From the associate editor’s desk

From the associate editor’s desk
By Ms. Lou Andersson, RN, MA, and
Dr. Cyril Danjoux, MD, DMRT, FRCPC
It has always been the intention of the
Rapid Response Radiotherapy Program to
provide our readers with the latest
information on medical and psychological
care of cancer patients based on the most
recent knowledge and experience of
cancer care providers.
Our August issue features our
important partner in care – pharmacy.
The insert prepared by Kim
Stefaniuk, BSP, gives helpful
information on medication and
pharmacy services. She also adds an
article on Toronto Sunnybrook’s
Pharmacy Services and Toronto
Sunnybrook Regional Cancer
Centre’s participation in providing
medication to a Third World country.
You will find Dr. Berry’s article on
Informed Decision Making for Palliative
Therapies covers some puzzling
problems we all encounter in palliative
Also, Part One – The
Transformation from Tragedy into
Grace in Terminal Illness by Dr. Mary
Vachon; Dr. Hayter’s Plants, Poisons
and Potions: Drug Treatment for
Cancer; and Dr. Rebecca Wong’s
Research Corner (with Dr. May Tsao
as co-author) on brain metastases are a
welcome read.
TSRCC pharmacy services
By Kim Stefaniuk, BSP,
Pharmacist, Toronto Sunnybrook
Regional Cancer Centre
The pharmacy at the Toronto
Sunnybrook Regional Cancer Centre
provides a range of services to meet the
unique needs of cancer patients.
Specially-trained technicians prepare
chemotherapy safely and accurately. A
small retail pharmacy fills prescriptions
for oral chemotherapy and supportive
care medications; also available is a
selection of over-the-counter products
designed especially for cancer patients.
In the warm, friendly atmosphere of the
new pharmacy, patients can consult
with the pharmacy team to address
medication-related issues. Experienced
staff can help smooth the complicated
drug insurance process, look after
drugs for over 70 clinical trials, and
help manage the many symptoms
associated with cancer and its
Our team of highly-trained
pharmacists works closely with
physicians, nurses, and other members
of the health care team to ensure
optimal drug therapy outcomes. Clinical
pharmacists can be found in the pain
clinic and the chemotherapy suite to
help manage pain, symptoms, and other
drug-related issues. Pharmacists are
also a valuable drug information
resource for questions ranging from
monoclonal antibodies to herbal
products. Some of our pharmacists are
actively involved in teaching students
and residents; they are also awardwinning authors, invited speakers, and
poster presenters at local, national, and
international events.
TSRCC’s pharmacy is open 0830-1700
Monday to Friday. The team is keen,
dedicated, eager to help, and has a
reputation for artistic, musical, and
culinary prowess! Pharmacy can be
reached at (416) 480-4671.
The Newsletter of the
Rapid Response Radiotherapy
Program of Toronto Sunnybrook
Regional Cancer Centre
Vol. 4, Issue 3, August 2002
Editor: Dr. C. Danjoux
Associate Editors:
Ms. L. Andersson, Dr. E. Chow,
Dr. R. Wong
Assistant Editor: Ms. L. Holden
Consultant: Dr. J. Finkelstein
Advisors: Dr. S. Berry, Dr. A. Bezjak,
Dr. M. Branigan, Dr. C. Hayter,
Dr. J. Kamra; Dr. L. Librach,
Dr. D.A. Loblaw, Dr. E. Szumacher,
Dr. M. Vachon
Editorial and Financial Manager:
Ms. D. Nywening
Toronto Sunnybrook Regional Cancer
Centre, 2075 Bayview Avenue,
Toronto, Ontario M4N 3M5
Tel: (416) 480-4998,
Fax: (416) 217-1338
E-mail: [email protected]
Website: RRRP.htm
Produced by
Pappin Communications
Pembroke, Ontario
In this issue: TSRCC pharmacy services; The transformation from tragedy into grace in
terminal illness - part one; Historical Vignette: Plants, poisons and potions: Drug treatments for cancer;
TSRCC pharmacy assists Third World countries; Informed decision-making in palliative care; Research Corner.
Insert - Accessing medication
The transformation from tragedy
into grace in terminal illness – part one
By Mary L.S. Vachon, RN, PhD
Kathleen Dowling Singh, PhD, a
transpersonal psychologist, has
worked in hospice for many years. In
The Grace in Dying: How We are
Transformed Spiritually as We Die
(Harper San Francisco, 1998), she
states that the period of dying is one
which begins with a personal sense of
tragedy with a terminal prognosis and
culminates, after the arduous process
of psychospiritual transformation, in
an experience of grace with the final
dissolution of personal consciousness.
