November 2017 Edition Vol.11, Issue 11

Experts Strategize Next-Generation Multidisciplinary Cancer Care

By Mark L. Fuerst

Strategies to overcoming challenges in multidisciplinary cancer care were discussed by a panel of experts at the Association of Community Cancer Centers (ACCC) 34th National Oncology Conference. One issue, in particular, how to facilitate multidisciplinary patient-centered care for patients with cancer, was a main driver of discussion.

“Oncology tends to lend itself to multidisciplinary care because of the complexity of treatment,” said ACCC president Mark Soberman, MD, Medical Director, Oncology Service Line at Frederick Regional Health System in Frederick, MD. “When a patient has a diagnosis of cancer, we need to organize care around the diagnosis. The driver is what’s best for the patient.”

A cancer patient may need multiple types of modalities based on diagnosis and stage, from surgery to chemotherapy to radiation. “At the first treatment planning consultation, we need everyone at the table to evaluate the patient. After that, we need coordination and communication during follow-up,” said Dr. Soberman.

Assembling a multidisciplinary team of physicians, nurses, social workers, physical therapists, pharmacists, and dietitians can be difficult. Janine Overcash, PhD, of The Ohio State University College of Nursing, who gave a presentation on a geriatric oncology program, noted that team development requires a great deal of negotiation with the administration for allocation of protected time. “Time must be dedicated to the team by each department and realistic discussions about the extent of the time and responsibilities required from each team member are important to create a foundation for the oncology clinic,” she said.

Dr. Soberman agreed and noted that integration of team members requires people who are committed. A navigator can help collaboration between physicians and the health system and provide a solid underpinning, he said.

There are multiple ways to open lines of communication, such as regular face-to-face multidisciplinary team meetings, which are ideal, but not always necessary. A tumor board also provides an option for team members to discuss patients individually. Technological advances, such as video conferences, may also offer benefits.

 

Neuro-oncology Multidisciplinary Care

The combined neuro-oncology program between St. Joseph Hospital in Orange, CA, and sister hospital St. Jude Medical Center in Fullerton, CA, uses high-resolution video during joint, monthly conferences. High-resolution video allows radiology and pathology slides to be presented with clarity.

Each research site has its own staff in attendance and each team is afforded equal opportunity to present its cases. “We alternate moderating the conference,” said Joy Nakhla, RN, Nurse Navigator for the Neuro-Oncology Program at St. Joseph Hospital. Case preparation is finalized when the case list is given to individual radiology and pathology departments, she said.

With the combined neuro-oncology program, the treatment of brain and nervous system cancers has increased by more than 50%, and attendance has doubled at neuro-oncology conferences, with 68 total patient cases presented in 2016, said Nakhla. “We have seamless patient access to specialized treatment and equipment. We have offered 8 high-grade glioma clinical treatment trials, with 50% of patients consenting. Remaining tumor and blood samples are donated to a biospecimen repository for research purposes,” she said.

Commenting on the combined neuro-oncology program, Dr. Soberman said: “Physicians went along willingly. With good coordination, specialists can work as a team and provide support of additional services. Over time, this is a win-win. When you develop a collaborative care model, more patients seek you out for care. If you provide high-value care, and do a better job, ultimately, you are rewarded.”

An MD Anderson Cancer Center multidisciplinary team is co-located at Dr. Soberman’s hospital, with shared office space on the same floor. In this community-based health system, a disease team meets weekly for a multidisciplinary clinic with a nurse navigator coordinating care and arranging other resources as needed, for example, bringing in a social worker or nutritionist to deal with specific patient issues, or additional specialists, whether it is an immuno-oncologist or an endocrinologist.

Dr. Soberman cited an example of how the navigator brought in a lung cancer patient who had an incidental nodule picked up on a computed tomography scan in the emergency department. The patient was referred to a thoracic surgeon who reviewed the scan. It appeared the patient had lymph node involvement, and the case was referred to the multidisciplinary team for consultation.

The multidisciplinary team — a medical oncologist, radiation oncologist, surgeon, financial advisor, and nurses — suggested the patient undergo additional staging, then chemotherapy and radiation. “The patient was restaged and then had surgery, with a navigator following up with the team throughout the treatment process,” said Dr. Soberman.

