Few heads are better than one: adopting a multi-disciplinary approach to breast cancer is best for patient care

"People who work together will win, whether it be against complex football defences, or the problems of modern society." - Vince Lombardi

Invasive breast cancer is the one of the two largest causes of cancer death of South African women in our society today. Historically breast cancer has been the preserve of the general surgeon, where excision was the primary method of control. Over the past thirty years there has been increasing recognition that breast cancer is a systemic disease with a natural history of recurrence without adequate systemic control. This has occurred at the same time as a realisation of the importance of early diagnosis in the patient’s prognosis and a movement towards new technologies and therapies to address premalignant and in-situ lesions and high-risk patients.

Management of breast disease has increased in sophistication and complexity, resulting in a sub-speciality field of breast surgery, and the increasing involvement and specialisation of oncologists, radiologists and pathologists. It is because of this that there has been a worldwide movement in oncology to the use of multi-disciplinary teams and meetings, where patients can be discussed thoroughly and a cohesive comprehensive individualised treatment plan determined. As described by an Australian government commission : “through their combined understanding… , all members of the team liaise and co-operate together and with the patient to diagnose, treat and manage the condition… to the highest possible standard of care.”

Can these models be applied to South Africa?

South Africa provides a complex variety of care models for a woman suspected of breast cancer. She will commonly visit a family doctor or general practitioner and then, depending on her insurance status and situation, she will be referred to a general surgeon in private practice, or a public clinic or hospital. Alternatively she may be referred, or self-refer to a surgeon or oncologist with an interest in breast disease.

In these models, breast cancer treatment can become fragmented and uncoordinated; all too often dependant on the judgement of individuals clinicians who may or may not possess an up-to-date interest in current breast cancer care. Adjuvant therapy may be based on one opinion alone and there is little access to clinical trials or therapeutic innovations. Even in the setting of multiple specialist consultations, many individual opinions are offered rather than a consensus leading to a confused and concerned patient.

The aim of a multi-disciplinary meeting (MDM) is to provide a cohesive environment where individual cases can be evaluated by many of the specialities involved in breast cancer care, allowing the patient access to a full range of diagnostic and management approaches which may be overlooked by single or sequential consultations. Studies worldwide have found that patients managed in a multi-disciplinary fashion have increased quality of life and reduced healthcare costs. They are less likely to die of their disease and are more likely to have breast-conserving therapy and adjuvant therapies such as chemotherapy and radiation. In one US study, patients presented for second opinion to a multi-disciplinary team had a change in management in 43% towards international ‘best practice’ guidelines, in particular noting a move towards breast-conserving surgery rather than mastectomy in more than 40% of those patients.

Another similar study found review of radiology changed interpretation in 45% of patients most commonly resulting in additional lesions found . This resulted in additional cancer found in 7% of patients. There was a change of management due to pathology review in nearly 10%, and a further 32% had a change in management based in the interpretation and discussion of appropriate international guidelines . In our MDMs, the participation of medical oncologists involved in multicentre trials allows knowledge of therapies otherwise unavailable, particularly to public-sector patients. In breast care, as in football, we work better when we work together.

Is it worth it? What are the benefits of a MDM?

The benefits of multi-disciplinary care are not just confined to cancer management strategies. One MDM with all protagonists and specialities present allows for effective decision making with the joint decision more accurate than the sum of the individual opinions. All patients can be treated according to the same guidelines and standards regardless of entry point (public or private) or referring clinician. There is a reduction in the time to definitive treatment (22 versus 44 days in one study ) with a reduction in unnecessary or repeated investigations.

Patients like multi-disciplinary teams; it gives them the peace of mind and confidence that they are being treated by a panel of experts and not just one professional’s opinion, however trustworthy that may be . Patients managed with a multi-disciplinary approach report significantly higher satisfaction with their health, with their physician and with their nursing care . There is a reduced time to psychological and other support services too.

Another interesting and often ignored part of this approach is the benefit of communication and discussion between different specialities. This leads to an increased understanding and respect for the different roles with their advantages and limitations that each member of the team has. It increases the opportunity for follow-up of patients and prevents them ‘falling through the cracks’ of modern service provision, particularly with the essential involvement of the patient’s general practitioner as part of the team, a key member often overlooked.

