Download The Multidisciplinary Cancer Clinic

MULTI-DISCIPLINARY CANCER
MANAGEMENT
John B. Hamner, MD, FACS
Assistant Professor
Surgical Oncology
Tulane University
OBJECTIVES

Define multidisciplinary care and who is involved

Show why multidisciplinary care is important

Brief case reviews highlighting how different
specialties work together to treat cancer patients
MULTIDISCIPLINARY CANCER
CARE: WHO IS INVOLVED?

Surgery/Surgical subspecialties

Medical Oncology

Radiation Oncology

Diagnostic/interventional Radiology

GI

Dermatology

PT/OT

Dieticians/nutritionists

Nurse navigators
CANCER: WHY IS A MULTIDISCIPLINARY
TEAM NEEDED?

Cancer is not a single disease

Increases options/availability for management
requiring involvement of different specialties

Increases use of appropriate adjuvant and neoadjuvant therapy
CANCER: WHY IS A MULTIDISCIPLINARY
TEAM NEEDED?

Some role reversal for specialties in particular cancers

In the past: Surgery  Radiation  Chemotherapy

now :
Chemo+/-Radiation  Surgery  Chemo
Surgery  Chemo  Radiation  Chemo
Chemo  Surgery for residual disease
CANCER: WHY IS A MULTIDISCIPLINARY
TEAM NEEDED?

Cancer and its treatment is often associated with
significant physical & psycho-social issues (patient &
family). Multidisciplinary teams increase use of:

psychiatric liaison

social worker/case managers

cancer visitor or support groups

dietitian, occupational therapy, physiotherapy, speech
pathology, stomal therapy

community services/education

palliative care services
CANCER: WHY IS A MULTIDISCIPLINARY
TEAM NEEDED?

Cancer patients and family need for knowledge often
greatly exceeds other illnesses

remarkable impact of cancer diagnosis compared to other
life threatening diseases

Increased consultation time for explanation of disease,
treatment options and prognosis and support

need for information material that reflects all aspects of
management

use of specialised disease based nurses

need for consistent information
CANCER: WHY IS A MULTIDISCIPLINARY
TEAM NEEDED?

The days of the single clinician working independently to
treat cancer are gone
MULTIDISCIPLINARY CANCER
CLINICS

Specialist clinic of different skills working together to optimise
patient care

Willingness to recognise, respect and to cooperatively use
the expertise of the other disciplines

provision of ‘one stop shop’ concept

usually disease site orientated
MULTIDISCIPLINARY CANCER
CLINICS

Multiple specialties working together

Surgical and surgical specialties

Medical oncology

radiation oncology

dental / oral surgery

pathology

Radiology diagnostic, interventional

Nursing (nurse navigators, research)

allied health

palliative care
MULTIDISCIPLINARY CANCER
CLINICS

Development of clinical practice guidelines that are

evidence based

consensus approved

quality assured care

timely investigation and therapy

Better outcomes
MULTIDISCIPLINARY CANCER
CLINICS

Increase accessibility to MDs with special skills

High volume of cases to attain and maintain skills

more likely to attract patients

Patients morel likely to be quickly investigated and treated

more likely to enlist in clinical trials

associated database can produce outcome data

integrated student/resident teaching

Better outcomes in high volume centers
MULTIDISCIPLINARY CANCER
CLINICS

Case Review or Tumour Board

New Case Clinic

Disease Site Clinic with new cases & all follow up cases

Should always be a clinic chairman
MULTIDISCIPLINARY CANCER
CLINICS

University Michigan

104 pt treated in multi-disciplinary melanoma clinic
matched to 104 treated in community, matched for site &
depth

surgical morbidity & survival similar

saving of USD 2600 per patient in multi-disciplinary clinic due
to differences in health care resources used
MULTIDISCIPLINARY
CANCER CLINICS