 

Cardio-Oncology Multidisciplinary Care

Dedicated comprehensive cardiovascular oncology care is located within some academic settings, such as the MD Anderson Cancer Center, Memorial Sloan Kettering Cancer Center, Vanderbilt-Ingram Cancer Center, University of Pennsylvania Abramson Cancer Center and Dana-Farber Cancer Institute. These programs have established the fundamentals for cardio-oncology programs, including the goals to impact cancer therapeutic-related cardiac dysfunction and improve quality outcomes and quality of life. However, the majority of cancer patients and survivors with heart issues are cared for within community-based cancer centers, said Laurie W. Fitzgerald, MSN, RN, of the University of Maryland Upper Chesapeake Health Kaufman Cancer Center.

Cardiotoxicities are a real issue in the care of the cancer patient, leading to short-term and long-term comorbidities, and impacting survival, said Fitzgerald. Cancer therapy may raise the risk of cardiovascular complications, including cardiac dysfunction, arrhythmias, valvular disease, accelerated atherosclerosis, and pericardial disease.

According to Fitzgerald, of the 14.5 million cancer survivors in U.S., about half of them die due to cancer, but one-third die from cardiovascular disease caused or exacerbated by cancer treatment. She suggested that a combination of earlier cancer diagnosis and increased use of traditional and new systemic treatments can decrease cancer-related mortality.

A cardio-oncology multidisciplinary team can provide an increase in coordination of services, communication, and collaboration between all team members involved with the care of the cancer patient. The development of the cardio-oncology program at Fitzgerald’s community cancer center, adapted from the Mayo Clinic’s recommendations and program, includes collaboration between the University’s Heart and Vascular Institute and the Kaufman Cancer Center.

The planning team includes oncologists, cardiologists, the executive director of the Kaufman Cancer Center, the director of the Heart and Vascular Institute, director of clinical oncology programs, a manager and office coordinator of infusion services, a clinical manager of cardiovascular ultrasound, and managers of physician practice.

“You need to open lines of communication between providers, including continuous program assessment and review,” said Fitzgerald. “Think outside-the-box. The focus of the program development is to provide cancer patients with the best possible therapy with the least amount of risk for cardiovascular toxicity or worsening cardiovascular health.”

Recently, the collaboration added an echocardiogram unit for the cancer center. “We can do an echocardiogram after chemotherapy infusion or prior to the next treatment. A cardiologist reads it in real-time. We work closely with the cardiologist for scheduling with our multidisciplinary staff,” she said.

Physician buy-in to the multidisciplinary team is a must. “Be diplomatic to get physicians on board. Find a way for physicians to see benefit to their patients, their practice and the group as a whole,” said Nakhla. “Recruit physician champions.”

 

HIV Oncology Multidisciplinary Care

It took one and half years of planning and testing to get an HIV oncology clinic operational at the Moffitt at Memorial Healthcare System in Pembroke Pines, FL. One of the challenges was to convince physicians that this type of clinic would work in one place, said Marco Ruiz, MD, MPH, Associate Member, Department of Malignant Hematology & Cellular Therapy at the South Florida hospital.

“One of our main issues was how to bill for providers and to prove it was worth it to bill separately. We showed the finances were feasible and it would be a productive clinic,” Dr. Ruiz.

Patient advocates identified areas of need for services, and discussions with HIV focus groups found patients wanted to have a multidisciplinary clinic. “An HIV specialist sees the patient first, and then brings in a hematologist. In weekly meetings, we discuss problems that patients present,” he said.

In six months, the clinic, called the Oncology T cell Clinic, has seen 1000 patients and plans to expand to 1300 patients with strong cancer center support. The clinic treats mostly malignant tumors, but will include patients with benign tumors as well now that is has established trust within the HIV community.

 

In Summary

Dr. Soberman pointed out that these forward-thinking programs represent thinking outside specialty silos as they organize care around patient needs. “This sparks reimagining care delivery, adding new roles, and collaborating with new partners to meet cancer patient needs,” he said.

Involvement in multidisciplinary cancer care can only benefit practicing oncologists. “The expertise that all disciplines can bring to the patient discussion enhances patient care practice, knowledge base, and collaboration,” said Nakhla.

Article Comments

Heather

quotes Thank you for this article. Working for a genetic counseling clinic for cancer patients and providers, we too agree with the idea of, “Oncology tends to lend itself to multidisciplinary care because of the complexity of treatment.” This also helps patients in receiving more personalized treatment plans. quotes

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