Interdisciplinary Breast Cancer Care: Declaring and Improving the Standard
Interdisciplinary Breast Cancer Care: Declaring and Improving the Standard
to many human diseases are
emerging as effective, patient-
centered strategies in diverse areas
such as cancer, neurology, and
cardiovascular disease. However, they
require significant organizational and
financial resources. Dr. Rabinowitz articulates
the key benefits of multidisciplinary
care for breast cancer, including
team planning and coordination of care.
There is not much objective information
to definitively prove that "centerbased"
care leads to superior outcomes
in terms of recurrence or survival. The
data cited in this review include improvements
in measures of patient comfort
and satisfaction with care, which
are important from an emotional standpoint
and even make business sense.
This alone should motivate cancer care
providers to organize breast centers that
are designed appropriately given the
size of the population served and the
Spectrum of Possibilities
Dr. Rabinowitz provides a well thought-out spectrum of choices ranging from loosely organized "virtual centers" to comprehensive centers that include all major modalities, tumor board conferences, and the availability of highly specialized procedures and clinical trials, all administered in a coordinated fashion. This continuum of possibilities provides practical solutions to smaller communities while emphasizing the common denominators of joint decision-making, coordination of scheduling, and efficient sharing of medical information. A key feature is team planning, or at the very least, representatives of two or more specialties exchanging information to complement each other's expertise. A more pragmatic aspect of center-based care is the interdigitating and prioritizing of the numerous activities that typically occur over the course of breast cancer diagnosis and treatment. One specialist might make an extra effort to reconsider or review the data, or to squeeze a patient into his or her schedule early to address a timesensitive matter. This is much less likely to occur when a patient is seeing numerous physicians at separate sites with no regular forum for interaction. Below are a few typical examples of the potential benefits of team planning that will resonate with any reader of this editorial who regularly cares for breast cancer patients:
- The pathologist's availability to sit down with the surgeon to determine the nature of a positive margin in order to plan the approach for reexcision
- The surgeon's appreciation of the growth of a primary tumor during attempted neoadjuvant therapy and rapid scheduling for surgery
- Genetic counseling and testing that affects surgery and reconstruction choices in a time frame that allows a patient to minimize the total number of trips to the operating room
- A psychologist's identification and management of significant depression that threatens the very relationships that will support the patient through her illness
- A radiologist, surgeon, pathologist, and radiation oncologist conferring over lymphoscintigraphy, nodal pathology, planned surgery, and the ideal postoperative radiation field
Advances in technology will bring even more need for interdisciplinary communication, an area that was not covered in the Rabinowitz article. Novel and expensive procedures might seem to one specialty to be the better option, whereas it may create new dilemmas for another specialist. One example is the increasing use of positron-emission tomography (PET) scanning, which seems like an obvious improvement to radiologists and surgeons who would like to stage patients with more certainty. While PET or PET/computed tomography may ultimately be a more accurate method, it can create significant anxiety over indeterminate results. Given that early detection of recurrence by imaging or serum markers in asymptomatic individuals has not been shown to improve outcome and is not recommended in follow-up guidelines from the American Society of Clinical Oncology, the optimal integration of these technologies will require prospective trials (which are very difficult to conduct in this area). Hence, selectivity in applying PET imaging only when it will change decisions and outcomes is best reached by consensus among disciplines via regular interactions and case discussions. Cost Considerations
Interdisciplinary care does require more organization, physician time, and administrative effort. Unfortunately, this translates into higher costs in an era of diminishing reimbursements. Very large centers might be able to leverage economies of scale in some areas, but in most settings, there will need to be a commitment by a parent organization such as a hospital or university, or perhaps a philanthropic or government grant. In general, any form of support is difficult in perpetuity if a "business plan" cannot be formulated that will eventually have the entire enterprise running in the black. As Dr. Rabinowitz points out, numerous organizations and grant mechanisms are available for the development of center- based approaches. However, most practices cannot avail themselves of these resources; they receive very limited support from hospitals or the community. Antitrust laws prevent the direct transfer of funds from one specialist to another when dealing with the same population of patients unless there is total integration of the practice. Political and administrative barriers also must be overcome for specialists to share resources. The impetus and finances with which to develop and maintain a center remain elusive for most providers. The Van Nuys Experience
Dr. Rabinowitz cites a valiant effort by Melvin Silverstein and colleagues who founded the Van Nuys Breast Center, which integrated thorough radiologic and pathologic assessment with innovative surgical techniques, and thereby generated seminal literature on the management of ductal carcinoma in situ (DCIS), emphasizing the importance of wide surgical margins and accurate pathologic grading on minimizing local recurrence without irradiation.[ 2] The impact of surgical and pathologic expertise was evident by the disparate findings of randomized multicenter clinical trials in DCIS involving smaller community practices (and some larger university centers) that were unable to replicate these findings, essentially concluding that nearly all DCIS cases warrant irradiation following breast-conserving surgery. However, economic forces including lower reimbursement and less hospital support ultimately led to the closing of the Van Nuys Center. One might argue that the Van Nuys experience was retrospective and this accounted for the different results, but even the National Surgical Adjuvant Breast and Bowel Project (NSABP) investigators have pointed out that the Van Nuys approach was highly specialized and unlikely to be replicated in other settings. In others areas, enhanced performance such as higher rates of breast-conserving surgery and lower rates of false-negative breast biopsies have been observed when performed in higher volume and more specialized settings.[4,5] However, differences in the important end points of recurrence and survival have not been shown. Conclusions
Many studies are now being performed to assess center-based or specialized care delivery models, and it is possible that improvement in hard outcomes and the mechanisms by which these occur will be better understood in the future. Dr. Rabinowitz is to be commended for highlighting the basic underpinnings of multidisciplinary care and for pointing out the areas in which improvements can be currently documented. Most importantly, an array of options is discussed, rather than a single formula. Even small movements toward multimodality care can be implemented in most practices. Although we cannot say at this time that patients will live longer with this approach, it does appear to improve the communication of options, satisfaction with care, and quality of life of patients-and possibly of care providers as well.
2. Silverstein MJ, Lagios MD, Groshen S, et al: The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med 340:1455-1461, 1999.
3. Fisher B, Dignam J, Wolmark N, et al: Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: Findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol 16:441-452, 1998.
4. Chang JH, Vines E, Bertsch H, et al: The impact of a multidisciplinary breast cancer center on recommendations for patient management. The University of Pennsylvania experience. Cancer 19:1231-1237, 2001.
5. Smith-Bindman R, Chu PW, Miglioretti DL, et al: Comparison of screening mammography in the United States and the United Kingdom. JAMA 290:2129-2137, 2003.