4-6 October 2017 -Buenos Aires, Argentina · Instituto de Oncología Ángel H. Roffo Buenos Aires, Argentina Declared no potential conflict of interest. Rationale, definitions and

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Rationale, definitions and benefits of working in a multidisciplinary team

4-6 October 2017 - Buenos Aires, Argentina

Disclosure

Marcos David Pereira

Medical and Radiation Oncologist

Head and Neck Cancer Unit

Instituto de Oncología Ángel H. Roffo

Buenos Aires, Argentina

Declared no potential conflict of interest

Rationale, definitions and benefits of working in a multidisciplinary

team

M. David PereiraInstituto de Oncología Ángel H Roffo

Universidad de Buenos Aires

Multidisciplinary teams in Head and Neck oncology

Why should we work in multidisciplinary teams?Why should we work in multidisciplinary teams?

Definitions of multidisciplinary teams in Head and Neck oncologyDefinitions of multidisciplinary teams in Head and Neck oncology

Working in multidisciplinary teamsWorking in multidisciplinary teams

How to success in multidisplinary teams integrationHow to success in multidisplinary teams integration

Why should we work in multidisciplinary teams?

Team working: Rationale

• Head and Neck Cancer requires multiple oncology specialists

Diagnosis

• Dentistry

• ENT

• H&N surgeons

• Stomatologists

• Radiologists

• Pathologists

Work up

• Radiologists

• H&N surgeons

• ENT

Treatment

• H&N surgeons

• ENT

• Rad Onc

• Med Onc

• Endocrinologists

• Dentistries

• Thorax surgeons

• Neurosurgeons

• Ophtalmologists

Social and medical support

• Speech therapists

• Nutrition specialist

• Psychiatrists

• Social workers

• Physiotherapists

• Palliative care specialists

Follow-up

• H&N surgeons

• ENT

• Radiologists

• Speech therapists

• Nutrition specialist

• Dentistry

• Stomatologists

COORDINATEDCOORDINATED

Head and Neck cancer treatment

Patient factorsPatient factors

Tumor factorsTumor factors

Medical team factors


Function factors

Function factors

Patient factors

• Age

• Performance status

• Tolerance

• Acceptation

• Work

• Lifestyle (alcohol / tobacco)

• Previous treatments

• Social and economic factors

Tumor factors

• Size (T stage)

• Site

• Localization (Sx accesibility)

• Bone proximity

• Bone or cartilage compromise

• Nodes (N stage)

• Pathology

• Previous treatments

Function factors

• Sight• Ear• Smell• Voice• Swallowing• Breath• Airway protection

≠≠≠≠

Function factors


• Skills and competences

• Surgeon• Radiation oncologist• Medical oncologist• Support services

• Teamwork capibilities• Tolerance• Confidence

Multidisciplinary teams: Potential Pros and Cons

Pros

• Less specialty bias

• High probability of evidence based decisions and clinical experience

• Improved quality

• More frequency of protocols formulation.

• Adequate outcomes evaluation

• Care continuity

Cons

• Time consuming

• Unpaid time in most of the systems

• Variable participation

• Diffuse responsibility limits

• Potential delay in decision-making

First choice treatment has a profoundimpact in long-term outcomes

Multidisciplinary decisions and changes in therapeutic approach

• UPenn:

– 41% changes in case interpretation when imagesevaluate in MTD.

– Treatment modifications in 98% of those cases

– 34% staging changes. Prognosis change in 95% ofthose patients.

– Tumour presence discarded in 2.5%

Loevner LA et al. AJNR Am J Neuroradiol 2002;23:1622–1626


• Australia

– 30% treatment changes

No

changes

Minor

changes

Major

changes

First specialist

Surgeon 72% 10% 18% p=0.15 (any change)p=0.05 (major changes)

Med/Rad Onc 58% 8% 34%

Bruner M et al. Head Neck 2015;37: 1046–50.


• Australia

– 30% treatment changes

Bruner M et al. Head Neck 2015;37: 1046–50.

No

changes

Minor

changes

Major

changes

First specialist

Surgeon 72% 10% 18% p=0.15 (any change)p=0.05 (major changes)

Med/Rad Onc 58% 8% 34%

Initialapproach

Surgery ±(Ch)RT

80% 10% 10%p= 0.001

(Ch)RT 71% 4% 25%


• Milan (Seccond consultation)

Bergamini C et al. Oral Oncol 2016;54:54–7

All patients

n (%)

Frequent

tumors

n (%)

Rare

histologies

n (%)

Staging 383 (49) 230 (46) 149 (52)

Change in diagnosis

21 (3) 5 (1) 17 (6)

Change in treatment

80 (10) 45 (9) 35 (12)

Multidisciplinary decisions and efficiency

• Australia

Kelly SL et al. Am J Otolaryngol 2013;34:57–60.