She speaks of death as being an
experience in which “higher energies
filter in”. Singh notes that wisdom
traditions have acknowledged this
phenomenon for millennia. In the
Middle Ages, Ars Moriendi, the “Art
of Dying” set forth a cartography of
dying in Christian religious terms. In
the East, Padmasambhava gave a
precise map of the dying process in
the Bardo Thodol, The Tibetan Book
of the Dead, in the eighth century.
Singh’s Psychospiritual Journey of
the Dying Process draws on many
spiritual traditions. Her model
includes phases of Chaos, Surrender
and Transcendence. The phases are
tied to points on the Karnofsky
Performance Scale. This article will
describe the phase of Chaos. The next
issue of Hot Spot will discuss the
next two phases.
Singh contrasts the travail of death
with that of birth. Death “is hard work
for every interrelated, interpenetrating
facet of our being: physical,
emotional, psychological, and
spiritual. The developmental task
placed before us in dying is the task of
finding the courage to be in the face
of a lonely death. The challenge of the
dying process is the challenge of
living while dying, rather than dying
while living” (p. 167).
Singh notes that Kübler-Ross’s
five-stage theory relates only to the
reaction of the “mental ego forced to
confront the death of the body in
which it presumes itself to reside” (p.
168). Singh’s model suggests that the
stages of dying also involve
psychospiritual transformation deep
into transpersonal levels.
“Transformation occurs through
subtraction. We begin, as we heal
successive dualities, as we approach
deeper and deeper levels of
integration, to eliminate the
nonessential. As we participate in the
process, we find paradoxically, that
the subtraction adds, that through the
exclusion of the nonessential from our
attention, we create movement and we
become more inclusively essential”
(p. 90-91).
The stages she describes are not
discrete; they are whirling aspects of
the self in the grip of a profound
transformation. The first phase of
Chaos is characterized by turbulence.
continued on page 4...
Historical Vignette:
Plants, poisons and potions: Drug treatments for cancer
By Charles Hayter,
Radiation Oncologist, TSRCC
Physicians have always hoped for the
development of effective drug treatments
for cancer. Dioscorides, a first century
Roman army surgeon, wrote the first
textbook of medical botany and
recommended an extract of Colchicum
lingulatum (colchicine) for treatment of
tumours. In the nineteenth century, doctors
experimented with compounds of lead and
arsenic, some of which showed promise
against cancer.
The emergence of medical oncology, a
field specializing in systemic therapies for
cancer, is one of the major developments
in the modern cancer system. Buoyed by
the early twentieth century discoveries of
chemical treatments for infectious,
metabolic, and deficiency diseases,
doctors envisaged effective drug
treatments for cancer. These dreams began
to become reality through the
serendipitous observation that mustard gas
used as a chemical weapon in WWI
caused damage to bone marrow cells. The
first promising human clinical trials of
nitrogen mustard took place at Yale in the
early 1940s.
The development of experimental
animal tumour systems allowed the testing
of many compounds for anti-cancer
activity, and from 1950 to 1970
many potentially useful drugs
were discovered. As
historians have pointed
out, many of these drugs
were derived from
research programs with
different objectives in
mind – methotrexate from
nutrition, cortisone from
arthritis, and
actinomycin-D from TB
research. Subsequent
trials showed that
combinations of these
drugs could actually cure
certain forms of cancer even
when metastatic – most notably,
choriocarcinoma, leukemias, lymphomas,
and testicular cancers. The observation
that chemotherapy could cure patients
with advanced cancer led to speculation
that it might enhance the probability of
cure in patients who had apparently
localized disease, but who were at high
risk for metastases. In the 1960s and 70s
chemotherapy began to be used as an
“adjuvant” to local treatments such as
surgery or irradiation. Clinical trials in
breast cancer showed that the risk of
relapse and death could be significantly
reduced by the use of adjuvant
Several useful chemotherapy
agents have been developed
from plants: vincristine from
periwinkle (depicted in
illustration), etopiside from the
May-apple root, and taxol from the
yew tree. Such discoveries are in keeping
with the ancient medical tradition of
obtaining remedies from plants that dates
back to Dioscorides.
TSRCC pharmacy assists Third World countries
By Kim Stefaniuk, BSP,
Pharmacist, Toronto Sunnybrook
Regional Cancer Centre
For several years now, the pharmacy
staff at TSRCC have been quietly donating
time, money, and medical supplies to Third
World countries. In many of these
countries, even basic medications are
unavailable; what is available may not be
easily obtained or paid for.