UK Papworth study

quick access multi-disciplinary service to investigate
suspected lung cancer

181 patients with NSCLC

47 (25%) underwent successful surgical resection

compared to general UK resection rate <10%
MULTIDISCIPLINARY
CANCER CLINICS

Scottish ovarian study


Br J Cancer
1987 all 533 cases ovarian Ca in Scotland
improved survival when

first seen by gynaecologist

operated on by a gynaecologist

residual <2cm

prescribed platinum chemotherapy

referred to a multispecialty clinic
MULTIDISCIPLINARY
CANCER CLINICS

Adjuvant Therapy: Additional cancer treatment
given after the primary treatment to lower the risk
that the cancer will come back. Adjuvant therapy
may include chemotherapy, radiation therapy,
hormone therapy, targeted therapy, or biological
therapy.

Neoadjuvant Therapy: Treatment given as a first
step to shrink a tumor before the main treatment,
which is usually surgery, is given. Examples of
neoadjuvant therapy include chemotherapy,
radiation therapy, and hormone therapy. It is a type
of induction therapy.
CASE 1

A 56 year old female is diagnosed with left breast
invasive ductal carcinoma, 3.4cm, ER/Pr-, Her2+.
Enlarged axillary node with metastatic disease by
FNA. Workup for distant metastatic disease
negative.

What are the surgical options?

Does the patient need chemotherapy?

Does the patient need radiation therapy?

What is the most appropriate sequence of therapy?
CASE 1

What are the surgical options?

Partial mastectomy (lumpectomy) with ALND

Total mastectomy with ALND

Bilateral mastectomy w left ALND

Unilateral or bilateral mastectomy with ALND and
immediate or delayed reconstruction
CASE 1

Does the patient need chemotherapy?

Yes

Multiple potential regimens

Adjuvant or neoadjuvant chemotherapy
CASE 1

Does the patient need radiation therapy?

Potentially

Lumpectomy- definitely

Total mastectomy- potentially based on final
pathology (size of tumor, # of +nodes)
CASE 1

What is the most appropriate sequence of
therapy?

Given +nodes, ER-, Her2+ most would favor
neoadjuvant chemotherapy followed by surgery
+/- Radiation after surgery.

Care should be carefully coordinated between all
specialties.
CASE 2

A 72 year old man with constipation and rectal
bleeding undergoes colonoscopy. He is found to
have a large mass in the rectum at 6cm from the
dentate line. Biopsy shows adenocarcinoma.

How is the patient further staged?

What specialties may be involved in the staging
workup?
CASE 2



How is the patient further staged?

Pelvic MRI or Endorectal US for local (T/N) staging

CT chest/abd pelvis for distant disease (M staging)
What specialties may be involved in the staging workup?

Radiology for CT/MRI

GI for EUS
Found to have T3N1 lesion with no metastatic disease

What specialties are needed to further treat this patient?

What is the preferred course of treatment?
CASE 2

What specialties are needed to further treat this
patient?
 Surgery
 Medical
Oncology
 Radiation

Oncology
What is the preferred course of treatment?
 Neoadjuvant
chemoradiation, followed by surgery,
followed by adjuvant chemotherapy
CASE 3

A 60 year old male with a long history of Hepatitis
C and cirrhosis is found to have a suspicious liver
mass on screening US. MRI confirms presence of
4.5cm Hepatocellular carcinoma in right lobe of
the liver.

Why is diagnostic radiology important in making
this diagnosis?

What specialties may be involved in primary
treatment of this HCC?

What are the treatment options?
CASE 3

Why is diagnostic radiology important in making this
diagnosis?


What specialties may be involved in primary treatment of this
HCC?


HCC can be diagnosed by radiologic features on liver directed
MRI or CT
Surgical oncology/HPB, Transplant surgery, medical oncology,
Interventional Radiology
What are the treatment options?

Resection if a good surgical candidate

Transplantation if criteria met

Operative or percutaneous ablation

Liver directed therapy (TAE, TACE). Can be used as primary
therapy or a bridge to transplantation