Herein, we report the 6-year update from the Johns Hopkins Pancreas Multidisciplinary Clinic (PMDC) and evaluate the impact of an MDC on the clinical care recommendations of patients with pancreatic cancer.
Shalini Moningi, BA, Amanda J. Walker, MD, Amar Srivastava, BS, Katherine Y. Fan, BS, Amy Hacker-Prietz, MS, PAC, Mary Hodgin, MS, RN, CMSRN, Daniel A. Laheru, MD, Ralph H. Hruban, MD, Lei Zheng, MD, Elliot K. Fishman, MD, Matthew J. Weiss, MD, Timothy M. Pawlik, MD, PhD, MPH, Christopher L. Wolfgang, MD, PhD, Joseph M. Herman, MD, MSc; Johns Hopkins Hospital
Background: Multidisciplinary clinics (MDCs) are increasingly prevalent in the management of cancer patients. This practice model has been shown to improve the accuracy of staging in breast, ovarian, and pancreatic cancers. Pancreatic cancer provides an ideal practice model for MDCs, because management recommendations require crossdisciplinary input, treatment is often multimodality, and initiating therapy in a timely manner is known to have a positive impact on clinical outcomes. Herein, we report the 6-year update from the Johns Hopkins Pancreas Multidisciplinary Clinic (PMDC) and evaluate the impact of an MDC on the clinical care recommendations of patients with pancreatic cancer.
Methods: The records of 1,040 consecutive patients evaluated by the weekly PMDC at our institution were prospectively collected from November 2006 to November 2012. Cross-sectional imaging, pathology, and medical history were evaluated by a panel of providers that included at least one medical oncologist, radiation oncologist, surgical oncologist, pathologist, diagnostic radiologist, palliative care specialist, and geneticist. Patient characteristics and changes in diagnosis and/or staging between the referring institution and the PMDC were recorded and compared.
Results: The patient population consisted of 513 females and 527 males. The median age at diagnosis was 64 years (range: 28–94 y). Seventy-three percent of patients had pancreatic adenocarcinoma, 6% had intraductal papillary mucinous neoplasms (IPMNs); 2% had cholangiocarcinomas; and the remainder (19.2%) had other tumor types, including neuroendocrine tumors, cystadenomas, and insulinomas.
Overall, 319 patients (30.7%) had a change in diagnosis based on imaging studies and/or review of histology that led to changes in treatment recommendations. Review of histological slides by pathologists specializing in the pancreas resulted in a change in the pathologic diagnosis for 66 patients (6.3%). The majority of changes were based on review of imaging submitted outside and imaging studies performed at Hopkins, including a 3D reconstructed pancreas protocol CT scan. Nineteen percent of patients were upstaged, and 8% were downstaged. Of those upstaged, the majority (115 patients, or 11% of the total population) were found to have previously unrecognized metastatic disease. A total of 32 patients (3%) who were referred with locally advanced pancreatic cancer were determined to have resectable disease after PMDC evaluation. Overall, 20% of patients underwent surgical resection after being seen in the PMDC, and 95.7% of these patients had margin-negative resections.
Seven patients initially diagnosed with a presumed locally advanced malignancy were found to have benign disease after evaluation at PMDC. For example, a patient referred for a presumed unresectable malignant mass in the tail of the pancreas was determined to have clinical and imaging findings consistent with pancreatitis.
Conclusion: The single-day multidisciplinary pancreatic cancer clinic provided a comprehensive and coordinated evaluation of patients that led to a change in therapeutic recommendations in approximately one-third of the patients evaluated. These results highlight the value of an MDC in the management of patients with pancreatic cancer.