Documents we should keep: a good summary (1-2 pages) of what has happened since the beginning, and of what has been done. This will enable us to remind all the doctors in the team as to precisely what has taken place. Moreover, it will make it easier to obtain a second opinion from another expert, should this be necessary.
In order to have a complete record of the case, this summary must be accompanied by at least 5 other documents: 1) the description of the surgical operation, 2) the result of the histological examination, 3) the results of any molecular tests performed on the tumor, 4) the reports of the CT, PET or other examinations performed for staging and for assessment of the efficacy of the therapy, and 5) the most recent blood test results.
1.The description of the surgical operation is extremely important, as it tells us exactly what the surgeon found and how difficult it was to remove the tumor. This document should indicate whether the tumor was completely removed or not. A good description is usually typed; if handwritten, it must be written perfectly legibly, so that it can be read by anyone. Three lines are not enough; the report should be at least 10-15 lines long.
2. The pathologist’s report: written by the doctor who analyzes under the microscope the removed tumor. This is perhaps the most important document of all, as it tells us what sort of disease we are dealing with and whether the tumor has spread locally.
If properly written, the pathologist’s report contains a description of the specimen analyzed, what the pathologist has seen under the microscope, and a summary of the most important information. For example, next to the name of the tumor, such as “adenocarcinoma” or “infiltrating ductal carcinoma” or similar, the pathologist usually writes an abbreviation such as pT2/G2/N0/Mx or Dukes’ B2 or Clarke level III; these abbreviations indicate the precise stage at which the tumor has been “caught”. Obviously, the doctor who has to express an opinion on the clinical case must consider this information together with the description of the surgical operation.
3. Any molecular tests and special examinations conducted on the tumor. These are very important in order to be able to consider all the possible therapies, including those most recently developed. In the case of breast cancer, for instance, the histological examination will be completed with the abbreviations ER, PGR, HER2, and Ki67. These abbreviations indicate special molecular features of the tumor, which enable the treatment to be chosen more accurately. The same applies (though the tests are different) to tumors of the lung and colon.
4. The reports of the initial staging examinations (i.e., those performed before therapy) and those of any reassessments made during therapy: CT, PET, magnetic resonance, and tumor markers. These provide an approximate estimate of how much progress has been made during therapy and how favorable or unfavorable the clinical course of the disease is.
5. The latest blood test results: these indicate whether or not the vital organs are working properly, and so whether any further therapy can be administered.