Principles of Multidisciplinary Management
INTRODUCTION
Successful treatment of gynecologic cancers depends heavily on the effectiveness of multidisciplinary collaboration. The increasing use of chemotherapy to treat gynecologic cancers and technologic advances in surgery and radiation therapy (RT) methods have increased the number and complexity of treatment options. In every phase of care—diagnosis and evaluation, treatment planning, treatment implementation, and surveillance—a team of providers must collaborate and communicate with each other, with the patient, and with the patient’s primary care providers to provide the highest quality of cancer care. To effectively discuss the pros and cons of various therapeutic options, providers must have specialized expertise in the management of gynecologic cancers and must also understand the basic principles governing each discipline’s interventions.
The first section of this chapter describes key components and characteristics of an effective multidisciplinary gynecologic oncology care team. Subsequent sections review general principles that influence the selection of single-modality and multiple-modality treatments and some of the specific surgical procedures and chemotherapies that are commonly used in combination with or as an alternative to RT. Specific applications of these principles are discussed in Chapters 10,11,12,13,14,15 and 16 and illustrated in the case studies accompanying those chapters.
THE MULTIDISCIPLINARY TEAM
Despite an increasing body of literature emphasizing the importance of teamwork and collaboration in the delivery of high-quality health care, very little research has focused on the specific characteristics of an effective multidisciplinary gynecologic oncology care team. However, there is ample evidence that poor teamwork and ineffective communication lead to treatment delays, errors, frustrated providers, and dissatisfied patients.1,2,3 There is also general agreement that the presence of a highly functioning multidisciplinary team improves the quality of care.
In general terms, a multidisciplinary team can be defined as “a group of people with various expertises, responsible for individual decisions, who hold a common purpose and meet together to communicate, share and consolidate knowledge from which plans are made.”4 The ways in which specialized expertise, communication and knowledge transfer, and collaborative planning are facilitated and applied to achieve the team’s common purpose influence the quality of decision making, treatment delivery, supportive care, and posttreatment management.
Members of the Team
The membership of an individual patient’s multidisciplinary gynecologic oncology care team depends on the specific diagnosis and phase of care.5 However, a care team is most effective if it is built around a group of key individuals with specialized expertise and defined roles and with established relationships and lines of communication. A truly collaborative environment can only flourish if the members of the team have confidence in each other’s knowledge and skills. Key members of the multidisciplinary gynecologic oncology care team include the following:
The surgeon. In North America, gynecologic oncologists are board-certified specialists who have 3 to 4 years of postresidency training specific to the surgical and chemotherapeutic management of gynecologic cancers. Gynecologic oncologists are typically at the hub of gynecologic cancer patient care and generally have close access to other subspecialists, including
dedicated gynecologic pathologists and diagnostic imagers. For this reason, biopsies and imaging studies obtained by a gynecologic oncologist are more likely to yield high-quality cancer-specific information than are studies obtained by a family physician or general gynecologist. Also, several studies have demonstrated that patients whose initial surgery is performed by a gynecologic oncologist are less likely to have inappropriate or failed procedures and tend to have better outcomes than patients whose initial surgery is performed by a nonspecialized surgeon.6,7
The radiation oncologist. Because fewer than 10% of new radiation oncology patients have gynecologic cancers, very few radiation oncologists can dedicate all or even most of their practice to the management of these cancers. There may be some point below which the number of gynecologic cases seen by a radiation oncologist is too small to provide an adequate base of experience, particularly experience with the more uncommon cancers and specialized techniques. When the frequency of gynecologic cases is low, radiation oncologists may also find it difficult to build relationships with other members of the multidisciplinary team. For this reason, it is recommended that radiation oncology practices identify one or two individuals who can commit significant effort to this subspecialty area. Whenever possible, complex cases should be referred to large centers with radiation oncologists who subspecialize in gynecologic cancer and are well integrated into multidisciplinary gynecologic oncology care teams.
The chemotherapy provider. Depending on the practice setting, chemotherapy may be prescribed and managed by a gynecologic oncologist or by a medical oncologist. Because gynecologic cancers are uncommon and because many patients with such cancers have chemotherapy given by a gynecologic oncologist, medical oncology practices may treat only very small numbers of gynecologic cancers. When chemotherapy is given by a medical oncologist, close collaboration between the radiation oncologist, gynecologic oncologist, and medical oncologist is particularly important to achieve appropriate coordination of combined-modality regimens.