Observing such meetings and discussion has significant value for junior doctors and doctors starting out in the speciality. It also provides valuable continuing professional development for all members, who may appreciate new research and technologies differently according to their speciality. Medico-legally there is also security and reassurance in a shared opinion of good practice.

One of the major challenges that face MDMs is the amount of time consumed in preparing for and taking part in them. Whilst they may be effective for the patient, in our time-constrained workplace they can eat into precious consultation or management time. It is particularly important to avoid time-wasting, particularly when involving specialities which may not be relevant for each case, such as reconstructive surgery or one individual’s general practitioner. Specialities such as medical oncology, radiology or pathology may be required to attend multiple MDMs if they do not specialise in breast alone, which may also be exceedingly time-consuming.

Who are the breast multi-disciplinary team?

So who should be present at an MDM? The simple answer is every speciality which is involved in breast cancer care. And not simply all breast cancer care, but each speciality involved in that particular individual woman’s (or man’s) breast cancer care. This obviously means the specialities which directly co-ordinate care, such as the specialist surgeon, the medical oncologist and the radiation oncologist. In addition there are many other fundamentally important specialities who contribute to the team: the reconstructive surgeons who work hand in glove with the oncology surgeons, and whose reconstructive approach may be altered by decisions such as radiation should be present; the interpretation of investigations and histology by the radiologists and pathologists involved may change the whole cancer management process; a psychologist informs on dimensions of the patients care which may otherwise be overlooked; and the family doctor, whether they are physically present or kept constantly informed, must be appreciated as an integral part of the team because once the patient’s active cancer treatment is at an end, it is the family doctor who will be the primary physician and it is important they have input into the patient’s care throughout the process. Many international guidelines suggest more than one doctor of each speciality, and we have found that having at least two doctors of most specialities adds an extra dimension of knowledge and expertise to our own meetings.

If specialists are working alone in private practice they may be physically isolated from colleagues making multi-disciplinary care difficult but all the more important . This can be combatted in the modern age with teleconferencing and specialised referral centres. It is important such centres are not viewed as ivory towers but easily accessible to all, whether family doctor, non-specialist hospital doctor or even patients.

Conclusions

A multi-disciplinary approach to breast cancer is one which provides patients with the optimal care centred on their own individualised breast cancer management strategy. It has been shown to have objective benefit for not only each patient , but for the healthcare professionals involved also . Breast cancer treatment in the 21st century can be a collaborative endeavour aimed at excellence in care for the disease and for the patient.

H Zorbas, B Barraclough, K Rainbird, at al (2003) Multidisciplinary care for women with early breast cancer in the Australian context: what does it mean? MJA 179: 528-531

H Zorbas, B Barraclough, K Rainbird, at al (2003)

H Zorbas, B Barraclough, K Rainbird, at al (2003) N Houssami, R Sainsbury (2006) Breast cancer: Multidisciplinary care and clinical outcomes Eur J Cancer 42: 1480-1491

J Chang, E Vines, H Bertsch et al (2001)The Impact of A Multidisciplinary Breast Cancer Center on Recommendations for Patient Management Cancer 91:1231–7.

E Newman, A Guest, M Helvie et al (2006) Changes in Surgical Management Resulting From Case Review at a Breast Cancer Multidisciplinary Tumor Board Cancer 107:2346–51 E Newman, A Guest, M Helvie et al (2006)

M Gabel, NE Hilton, SD Nathanson (1997) Multidisciplinary breast cancer clinics – Do they work. Cancer 79:2380–4. E Choya, A Chiua, P Butowb et al (2007) A pilot study to evaluate the impact of involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan Breast 16, 178–189

M Frost, R Arvizu, S Jayakumar (1999) A multidisciplinary healthcare delivery model for women with breast cancer: patient satisfaction and physical and psychosocial adjustment. Oncol Nurs Forum. Nov-Dec;26(10):1673-80

H Zorbas, B Barraclough, K Rainbird, at al (2003)

J Chang, E Vines, H Bertsch et al (2001)

EJ Macaskill, S Thrush, EM Walker, JM Dixon (2006) Surgeons’ views on multi-disciplinary breast meetings Eur J Cancer 42: 905-908