Odds of beating cancer boosted through cooperation among doctors in multiple specialties
JGH clinic for melanoma and non-melanoma skin cancer is unique in Canada
When a lesion on Monique Verrette’s left leg necessitated a visit to the JGH in 2022, she expected a thorough examination, but she was momentarily stunned by what she now describes as “an abundance of riches.”
Ms. Verrette had been referred to a special skin cancer clinic in the hospital’s Division of Dermatology where, as expected, Dr. Osama Roshdy, a staff physician and co-founder of the clinic, took a close look at her leg.
Dr. Osama Roshdy chats with patient Monique Verrette about her skin cancer treatments. (Click to enlarge.)
However, at the same time, he was joined in the exam room by Dr. Alex Mlynarek, a head and neck surgical oncologist (another of the clinic’s co-founders), plus a medical specialist whose name Ms. Verrette does not recall.
“It was just little old me, and here were these three doctors coming in to see me,” she recently recalled with a chuckle. “I appreciated it, because they took a lot of care and really checked me out. I was very well looked after.”
The purpose of this multi-physician presence was not just to arrive at a consensus about diagnosis and treatment. The unique structure of the clinic—where doctors from several specialties regularly convene to see patients in the Division of Dermatology—spared Ms. Verrette the time, anxiety and considerable effort of having to book appointments with one doctor after another.
In conventional circumstances, Ms. Verrette would have started by seeing a dermatologist and then moved on to an oncologist, possibly followed by a visit to either an oncologic surgeon or an oncologic radiologist. But in 2022, the relevant physicians were all coming to her, just as they did at a visit in April of this year.
This is just the sort the streamlined process Dr. Roshdy was hoping to create when he and two colleagues opened a non‑melanoma skin cancer clinic at the JGH in 2018. So strong was the initial response that a few months later, the clinic’s work expanded to include melanoma.
According to Dr. Roshdy, the clinic was unprecedented when it was launched and it remains the only hospital-based facility of its kind in Canada.
7,000 patients in seven years
Today a total of about 100 patients, who come to the clinic by referral, are seen on two Fridays per month: one five-hour session for 50 who have melanoma and, two weeks later, a similar session for another 50 with non-melanoma skin cancer.
Dr. Roshdy estimates that over the past seven years, the clinic has served at least 7,000 patients.
“With so many doctors in the room together, some patients might feel a bit uneasy,” says Dr. Roshdy, “but we all cooperate to create a warm, friendly atmosphere. You could say we practice in a kind of family style.”
“We have a good mix of personalities that complement one another,” adds Dr. Mlynarek. “None of us is the type to work in a bubble.”
Patient-centred inter-disciplinary collaboration is a long-standing tradition at the JGH and has become a hallmark of CIUSSS West-Central Montreal.
It means that certain aspects of cancer care at the JGH sometimes range beyond the Segal Cancer Centre, drawing on the expertise of medical staff in divisions such as Dermatology, and Allergy and Immunology (for more about the latter, see below).
The dermatology clinic also fits squarely into Care Everywhere, the CIUSSS’s broad, user-based approach to care, which strives to achieve the right outcomes by providing the right care at the right time in the location that is the safest, most appropriate and most convenient for users.
Who’s who in the Melanoma and Non-Melanoma Skin Cancer Clinic
From left: Dr. Khalil Sultanem, Dr. Philippe Lefrançois and Dr. Karyne Martel. From right: Dr. Wilson Miller, Dr. Alex Mlynarek and Dr. Osama Roshdy. Paying them a visit is Dr. Khashayar Esfahani (centre), a medical oncologist. (Click to enlarge.)
- Dr. Osama Roshdy, dermatologist and co-founder of the clinic
- Dr. Khalil Sultanem, Chief of the Division of Radiation Oncology and co-founder of the clinic
- Dr. Alex Mlynarek, head and neck oncologic surgeon and co-founder of the clinic
- Dr. Wilson Miller, Director of the Clinical Research Unit at the Lady Davis Institute for Medical Research
- Dr. Karyne Martel, oncologic surgeon
- Dr. Philippe Lefrançois, dermatologist
Outpatient surgery on the premises
“The structure of our clinic is much more efficient for the patient,” says Dr. Roshdy. “Normally, someone might spend six to eight weeks waiting for and going to various medical visits, in order to arrive at an understanding of their condition. Then they’d have to arrange for treatment.
