Multidisciplinary, Interdisciplinary Approach to Management of Cancer

"The 1st decision is the most important determination of success in cancer treatment and this should be a multi-modal effort."

For many years, the traditional approach to the treatment of cancer patients has been almost exclusively oriented towards specialized decision–making. Consequently, certain neoplasms in both adults and children have been characterized as either “surgical” or “radiotherapeutic” diseases. More recently, the medical oncologist has been involved in the primary and almost exclusive responsibility for particular neoplastic diseases and all disseminated solid tumors. The empirical connection of diseases with particular clinical specialties or disciplines has caused numerous obstacles to progress in the treatment of cancer in general.

Today, modern treatment has shifted from specialization to integration for every single cancer. A given neoplasm is no longer considered to be within the exclusive domain or under the initial control of a certain clinical discipline, but rather cancer treatment must be conceived and carried out strategically using the therapeutic potential of several modalities in the attempt to destroy all the sites of disease (combined modality treatment or MULTIDISPLINARY APPROACH to the management of cancer).

The management of cancer must be multi-disciplinary interdisciplinary, with each discipline respecting the specialty expertise of the other, all for the benefit of the cancer patient, with consideration of the current state of the art of cancer management.

The essential elements for combined modality treatment are:

1. Knowledge of the natural history
   • Neoplasm or stage or subgroup at high risk of early dissemination especially hematogenous spread
   • Histologic type at high risk of relapse
   • New diagnostic methods for better determination of the anatomical extent
   • Neoplasm responsive to radio- and /or chemotherapy
2. Knowledge about the efficacy of various modalities
   • Efficacy/ Limitations of radical surgery
   • Efficacy/ Limitations of radical radiotherapy
   • Efficacy/ Limitations of extensive or adjuvant irradiation in some neoplasms
   • Efficacy/ Limitation of chemotherapy or hormonal therapy
   • Neoplasm in which one or more drugs have recently been shown to be effective
3. Local facilities
   • Uniformity of clinical, oncologic approach
   • Presence, in the same center, of experts in the various diagnostic and therapeutic branches (pathology, radiobiology, endoscopy, surgery, medical oncology, pain and rehabilitation therapy).
   • Adequate number of doctors, nurses and secretaries
   • High-energy radiotherapy
   • Outpatient clinic and day hospital
   • New anti-neoplastic drugs
   • Adequate supportive therapy

THERAPEUTIC MODALITIES AGAINST CANCER

The finality of treatment of a cancer patient demands that therapy be undertaken only by those who are capable and properly trained. There are few situations in medicine where the stakes are high and the therapeutic procedures as decisive for cure or death. The responsibility is great and the judgement is critical. This is reflected in the emergence of specialties in virtually all major discipline – i.e. radiation oncology, medical oncology, surgical oncology, gynecologic oncology, and pediatric oncology. The first decision is the most important determination of success in treatment and this should be a multi-modal effort.

"The second most important principle in therapy is to cure or to control the disease or to palliate the symptoms of the patient with minimal functional and structural impairment."

The decision as to how radical treatment should be, is determined by:

• the aggressiveness of cancer, the predictability in regard to its spread,
• the morbidity and mortality of the therapeutic procedure,
• and the cure rate for the therapeutic procedure under consideration.

The treatment of patients with malignant disorders is characterized by the following reasoning:

• What is the goal of the treatment?
• Do benefits outweigh risks in achieving these goals?
• Is difference between potential benefit and harm worth the cost?

