of the disease in detailed medical terms, they also discuss the patients in individual terms and explain how their medical and personal circumstances have shaped the proposed treatment plans.
Many of the patients are elderly and frail and suffering from other conditions that may contraindicate surgery or even radiology treatment. Some live alone, so the Macmillan Nurses, who play a key role in the treatment, have to consider bringing in community care so they can be looked after at home.
Sometimes, a resigned hush momentarily fills the room as even members of the non-surgical MDT can see that a cancer is so far advanced and there is little hope of treating the patient. It’s now the turn of the palliative care nurses to suggest how they can help the patient manage their symptoms and remain at home in comfort and dignity.
Then there’s the case of a cancer patient who has said: “No more, doctor”. After three operations another cancer has been diagnosed and he believes he can’t take any more. The surgeons know they have to operate, but for the time being they agree to respect the patient’s wishes and let him build up his health before attempting to persuade him of the need for more treatment again.
All these patients have come under the care of the Southern General’s Oral Cancer Maxillofacial/Head & Neck MDT from referrals from dentists and doctors.
In Glasgow, when patients are referred, they attend a consultation with Dr John Devine, Maxillofacial Head & Neck Surgeon, or one of his four fellow consultants at the Southern General’s Maxillofacial Department, to assess their condition.
If cancer is suspected, each patient will have a biopsy, a CT scan and a general health check to assess whether they are fit enough to undergo any treatment that is recommended.
Once the results are known, they are prepared for discussion at the Friday morning meeting which, in addition to the clinical teams involved, such as surgeons, pathologists, oncologists, radiologists and maxillofacial prosthetics, also includes clinical and ward nurses and specialist Macmillan Cancer Support Head & Neck nurses. The Macmillan nurses play a key role in supporting the patient from the time of diagnosis, through cancer treatment, and during the long period of rehabilitation.
And there are specialists present in nutrition, diet, speech therapy, dental hygiene and occupational therapy to address post-surgery issues such as difficulties in eating or speaking and adapting to any prosthetics.
Dr Devine said that these Friday meetings are crucial to understanding the needs of the patients and preparing to support them on and after their treatment journey.
“The most important part of the meeting is where we discuss the treatment plans and everyone has a say about the support they can offer the patients.
“We’ve certainly learned a lot about working together over the years and we are always finding new ways to help the patients through their treatment.
“That’s what is so exciting about these meetings – you really get a feel for the dedication of everyone in the room trying to do the very best for our patients.
“I’ve never worked with a more dedicated bunch of people,” added Dr Devine.
Chairing the Friday meeting discussions and keeping everyone to the strict two-hour timetable is Dr David Houghton, Consultant ENT/Head & Neck Surgeon, who said this MDT approach has really enhanced patient care.
He said: “We can now ensure that we tick all the boxes when it comes to patient care. By having all the pathologists, surgeons, radiographers and ancillary and paramedical staff in the one room, everyone gets a formal presentation of each patient, and the opportunity to input into the proposed treatment plans so that nothing is overlooked.
“I think dentists are doing an excellent job of referring their patients to us and we ensure that they are not left out of the process as we will always send them a letter outlining the treatment plan we have devised.”
The benefits of the MDT to patient care are enormous, not just in the quality of their treatment, but also in the logistics and emotional support they receive. Everything is under one roof at the hospital’s Maxillofacial Department and the process is well co-ordinated so that patients benefit from seeing the same specialists and don’t have to wait long between appointments.
Since the majority of oral cancer treatment involves surgery, the MDT is very conscious of the need to provide ongoing support after the operation to ensure that patients can get back to a normal as life as possible.
Dr Houghton explained: “We have to balance the amount of surgery required to remove the area affected by cancer, with the residual function of the patient.
“In the last 10 years there has been a greater focus on how the patient will function after surgery, and this is very much at the front of our minds when we devise our treatment plans.
“Our aim is to provide the best treatment and after-care for oral cancer patients in the world – that’s not being arrogant – it’s what we truly aim for,” he added.
MAXILLOFACIAL PROSTHETIC TEAM
Advanced oral cancer tends to be treated by surgery rather than radiology or chemotherapy because of the localised nature of the disease and the difficulty of accessing its occurrence in the mouth, jaw or skull.
Surgical resections often create large defects accompanied by dysfunction and disfigurement that can adversely affect speech, swallowing, control of saliva, and mastication. If these cosmetic and functional impairments are not corrected or minimised, the patient may be unable to resume a normal life.
This is the job of the specialist Maxillofacial Prosthetic Team, part of the MDT which helps to plan and ‘fix’ the results of reconstructive surgery.
Maxillofacial Prosthetic Technologist Barbara Thomson modestly summed up their work as simply “replacing anything that has been removed by surgery”.
However, the work itself is far from simple. It involves an advanced understanding of physiology and skeletal structure as well as the ability to interpret CT scans to create 3D computer models of the patient’s skull and soft tissues.
This not only helps surgeons to understand the extent of the cancer and plan their resections, but is essential for the technologist to develop suitable prosthetics to fill or cover up the extent of the surgery and alleviate any problems with breathing, speaking or eating.
In the case of complex surgery, a life-size three-dimensional plastic model will be created so that the surgeon can plan the treatment in detail.
After surgery the two most common ways of dealing with the void created by the
removal of tissue is a ‘flap’, a skin graft from the arm, leg of buttocks, or an obturator, which is a silicone ‘bung’ and associated denture to fill the void created by surgery and replace lost teeth.
In severe cancer cases patients might lose some of their nose or even their eyes and surrounding area so the team is skilled in creating life-like prosthetics, even down to matching skin texture and hand painting the pattern of the iris on an artificial eye.
The team spends a great deal of time with the patients to ensure that the individually crafted prosthetic is to their liking and can be used with a minimal amount of fuss.
Maxillofacial Prosthetic Consultant Fraser Walker is always impressed with the resilience of the patients throughout this traumatic experience. He said: “Their lives change forever after that first appointment with the consultant. In many cases patients can’t speak, eat or breathe properly after surgery, so it is wonderful that our prosthetics can help them achieve the simple things we take for granted and give them the ability, dignity and confidence to carry on with their lives.
MACMILLAN CANCER SUPPORT NURSES
Even if people suspected it, Janice Brown knows to have your fears confirmed that you have cancer can come as a severe psychological shock to most people.
She is one of two specialist Macmillan Cancer Support Head & Neck Nurses who play a key role in the multi-discipline oral cancer team, providing help and support throughout the patients’ treatment and beyond.
Janice explained: “People can be devastated to hear that they have cancer, so it is important that we are there when they are first told to help cushion the blow.”
Their role is to meet with the patient and their family and answer all the questions they might have about the disease and the possible treatments.
Once the treatment plan has been decided then the nurses visit the patients at home to provide another opportunity to talk about the treatment and their individual care needs.
It’s an emotionally demanding job as they develop a close relationship with a patient and their family, but for Janice it’s a privileged role to have.
“It’s very rewarding to know that you are helping people through this traumatic period in their life,” she said.