Multi-Disciplinary Cancer Managment
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Transcript Multi-Disciplinary Cancer Managment
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