There are therefore, two major modalities of cancer treatment:

LOCOREGIONAL TREATMENT MODALITY

1. Surgery
2. Radiotherapy – teletherapy (cobalt, linear accelerator, IMRT, IGRT, tomotherapy) or brachytherapy

SYSTEMIC TREATMENT MODALITY

1. Cytotoxic chemotherapy
2. Hormonal therapy
3. Immunologic therapy
4. Gene therapy

SURGICAL ONCOLOGY
To cure…To control…To palliate

When treating a patient with newly diagnosed cancer, the surgeon (surgical oncologist, colorectal surgeon, gynecology-oncologist, urologist, thoraco-vascular surgeon, neurosurgeon, orthopaedic oncologist, otolaryngo-oncologist) has several responsibilities within the context of multidisciplinary-interdisciplinary approach to cancer patient care (see links to different societies and members):

1. Biopsy for tissue diagnosis
2. Surgical resection of the tumor when appropriate with attention given to the needs of other consultants such as marking residual tumor for irradiation, or removing lymph nodes for staging purposes, or getting fresh specimen for tumor marker assay, and
3. Adequate staging
4. Consultation with medical, pediatric and radiation oncologists as to the indications for adjuvant therapy
5. Surgical resection for cure, control or palliation , and
6. Appropriate follow-up of patient with inter-disciplinary modality approach.

Surgery is the main treatment modality of early stage solid tumors and usually with an aim for cure. Surgery can be done in all tertiary hospitals and medical centers in the Philippines.

RADIO-ONCOLOGY
To control…To palliate

Radiation therapy involves radiation inactivation of cancer cells. The ideal in radiation therapy of malignant disease is achieved when the tumor is completely eradicated and the surrounding normal tissues show minimal evidence of structural and functional injury.

Radiotherapy can be given as an external beam (teletherapy) or close to or within the tumor (brachytherapy).

Radiotherapy is the responsibility of the Radio-Oncologist, working in the context of multidisciplinary interdisciplinary approach to cancer management. There are a limited hospital centers with radiation facilities – see website for directory.

MEDICAL / PEDIATRIC ONCOLOGY
To cure… To control… To palliate

Chemotherapy refers to the use of drugs in the treatment of any disease. Chemotherapy has been indelibly linked to cancer because of the reputation of anti-cancer drugs and their effects on the patient. In truth, chemotherapy involves the use of not only cytotoxic agents, but of other agents such as hormones, anti-hormones, and cellular products. All have a systemic effect on the patient.

Chemotherapy must be in the hands of the Medical Oncologist (for adult patients) or of the Pediatric Oncologist (for children) – in their absence under the Internist or the Pediatrician, working in the context of multidisciplinary interdisciplinary approach to cancer management. There are now evolving sub-sub-specialty IM oncologist – like neuro-oncology.

The types of systemic therapy include the following:

• CYTOTOXIC chemotherapy – the drugs usually attack rapidly dividing cells.
• HORMONAL therapy – can be hormones or anti-hormones, used against hormone-sensitive tumors.
• IMMUNOLOGIC therapy – the use of biologic response modifiers, natural cellular products, as main modality or adjunct therapy against cancer.

Chemotherapy for cancer treatment is classified according to its goal in combination with other modalities of treatment:

• PRIMARY chemotherapy – Chemotherapy is the main modality of treatment. Usually, these is in the setting of aggressive tumors with high probability of systemic involvement (e.g., lymphoma, leukemia, small cell lung cancer).
• ADJUVANT chemotherapy – Chemotherapy given after a loco-regional therapy (surgery or radiotherapy) with the aim of controlling micro-metastatic disease, prolonging disease-free and overall survival (e.g., breast, colon, rectum, ovary, osteosarcoma cancers).
• NEO-ADJUVANT chemotherapy – Chemotherapy given before a definitive loco-regional therapy (surgery or radiotherapy) with the purpose of decreasing tumor size or better loco-regional control later, as well as controlling micro-metastasis and prolonging disease-free and overall survival (e.g., breast, non-small cell lung, head & neck cancers).
• CONCURRENT chemotherapy – The simultaneous use of chemotherapy and radiotherapy in the management of cancer (e.g., head & neck, lung cancers).

Many tertiary hospitals and medical centers in the Philippines are with Medical Oncologists – see website for directory.

