Interdisciplinary Breast Cancer Care: Declaring and Improving the Standard

The contemporary management of breast cancer is a complex endeavor that requires the involvement of multiple medical specialists.[ 1] In the traditional multidisciplinary model, patients are referred to individual specialists who may consult with each other at specific points in the management process. Often, however, each physician makes critical decisions in isolation.[2] With the availability of more precise diagnostic techniques and new therapeutic agents, breast cancer management has become increasingly specialized and multimodal (as when systemic neoadjuvant therapy in locally advanced breast cancer is followed by surgery and radiation).[3,4] Thus, effective breast cancer management now requires a truly collaborative team approach, characterized by ongoing communication and active information-sharing among the multiple disciplines involved. This article reviews the evolution of comprehensive, interdisciplinary breast cancer care and the development of the multidisciplinary team approach to care. Multidisciplinary Care Today According to Claudia Lee in a recent review for the American Society of Breast Disease Advisor, many women in the United States with breast cancer do receive multidisciplinary care; ie, they receive care from numerous physicians representing a range of multiple medical specialties.[5] Often, however, the physicians they see do not specialize in breast cancer diagnosis and treatment, but rather incorporate breast cancer care into broad and diverse practices. Although the women generally receive adequate breast care, the process is usually "fragmented, lengthy, and frightening, resulting in 'episodic' care laden with psychological morbidity."[5] The author further observes that when a woman diagnosed with breast cancer sees multiple physicians, she frequently hears multiple messages that may sound contradictory, leading her to question who is managing her care and whether any of her physicians actually talk to each other. Perhaps most distressing is that women with breast cancer usually feel that they must make life or death decisions based on little or no knowledge or information about their disease and its treatment.[5] Emergence of Comprehensive Breast Centers These observations reflect the flaws of a fragmented, specialized breast cancer care system. These issues and concerns were the principal drivers behind the development of comprehensive breast care programs that began nearly 25 years ago in Van Nuys, Calif, when Mel Silverstein, MD, established a freestanding comprehensive breast center.[6] Other programs designed to provide comprehensive breast cancer management soon followed, as specialists involved in the diagnosis, treatment, and rehabilitation of women with breast cancer began to organize themselves into multidisciplinary breast care teams.[7] The preferred approach to comprehensive breast care has been to create a comprehensive breast center "with walls." Generally, these comprehensive breast centers are housed at community-based hospitals/medical centers or university teaching hospitals. In this ideal model, most of the services a woman requires, from diagnosis and treatment to long-term follow-up are usually physically contained within one facility or in a designated area within a larger building. However, in some cases, the comprehensive program is housed within large institutions, and a separate building is not required.[7,8] Breast Centers 'Without Walls'
An alternative approach to comprehensive breast care is the "breast center without walls."[7] In this model, the many clinicians involved in breast care, including medical, surgical, and radiation oncologists, maintain separate practices in different locations. Although women do not receive their care in a single location or facility, a nurse coordinator typically schedules the visits.[9] Breast Care Team Members
The coordinated breast care teams and programs developed over the past 25 years share many common goals (Table 1).[2,5,8] The composition of breast care teams is also consistent (Table 2). Patients attending comprehensive breast centers receive care from a broad-based multidisciplinary team that includes surgeons, radiologists, pathologists, medical oncologists, radiation oncologists, plastic/ reconstructive surgeons, primary care physicians, gynecologists, nurses, social workers, patient advocates, genetic risk counselors, and research nurses. Staff at such centers generally also includes a program administrator, a dedicated breast imager, radiology technologists, and a care coordinator or "breast health specialist." This individual is typically a registered nurse who oversees the patient's progress through the diagnosis and treatment process and provides education, emotional support, and resources as needed.[6,9,10] Consensus Planning Conferences
At the heart of both breast center models is the establishment of consensus planning conferences that bring together team members on a regular basis to discuss individual patient cases and develop comprehensive treatment plans.[7,9-11] These (usually weekly) conferences allow physicians to share their expertise and offer patients the advantage of multiple opinions regarding their treatment options. Intensive focus on patient disease, history, and treatment offers a forum for alternatives to be discussed.[1,2,7,10] A prominent feature of the comprehensive care model and the consensus conference is that individual patients are presented and discussed multiple times-usually at the most significant points along the trajectory of their disease. This further distinguishes the interdisciplinary or multidisciplinary team approach from sequential delivery of care, in which specialists in imaging, pathology, surgical radiation, and medical oncology seldom, if ever, come together. The multidisciplinary conference is discussed at length later in this review. How Team Members Work and Interact As noted above, a wide range of specialties are represented on the comprehensive breast care team. Primary care physicians and obstetricians/gynecologists usually continue their traditional roles as overseers of preliminary breast cancer screening and provide referrals to the comprehensive breast center.