Treatment
Patients within the NHS are usually treated under a Multi-Disciplinary Team of medical experts who will review the evidence and treatment from different angles. CUP requires close collaboration between radiologists, pathologists, and clinicians (including nurses and palliative care experts) who will examine and re-examine the patient's medical history, physical findings, and the results of the laboratory data.
There are a number of options open to the cancer specialist (the oncologist) once he or she has pulled together all the available evidence. The oncologist will weigh-up the treatment options in relation to the evidence (sites of presentation), the patient’s resilience and Quality of Life factors (and if one chemo regime has been tried, its responsiveness in determining whether to try another). Possible routes include surgery, chemotherapy, radiotherapy, hormonal treatment, and immunotherapy.
The classification of the patient’s symptoms are important to determine the treatment options.There are few standard treatments for CUP patients.
A combination of procedures is possible e.g. after an operation to remove a cancerous tumour, chemotherapy may be given to 'mop up' any remaining cells. Suitability for treatment, and the type of treatment, is usually asessed by the Multi-Disciplinary Team (MDT).
For someone who is frail the treatment options may sound very intimidating. As well as the positives, the oncologist will consider with the patient the negatives of investigation and treatment, and alternative options such as palliative care. Further understanding of cancer therapies can be gained from Cancer Research UK.
Arriving at a treatment decision for advanced cancer patients
Whilst many CUP patients will receive a combination of cancer treatment with palliative care, some patients with advanced cancer may reach a point where they face a difficult choice between (continuing) anti-cancer treatment (such as chemotherapy), or supportive (palliative) care with no (further) curative interventions.
For the patient in this bewildering environment it may help to work-through, and then weigh-up, the pros and cons. Chiew et al (2007) have developed a 7 step process for advanced cancer patients to aid decision making.
1. Understand your situation
2. Learn about your treatment options
3. Review the pros and cons of these options
4. Decide how important these pros and cons are to you (see Note)
5. Do you want more information or discussion with your doctor?
6. Decide who should take the decision: you, your doctor, or a shared decision involving you, your doctor and family members?
7. Where are you leaning - towards anti-cancer treatment or towards supportive care?
Note: Weighing-up the pros and cons might involve considering the pros of chemo (e.g. I may live longer, my cancer symptoms may improve, I'm going to fight this because...) with cons (e.g. chemo side effects, frequent trips to hospital, no guarantee that the treatment will work, costs). Once you have a list of pros and cons, which may be long or short, you can then revisit it to ask more questions of the doctor or ascribe a weighting to each such as: very important, somewhat important, not important.
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Top-up payments. The recent Richards Review endorsed by the Secretary of State states: "no patient should lose their entitlement to NHS care they would have otherwise received, simply because they opt to purchase additional treatment for their condition".
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