Indicator Pre MDT Post MDT p

Dental evaluation 22% 59% <0.0001

Nutritional evaluation 39% 57% 0.015

Time from surgery to Radiotherapy 61 días 48 días 0.009

Consideration of ChRT over RT in III/IV stages

16% 66% <0.0001

Consideration of ChRT in +ve margins orECE

16% 49% <0.0001

Writing TNM 53% 87% 0.001

Multidisciplinary decisions and survival impact

• MD Anderson Cancer Center: Impact according adherence to MDT decision

– Treatment congruent with MDT decision• Stage-adjusted OS HR 0.41 (0.21-0.80) p< 0.01

– Treatment adapted to NCCN guidelines• Stage-adjusted OS HR 0.56 (0.30-1.05) p=0.07

Lewis CM et al. Head Neck. 2016 Apr;38 Suppl 1:E1820-5

Most of the difference between MDT and NCCN recomendation were related ot chemo indications (Sub or over prescription)

• Taiwan: Survival impact

Cancer-specific survival Overall survival

78% vs 83% 5 years

64% vs 70% 5 years

Liao CT et al. Head Neck. 2016 Apr;38 Suppl 1:E1544-53


• Taiwan: Survival impact

2003: MDT start

Liao CT et al. Head Neck. 2016 Apr;38 Suppl 1:E1544-53


Taiwan, n=19513

HR 0.68 HR 0.74

HR 0.89

Wang Y-H et al. Oral Oncology 2012;48:803–810



1Lassig AA et al. Otolaryngol Head Neck Surg. 2012 Dec;147(6):1083-92

2Friedland PL et al. Br J Cancer 2011;104:1246-1248 3Patil RD et al. Laryngoscope, 2016;126:627–631

5 years OS: 33 vs 53%1

HR 0.69

5 years OS: 50 vs 61%3


Multidisciplinary team members

Minimal components

• Rad Onc

• H&N Surgery

• Med Onc

• Pathology

Central Core

• Rad Onc

• H&N Surgery

• Med Onc

• Pathology

• ENT• Speech therapy• Dentistry• Endocrinology• Nutrition• Radiology• H&N Nurse• Social work• Reconstructive surgery

Extended group

• Rad Onc

• H&N Surgery

• Med Onc

• Pathology

• ENT

• Speech therapy

• Dentistry

• Endocrinology

• Nutrition

• Radiology

• H&N Nurse

• Social work

• Reconstructivesurgery

• Epidemiology

• Stomatology

• Neurosurgery

• Ophtalmology

• Paliative care

• Psychiatry

• Thorax surgery

• Physiotherapy

• Dermatology

Evaluation and treatment process

Tumor commiteeTumor commiteeConsensual

decisionConsensual

decision

Evidence or protocol treatment

definition

Evidence or protocol treatment

definition

• Participation of ALL involved specialists• Decisions include treatment sequence and time intervals

Evaluation and treatment process

Treatments should be evidence-basedTreatments should be evidence-based

High quality treatment is a must: Identify limitations!High quality treatment is a must: Identify limitations!

High clinical experience is required for high quality treatmentsHigh clinical experience is required for high quality treatments

Avoid unnecesary delays in te diagnosis process and treatment startAvoid unnecesary delays in te diagnosis process and treatment start

Multidisciplinary treatment must be based in multidisciplinay decisionMultidisciplinary treatment must be based in multidisciplinay decision

Take care of psychosocial aspects and patient-doctor relationshipTake care of psychosocial aspects and patient-doctor relationship

How to success in multidisplinaryteams integration

How to success in multidisplinaryteams integration

RespectRespect

Expertise and EducationExpertise and Education

FlexibilityFlexibility

Roles and responsabilityRoles and responsability

ConfidenceConfidence

Head and Neck Unit at Instituto Roffo

• Rad Onc• H&N Surgery• Med Onc• ENT• Speech therapy• Dentistry• Stomatology• Endocrinology• Epidemiology• Pathology• Physiotherapy

• H&N Nurse• Skin Surgery• Thorax Surgery• Neurosurgery• Ophtalmology• Psychiatry• Vascular Surgery• Skullbase Surgery• Palliative care• Nutrition• Sarcoma-melanoma

Oncology Unit• Dermatology• Social work


• Rad Onc– M David Pereira

• H&N Surgery– Roque Adan– Lucia Adamo– Barbara Berenstein– Emiliano Garayalde– Mauricio Jacianski– Ismael Tayagüi

• Med Onc– Raúl Giglio– Juan Manuel Carrera– Celeste Diaz– Martín Paskevicius

• ENT– Gonzalo Zeballos

• Speech Therapy– Gabriela Brotzman– Mariné Valverde

• Thorax Surgery– Luis Thompson

• Neurosurgery– Alejandro Mazzon

• Ophtalmology– Martín Devoto

• Psychiatry– Mercedes Califano– Romina Infantino

• Vascular Surgery (external)• Skullbase Surgery

– Stuart Ross (externo)

• Palliative Care– Alvaro Sauri

• Nutrition– Viviana Candlish

• Sarcoma – Mealnoma Oncology Unit– Gabriela Cinat

• Dermatology– Roxana del Aguila– Romina Cozzani

• Social Work– Elsa Ramazzoti

• Dentistry– Marcela

Valsangiacomo– María Ester Venditi

• Stomatology– Patricia Masquijo

• Endocrinology– Ines Califano

• Epidemiology– Marta Vilensky

• Pathology– Mario Rivero

• Physiotherapy– Mirtha Kwiatkowski– Marcelo Bussalino

• H&N Nurse– Arcilia Godoy

• Skin Surgery– Abel Gonzalez


• Tuesday: – Pre-Surgical Committee

• Thursday:– Post-Op Committee

– Journal Club

– Morbimortality Committee

– Case-problems and review

• Friday: – Second opinion and initial patient evaluation

Dentistry

Endocrinology

ENT

Speech Therapy

Pathology

Radiology

Stomatology

Administration

Epidemiology

Med Onc

H&N Surgery

Rad Onc

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4-6 October 2017 -Buenos Aires, Argentina · Instituto de Oncología Ángel H. Roffo Buenos Aires, Argentina Declared no potential conflict of interest. Rationale, definitions and