[2] However, the roles of many team members have changed significantly over the past 2 decades as a result of new technology and therapeutic advances. The introduction of hormonereceptor assays and sentinel node biopsy, for example, expanded the roles of pathologists and radiologists in breast cancer management. Information about node involvement and disease metastases, hormone-receptor status, or HER2/neu expression now helps guide the management team in adjuvant decision-making and surgical options.[11,12]. As noted by Claudia Lee, a highly regarded breast center consultant and board member of the American Society of Breast Disease (ASBD), "the quality of the relationship between breast radiology and pathology has become paramount and must be nurtured, as it forms the bedrock to support prospective treatment planning." Identification by the breast radiologist of the image-detected breast cancer can be life-saving. Similarly, the meticulous handling of the breast specimen by the pathologist, with accurate reporting of tumor characteristics, measurements, and margins will greatly influence the treatment planning process. As Lee observes, "with an organized and effective breast program, the radiology/pathology correlation is mandatory, timely, and always resolved if discordant."[5] The interdisciplinary approach has also had an impact on the surgical management of breast cancer. It is clear that patients are best served when surgeons consult with other members of the team, including the medical and radiation oncologist if breast-conserving treatment is an option, and/or with plastic and reconstructive surgeons if reconstruction is planned.[2] It has been strongly recommended that for women requiring or choosing mastectomy, breast reconstruction must be considered with a plastic or reconstructive surgical consult prior to any surgery.[2] Medical oncology's involvement has been evolving and it now plays a critical role, often early in the treatment- planning process.[2] As noted, before the initiation of definitive surgical treatment, the medical oncologist should now have the opportunity to suggest neoadjuvant approaches and to advocate for the use of specific staging studies.[2] Other team members may include patient advocates, social workers, psychologists, physical therapists, and other allied health-care professionals, as they greatly aid in addressing the quality-of-life issues for women with breast cancer. Finally, a vital team member described as the "glue" that holds the team together, is the care coordinator or breast health specialist. The care coordinator's role ranges from scheduling patient consultations with specialists and support services to organizing and facilitating treatment planning conferences-both in actual centers and in "virtual" breast center settings.[9] The Multidisciplinary Breast Care Conference As noted earlier, the optimal management of women with breast cancer requires evaluation and treatment by specialists in multiple disciplines, as no single physician can be expected to excel in all aspects of care. These specialists can work together effectively only if their involvement with an individual patient's care is prospective, interactive, and ongoing.[ 2,11] Thus, the multidisciplinary consensus planning conference has become the means of achieving stateof- the-art comprehensive breast cancer care both in formal breast centers and in centers "without walls." The ultimate goal of this regularly scheduled meeting, attended by each member of the breast cancer team, is to obtain informed, current opinions from each of the experts in their respective fields regarding the development of the treatment plan, with options then offered to the patient.[11] This interactive and dynamic forum has become integral to the management of breast diseases in all comprehensive care programs, resulting in an increased level of communication between the participating health-care professionals and the patients they treat. Conference participants share the philosophy that dialog among breast imagers, pathologists, surgeons, medical oncologists, radiation oncologists, plastic and reconstructive surgeons, nurses, genetic counselors, and patient advocates can enhance the level of care provided to the patient.[11] One recent report from the University of Louisville comprehensive breast care center describes the synergy between experts that elevates the level of care and refines the prescribed treatment for most patients. In addition, the cases presented at the conference offer the team members "a broader exposure to breast cancer management that may exceed the experience found in any individual practice." This exposure allows for a dynamic and meaningful exchange of ideas among disciplines.[11] Thus, as noted by Lee, this synergistic collaboration among professionals "creates an end product that is more than the sum of the parts."[5] This author's ongoing communications with breast care teams across the country confirm the benefits of this collaborative, interdisciplinary approach. The high-quality discussions in the open forums such as those provided at the University of Louisville's multidisciplinary breast conferences result in state-of-the-art approaches to difficult cases. The conferences also provide an invaluable educational opportunity for students and residents of all disciplines, who quickly recognize the complexities of diagnosis and treatment.[11] Patient Benefits of the Interdisciplinary Approach Many articles in the literature describe the benefit patients receive from a multidisciplinary team approach to breast care.[2,12-16] Research by August et al, for example, found a high level of satisfaction on multiple parameters among women treated in comprehensive breast center settings.[ 2,13] Overall, patients believed that they received high-quality, convenient care. Their survey responses suggest that they spent sufficient time with clinicians and that they sensed their physicians were concerned with their personal situations. Especially important was the level of physician involvement and concern with their medical care. The patients did not perceive any compromise in the doctorpatient relationship or the "personal touch" resulting from the multidisciplinary style of care.