OTHER DISCIPLINES involved in the multidisciplinary care of the cancer patient are:

• Pathology specialists
• Pain specialists
• Psychosocial counsellors
• Rehabilitation specialists
• Oncology nurses
• Nutritional counsellors
• Spiritual counsellors

A. Philippine Charity Sweepstakes Office

http://www.pcso.gov.ph/

INDIVIDUAL MEDICAL ASSISTANCE PROGRAM (IMAP)

Under this PCSO program, medical assistance is given to individual patients through the issuance of guarantee letters to hospitals where the patients are confined. A guarantee letter is a certification issued to hospitals for a particular charity patient under the PCSO medical assistance program where the agency assumes the obligation of settling the cost of hospitalization, including the medicines, medical, surgical or blood supplies, and diagnostic procedures.

OBJECTIVES

General : Restoration of social functioning (Physical recovery) through medical assistance
Specific : Provide assistance for hospitalization expenses, laboratory procedures and purchase of medicines, chemo drugs, dialysis solutions, antibiotics, implants, devices and other medical need.

DOCUMENTATION REQUIREMENTS

Letter Request to Chairman/General Manager
Medical Abstract
Treatment Protocol
Bill/Quotation/Costing from Hospital Pharmacy/Supplies –
Laboratory Request/Medicine Prescription
Histopathology Result
Endorsement/Acceptance letter from Hospital Social Services/Credit Collection Office – Barangay DSWD endorsement

Request your doctor to assist you on the Medical Abstract, Treatment Protocol, Medicine Prescription, Radiotherapy Needs. Always have a copy of your histopathology results – keep one file for your files.

Cueing at the PCSO requires early arrival (5 am) and much patience.

PCS also refers patients in need to PCSO for assistance.

B. The Carewell Community Foundation, Inc.Carewell

Incorporated in 2005, the Cancer Resource and Wellness (Carewell) Community is a nonprofit foundation that provides support, education, and hope to persons with cancer and their loved ones. Carewell was envisioned by the late Jessica ‘Jackie’ Fernandez-Suntay, and her husband, Robert ‘Bobbit’ Suntay. Their commitment to establishing Carewell was inspired by their experiences at The Wellness Community (TWC).
Headquartered in the US, TWC is the largest international, community-based psychosocial support organization that provides free resources and services to persons living with cancer.
Details on support can be seen at http://www.carewellcommunity.org/resources.cmc. The address and contact in the Philippines:

6th Floor, S & L Building dela Rosa
Corner Esteban Streets Legaspi Village,
Makati City 1200 Philippines

Phone: (632) 815-1294
TeleFax: (632) 751-0242
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Website: www.carewellcommunity.org

The local oncology societies have the responsibility of keeping up to date with oncology management towards the state of the art care of oncology patients. Multidisciplinary interdisciplinary consultations, meetings, conferences, and seminar are the venue for updates, which the societies engage in on a regular basis. The core local oncology societies include:

• Philippine College of Surgeons and its member societies | http://pcs.org.ph/
• Philippine Society of Medical Oncologists | http://www.psmo.org.ph/
• Philippine Society of Hematology & Blood Transfusion | http://pshbt.yocal.ph/
• Philippine Society of Pediatric Oncologists | http://pspediatriconcology.weebly.com/
• Philippine Radiation Oncology Society | http://philradonc.com/
• Philippine Society of Pathologists | http://www.psp.org.ph/
• Philippine College of Radiology | http://philippinecollegeofradiology.org
• Philippine Society of Oncology | http://www.pso.org.ph/

See Treatment Modalities and Facilities for more quick links to local oncology-related societies.

Hospice and Palliative Care is care for the terminally-ill which aims to provide comprehensive relief of symptoms using the skills of a mix of health disciplines, together with education and assistance for both patient and family so that they are able to maintain care in the place which best suits the patient’s needs.