Often people ask what to do with
medications they no longer need or when a
family member dies and leaves a number
of partly-used prescriptions. Canadian laws
prohibit reusing medications that have
already gone to a patient, but medications
that are in good condition, clean, properlystored, and clearly labelled can be a real
gift to needy patients in disadvantaged
countries. With the exception of
refrigerated drugs, the pharmacy at
TSRCC is happy to accept donations of
these medications or unused medical
supplies. Some medications have been sent
to various aid groups such as Medical
Ministries International. More recently, we
have been sending these donations to an
American physician, Dr. William Hobbs,
who runs a medical outreach clinic in a
remote area of Guyana, South America.
Dr. Ewa Szumacher, one of TSRCC’s
radiation oncologists, has visited Dr.
Hobbs’ clinic and seen for herself the
desperate need of these people. On a
recent visit to Canada and TSRCC, Dr.
Hobbs expressed his deep appreciation for
the donated medical supplies. “How these
people survive is a miracle,” he says.
Pharmacy staff collect the medication,
remove confidential patient information,
and pack the medications for mailing to
Dr. Hobbs. Donated clothing and school
supplies are also welcome; both Kim
Stefaniuk in the pharmacy and Dr.
Szumacher have been mailing parcels for
the outreach clinic.
Dr. Hobbs cited several examples of
how the donations have been used to help
his patients; the packages do reach him
and are immediately put to good use. Here
at home, patients and their families derive
comfort from knowing their medications
will not be wasted, but will instead
directly benefit needy people in a very
poor country. For further information
contact Kim Stefaniuk at (416) 480-4671.
The TSRCC pharmacy staff with Dr. Bill Hobbs.
Informed decision-making in palliative care
By Scott Berry,
A 45-year-old woman with metastatic
breast cancer presents to the bone
metastases clinic with a very painful
solitary vertebral metastases that has
progressed despite several hormonal
therapies and previous radiation to the
site. Within a short time, she will be
assessed by the various team members and
offered advice about the relative merits of
therapies that might help improve her
pain. It is a rather daunting task –
someone who is already faced with the
stress of having an incurable illness and
the distress of pain has to make important
decisions with her physicians about what
treatment is best for her.
Patients coming to see oncologists for
palliative anti-cancer therapies want us to
help them feel better. As clinicians, we
want to ensure that our patients can make
an informed decision about their
treatment. Informed decision-making
about any therapy, including palliative
cancer treatments, is a cornerstone of
preserving a patient’s autonomy – their
ability to live their life according to their
own plans and desires.
So, how good are we at helping people
make informed decisions about palliative
An Australian group has recently
published some interesting results from a
qualitative study they performed to try and
answer this important question (Gattelari
et al., JCO, 2002). Consultations with
oncologists were taped and analyzed for
more than 100 patients presenting for
discussion of palliative therapies. The
analysis revealed that most patients were
well-informed about the aim of treatment
and the fact that their disease was
incurable. However, they found that there
were significant gaps in information
provided about prognosis and alternatives
to anti-cancer treatment that could have
impacted on a patient’s ability to make an
informed decision.
Empirical research about ethical
issues in cancer care like this Australian
study is very important. Theoretical
musings about the importance of
autonomy and informed decision-making
are also important, but rather empty if
they do not reflect what is happening in
the clinic or at the bedside. This study
has pointed out some potential gaps in
informing patients about palliative
therapies that we can consider when we
deal with our own patients. This can
serve as a foundation for future research
to help us be even better at properly
informing our patients.
Research Corner
By May N. Tsao, MD, FRCPC,
and Rebecca Wong,
“How would I benefit from whole
brain radiotherapy?” a patient with
brain metastases asked of her
radiation oncologist.
It is actually quite humbling how we
have difficulty answering this question.
While brain radiotherapy for patients
with brain metastases is part of standard
therapy, the degree of symptomatic
benefit it may (or may not) provide
remains elusive. Conventionally,
treatment outcomes, including survival
and local control, are the outcomes used
to assess the effectiveness of whole brain
radiotherapy. While these outcomes are
important, we have come to appreciate
that quality of life plays a much bigger
role in evaluating the usefulness of
treatment, particularly since treatment is
palliative in nature.
Dr. Vachon – continued from page 2...
