General Practice Guidelines for Treatment

According to best practice, cancer is most efectively diagnosed, treated and prevented by a multiplicity of experts in diferent fields of specialization. For the benefit of the patient, standard practice, where there are adequate numbers of trained personnel, requires that the following practice disciplines (principles) be observed as much as possible. Treatment modalities depend on the extent of the cancer and are usually combined as depicted below.

  • Localised cancer is mainly treated by surgery.
  • Loco-regional disease by radiotherapy.
  • Widespread disease by chemotherapy, hormonal therapy, or biotherapy.

Before any cancer treatment is instituted, there must be clear justification. This must be for the benefit of the patient. Most of cancer treatments administered in low-income countries with an aim to cure do not achieve this benefit because the patients usually present at the late stages with terminal disease requiring only palliative approaches. There should always be careful consideration concerning cancer treatment on:

  • When to ofer,
  • When to abandon,
  • When to avoid altogether.

The Ministry strongly recommends that appropriate multidisciplinary approach to cancer management should be adopted to achieve the safest and most cost-efective care. As such, all facilities treating cancer should establish “Multidisciplinary Tumour Boards”. This will avoid wastage of scarce resources and facilitate consideration of all aspects of the patient’s condition. Further, the multidisciplinary approach creates a framework for selecting patients for clinical trials, continuous professional development, audit and research.

Roles of Various Disciplines in Cancer Management

The roles of the various disciplines need to be clearly defined. This helps in:

  • Referral for maintenance of the best standards of care;
  • Regulation;
  • Accountability.

The era of “Jacks of all trades” in cancer care should be easing of. Roles should follow the order given. Where the group that comes first is inaccessible then the next should apply. There should be systems/criteria for verifying competencies of the experts in each area. This should be done with regulatory and professional bodies taking a lead in the verification processes to protect patients from abuse and exploitation. Biopsies should be carried out in the order given:

  • Surgeons/gynaecologists
  • Surgical/gynaecologic oncologists
  • Internists (physicians)
  • Paediatricians
  • General duty medical ofcers
  • Haematopathologists/haematologists
  • Imaging experts
  • Clinical ofcers

Fine needle aspiration (FNA)

  • Pathologists
  • Imaging experts
  • Surgeons
  • Surgical/Gynae-oncologists
  • Haematopathologists
  • Haematologists
  • Internists (physicians)
  • Paediatricians
  • General duty medical ofcers
  • Clinical ofcers

Diagnostic imaging

  • Imaging specialists
  • Others with the appropriate expertise.

Cancer Staging

  • Imaging specialists
  • Surgical/gynae-oncologists
  • Surgeons
  • Gynaecologists
  • Histopathologists
  • Adult/paediatric medical oncologists
  • Haematologists
  • Haematopathologists
  • Radiation oncologists
  • Clinical oncologists
  • Internists(physicians)
  • Paediatricians

Chemotherapy

  • Medical oncologists (adult and paediatric)
  • Haematologists/haematopathologists
  • Clinical oncologists
  • Radiation oncologists
  • Internists (physicians)
  • Paediatricians
  • Surgeons
  • Clinical Pharmacists

Radiotherapy

  • Radiation oncologists
  • Clinical oncologists

Nuclear medicine

  • Nuclear medicine specialists

Palliative care

  • Palliative care specialists.
  • All the rest, depending on the required modality.

End of life issues

  • Trained counsellors
  • Palliative care specialists
  • Spiritual leaders

All the other disciplines as required for the chosen modality. It’s acknowledged that such experts are in short supply in our country and efort should be made to train more.

Cite: National Guidelines for Cancer Management Kenya