Challenging gestational trophoblastic disease cases and mimics: An exemplar for the management of rare tumours

OBJECTIVE

Rare tumour management is challenging for clinicians as evidence bases are limited and clinical trials are difficult to conduct. It is even more difficult for patients where self-reliance alone is insufficient to overcome the challenges of navigating care which is often poorly evidence based. In Ireland, a national Gestational Trophoblastic Disease (GTD) service was established as one of 3 initiatives for rare tumours by the National Cancer Control Programme. The service has a national clinical lead, a dedicated supportive nursing service and a clinical biochemistry liaison team. This study sought to assess the impact of a GTD centre using national clinical guidelines and integrating and networking with European and International GTD groups on the clinical management of challenging GTD cases and to consider the application of this model of care to other rare tumour management.

STUDY DESIGN

In this article, we analyse the impact of a national GTD service on five challenging cases, and review how the service affects patient management in this rare tumour type. These cases were selected from a cohort of patients who were voluntarily registered in the service based on the diagnostic management dilemma they posed.

RESULTS

Case management was impacted by the identification of GTD mimics, the provision of lifesaving treatment of metastatic choriocarcinoma with brain metastasis, networking with international colleagues, the identification of early relapse, the use of genetics to differentiate treatment pathways and prognosis, and supportive supervision of treatment courses of up to 2 years of therapy in a cohort of patients starting or completing families.

CONCLUSION

The National GTD service could be an exemplar for the management of rare tumours (such as cholangiocarcinoma) in our jurisdiction which could benefit from a similar constellation of supports. Our study demonstrates the importance of a nominated national clinical lead, dedicated nurse navigator support, registration of cases and networking. The impact of our service would be greater if registration was mandatory rather than voluntary. Such a measure would also ensure equity of access for patients to the service, assist in quantifying the need for resourcing and facilitate research to improve outcomes.

Exercise Rehabilitation Services Provided by Physiotherapy Departments in Cancer Care in Ireland

Aims This study aimed to identify the physiotherapy exercise rehabilitation services available to patients with cancer in Ireland and to identify barriers to the provision of services. Methods Physiotherapy department managers in specialised cancer centres, public and private hospitals and palliative care settings were surveyed to establish the availability of exercise rehabilitation services for patients with cancer. Results Of 40 managers contacted, 24 responded providing information about 26 services. Ten services employed a dedicated oncology physiotherapist. Exercise classes were offered to patients with cancer by five services, primarily within the palliative care setting. In the 17 hospitals which provided surgery, ten provided oncology specific post-operative exercise rehabilitation and one offered a prehabilitation programme. Limited human and physical resources and absence of established physiotherapy pathways were cited barriers to service provision. Conclusion Exercise rehabilitation is not an element of standard care for patients with cancer in Ireland.