multi-disciplinary cancer management the pah experience

Multi-disciplinary Cancer Managementthe PAH Experience

Damien B Thomson

Director of Oncology

Princess Alexandra Hospital

Cancer: why do we needmulti-disciplinary teamwork? 1

cancer is not a single disease

ing options for management requiring involvement of different specialties

ing use of appropriate adjuvant and neo-adjuvant therapy


some rôle reversal for specialties in particular cancers

less common: S R C now sometimes: C+R S C

S C R C or: C S residual

disease


cancer and its treatment often associated with significant physical & psycho-social issues (patient & family) appropriate use:• psychiatric liaison• social worker• cancer visitor or support groups• dietitian, occupational therapy, physiotherapy,

speech pathology, stomal therapy• community services• palliative care services

Cancer: why do we needmulti-disciplinary teamwork? 4 Patient and family need for knowledge

often greatly exceeds other illnesses • remarkable impact of cancer diagnosis

compared to other life threatening diseases consultation time for explanation of disease

and prognosis and support• need for information material that reflects all

aspects of management

use of specialised disease based nurses need for consistent information


the days of the single clinician working independently are numbered

The multi-disciplinary cancer clinic What is it? 1

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

increase of knowledge provision of ‘one stop shop’ concept usually disease site orientated

The multi-disciplinary cancer clinic What is it? 2

cross disciplines• surgical surgical specialties• medical eg. oncology, respiratory• radiation trend to site specialisation• dental / oral surgery• pathology• radiology diagnostic, interventional• nursing nursing rover, research• allied health• palliative care

The multi-disciplinary cancer clinic:is it useful? 1

Development of clinical practice guidelines

that are: evidence based consensus approved

producing quality assured care timely investigation and therapy


increase of special skills with > minimum number of cases to attain and

maintain skills more likely to attract more patients likely to be more quickly investigated and

treated more likely to enlist in clinical trials associated database outcome data integrated student teaching


YES……. but

$ resourcing has lagged behind so badly• inadequate staffing for current workload• unable to set up further clinics due to

inadequate funding

poor literature resource very little published in past 20 years

The multi-disciplinary cancer clinicliterature review 1

University Michigan J Amer Acad Derm

• 104 pt treated in multi-disciplinary melanoma clinic matched to 104 treated in community, matched for site & depth

• surgical morbidity & survival similar• saving of USD1600 per patient in multi-

disciplinary clinic due to differences in health care resources used


UK Papworth study Thorax

• 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% &

USA + European resection rate of >20%


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 joint clinic


Mid-west breast cancer Oncol Nursing Forum• 55 patients Med Oncol consult as inpatient

compared 66 patients consult in multi-disciplinary clinic:

MDS physical function satisfaction with health care satisfaction with physician (doctor) care satisfaction with nursing care

The multi-disciplinary cancer clinic Types of clinics

Case Review or Tumour Board New Case Clinic (old cases new problem) Defined Site Clinic with new cases & all

follow up cases, no therapy Defined Site Clinic with new cases & all

follow up cases, and therapy

a Clinic member also in private practice is more likely to refer in the same patterns

should always be a clinic chairman

The multi-disciplinary cancer clinic Case Review or Tumour Board 1

absent patient pre-evented history and clinical findings

presented by one member often involves radiology and or pathology

being presented and discussed case discussion care plan actioned next

clinic clinic may follow immediately or very soon

after to implement care plan


Lymphoma Case Meeting• haematologists• medical oncologists• radiation oncologists• radiologist• pathologist• laboratory scientists

• pathology

• haematology

• research nurse


Lung cancer meeting• respiratory physicians• thoracic surgeon• radiation oncologists• radiologist: diagnostic & interventional• pathologist (retired!!!)• medical oncologist * (if available)


Orthopaedic oncology meeting• orthopaedic surgeons• radiation oncologists• radiologist• pathologist

• sometimes the final pathological diagnosis depends on the radiology findings

• medical oncologist * (if available)


Breast clinic pathology meeting• breast surgeons• radiation oncologists• pathologist• medical oncologists

The multi-disciplinary cancer clinicNew Case Clinic 1

Case clerked in clinic• new cases• old cases with new problem

all patients reviewed by all relevant staff case presented by one member and

discussed at clinic meeting care plan actioned at clinic

patient seen immediately again by relevant staff

The multi-disciplinary cancer clinicNew Case Clinic 2

Head and Neck Clinic• ENT surgery• plastic surgery• dental - oral surgery• general surgery• radiation oncologists• medical oncologist• speech pathology• dietitian• social worker• research nurse

The multi-disciplinary cancer clinicDefined site clinic, no Rx 1

New patients seen by relevant staff case presented by one member to rest of

team care plan actioned at clinic old cases reviewed by relevant staff only new problems in old cases reviewed by

all clinic staff not a therapy clinic

The multi-disciplinary cancer clinicDefined site clinic, no Rx 2

Upper GI Clinic• upper GI surgeons• radiation oncologists• medical oncologists• research nurse• radiation nurse• data manager• dietitian

• need for tight programming

The multi-disciplinary cancer clinic Defined site clinic, with Rx 1

patients streamed and seen by relevant staff new case or new problem presented by one

member to rest of team care plan old cases reviewed by relevant staff

• follow up by surgical team and radiation oncology

• radiation planning time arranged• chemotherapy by medical oncology


Breast Clinic• breast surgeons• medical oncologists• radiation oncologists• research nurse• radiation nurse

• need for tight programming• pathology review of new cases at end of clinic


Colo-rectal Clinic & GI Adjuvant Clinic• colo-rectal surgeons• medical oncologists• radiation oncologists• research nurse• colo-rectal nurse • radiation nurse

• need for tight programming


Melanoma Clinic• melanoma surgeons• medical oncologists• radiation oncologists• dermatologist• research nurse


Germ Cell Clinic• medical oncologists• urology surgeon• radiation oncologist

The multi-disciplinary cancer clinichas it all been successful? 1

YES: largely driven by the surgeons coordination follow up research

germ cell: +++ +++ +++ colo-rectal: +++ +++ ++ head & neck +++ +++ ++ breast +++ +++ ++ upper GI +++ +++ +++ lymphoma +++ +++ +++ melanoma +++ +++ +++


Generally YES but

coordination follow up research

lung ++ ++ + orthopaedic ++ ++ +

these clinics represent some of the difficulties in setting up a MDC• personality• territory


NO lack of resources esp medical oncology for

multi-disciplinary clinics in• CNS evidence• prostate for• bladder improved• pancreas QoL• liver survival• lung cost

effectiveness

urgent need for funding: staff, drugs

The multi-disciplinary cancer clinicNCI Cancer Facts 1

“A diagnosis of cancer may be the most difficult challenge, you or your loved ones will ever face. That is why it is important to find help and try to maintain your sense of hope no matter what your situation. Your team of health care professionals is knowledgeable about the many different aspects of cancer: medical, physical, emotional, social, and spiritual.”

The multi-disciplinary cancer clinic NCI Cancer Facts 2

“They are available to you as much or as little as you need, but it is difficult for them to know if you need help unless you ask for it. Don't be afraid, embarrassed, or hesitant to ask questions; voice your opinion, and seek the care you feel you need and deserve.”

“Your Health Care Team: Your Doctor Is Only the Beginning”

The multi-disciplinary cancer clinic

a thank you to the many surgeons, radiation oncologists, medical oncologist, pathologists, radiologists, allied health professionals, nurses and resident staff whose continued dedication and hard work in the face of fiscal hardship is amazing and makes working at PAH worth while.