CASE SUMMARY
Mr Fuentes (a pseudonym) is a 63-year-old construction worker with type II diabetes mellitus, mild renal insufficiency, and mild congestive heart failure (CHF) who sees his primary care physician (PCP; Dr A) two to three times a year through a Parkland community-oriented primary care clinic. In 2014, he experienced bleeding per rectum, change in bowel habits, and some unexplained weight loss. Dr A suspected rectal cancer and initiated a referral for a GI evaluation. It took 4 weeks to obtain a colonoscopy, which identified an obvious rectal cancer. The patient was then referred to a medical oncologist (Dr C).
Dr C obtained staging studies suggesting the cancer was localized and potentially curable. Dr C outlined a multidisciplinary treatment approach to include preoperative chemotherapy concurrent with radiation therapy (neoadjuvant therapy), followed by surgical resection; then, the patient would complete a course of chemotherapy (adjuvant therapy). Input from colorectal surgery (Dr S) and radiation oncology (Dr R) was necessary to initiate this plan. More delays to the initiation of therapy were incurred as a result of sequential scheduling of surgery and radiation therapy visits. Eight weeks after seeking advice from Dr A, Mr Fuentes began chemotherapy with oral capecitabine administered concurrently with radiation therapy. He completed 5 weeks of chemoradiotherapy with minimal toxicities and then underwent surgery. Pathology from surgery found residual cancer and two of 12 lymph nodes with metastatic carcinoma. The postoperative stage was ypT3N1M0 stage III rectal cancer.
Four weeks after surgery, Mr Fuentes was seen by Dr C to initiate the planned additional chemotherapy but needed a mediport, which was then placed by surgery in the operating room because of scheduling delays with interventional radiology. Even with the port, delays occurred in getting the patient scheduled for chemotherapy. Eight weeks postsurgery, Mr Fuentes began his adjuvant FOLFOX (infusional fluorouracil, leucovorin, and oxaliplatin) chemotherapy. Initially, he tolerated his therapy well, receiving chemotherapy and scheduled antiemetics, including corticosteroids. Chemotherapy treatments were administered every 2 weeks. Mr Fuentes was not advised to continue to follow-up with Dr A.
Eight weeks after beginning adjuvant chemotherapy, Mr Fuentes presented to the Parkland urgent care center with moderately elevated blood sugars and mild bipedal edema. He was treated with short-acting insulin and furosemide and urged to visit his PCP. Three weeks later, Mr Fuentes saw Dr A. During the interim, his symptoms had worsened, and routine activities of life had become more difficult. Dr A noted his diabetes to be uncontrolled and his CHF uncompensated and admitted the patient to hospital. Notably, Dr A had received minimal information regarding the patient’s overall treatment plan from Dr C; she had received no information regarding the patient’s complicating problems and few blood sugar laboratory results over the prior 8 to 10 weeks of chemotherapy treatment. Mr Fuentes was seen 2 days postdischarge by Dr A. He resumed his adjuvant chemotherapy after a 1-week delay. Dr C, recognizing the role of treatments in aggravating his course, made significant adjustments to eliminate the routine use of corticosteroids and ensured that blood sugars were monitored. He encouraged Mr Fuentes to keep his routine appointments with Dr A.