[13] Other reports cite significant patient benefits derived from an integrated, multidisciplinary breast cancer evaluation, most notably the opportunity to receive second opinions leading to less invasive treatments. In a recent study by Chang et al, the evaluation of previously diagnosed patients by the multidisciplinary breast cancer team from the University of Pennsylvania led to a change in treatment recommendations in 43% of the women studied. Many of these women who received different treatment recommendations from the multidisciplinary team (41%) received breastconserving treatment instead of mastectomy as proposed originally by physicians outside the comprehensive breast center setting.[14] Thus, although specific outcomes studies have not yet been conducted, anecdotal reports suggest that interdisciplinary breast care may facilitate timelier treatment as well as less invasive surgery and better patient satisfaction. Throughout the published reports, women consistently praise the "one stop shopping convenience" provided by comprehensive, multidisciplinary team care.[2,12,17] Women also speak of the sense of coordination they perceive among people charged with their care and the decrease in previously experienced fragmentation. In addition, women consistently cite the decrease in anxiety that is engendered in part by the breast center team's efficiency in moving the process forward, the coordination (usually by a nurse who paves each step of the way), and the availability of support staff on site.[7] At the Oncology Breast Clinic of the Mayo Clinic, women consistently gave high marks to the comprehensive breast cancer care they received. For example, when women were asked to evaluate their overall experience at the clinic, 63% of those surveyed described it as "wonderful," "very positive," "excellent," "very good," "perfect," "very helpful," or" very beneficial." An additional 27% described their experience as "good" or "fine."[15] The areas reported most frequently as helpful included clarification of the clinical facts provided or having their questions answered, the time spent with them, the willingness of providers to listen, and the efficiency and teamwork of the physicians and nurses.[15] In another recent multidisciplinary breast cancer clinic study, investigators conducted retrospective chart reviews to assess treatment timeliness and used anonymous questionnaires to assess patient satisfaction.[16] Here again, the authors found that treatment in the multidisciplinary clinic increased patient satisfaction, in this case, by encouraging the involvement of friends and family and by helping patients make treatment decisions (P < .001). The time between diagnosis and initiation of treatment was also significantly decreased (42.2 vs 29.6 days, P < .0008; Figure 1).[16] Challenges to Providing Interdisciplinary Breast Care In spite of the many benefits to patients and clinicians, many challenges must be met to provide interdisciplinary care in clinical practice. Logistic Issues
Many of these challenges are logistic. Although most breast cancer professionals acknowledge that multidisciplinary teams function best in a dedicated center where patients can easily obtain care from different specialists and medical records can be easily shared, this is often not possible. As former ASBD president Debu Tripathy, MD, has observed, "given the fractured nature of medicine in the United States, true multimodality care is rarely given under one roof."[4] Although comprehensive breast centers may represent the ideal option for interdisciplinary care, technology now offers us new and creative ways to achieve our goals. For example, breast health coordinators can efficiently schedule and coordinate patient visits and arrange for and facilitate "virtual" team conferences that allow for the review of diagnostic imaging reports, pathology specimens, and the results of surgical procedures. Education
Other important issues that need to be addressed include education and the timely dissemination of relevant information to clinicians and patients. Tripathy believes that this can be especially challenging when crossing disciplines.[4] Medical oncologists, for example, tend to share information regarding the benefits and toxicities of chemotherapy, whereas exchanges on the technical aspects of sentinel node procedures after neoadjuvant therapy are more likely to occur among surgical oncologists. Nuances of imaging to guide further surgery after systemic therapy requires that radiologists and surgeons find common ground in interpretation.[4] Consensus treatment planning conferences can help to facilitate this information exchange and may help to determine a patient's comprehensive treatment plan. Facilitating Interdisciplinary Care To be successful, interdisciplinary care generally requires a broad base of action that includes community care providers, academic centers, managed care and governmental agencies, as well as patient advocates.[4] Logistic issues, particularly among private practice physicians, represent a major stumbling block to facilitation of the process-hence, the importance of the once-a-week conference that brings everyone together. Similarly, the challenges posed by differences in knowledge levels among private practice physicians can also be managed with multidisciplinary conferences that encourage evidence-based discussion and debate. Organizations That Support Interdisciplinary Care Organizations such as the ASBD, the National Cancer Institute, the American Society of Clinical Oncology, the American Cancer Society, the American College of Surgeons, the National Consortium of Breast Centers, and the Susan G. Komen Breast Cancer Foundation all promote interdisciplinary breast care and research. These organizations recognize that a collaborative, dynamic multidisciplinary team approach provides the cornerstone of excellence in breast care and management. Health-care professionals engaged in this approach share a common belief in the improved patient care that interdisciplinary collaboration provides and in the need for

• Forums for sharing current information on breast disease
• Timely, authoritative, and useful information made available to physicians and allied health-care professionals
• Training and professional development programs, and
• A national breast disease research agenda.