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New paradigm in pancreatic cancer promotes coordinated patient care

New paradigm in pancreatic cancer promotes coordinated patient care

ABSTRACT: Experts agree that a multidisciplinary approach offers an unparalleled level of patient care, but differ on the best way to bring specialists together to treat a notoriously difficult disease.

Between YouTube and MySpace, it doesn’t take much to become an Internet sensation. But Randy Pausch, PhD, may have been one of the few Web stars who deserved the attention.


In 2006, Dr. Pausch, a computer science professor at Carnegie Mellon University in Pittsburgh, was diagnosed with pancreatic cancer. His 2007 “last lecture” focused on the achievement of his dreams, rather than his impending death, and was viewed by millions online. A book based on the talk leapt to the top of the bestseller list.


Before his death 2 months ago, Dr. Pausch lobbied for more funding for pancreatic research, a disease that has historically offered patients terrible odds: The 1-year survival rate for metastatic pancreatic cancer is only 26%, while the 5-year survival rate is 5%, according to the American Cancer Society. Even in localized disease, the 5-year survival rate is 20%. Rapid metastases and difficult surgical removal are two of the main reasons survival rates are so dismal.


When a disease is notoriously difficult to treat, consensus on how to manage these patients can be elusive. Two U.S. institutions believe the trick to coordinating and improving patient care lies in a multidisciplinary approach. While a marriage of multiple specialists sounds worthwhile, however, it may be as tricky to contend with as the pancreatic cancer itself. ONI spoke with experts on the pros and cons of establishing dedicated pancreatic cancer teams.


Coordinated care

Single-site, single-day multidisciplinary clinics for pancreatic cancer are uncommon. ProponentsLecture say these clinics offer significant benefits for patients, including easier access to care and improved staging and treatment.


A recent study by a team at Johns Hopkins Hospital in Baltimore demonstrated improved outcomes for pancreatic cancer patients seen in a dedicated clinic.


“With a multidisciplinary clinic and conference, the review of patient data is so much more comprehensive,” said study leader Joseph Herman, MD, assistant professor of radiation oncology at the hospital.


The pancreatic multidisciplinary clinic brought together medical and surgical oncologists, pathologists, radiologists, and radiation oncologists at the Sol Goldman Pancreatic Cancer Research Center to review the cases of 203 patients referred to Johns Hopkins from outside institutions.


The clinic reviewed routine blood work and 3D CT studies, as well as physical exam and patient history as provided by support services and other hospital staff. The group analysis prompted changes in staging of disease in 19% of patients and new treatment recommendations in 24%.


With the initiation of the clinic, patient enrollment into the National Familial Pancreas Tumor Registry increased from 49.2% to 77.8% over a 2-year period, according to the authors (Ann Surg Oncol 8:2081-2088, 2008).


Figure 1“Little things that are ordinarily missed were not missed because of the coordination of care by different specialists. It also provided reassurance for patients—they could be seen by different specialists in one trip, which helped ease their anxiety,” Dr. Herman said.


Finally, the clinic served as an educational tool for young physicians and improved communication among the different disciplines at the hospital, he added.


At St. Vincent’s Hospital in New York City, the Pancreas and Biliary Center was recently opened as a “one-stop shopping” resource center. Patients have access to specialists, diagnostic tests, and support services in one location, said Franklin Kasmin, MD, the center’s medical director for endoscopic ultrasound.


At the center, patients are seen for an initial evaluation by a hepatobiliary surgeon, specializing in pancreatic cancer, and a gastrointestinal biliary specialist. After biopsy, a clinical oncologist evaluates the patient on the same or next day. All cases are reviewed in regular multidisciplinary conferences.


“The therapy of pancreatic cancer is a race against time. Coordinated care helps us achieve rapid and appropriate treatment and also eases patients’ anxiety and fear,” Dr. Kasmin said. Because specialists are available in one space, diagnosis and plans for treatment take less time, and patient questions can be more easily and quickly answered, he said.


Ideal but inefficient


Setting up a dedicated pancreatic clinic requires significant financial investment, however, not to mention staff. Even for the most comprehensive cancer center, a niche clinic is a tall order.


“It is just not efficient for all our specialists to be at the same place at the same time in a multidisciplinary clinic,” said John Marshall, MD, director of gastrointestinal oncology at Georgetown University’s Lombardi Cancer Center in Washington, DC.


Patient throughput is one major obstacle: A single specialist can fit more patients into his or her day than can a multidisciplinary team, which may only see only five patients in half a day, Dr. Marshall said.



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