The pathologist. The importance of expert pathology review of cancer specimens cannot be overemphasized. Critical prognostic information about surgical margin status, sites of lymph node involvement, and other tumor features can easily be lost if surgical specimens are handled incorrectly. Misdiagnosis and under- and overdiagnosis of histologic risk factors by inexpert pathologists have undoubtedly caused clinicians to give inappropriate treatments and to fail to give necessary treatments to patients with gynecologic cancers (Chapter 2).8
The diagnostic imager. Multidisciplinary decision making and radiation oncology practice are heavily dependent on accurate and complete diagnostic imaging interpretation. The use of optimized techniques can markedly improve the utility of gynecologic diagnostic imaging modalities (Chapter 4). Specialized understanding of the behaviors of gynecologic cancers and their treatment typically leads to diagnostic reports that are more accurate and informative.
The primary care provider. The importance of the primary care provider’s specialized expertise—namely, his or her knowledge of the patient and the patient’s precancer health care history—should not be underestimated. Communication between oncology and primary care providers is essential to provide continuity throughout the phases of cancer treatment and follow-up, to identify and manage comorbid conditions that may affect cancer treatment, and to coordinate supportive care.9
Nurses. Nurses play a vital role in patient care and communication within the multidisciplinary team. Radiation oncology nursing is becoming a well-recognized nursing subspecialty. Gynecologic radiation oncology nursing requires special skills, particularly related to the nursing of brachytherapy patients.
Social workers. Gynecologic cancer patients are frequently burdened by a host of social problems that can compromise the quality and continuity of their care. A skilled social worker who can facilitate access to social services and who understands the nature and imperatives of gynecologic cancer treatments can provide critical assistance to patients who are trying to complete complex treatments while juggling financial, family, and personal concerns. Early involvement of social services can reduce missed appointments and treatment delays, improving the quality of treatment and the quality of the patient’s experience.
Other consulting specialists. Gynecologic cancer treatments are complex, and patients often benefit from consultation with other specialized providers. Most patients benefit from consultation with a dietician. A pain management consultant can help to optimize pain control. Depending on the patient’s individual needs, interventional radiology, gastroenterology, urology, anesthesiology, audiology, and other consultants may be needed to optimize management (Chapter 7). Although these providers are not always part of the patient’s primary care team, it is helpful for the primary care team members to have well-established working relationships with consultants who understand the specific needs of patients with gynecologic cancers treated with radiation.
Ideally, all primary members of the multidisciplinary gynecologic oncology care team should have gynecologic cancer as a major focus of their practice. However, this may not always be possible. In the United States, patients are often treated in small, nonacademic private care centers by providers who have limited expertise in management of uncommon gynecologic cancers. Studies have shown that patients with rare, complex problems such as locally advanced cervical cancer are less likely to complete all the elements of treatment in a timely manner if they are treated in small, nonacademic centers.10,11
Many factors contribute to such disparities, but the risk of suboptimal care can be lessened if generalist providers understand their limits and those of other team members, are willing to seek specialized opinions to supplement their knowledge, and have a low threshold for referral of patients to providers with specialized skills. However, even specialists with the most advanced training in gynecologic cancer management can fail to provide optimal care if they lack a robust system for communication between members of the multidisciplinary team.
Many factors contribute to such disparities, but the risk of suboptimal care can be lessened if generalist providers understand their limits and those of other team members, are willing to seek specialized opinions to supplement their knowledge, and have a low threshold for referral of patients to providers with specialized skills. However, even specialists with the most advanced training in gynecologic cancer management can fail to provide optimal care if they lack a robust system for communication between members of the multidisciplinary team.
Communication among Team Members
The correlation between characteristics of the multidisciplinary team and patients’ survival or disease recurrence rates has never been studied directly. However, poor communication between providers and between providers and patients undoubtedly leads to diagnostic and scheduling errors that impair the process of care in ways that are known to affect outcomes. Providers who fail to share information and opinions or who deliver mixed messages erode trust and promote patients’ anxiety. In the context of gynecologic radiation oncology, consequences of poor communication include the following:
Failure of key providers to make appropriate referrals for RT
Delayed or protracted RT
Poor coordination of chemotherapy and RT resulting in missed or improperly scheduled treatments
Inaccurate radiation target delineation because of inaccurate or missing diagnostic information
Suboptimal management of tumor or treatment sequelae
Patients who are frustrated by unmet informational needs and inconsistent messages about the goals and expectations of treatment
The members of a robust multidisciplinary team communicate with each other frequently in a variety of ways. The methods and nature of the interactions may vary according to the practice setting but should be designed to enhance the team as a whole and to meet the specific needs of individual patients.
