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Therese Mulvey, MD.

Nothing is easier than self deception. For what each man wishes, that he also believes to be true.¹

We all have been taught, and wish for, a multidisciplinary setting in which we can care for our complex cancer patient. Our model of multidisciplinary care seeks to fuse all of the relevant specialties into one comprehensive care plan from the initial treatment plan and throughout the patient's care. The objective of multidisciplinary care may be the patient's care plan, an educational objective, cost efficiency or a disease-specific outcome. Defining multidisciplinary care can be as elusive as the cure for cancer itself. The definition often used is "the means of achieving the best practice management of a specific cancer through the combined understanding of a team.... to cooperate together and with the patient to diagnose, treat and manage the condition."² But does this guarantee the best opportunity for quality care and improved survival?

In this issue of the Journal of Oncology Practice, Dillman and Chico seek to answer the question as to whether multidisciplinary care improves 5-year survival. Their investigation of the survival of patients before and after the development of a single-site community cancer center moves us closer to an answer. The authors compared tumor registry data from 1986 to 1991, before their cancer center opened, and data from 1992 to 1999, after the opening of their cancer center. They compared these two time periods to a benchmark of survival data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry program for the same time periods. This study provides some insight into the importance of multidisciplinary care but leaves many more lingering questions than answered.

Dillman and Chico demonstrated an improvement in 5-year survival for patients with local and regional disease from 1986-1999 to 1992-1999. However, the survival of patients with the three most common malignancies—breast, colon and lung cancer—did not improve over the two time periods for those patients with distant disease. Perhaps other measures such as time to tumor progression would have supported the premise that multidisciplinary care resulted in improved survival. For patients with local and regional disease, a marked improvement in the number of patients with earlier stage disease may have accounted for all of the improvement in survival seen between the two time periods. Patients at the cancer center demonstrated improved survival when compared to the SEER data for both time periods. Unfortunately, survival data are not available by stage in the two time periods as compared with the SEER data, making any meaningful conclusions about improvement in survival as a result of the introduction of multidisciplinary care difficult. A nagging question remains after reviewing the survival data; why did the survival for cervical cancer patients not change between the two time periods? Here is a disease for which multidisciplinary care became the standard in the second time period. If multidisciplinary care was integrated into the care of these patients, the survival should have increased for those patients with regional disease.³

Survival as an end point is most often the tool used to measure the efficacy of a cancer treatment. Because of the potential for referral bias, for "stage migration" over time, and other subtle bias, an alternate option could be a local community hospital with an American College of Surgeons–certified tumor registry. The fact that the authors looked closely at their data is to be applauded, but the conclusions of improved survival attributable solely to the introduction of multidisciplinary care is not supported by the data.

Multidisciplinary care models have been used in a variety of disease states. For dermatologic care, multidisciplinary care has been shown to be cost effective. This model allows for less duplication of services and a faster time to treatment.⁴ Patients with a variety of malignancies treated in a multidisciplinary clinic report a higher percentage of patient satisfaction because of attention to psychosocial needs.⁵ Patients attending a multidisciplinary clinic for amyotrophic lateral sclerosis (ALS) in Ireland have seen an improvement in survival over patients with ALS attending a general neurology clinic. However, the patients treated at the multidisciplinary clinic were younger, often with familial ALS and presented with an earlier stage of disease.⁶ Cancer care in a single-site multidisciplinary setting is cost effective and results in a higher number of patients receiving multimodality care. But does this improve survival stage for stage over care given in the community?

The authors make a cogent argument for the implementation of multidisciplinary conferences to improve communication between specialists. Physician time is more efficient when all parties are brought together and the overall care in a multidisciplinary setting is likely to be more cost efficient. Shared responsibility for the care of patients with complex medical problems improves physician satisfaction and can prevent burnout.⁷ Educational opportunities can be improved for all physicians involved in mutimodality care.

Quality of care, quality of life, and cost effectiveness are also useful measurements in determining optimal care. Multidisciplinary care should result in improved availability of all modalities of care, improved time to the initiation of treatment and improved patient involvement in decision making. Patients report that attention to the nonmedical decision aspects of their care improve their physician-patient interaction, particularly the attention to psychosocial issues. Other studies of multidisciplinary care, in a community setting, are needed to document these important aspects of patient care.

Does multidisciplinary care require a single site of care as Dillman and Chico suggest? This question poses the greatest problem for oncology specialists working in the community. Can participation in a multidisciplinary weekly tumor conference substitute for care in a clinic setting where all specialties are represented? Does the repetitive care for a single disease result in improved skill and translate into improved survival outcomes for patients. For surgeons this question has been asked and answered affirmatively.⁸ For cardiac care, centers of excellence have shown improvement in outcomes and 30-day mortality.⁹ We should expect the same for cancer care.

Dillman and Chico have asked a very important question but unfortunately a retrospective analysis of a single cancer center data compared to an uncontrolled registry cannot answer the question with a degree of certainty to recommend a change in practice patterns. Questions remain as to the best model for multidisciplinary care not only for survival but also patient satisfaction. The authors should be congratulated for asking a difficult question, one for which everyone seems to know the answer. Simply because we believe multidisciplinary care is better than single source of care does not make it so. Asking if the emperor is wearing clothes, while everyone says it is so, is the essence of truth and the heart of scientific investigation.

	Notes

 
Therese Mulvey, MD is a community oncologist practicing in Dorchester and Quincy, Massachusetts. She is president of the Massachusetts Society of Clinical Oncologists.

	References

Top References

 

1. Third Olynthiac. Olynthiacs, Phillippics, Minor Public Speeches (translation, JJ Vince). Demosthenes:; 1954, pp 53
2. National Breast Cancer Centre: Multidisciplinary Care in Australia: A National Demonstration Project in Breast Cancer. Sydney, Australia, National Breast Cancer Centre, 2003
3. Rose PG, Bundy BN, Watkins EB, et al: Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. New Engl J Med 340:1144-1153, 1999[Abstract/Free Full Text]
4. Fader DJ, Wise CG, Normolle DP, et al: The multidisciplinary melanoma clinic: A cost outcomes analysis of specialty care. J Am Acad Dermaltol 38:742-751, 1988
5. Walker MS, Ristvedt SL, Haughey BH: Patient care in multidisciplinay cancer clinics: Does attention to psychosocial needs predict patient satisfaction? Psychology 12:29-300, 2003
6. Traynor BJ, Alexander M, Corr B, et al: Effect of a multidisciplinary ALS clinic on ALS survival: A population based study 1996-2000. J Neurol Neurosurg Psychiatry 74:1258-1259, 2003[Abstract/Free Full Text]
7. Haward R, Amir Z, Borrill C, et al: Breast cancer teams: The impact of constitution, new cancer workload, and methods of operation on their effectiveness. Br J Cancer 89:15-22, 2003[CrossRef][Medline]
8. Birkenmeyer JD, Stukel TA, Siewers AE, et al: Surgeon volume and operative mortality in the United States. New Engl J Med 349:2117-2127, 2003[Abstract/Free Full Text]
9. Cram P, Rosenthal GE, Vaughan-Sarrazin MS: Cardiac revascularization in specialty and general hospitals. New Engl J Med 352:1454-1462, 2005[Abstract/Free Full Text]

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