Multidisciplinary Cancer Care: The Role of Interventional Oncology

Multidisciplinary care teams have been utilized throughout the world for many years to improve patient care and treatment planning by combining the expertise of multiple specialists. The US National Guideline Clearinghouse lists over 2,700 clinical practice guidelines and more than 25,000 new clinical trials are published each year. It is not only difficult for one person to absorb this amount of information, but it is potentially harmful to treat patients without the adequate amount of knowledge. For this reason, care teams have been created for cancer care as well as other aspects of medicine. Tumor boards generally consist of oncologists, surgeons, pathologists, diagnostic radiologists, interventional radiologists, and radiation oncologists. Each of these specialists adds knowledge from their specialty specific literature to come to a consensus management on a patient specific basis. Clearly, working as a part of a team to plan care on an individual basis should result in personalization of treatment and potentially improved outcomes. The interventional radiologist/oncologist plays a key role in this group now and will have a larger role in the future as molecular medicine continues to grow.

Personalized medicine in oncology care is a trend that requires an immense amount of knowledge about the cancers being treated that can only be attained by specialists in that particular subspecialty. A large number of genetic mutations are being identified for each cancer type that change the cancer’s susceptibility or response to current therapeutics. Examples include estrogen receptor or HER2-positive breast cancer, non-small cell lung cancer with epidermal growth factor activating mutations, colorectal cancer with KRAS mutations, and malignant gliomas with hypermethylation of the methyl guanine methyl transferase (MGMT) gene. This rapidly growing field of knowledge in tumor biology and patient pharmacokinetics will change the paradigms of treatment for individual cancer patients. It will be even more important going forward that physicians work together as part of teams to reconcile this growing fund of knowledge to offer the best and most effective treatment to their patients.

The American College of Surgeon’s Commission on Cancer Program accreditation requires all accredited cancer programs to have a multidisciplinary cancer conference that meets at least monthly and prospectively reviews cases and discusses management options.¹ Multidisciplinary care teams exert considerable impact on clinical care decisions and have shown an improved adherence to clinical practice guidelines.² With such a large role in the treatment paradigm, especially at large academic medical centers, it is extremely difficult to study the impact of teams on patient survival. However, it should be our goal to include expert review of radiology and pathology, consider comorbid medical conditions, and consider patient choice when making care decisions as a team.

At our institution, there are weekly multidisciplinary tumor boards specializing in hepatobiliary, colorectal, pancreatic, lung, and musculoskeletal malignancies that are attended by subspecialized interventional radiologists, oncologists, pathologists, surgeons, radiation oncologists, and diagnostic radiologists. All of the members of the care team are encouraged to submit patients for discussion in advance. The physician who submitted the case typically presents a brief history and course of treatment for each patient followed by a discussion of the patient’s imaging by the diagnostic radiologist. Following identification of findings, a plan of care is determined by the team directing the patient to the appropriate member of the team for that management. Interventional radiology leads the hepatobiliary conference at our institution, which emphasizes the important role that interventional radiology plays in the management of patients with liver malignancy. When patients are not a surgical candidate, locoregional therapies provided by the interventional oncologist has become the primary treatment paradigm for these patients. Other examples of how the interventional oncologist is an important member of the care team include the growing utility of ablation in patients with primary and metastatic lung malignancy as well as ablation of bone tumors for palliation of pain.

Patients who benefit most from multidisciplinary decision making are patients who do not have a clear option for treatment based on marginal indication for surgery, poor theoretical success of systemic therapies, and potential treatment with unproven therapeutic options. Locoregional therapy by interventional radiology frequently arises in these situations and it is important that interventional radiology be a part of this team to explain how interventional oncology techniques complement traditional medical, radiation, and surgical options. As cancer therapeutics continue to change, interventional radiology will be central in both the diagnostic and therapeutic aspects of targeted and personalized therapy.

References

1. Keating NL, Landrum MB, Lamont EB, Bozeman SR, Shulman LN, McNeil BJ. Tumor boards and the quality of cancer care. J Natl Cancer Inst. 2013;105(2):113-121.

2. Lamb BW, Brown KF, Nagpal K, Vincent C, Green JS, Sevdalis N. Quality of care management decisions by multidisciplinary cancer teams: a systematic review. Ann Surg Oncol. 2011;18(8):2116-2125.