Communication that Enhances the Team as a Whole
A multidisciplinary team with an effective communication strategy will have mechanisms in place that enhance the overall multidisciplinary care environment by
Providing continuing education about the nature and needs of each member’s specialty and possible indications for various treatments
Enabling members to discuss treatment guidelines and implementation of new research findings
Providing a forum for discussion of adverse outcomes and quality improvement measures
Tumor boards are the classic forum for addressing these needs. These multidisciplinary meetings have been used and accepted as an established part of cancer management for decades.12 Among the American College of Surgeons requirements for accreditation of cancer programs is that the program must have a multidisciplinary cancer conference with prospective review of cases and discussion of management decisions. At their best, tumor boards serve a critical role, bringing members of the team face-to-face to address real diagnostic and therapeutic problems.
However, the degree to which tumor boards meet ongoing needs of the multidisciplinary gynecologic oncology care team depends on many factors, including the agenda of the meetings, expertise of the attendees, number of attendees, and frequency of the meetings. General tumor boards tend to be less effective than specialized tumor boards, particularly for patients with gynecologic cancers, who account for only a small proportion of the cancer patients seen in a hospital or network.12 Monthly or biweekly tumor boards are less useful than weekly meetings for planning the treatment of individual patients but can still serve an important function by bringing specialists and other members of the team face-toface to discuss shared management problems.
Communication that Enhances Individual Patient Care
A robust multidisciplinary gynecologic oncology care team will have in place solid lines of communication that enable team members to:
Develop coordinated, consensus-driven treatment plans for each patient
Share all clinical findings and test results
Provide all involved team members with frequent updates about the progress of patients’ ongoing treatments
Disseminate information about ongoing patient needs and concerns
Communicate with patients in a consistent and effective manner
Develop and implement a coordinated plan for long-term follow-up
The most effective communication probably occurs when team members are in the same location, which permits face-to-face discussion between multiple team members and the patient. This is particularly true for management of complex gynecologic oncology problems. Clinicians working together in multidisciplinary clinics can readily compare and achieve consensus about physical examination findings, discuss the patient’s proposed treatment plan in concert, and coordinate recommendations, thereby reducing the risk of delivering mixed messages.
A shared electronic medical record system also greatly facilitates communication of a patient’s past treatment history, test results, and clinical findings and the status of ongoing treatments.
When collocation of team members is not possible, the treatment plan must be developed and carried out using a virtual team strategy.5 In this situation, it is particularly important that the content of individual patient visits be documented in detail and shared with team members. If members of the team do not have open access to portions of a patient’s medical record, they must develop another reliable, rapid method of information sharing. Patient care that is delivered using a virtual team model depends heavily on the use of staff and clinic coordinators to ensure that paths of communication are open and effective. However, physicians are ultimately responsible for assuring that potential communication barriers do not prevent them from obtaining effective shared access to the patient’s medical information.
Nothing can replace direct communication between key providers. An ambiguous pathology report should always be clarified by direct communication with the pathologist and, if necessary, should be sent for review by an outside expert. Ambiguous or equivocal diagnostic imaging findings should always be clarified by email, telephone, or joint review of the images together with the diagnostic imager. Key physician providers should always communicate directly before the initial treatment plan is finalized and at major decision points in patients’ care.
External Factors Influencing Team Function
A variety of factors can all have major influences on the cohesiveness and effectiveness of multidisciplinary care, including demographic characteristics of the community, competition within the medical marketplace, reimbursement mechanisms and rates, and the quality of the information technology infrastructure. Radiation oncologists have a responsibility to advocate for systems and infrastructure that enhance multidisciplinary collaboration.
CHOOSING AND SEQUENCING LOCOREGIONAL TREATMENTS
The locoregional management of gynecologic cancers is discussed by disease site in Chapters 10,11,12,13,14 and 15. However, there are some general principles that guide decision making, particularly for lower genital tract and endometrial cancers. An understanding of these commonalities can help to put the management of individual cases in a broader context. Many factors, including the experience and skill set of individual team members, may influence decisions about the roles and application of surgery, RT, and chemotherapy. Close collaboration in an environment of mutual respect is essential to the treatment planning process.