Hospice home care started in the Philippines in October 1991 through the initiative of then PCSI President, the late Dr. Mita Pardo de Tavera, which also paved the way for the creation of different hospices in the country and the establishment of the National Hospice and Palliative Care Council of the Philippines (NHPCCP), or Hospice Philippines, in 2004.

Past and present officers of Hospice Philippines pose for posterity during the association’s General Assembly held at the PCS Patients Lounge. PCS sits as member of the Board of Directors and as corporate secretary.

Since the formation of Hospice Philippines, the PCSI has embarked on other noble and fruitful undertakings to advance the concept for quality end-of-life care.

Hospice and Palliative Care continue to be part of the PCS’ programs which cater to terminally-ill cancer patients. Since the concept and the specialty is relatively new to the country, a major part of hospice advocacy is in organizing the training for health professionals and volunteers. Aside from Metro Manila, PCS helped organize workshops in the cities of Cagayan de Oro (Mindanao) and Dumaguete (Visayas).

The joint PCS-SM Foundation-Lung Center of the Philippines’ project Felicidad T. Sy Pediatric Hospice Center based in the same hospital celebrated its 1st year of operation in 2012.

The PCS sits as board member and corporate secretary of the National Hospice and Palliative Care Council of the Philippines (NCHHP), an association that networks all existing hospice and hospice support systems in the country.
The PCSI has been an active partner in the Technical Working Group (TWG) that works on policies for the provision and distribution of free morphine tablets to concerned groups including Hospice Philippines. The TWG was an offshoot of the Department of Health’s Integrated Pain Control Program which is an essential component of the Philippine Cancer Control Program.

The following are the local Hospice Care Groups:

At Home Hospice Foundation Inc.
Room 513, Medical Arts Bldg.
St. Luke’s Medical Center
279 E Rodriguez Sr. Ave, New Manila
Quezon City, Luzon, 2795, Philippines
Tel: (63) 2 723-1023
Fax: (63) 2 723-1023
Dr. Cenon R. Cruz, President

Asian Institute of Health Care
65 Camaro St. Fairview, Quezon City, 1118 Philippines.
Name of Person in Charge: AGNES G. ENGUITO-ABAD
Telefax: 632-9361567
E-Mail: This email address is being protected from spambots. You need JavaScript enabled to view it.
Website: www.hospiceasia.org

Ayala Alabang Hospice Care Foundation Inc.
Haven for Children
Alabang-Zapote Road, Alabang, Muntinlupa City
Metro Manila, Luzon, Philippines
Tel: (63) 2 401-1018
Fax: (63) 2 887-2124
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Atty. Asuncion B. Kalalo, President
Home Care Service

Bigkis ng Tayabas Inc.
F. Perez St. Barangay Baguio Tayabas,
Quezon, Luzon, Philippines
Tel: (63) 42 793-2172
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Ms. Maria Delsie A. Horak, Presiden
Home Care Service
Outpatient Clinic

Cancer Care Center
San Pedro Hospital
R. de Guzman St., Davao City
Mindanao, 8000 Philippines
Tel: (63) 82 225 5934
Fax: (63) 82 300 3879
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Elsa G. Villagomeza
Home Care Service
Outpatient Clinic

Cancer Center Palliative Care Service
The Medical City
Ortigas Avenue, Pasig City
Metro Manila, Luzon, Philippines
Tel: (63) 2 6356789
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Website: http://www.themedicalcity.com.ph
Dr. Maria Fidelis Manalo,
Palliative Care Consultant
In-patient Service
Palliative Care Consultancy
Home Care Service

Cebu Cancer Institute
Perpetual Succour Hospital
F. Sutto Drive Cebu City
Visayas, 6000 Philippines
Tel: (63) 32 233 8620
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Dennis M. Tudtud, Medical Director
Palliative Care Unit

