Multi-disciplinary Cancer Management
the PAH Experience
Damien B Thomson
Director of Oncology
Princess Alexandra Hospital
Cancer: why do we need
multi-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
Cancer: why do we need
multi-disciplinary teamwork? 2
some rôle reversal for specialties in
particular cancers
less common: SRC
now sometimes: C+R S C
SCRC
or: C S residual disease
Cancer: why do we need
multi-disciplinary teamwork? 3
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 need
multi-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
Cancer: why do we need
multi-disciplinary teamwork? 5
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
The multi-disciplinary cancer clinic:
is it useful? 2
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
The multi-disciplinary cancer clinic:
is it useful? 3
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 clinic
literature 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
The multi-disciplinary cancer clinic
literature review 2
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 20%
The multi-disciplinary cancer clinic
literature review 3
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
The multi-disciplinary cancer clinic
literature review 4
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
The multi-disciplinary cancer clinic
Case Review or Tumour Board 2
Lymphoma Case Meeting
• haematologists
• medical oncologists
• radiation oncologists
• radiologist
• pathologist
• laboratory scientists
• pathology
• haematology
• research nurse
The multi-disciplinary cancer clinic
Case Review or Tumour Board 3
Lung cancer meeting
• respiratory physicians
• thoracic surgeon
• radiation oncologists
• radiologist: diagnostic & interventional
• pathologist (retired!!!)
• medical oncologist * (if available)
The multi-disciplinary cancer clinic
Case Review or Tumour Board 4
Orthopaedic oncology meeting
• orthopaedic surgeons
• radiation oncologists
• radiologist
• pathologist
• sometimes the final pathological diagnosis depends
on the radiology findings
• medical oncologist * (if available)
The multi-disciplinary cancer clinic
Case Review or Tumour Board 5
Breast clinic pathology meeting
• breast surgeons
• radiation oncologists
• pathologist
• medical oncologists
The multi-disciplinary cancer clinic
New 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 clinic
New 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 clinic
Defined 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 clinic
Defined 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
The multi-disciplinary cancer clinic
Defined site clinic, with Rx 2
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
The multi-disciplinary cancer clinic
Defined site clinic, with Rx 3
Colo-rectal Clinic & GI Adjuvant Clinic
• colo-rectal surgeons
• medical oncologists
• radiation oncologists
• research nurse
• colo-rectal nurse
• radiation nurse
• need for tight programming
The multi-disciplinary cancer clinic
Defined site clinic, with Rx 4
Melanoma Clinic
• melanoma surgeons
• medical oncologists
• radiation oncologists
• dermatologist
• research nurse
The multi-disciplinary cancer clinic
Defined site clinic, with Rx 5
Germ Cell Clinic
• medical oncologists
• urology surgeon
• radiation oncologist
The multi-disciplinary cancer clinic
has 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 +++ +++ +++
The multi-disciplinary cancer clinic
has it all been successful? 2
Generally YES but
coordination follow up research
lung ++ ++ +
orthopaedic ++ ++ +
these clinics represent some of the
difficulties in setting up a MDC
• personality
• territory
The multi-disciplinary cancer clinic
has it all been successful? 3
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 clinic
NCI 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.