Multi-disciplinary Cancer Management the PAH Experience

1. Multi-disciplinary Cancer Managementthe PAH Experience Damien B Thomson Director of Oncology Princess Alexandra Hospital

2. 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

3. Cancer: why do we needmulti-disciplinary teamwork? 2 • 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

4. Cancer: why do we needmulti-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

5. 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

6. Cancer: why do we needmulti-disciplinary teamwork? 5 • the days of the single clinician working independently are numbered

7. The multi-disciplinary cancer clinicWhat 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

8. The multi-disciplinary cancer clinicWhat 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

9. 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

10. 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

11. 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

12. 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

13. The multi-disciplinary cancer clinicliterature 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 <10% & USA + European resection rate of >20%

14. The multi-disciplinary cancer clinicliterature 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

15. The multi-disciplinary cancer clinicliterature 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

16. 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

17. 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

18. 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

19. 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)

20. 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)

21. The multi-disciplinary cancer clinic Case Review or Tumour Board 5 • Breast clinic pathology meeting • breast surgeons • radiation oncologists • pathologist • medical oncologists

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. The multi-disciplinary cancer clinic Defined site clinic, with Rx 4 • Melanoma Clinic • melanoma surgeons • medical oncologists • radiation oncologists • dermatologist • research nurse

30. The multi-disciplinary cancer clinic Defined site clinic, with Rx 5 • Germ Cell Clinic • medical oncologists • urology surgeon • radiation oncologist

31. 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 +++ +++ +++

32. The multi-disciplinary cancer clinichas 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

33. The multi-disciplinary cancer clinichas 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

34. 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.”

35. 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”

36. 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.