Central Luzon Pain Management & Hospice Care Center
35 Gordon Avenue
Pag-Asa, Olongapo City
Luzon, Philippines
Tel: (63) 47 224 1172
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Ilirmo E. Edejer, Director
Home Care Service
Outpatient Clinic

Children’s Hospital of the Philippines Foundation Inc.
Philippines Children’s Medical Center
Private Clinic Rm 11, Quezon Avenue
Manila, Luzon, 1100, Philippines
Tel: (63) 2 924 6601
Fax: (63) 2 924 0840
Ms. Maria S. Rafael
Palliative Care In-patient

De La Salle Hospice Care Program
De La Salle University Cancer Institute
Dasmarinas, Cavite 4115
Luzon, Philippines
Tel: (63) 2 416 0226
Fax: (63) 2 826 6446
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Jhade Lotus Peneyra, Medical Oncologist
Home Care Service

Francis Regis Clet House & Pain Clinic
Mother Seton Hospital
Roxas Avenue (Diversion Road)
Naga City, Luzon, Philippines
Tel: (63) 54 472 4027
Sister Luz Roma, Daughters of Charity
In-patient Hospice
Home Care Service
Outpatient Clinic

FEU-NRMF Medical Center Hospice & Palliative Care Service
Dept. of Community & Family Medicine,
NRMF Medical Center
Regalado Avenue, West Fairview
Quezon City, Luzon, Philippines
Tel: (63) 2 427 0213
Fax: (63) 2 427 0213
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Website: www.feu-nrmf.ph
Dr. Agnes Bausa, Palliative Care Consultant
In-patient Service
Palliative Care Consultancy
Home Care Service

Davao Medical Center Hospice Clinic
Family Medicine Dept.
JP Laurel Ave., Davao City
Mindanao, Philippines
Tel: (63) 920 924 0471
Dr. Jeanne Maningo
In-patient Service
Palliative Care Consultancy

Home Care Service
HOME Inc (Hospice of Manila Empowerment Inc)
7th Floor Builders Centre
170 Salcedo Street, Legaspi Village
Makati, Manila, Luzon, Philippines
Tel: (63) 2 750 5143
Dr. Susan D. Reyes, Managing Director
Home Care Service

Hospice & Family Care Foundation of the Philippines Inc.
c/o Department of Family & Community Medicine
Western Visayas Medical Center, Mandurria
Iloilo, Visayas, 5000 Philippines
Tel: (63) 33 329 4898
Fax: (63) 33 321 1797
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Annabelle P. de Guzman, President
In-patient Service
Home Care Service
Outpatient Clinic

Hospice of Manila Environment
Susan D Reyes
170 Salcedo Street, Legaspi Village 7th floor
Makati, Metro Manila 
1229 Philippines
Tel: (632) 756 1045 / 
(632) 756 1045
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Hospital ng Maynila
Pres. Quirino Ave., Roxas Blvd 
Manila, PHILIPPINES
Tel: (63) 524 6001
Contact Person: Dr Anita Ocampo-So
Nature of Services: In-patient

Iloilo Mission Hospital Pain & Palliative Care Clinic
Mission Rd., Jaro
Iloilo City, Visayas, 5000 Philippines
Tel: (63) 918 925 6451
Dr. Celina G. Vilches, Director
In-patient Service
Home Care Service
Outpatient Clinic

Madre de Amor Hospice Foundation Inc.
Madre de Amor Hospice Center
9957 Amethyst St., Los Banos Subd.
Laguna, Luzon, 4030, Philippines
Tel: (63) 49 536 0644
Fax: (63) 49 586 0644
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Website: www.hospice.org.ph
Dr. Rhodora Ocampo, Hospice Program Director
Home Care Service
Day Care Centre

Medicus Inc Palliative & Hospice Care Clinic
Medicus Inc, Luna St.
Iloilo City, Visayas, Philippines
Tel: (63) 918 526 5655
Dr. Ed Marie Togonon
Palliative Care Consultancy
Home Care Service

