Multidisciplinary care of cancer patients: a passing fad or here to stay?

Abstract

For most of the 20th century, treatment with curative intent for patients with most forms of cancer was undertaken primarily by surgeons, who understandably came to regard cancer treatment as their bailiwick. However, over the past two decades or so, that situation has changed in a major way with the introduction of effective non-surgical therapies for many cancer types. As a result, ‘multidisciplinary care’ has become a popular catchcry used by those involved in the care of cancer patients. This involves coordinated management by members of all relevant specialties (a multidisciplinary team) following evidence-based discussion of diagnostic and treatment options, and clinical trial eligibility. By way of example, for melanoma patients the specialties providing input may include not only surgeons – surgical oncologists, general surgeons, plastic and other subspecialty surgeons (e.g. neurosurgeons, thoracic surgeons) – but also medical oncologists, radiation oncologists, pathologists, dermatologists, diagnostic and interventional radiologists, nuclear medicine physicians, oncology nurses, clinical trial staff, physiotherapists, psychologists and palliative care physicians and nurses. Similar multidisciplinary teams are today involved in the care of patients with breast cancer, colorectal cancer, gastric cancer, pancreatic cancer, head and neck cancers, thyroid cancer, lung cancer and many other tumour types – all predominantly managed almost exclusively by surgeons in years gone by. For all forms of cancer, multidisciplinary input may be of value not only for patients with metastatic disease, but also for those with high risk primary tumours where adjuvant medical therapies and/or radiation therapy may be effective. The desirability of multidisciplinary care for patients with cancer gradually became apparent as the task of managing them grew ever more complex, with a sometimes overwhelming range of treatment options becoming available and a burgeoning evidence base. The natural assumption was that wider discussion and input would lead to better outcomes for patients, even though clinical trial evidence of the value of multidisciplinary care was lacking. We undertook a comprehensive search of the medical literature to identify studies that had measured outcomes for cancer patients who had been provided with multidisciplinary care. Thirteen studies were found, of which only six were randomized trials. Most of the studies were small, and had short follow-up. Trial outcomes included measurements of quality of life, physical function, depression, anxiety and patient satisfaction with care. While reports of treatment series included survival outcome data, the lack of comparators for these outcomes made it difficult to interpret the effect of multidisciplinary care on survival relative to standard care. Indeed, outcomes across the trials showed few differences between those receiving multidisciplinary care and standard care, although there was a tendency for small gains in quality of life and mental health in the former group. Overall, it must be concluded that the evidence for implementing multidisciplinary care in cancer patients is still sparse. Yet, despite this paucity of evidence, it is widely advocated for cancer patients. It has, for example, been implemented in most centres specializing in the care of patients with melanoma, and was recommended in recently updated evidence-based Australian Melanoma Clinical Practice Guidelines, even though it was supported by only a grade C level of evidence. It is interesting to consider why multidisciplinary care has become standard practice without an extensive evidence base for its introduction. Clearly, the differences in outcomes for patients discussed at formal multidisciplinary team meetings and those whose care is based on informal discussion between individual specialists managing patients with complex problems, which is the alternative, would be difficult to measure, given the immense variability in other treatment factors in these often complicated patients. Patient outcomes are not limited to survival and physical function but encompass many issues such as avoiding futile treatments, attending fewer unhelpful appointments, and perhaps minimizing confusion from varying messages given by different clinicians. While such outcomes undoubtedly improve quality of life, they are not well captured by standard measurement tools. Nevertheless, it seems highly likely that multidisciplinary care will result in benefits to patients, and highly unlikely that it will cause them harm, given the safeguard of review by many specialists. On this basis, when clinical management guidelines are developed, recommendations may be made even though the evidence supporting them is weak, because the benefits of a particular management strategy in that circumstance are clearly apparent. With the recent explosion of new medical, surgical and radiation treatment paradigms for patients with cancer, particularly new systemic therapies developed on the background of specific genomic profiles, it is unlikely that any single specialist can keep abreast of all these matters. Bringing together a group of clinicians and allied health professionals with a range of expertise and experience enables all in the multidisciplinary team to be better informed, and available clinical trial options discussed. Shared decisions about treatment recommendations, particularly when they relate to difficult issues such as when not to recommend invasive or toxic therapies and to simply refer for palliation, one perhaps more confidently raised with patients if they have already been discussed and debated by an expert group, rather than conducting the discussion in isolation. Although there have to date been no large, well-designed, randomized trials to measure the efficacy of multidisciplinary care in cancer patients, it is difficult to imagine that this process will not be