1. MULTI-DISCIPLINARY CANCER MANAGEMENT John B. Hamner, MD, FACS Assistant Professor Surgical Oncology Tulane University

2. 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

3. MULTIDISCIPLINARY CANCER CARE: WHO IS INVOLVED?  Surgery/Surgical subspecialties  Medical Oncology  Radiation Oncology  Diagnostic/interventional Radiology  GI  Dermatology  PT/OT  Dieticians/nutritionists  Nurse navigators

4. 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 neo- adjuvant therapy

5. 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

6. 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

7. 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

8. CANCER: WHY IS A MULTIDISCIPLINARY TEAM NEEDED?  The days of the single clinician working independently to treat cancer are gone

9. 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

10. MULTIDISCIPLINARY CANCER CLINICS  Multiple specialties working together  Surgical and surgical specialties  Medical oncology  radiationoncology  dental / oral surgery  pathology  Radiology diagnostic, interventional  Nursing (nurse navigators, research)  allied health  palliative care

11. MULTIDISCIPLINARY CANCER CLINICS  Development of clinical practice guidelines that are  evidence based  consensus approved  quality assured care  timely investigation and therapy  Better outcomes

12. 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

13. 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

14. 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

15. 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%

16. 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

17. 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.

18. 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?

19. 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

20. CASE 1  Does the patient need chemotherapy?  Yes  Multiple potential regimens  Adjuvant or neoadjuvant chemotherapy

21. CASE 1  Does the patient need radiation therapy?  Potentially  Lumpectomy- definitely  Total mastectomy- potentially based on final pathology (size of tumor, # of +nodes)

22. 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.

23. 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?

24. 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?

25. 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

26. 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?

27. CASE 3  Why is diagnostic radiology important in making this diagnosis?  HCC can be diagnosed by radiologic features on liver directed MRI or CT  What specialties may be involved in primary treatment of this HCC?  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