Choosing between Surgery and RT for Initial Treatment
To determine whether the initial treatment should be surgical resection or RT, several questions should be considered once distant metastases have been ruled out:
Is there a high probability that treatment with surgery alone will be sufficient to cure the patient? If the answer is yes, and if the morbidity of the necessary operation is expected to be low, surgery is usually the preferred treatment. However, if there is a high likelihood that adjuvant treatment will be required, the risks and benefits of combined-modality treatment versus definitive RT should be weighed carefully through multidisciplinary discussion.
Can the primary tumor be resected with clear margins? If not, primary RT is usually preferred over surgery. There is little evidence that subtotal tumor “debulking” improves the ability to achieve local control with radiation or chemoradiation—the dose of radiation required to sterilize positive surgical margins (usually at least 60 Gy) is often similar to that required to treat unresected gross disease. Furthermore, an extensive operation in which tumor is peeled off adjacent bowel or bladder can compromise the local vascular supply, worsening the adverse effects of high-dose RT.
Would definitive surgical resection compromise critical organ function? The fact that the reproductive organs are adjacent to critical structures means that definitive surgical resection frequently cannot be achieved without removing or damaging critical organs. In most cases, definitive RT is preferred over ultraradical surgical procedures that sacrifice bowel or bladder function.
Could surgical resection compromise the ability to deliver an adequate dose of radiation to the target volume? Removal of the uterus or upper vagina limits brachytherapy options, often making it difficult to safely deliver high-dose RT to a site of residual disease at a resection margin.
Is the patient medically fit? If the risk of major postoperative morbidity or mortality is high, this risk may outweigh any potential advantages of initial surgery over primary RT.
What is the risk of major perioperative complications that could delay necessary postoperative RT? For reasons discussed below, delays of more than 6 weeks between surgery and RT may reduce the effectiveness of postoperative RT. This is an important consideration in the management of locally advanced vulvar cancer; extensive resections in this area are frequently complicated by wound separations and infections that delay adjuvant treatment; these may in turn increase the risk of recurrence and contribute to late scarring and fibrosis.
Although the above considerations are relevant to treatment planning for all gynecologic cancers, the anatomic relationships between the reproductive organs and adjacent structures mean that certain treatments are used more often than others to treat cancers at specific sites. Because the serosally covered uterine fundus is anatomically separated from adjacent structures, even very large cancers confined to the body of the uterus can usually be removed with hysterectomy, which is the standard initial treatment in most cases.
In contrast, because most of the vagina is within 5 mm of bladder, urethra, or rectum, most cancers that primarily or secondarily involve the vagina are treated with RT because definitive surgical resection of even very small cancers would usually require a partial or total exenteration. The optimal treatment for cervical and vulvar cancers depends on the location of the lesion and the likelihood that it can be completely resected without damaging critical structures.
In contrast, because most of the vagina is within 5 mm of bladder, urethra, or rectum, most cancers that primarily or secondarily involve the vagina are treated with RT because definitive surgical resection of even very small cancers would usually require a partial or total exenteration. The optimal treatment for cervical and vulvar cancers depends on the location of the lesion and the likelihood that it can be completely resected without damaging critical structures.
Types of Hysterectomy and Associated Complications
Most gynecologic cancers involve either the fundus or cervix of the uterus. Because the uterus is no longer critical once childbearing is complete, hysterectomy is the treatment of choice for many uterine and cervical cancers. Although a simple hysterectomy is sufficient for treatment of most endometrial and some very early cervical cancers, most cancers that involve the cervix are treated with more radical procedures that include resection of varying amounts of paracervical tissue. Technical variations in the procedures termed “radical hysterectomy” have led to several attempts to classify hysterectomies according to the extent of the paracervical resection (Table 3.1).13 More radical procedures are generally used in patients with locally advanced (stage IB2 or greater) cancers.
TABLE 3.1 Types of Hysterectomy | |||||||||||||||||||||||||||||
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The most common long-term complication of radical hysterectomy is bladder dysfunction (atony or incontinence) caused by partial disruption of the autonomic nerve supply to the bladder. Disruption of autonomic nerves can also cause chronic constipation. The severity of complications of hysterectomy is related to the radicality of the procedure, particularly the extent of the vaginal resection.14 For this reason, it is inappropriate to compare the incidence of major complications from surgical versus radiation treatment of cervical cancer unless the comparison groups have tumors of similar size, stage, and extent of vaginal involvement.
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