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Multidisciplinary Team Approach to the Management of Breast Cancer
Implementation of a Multidisciplinary Care Program
When setting up a multidisciplinary treatment program ( Fig. 2.1 ), several areas must be evaluated, which include selecting the needed personnel, their proximity to the primary treatment site(s), and their ability to attend meetings in-person or virtually. The types of meetings that can be arranged include multidisciplinary tumor boards (case presentations) and multidisciplinary clinic conferences (patient seen and examined by the team) also known as multidisciplinary care centers (MDCC). The difference includes whether there is only a discussion of the patient’s relevant history, physical examination, radiologic studies, and pathology versus the direct patient evaluation with the patient physically present to be examined by the team and participating in the treatment discussion. There are benefits and drawbacks of each approach. For tumor board presentations, clinicians may be present in one location, or may join remotely. The relevant history and findings can be shown to the group by radiology and pathology, and an agreement of the proper treatment pathway can be reached with one member of the team designated to convey the information to the patient and implement the treatment plan. The drawback is that the patient may need to make several visits to the clinicians, and therefore it may not be the most time-effective approach. Some recent studies have recommended patients receive their first course of therapy within 30 days of diagnosis. Delays in treatment implementation may lead to earlier recurrence or reduction in cure rate. In the MDCC model, the patient is seen and examined by the relevant members of the team (typically surgery, medical, radiation oncology, and plastic surgery (when needed), and a decision about treatment is reached and implemented by the chosen team member. Radiologists and pathologists with an interest in breast cancer may also be present or available upon request to review imaging and pathology and/or for surgical planning. Patients are also seen by a nurse navigator to assist in logistics of the treatment implementation, as well as referral to plastic and reconstructive surgeons, social workers, integrative and complementary medicine specialists, nutritionists, physical therapists, and genetic counseling as needed. Drawbacks of this approach include the potential for time inefficiency for the clinician who may need to wait for other members of the multidisciplinary team to complete their evaluations. Often a hybrid model can be effective where the patient’s case is presented to the larger group of clinicians, and a smaller, select group then gathers to meet and examine the patient and have a discussion with the patient regarding the proposed treatment pathway.
Program Components
Multidisciplinary breast cancer treatment teams include the following physician specialties: surgery (breast surgery, surgical oncology, and/or general surgery), plastic and reconstructive surgery, medical oncology, radiation oncology, breast radiology, and pathology. The following ancillary service representatives are recommended to assist the core multidisciplinary team: tumor registry, nurse navigation, research, and genetics. Other areas may be added at the discretion of the site, including complementary and integrative health, fertility specialists, physical and occupational therapy, nutrition, pastoral care, as well as trainees in medicine, nursing, and other allied health fields. For the initial evaluation of the patient, the three major disciplines—surgery, medical oncology, and radiation oncology—should be available to assess and examine the patient. Residents and fellows of the appropriate disciplines are encouraged to attend as well.
Value of Multidisciplinary Care
In a system with a well-defined treatment paradigm and well-defined pathways for care, the implementation of multidisciplinary care teams and pathways allows for the most accurate, up-to-date evidence-based and cost-effective care ( Fig. 2.1 ). Patients are seen by the key members of the treatment team, and treatment decisions are made in a collaborative format using the best evidence. Patients and their families can be part of the decision-making process and feel empowered by their inclusion. Multidisciplinary treatment teams provide a high level of patient and family satisfaction and allow patients to both participate and understand the scientific/medical basis for the treatment decisions. In this setting, patients are encouraged to participate in the shared decision-making process when options are presented. Patients can then be presented and evaluated again during times of treatment change, further allowing refinement and clarification of the individualized care plan.
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