Chaos involves the five psychological
phases enunciated by Kübler-Ross
(On Death and Dying. New York:
Macmillan, 1969): denial, anger,
bargaining, depression and
acceptance. In addition, it involves the
deeper experiences dying persons may
pass through in the course of
transformation: the experience of
alienation, anxiety, the despair that
leads to “letting go,” and the dread of
Chaos begins with facing the threat
of death, goes through a time
involving a pattern of living
significantly altered by physical
decline, and typically comes to a close
with the approach of death itself in the
nearing death experience. Tumult,
conflict, confusion, and emotional
suffering characterize Chaos. In the
early to middle phases of terminal
illness, people experience great and
virtually inexpressible anguish. “The
will to live bounces against the painful
emotions of denial, guilt, fear,
depression, loneliness, apathy, and
despair. The will to live crashes, over
and over, into the disease process
itself, engendering turmoil, suffering
and confusion” (p. 176). Strong
desires and emotions move toward a
At the Toronto Sunnybrook
Regional Cancer Centre, a study
entitled “Quality of Life in Patients
with Brain Metastases Treated with a
Palliative Course of Radiotherapy” is
now open to accrual. This is a
prospective study with a sample size of
60 patients and 60 caregivers. Quality
of life, using a validated quality of life
scale (FACT-BR), will be assessed as
well as caregiver agreement with
patient quality of life scores.
The primary objective of this study
is to assess whether there is an
improvement in quality of life for
patients with brain metastases after a
course of palliative radiotherapy (at
one month and two months) as
compared to quality of life assessments
taken while on decadron and before
radiation. The secondary objective is to
assess whether caregivers serve as
valid proxies for the assessment of a
patient’s quality of life.
Inclusion criteria:
1. histologic or radiographic diagnosis of
brain metastases
2. treatment with decadron (12-16 mg
per day) for at least 48 hours before the
first quality of life assessment
3. whole brain radiotherapy (2000 cGy in
five fractions daily)
4. mini-mental scores greater than or
equal to 25/30
Exclusion criteria:
1. patients with a single brain metastases
eligible for surgical resection
2. inability to read/write English
3. no proxy
4. contraindication for radiation
It is with studies such as these, that we
would come to gain a better
understanding of how we are impacting
on our patients’ lives, an essential step
towards helping our patients live better
with their cancer.
For further information, please contact
Dr. May Tsao at the Toronto Sunnybrook
Regional Cancer Centre (416) 480-4806.
Funded by the Toronto Sunnybrook
Regional Cancer Research Fund.
heaviness and an almost unendurable
Mary Vachon, RN, PhD, is a
sense of isolation. On the Karnofsky
psychotherapist in private practice.
Scale, Chaos could be characterized
She can be reached at
by scores ranging from 100 down to
about 40, or even 30%. The turbulence [email protected]
of Chaos begins at different points for
different people. It begins
at the moment when the
The newsletter of the Rapid Response
idea of the reality of one’s Radiotherapy Program of Toronto Sunnybrook
own rapidly approaching
Regional Cancer Centre is published through
mortality enters
the support of:
consciousness. At a level
of 50 per cent, almost
literally seeing our healthy
Abbott Laboratories, Limited
functioning diminishing
by half, we begin to lose
our accustomed sense of
who we are. We can no
longer fulfill the imagined
reality of who we were.
We no longer have our
“stance” in the world. At
Karnofsky levels of 40 to
30 per cent, often
involving incontinence
“most people begin to ask
Knoll Pharma Inc.
themselves, Where is the
‘me’ who had all those
Ortho Biotech
faces, all those cherished
parts to play, all those
Purdue Pharma
ways of navigating the
world? Who am I now?”
(p. 178).
Theratronics - a division
of MDS Nordion
Accessing medication
By Kim Stefaniuk, BSP, Pharmacist, TSRCC
Private Insurance
ODB Formulary
• Third party insurance pays for
drugs according to individual plan
• Coverage not guaranteed; some
plans follow ODB formulary and
may require justification for use of
agents outside the formulary
• Patient can call insurer with DIN
(drug identification number) to
check coverage
• Co-pay ranges from 0-50% of
prescription cost; many have a cap
on benefits
• Many plans require patients to pay
first then submit claim
• Prescribing/reimbursement
guide, sent to all Ontario
physicians and pharmacies
• List of quality-assured drug
products reviewed for efficacy
and interchangeability
• Listed drug products are
covered (benefits); not
• Benefits subject to small
co-pay for each prescription
Ontario Drug Benefit
• Drug coverage (general listing,
limited use, Section 8, nutritional
products) with valid health card
for the following groups:
• Seniors age 65 and over
(usually $100 annual deductible)
• Patients receiving professional
services under Community Care
Access Services (home care)
with a drug card. Coverage
only for duration of services,
renewable monthly. Home care is
not a drug plan by itself.
