Principles of Multidisciplinary Management



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.


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.


Sep 29, 2018 | Posted by in ONCOLOGY | Comments Off on Principles of Multidisciplinary Management
Premium Wordpress Themes by UFO Themes