In an operating room in the Division of Dermatology, Dr. Norah Alnafea, a fellow in head and neck oncology, removes a tumour from the left shoulder of a patient.
“In our clinic, the conclusion is reached in a single session, because we’re all there to agree on the diagnosis and the best treatment. Speed is really important, because the sooner treatment starts, the better the patient’s chances for a good recovery.”
The Division of Dermatology even includes two compact operating rooms, where a fellow in head and neck oncology can surgically remove some types of tumours (using a local anesthetic) on an outpatient basis.
Although surgery in these rooms is generally scheduled by appointment, Dr. Roshdy says it’s not uncommon for some patients to be fast-tracked—that is, examined, diagnosed and operated on, all on the same day.
He notes the clinic has also become an ideal learning environment for medical residents in dermatology and for medical students, since it routinely serves patients from many racial and ethnic backgrounds, with a broad spectrum of skin colours.
“The same disease might look different on skin that varies in colour from one person to another,” he explains.
Fighting the side effects of anti-cancer medication
The inter-disciplinary war against cancer is also being waged in the Division of Allergy and Immunology, where support is provided to patients who are allergic to—or who develop an allergy to—certain medications used in chemotherapy or other types of anti-cancer treatments.
“A common scenario might involve a patient with a gynecological malignancy who becomes allergic to carboplatin, which is used in treating cancer of the ovaries,” explains Dr. Jesse Schwartz, Chief of the Division.
“Sometimes a patient may initially tolerate a particular medication and absolutely nothing happens. Then at some point, perhaps after the sixth or seventh or 10th infusion, they develop a rash or vomiting or dizziness during an infusion.
“When we perform a skin test, the results can come back positive or negative, just as they would when we test for something like peanuts or ragweed.”
Dr. Schwartz says that wherever feasible and safe, another drug is used to avoid exposing the patient to the medication they’re allergic to. However, if the original drug is the best for that patient, and if no acceptable alternative can be found, an attempt can be made to desensitize the patient to the drug.
This is accomplished by diluting the medication and slowly giving it to the patient in its weakest form. If there is little or no reaction, the concentration of the drug is increased and it is administered more quickly, depending on what the patient can safely tolerate.
A solution that worked like magic
As it turns out, there’s another way to describe how Dr. Schwartz achieves the desired result: “Magic!” his patient, Giovanna Pasculli Falcon, says with a laugh. “I don’t know how else to explain what he did.”
Ms. Falcon has been treated on a recurring basis for melanoma since 2000 and is followed by Dr. Robin Billick, Chief of the Division of Dermatology, whom she describes, along with Dr. Schwartz, as “my two heroes.”
In the Clinical Research Unit of the JGH, Giovanna Pasculli Falcon undergoes chemotherapy—with no debilitating side effects—while chatting with Nurse Clinician Karine Silva.
Her condition took a serious turn for the worse in the spring of 2020 when a series of immunotherapy sessions was ordered after Ms. Falcon underwent various cancer-releated treatments.
What followed was a hellish three months, when her medication caused her face and ears to become so inflamed that she had to apply the kind of skin cream that is usually reserved for burn victims. “It was horrible,” she recalls, “and at night it was even worse. I had to sleep with a bowl of ice and a towel next to me. I suffered a lot.”
At one point, Ms. Falcon also came down with severe cramps in her kidneys and lungs, which prevented her from breathing properly.
But that’s all behind her now, she says with a smile of relief. Since July 2024, she has been receiving chemotherapy for melanoma, but “I feel great. Dr. Schwartz worked very hard to fix the problem. There’s no pain, no burning. I’m getting treatment today, and tomorrow I’ll be able to work in my garden.”
“Our course of action is the result of a discussion among the treating physician, the patient and me,” Dr. Schwartz explains. “Our decision is based on needing to help the patient with their allergy, plus the extent to which the original medication is preferable to any other option.
“If desensitizing the patient seems like the best course of action, we go ahead as long as the patient is amenable to it. Fortunately, the success rate is good.”
The goal, whether in the Division of Dermatology or the Division of Allergy and Immunology, is to maximize collaboration among staff to substantially increase the patient’s odds of beating cancer.
Dr. Roshdy says with a smile, “I’m glad to say we have saved numerous lives and have given renewed hope to many, many families.”
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