• Residents of long-term care
facilities or homes for
special care
• Ontario Works or Ontario
Disability Support Program
• Patients enrolled in Trillium
Drug Program
a) General Listing
• Listed products (formulary
section III) require regular
prescription only
b) Limited Use (LU)
• Drugs reimbursed only for
specific clinical criteria
(formulary section XII) (ie.
Celebrex covered for
rheumatoid arthritis, but not
for antiangiogenesis)
• LU prescription pads sent to
physicians. Additional forms
available at 1-888-234-1365
• Form must be completed in
full by physician with
appropriate LU code. Codes
and forms are audited by
• Without complete LU
prescription, patient pays full
cost of prescription
• LU forms do not confer
ODB benefits; patient must be
ODB eligible
• LU prescriptions provide
coverage for up to one year.
Abbott Laboratories
Leaders in Oncology
Partially funded by grants from Amgen Canada Inc. and Abbott Laboratories
Non-narcotic refills may be
telephoned or written on a
regular prescription.
c) Section 8
• Individual clinical review for
drug product not on formulary
or limited use (ie. filgrastim for
patients treated with curative
intent using myelosuppressive
chemotherapy and
experiencing persistent
section VIII)
• Patients must be on ODB:
Section 8 approval does not
confer ODB benefits
• Physician must fax letter to
ODB (416) 327-7526
requesting drug product
coverage with the following
- Patient name, age, gender,
date of birth, OHIP number
- Name, strength, dosage
form, DIN, and duration of
therapy for drug product
- Reason for use, supporting
literature, prior therapy,
why formulary agents not
appropriate, lab data and
other relevant medical
- Name, phone, fax of
pharmacy where patient
will get prescription
- Name, address, fax, CPSO
number & signature of
requesting physician
• Requests reviewed
individually (may take several
weeks); coverage not assured
• If covered, physician
receives authorization letter
• Coverage NOT retroactive,
valid only for dates indicated
on letter
• If denied, physician receives
letter requesting more
information or listing reasons
for denial. Appeal is possible.
• Renewals not automatic. Reapply with updated patient
information by faxed letter
four weeks before expiry date.
• Coverage is Drug
Identification Number (DIN)
specific; dosage form or
strength changes require new
letter. Consider requesting
multiple DINs for different
strengths on initial letter (ie.
interferon pens)
• Section 8 letter is not a
prescription; valid prescription
is required
d) Nutritional Products (NP)
• Covered for ODB-eligible
patients with NP form;
coverage valid for one year
• Covered only if NP is sole
source of nutrition (po or tube)
- oropharyngeal or
gastrointestinal disorders:
dysphagia prevents eating
- maldigestion/malabsorption/gut failure where
food not tolerated
- elemental diet as primary
treatment of diseases where
therapeutic benefit
Trillium Drug Program
• Confers ODB prescription drug benefits
to Ontario residents (with valid health
card) and members of the immediate
family living with applicant
• Deductible (payable quarterly)
proportional to previous year’s family
• May appeal deductible if financial status
changed since last year
• Usually processed in four to six weeks
• If deductible overpaid, Trillium will
reimburse patient
• Forms available in any pharmacy
• Can be used with private insurance; copay can be applied to Trillium deductible
Special Circumstances
• Cancer Care Ontario free drug service for
oral or some subcutaneous chemotherapy
agents only, not supportive care. Access
is via Social Work only through regional
cancer centre/Princess Margaret Hospital
• Health Canada Special Access program
for non-marketed drugs (613) 941-2108
• Refugees, patients without OHIP or other
coverage to be assessed by social work.
Community groups or ODB assistance
may be possible.
• Programs supported by pharmaceutical
industry in collaboration with third party
payors to facilitate reimbursement
• Neupogen care line
1-888-706-4717 for filgrastim
• Eprex Assistance Program
1-877-793-7739 for erythropoeitin
• Care Line 1-800-363-3422
for interferon
Supplement to Hot Spot, the newsletter of the Rapid Response Radiotherapy Program of Toronto Sunnybrook Regional Cancer Centre - August 2002
Accessing medication
By Kim Stefaniuk, BSP, Pharmacist, TSRCC
Abbott Laboratories
Leaders in Oncology
Partially funded by grants from Amgen Canada Inc. and Abbott Laboratories