National Hospice & Palliative Care Council of the Philippines (Hospice Philippines)
c/o Ayala Alabang Hospice Care Foundation Inc.
Haven for Children, Alabang-Zapote Road Alabang, Muntinlupa City, Metro Manila, Luzon Philippines
Tel: (63) 2 401- 1018
Fax: (63) 2 887-2124
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Atty. Asuncion B. Kalalo, President

PALCARE Volunteer Group
3/F Unit 308, 1336 West East Center Bldg.
Taft Ave., Malate, Manila, Luzon, Philippines
Tel: (63) 2 727 8110
Fax: (63) 2 527 8810
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Website: www.palcareph.com
Dr. Agnes Bausa, Program Director
Home Care Service
Training & Counselling

Patmas Retreat House
Calabanga, Camarines Sur
4400, Luzon, Philippines
Tel: (63) 54 475 2291
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Rev. Fr. Dindo “Bruno” C. Cuario, D.S.
Home Care Service
In-patient Spiritual Support

Precious Jewels Ministry
Quezon City, Philippines
Tel. 63 2 921 8076
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.
Contact Person: Ms Lorraine Anderson, Project Director
Area of Eligibility: Metro Manila
Requirement: Terminal illness, Children with HIV-AIDS
Nature of Services: Respite Care Facility/ Home Visits

Ramon Aboitiz Cancer Foundation Inc
35 Lopez Jaena Street
Cebu City, Visayas, Philippines
Tel: (63) 32 254 6351
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Website: www.rafi.org.ph
Mr. Ronald M. De Los Reyes,
Program Co-ordinator
Contact Person: Mr Generoso Monterde
Requirement: Cancer patients
Nature of Services: Home Care

St. Michael’s Hospice Foundation
135 Capricorn St., Cinco Hermanos Subd.
IVC, Marikina City, Metro Manila, Philippines
Tel: (63) 2 681 8510
Fax: (63) 2 413 4968
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Amado M. San Luis, President
Contact Persons: Dr Cynthia San Luis,
Ms Cecile Tingala, Secretary
Area of Eligibility: Marikina City
Nature of Services: Home Care

Starfish Palliative Care Program
San Lazaro Hospital
Quiricata St., Sta. Cruz, Manila 1014
Tel: (63) 2 732 3776
Fax: (63) 2 711 6979
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Cirena R. Cabanban, Chairman
Palliative Care Consultancy
Quarterly Workshops

Supportive Palliative & Hospice Care Program
Dept. of Family & Community Medicine
Philippine General Hospital
3rd Floor Room 304, OPD Building Avenue
Taft Ave., Manila, Luzon 1000, Philippines
Tel: (63) 2 521 8450
Fax: (63) 2 523 2358
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Agnes Bausa, Program Co-ordinator

University of Santo Tomas Hospital Hospice
UST Hospital, Pain Clinic, 3rd Floor
Espana Blvd., Manila 1008, Luzon, Philippines
Tel: (63) 2 732 3001
Website: www.usthospital.com.ph

UPHRMC Home Care Program
7th Floor, Medical Arts Building
UPHRMC medical Centre Compound
Alabang-Zapote Road, Pamplona, Las Pinas City
Metro Manila, Luzon, Philippines
Tel: (63) 2 874 8515
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Rumalie Corvera
Home Care Service

Vineyard Medical Foundation
27 Pabayo St., Corner Gerlan Street
Cagayan de Oro, Mindanao 9000, Philippines
Tel: (63) 88 857 3000
Fax: (63) 88 857 3000
Dr. Francisco M. Hipona, Chairman
Home Care Service
Outpatient Clinic

Wingless Angels of Lucena Hospice
Cancer Detection Cancer
Quezon Memorial Hospital Compound
Lucena City, Luzon, Philippines
Tel: (63) 2 788 6719
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
Dr. Lina Pagkatipunan, President
Home Care Service