Clinicians agree that multi-disciplinary teams are the optimal approach to managing advanced melanoma, for they aim for consistent messaging to patients about treatment and require that physicians who are members of the team support their therapeutic choices with evidence. However, obstacles include geographical challenges in community care, treatment sequencing and bias, and physician communication.
A collaborative treatment approach for patients with advanced skin cancer is best achieved through the formation of multi-disciplinary teams (MDTs), according to experts. This approach provides patients with reassurance that numerous physicians have been involved with the development of the treatment plan.
Clinicians including a dermatologist, medical oncologist, and surgical oncologist discussed the challenges in delivering care through the MDT approach at the 9th annual Canadian melanoma conference.
Merrick Ross, M.D.When care is delivered in the community, as opposed to academic centers, there are more obstacles to developing a MDT care model, explained Merrick Ross, M.D., a surgical oncologist, chief, melanoma section and department of surgical oncology and the Charles McBride professor of surgical oncology at the University of Texas MD Anderson Cancer Center in Houston.
"A lot of melanoma treatment is not being delivered in academic centers," Dr. Ross says. "It is being delivered in the community, where it is more difficult to implement a multi-disciplinary approach. The offices (of various clinicians) are not necessarily located nearby, making it inconvenient (for physicians and for patients). Travelling for the patient to go see this person and that person may not be convenient."
Indeed, community care often means that clinicians work in separate silos, and are not in frequent communication with each other about patients, but multi-disciplinary care means various specialists need to speak with each other, Dr. Ross explains.
"This gives the patient more consistent messaging,” he says. “It is very satisfying and encouraging from the patient's point of view when various physicians are talking to each other, and there is a plan moving forward. An integrated approach to care gives patients a greater sense of security."
Clinicians may have a bias in the treatment that they offer based on their specialty, deciding to choose systemic therapy if their focus is medical; and surgery if they are surgeons, according to Dr. Ross. This bias may also affect the view of sequencing of modalities.
"Medical oncologists will offer systemic therapy, and the surgical oncologists will offer surgery," Dr. Ross says. "The better scenario is when the medical oncologists will consider surgery as an important component in an individual's care, and surgical oncologists will recognize the importance of systemic therapy."
Patient expectations are such that they are seeking experts on various skin cancers like advanced or recurrent melanoma, and that expertise typically resides at academic centers. Clearly, it is a challenge to form MDTs if health professionals are in short supply and resources will vary from region to region.
What multi-disciplinary care does is highlight where there may be under-representation of qualified cancer care expertise in various communities, Dr. Ross says, and technology solutions like videoconferencing, where experts can offer their opinions to remote, geographic locations, make up for that under-representation.
"Recommendations may be received through videoconferencing," Dr. Ross says, but liability has to be clear that the physician providing the recommendation is not the treating physician.
However, multi-disciplinary care is not always required for melanoma, notes Scott Ernst M.D., F.R.C.P.C., head, division of medical oncology, London Regional Cancer Program, London, Ontario, Canada.
Scott Ernst M.D."With early stage melanoma or early stage basal cell carcinoma, the dermatologists are perfectly capable of diagnosing those cases and managing those cases,” Dr. Ernst says. “But when the disease is at a more advanced stage, you need a team approach. There is little debate that multi-disciplinary care is what we should implement. The debate is around how to functionally pull it off in your own regional context."
To Dr. Ernst, multi-disciplinary care starts with a face-to-face meeting of specialists for several reasons, including the presentation and discussion of the case. Key members of the MDT include a dermatologist, medical oncologist, radiation oncologist and surgeons including a plastic surgeon, head and neck surgeon, surgical oncologist and sometimes a neurosurgeon if the melanoma has metastasized to the brain or spine. The face-to-face meeting provides an opportunity to review the pathology of the melanoma and to review the pertinent radiological findings.
"No members of the clinical team are experts in imaging, and our decisions are often based on the interpretation of the imaging, and radiologists are not frequently present at tumor boards," Dr. Ernst explains.
Minutes are taken at the face-to-face meeting, and a summary is produced that contains the recommendations of the group and is entered in the patient's chart, Dr. Ernst says.
"It is not binding to the treating physician because the treating physician may be aware of information that the tumor board was not," Dr. Ernst says. "It is the responsibility of the treating physician to explain the treatment plan to the patient and ensure the plan is followed."
Indeed, there is a general movement globally toward using MDTs in oncology settings. Previous research has concluded that the use of MDTs increases compliance to evidence-based guidelines and is an avenue for education for less experienced physicians.1
"There is an accountability that is created when you are doing this (multi-disciplinary care)," Dr. Ernst adds. "You may be called upon to provide evidence from the medical literature to support your opinion."
Multi-disciplinary care helps to avoid "outliers" from being able to practice in isolation, and everyone becomes accountable to each other for patient recommendations, said Dr. Ernst.
Members of the MDTs have the responsibility to stay current with any new therapeutic developments and to introduce this information, for it may alter a patient's treatment plan, Dr. Ernst says.
"In medical oncology, there are always new drugs, new clinical trials, and new indications," he says. "If there is an important development in the field, it behooves me to inform the group about what that is and the impact it might have for our treatment paradigm."
Despite the fact that MDTs are not a brand-new concept in care and have been implemented in many healthcare systems in the world, their existence has not addressed one of the most frequent patient concerns in cancer care, Dr. Ernst notes.
"Delays in referral are not infrequent," Dr. Ernst says. "For many reasons, it has taken a long time for the patient to be assessed by the MDT. Especially in cases of advanced disease, referrals should occur promptly."
It may not be geographical barriers which prevent timely referrals, but rather a communication barrier between physicians, he says. "They (patients) are not referred because physicians don't know who to refer them to," he adds.
Joël Claveau M.D.The dermatologist can have a significant position in the multi-disciplinary team, notes Joël Claveau M.D., dermato-oncologist, Melanoma and Skin Cancer Clinic, Hôtel-Dieu de Québec Hospital, Quebec City, Canada.
"It is about effective team work," Dr. Claveau says. "I think the dermatologist can play a key role in the multi-disciplinary team. The first role of the dermatologist is to diagnose skin cancers in collaboration with dermato-pathologists. I follow many high-risk patients, and I think an important role for dermatologists is to detect recurrences. I am also very involved in cases where there is care for metastatic disease."
Patients with metastatic disease need to be closely followed by dermatologists if they are being treated with BRAF inhibitors while patients who are receiving immunotherapy are not followed as frequently, Dr. Claveau explains.
Patients with metastatic disease can develop skin rashes, papillomas, calluses, squamous cell carcinomas, as well as secondary melanomas, he added, noting these complications can develop as a result of targeted therapies.
1Patkar V, Acosta D, Davidson T, et al. Cancer multidisciplinary team meetings: evidence, challenges, and the role of clinical decision support technology. Int J Breast Cancer. 2011;2011: 831605.