Interdisciplinary Breast Cancer Care: Declaring and Improving the Standard

Multidisciplinary approachesto many human diseases areemerging as effective, patient-centered strategies in diverse areassuch as cancer, neurology, andcardiovascular disease. However, theyrequire significant organizational andfinancial resources. Dr. Rabinowitz articulatesthe key benefits of multidisciplinarycare for breast cancer, includingteam planning and coordination of care.There is not much objective informationto definitively prove that "centerbased"care leads to superior outcomesin terms of recurrence or survival. Thedata cited in this review include improvementsin measures of patient comfortand satisfaction with care, whichare important from an emotional standpointand even make business sense.This alone should motivate cancer careproviders to organize breast centers thatare designed appropriately given thesize of the population served and theresources available.Spectrum of Possibilities
Dr. Rabinowitz provides a wellthought-out spectrum of choices rangingfrom loosely organized "virtualcenters" to comprehensive centers thatinclude all major modalities, tumorboard conferences, and the availabilityof highly specialized proceduresand clinical trials, all administered ina coordinated fashion. This continuumof possibilities provides practicalsolutions to smaller communities whileemphasizing the common denominatorsof joint decision-making, coordinationof scheduling, and efficientsharing of medical information.A key feature is team planning, or atthe very least, representatives of two ormore specialties exchanging informationto complement each other's expertise.A more pragmatic aspect ofcenter-based care is the interdigitatingand prioritizing of the numerous activitiesthat typically occur over the courseof breast cancer diagnosis and treatment.One specialist might make anextra effort to reconsider or review thedata, or to squeeze a patient into his orher schedule early to address a timesensitivematter. This is much less likelyto occur when a patient is seeingnumerous physicians at separate siteswith no regular forum for interaction.Below are a few typical examples ofthe potential benefits of team planningthat will resonate with any reader ofthis editorial who regularly cares forbreast cancer patients:

• The pathologist's availability tosit down with the surgeon to determinethe nature of a positive margin in orderto plan the approach for reexcision
• The surgeon's appreciation ofthe growth of a primary tumor duringattempted neoadjuvant therapy andrapid scheduling for surgery
• Genetic counseling and testingthat affects surgery and reconstructionchoices in a time frame that allowsa patient to minimize the totalnumber of trips to the operating room
• A psychologist's identificationand management of significant depressionthat threatens the very relationshipsthat will support the patientthrough her illness
• A radiologist, surgeon, pathologist,and radiation oncologist conferringover lymphoscintigraphy, nodalpathology, planned surgery, and theideal postoperative radiation field

Effect of Technologic Advances

Advances in technology will bringeven more need for interdisciplinarycommunication, an area that was notcovered in the Rabinowitz article. Noveland expensive procedures might seemto one specialty to be the better option,whereas it may create new dilemmasfor another specialist. One example isthe increasing use of positron-emissiontomography (PET) scanning, whichseems like an obvious improvement toradiologists and surgeons who wouldlike to stage patients with more certainty.While PET or PET/computed tomographymay ultimately be a moreaccurate method, it can create significantanxiety over indeterminate results.Given that early detection of recurrenceby imaging or serum markersin asymptomatic individuals hasnot been shown to improve outcomeand is not recommended in follow-upguidelines from the American Societyof Clinical Oncology,[1] the optimalintegration of these technologieswill require prospective trials (whichare very difficult to conduct in thisarea). Hence, selectivity in applyingPET imaging only when it will changedecisions and outcomes is best reachedby consensus among disciplines via regularinteractions and case discussions.

Cost Considerations

Interdisciplinary care does requiremore organization, physician time,and administrative effort. Unfortunately,this translates into higher costsin an era of diminishing reimbursements.Very large centers might beable to leverage economies of scale insome areas, but in most settings, therewill need to be a commitment by aparent organization such as a hospitalor university, or perhaps a philanthropicor government grant. In general, anyform of support is difficult in perpetuityif a "business plan" cannot be formulatedthat will eventually have theentire enterprise running in the black.As Dr. Rabinowitz points out, numerousorganizations and grant mechanismsare available for the development of center-based approaches. However, mostpractices cannot avail themselves ofthese resources; they receive very limitedsupport from hospitals or the community.Antitrust laws prevent the directtransfer of funds from one specialist toanother when dealing with the same populationof patients unless there is totalintegration of the practice. Political andadministrative barriers also must beovercome for specialists to share resources.The impetus and finances withwhich to develop and maintain a centerremain elusive for most providers.

The Van Nuys Experience

Dr. Rabinowitz cites a valiant effortby Melvin Silverstein and colleagueswho founded the Van Nuys Breast Center,which integrated thorough radiologicand pathologic assessment withinnovative surgical techniques, andthereby generated seminal literature onthe management of ductal carcinomain situ (DCIS), emphasizing the importanceof wide surgical margins and accuratepathologic grading on minimizinglocal recurrence without irradiation.[2] The impact of surgical andpathologic expertise was evident by thedisparate findings of randomized multicenterclinical trials in DCIS involvingsmaller community practices (andsome larger university centers) that wereunable to replicate these findings, essentiallyconcluding that nearly allDCIS cases warrant irradiation followingbreast-conserving surgery.[3] However,economic forces including lowerreimbursement and less hospital supportultimately led to the closing of theVan Nuys Center.One might argue that the Van Nuysexperience was retrospective and thisaccounted for the different results, buteven the National Surgical AdjuvantBreast and Bowel Project (NSABP) investigatorshave pointed out that theVan Nuys approach was highly specializedand unlikely to be replicated inother settings. In others areas, enhancedperformance such as higher rates ofbreast-conserving surgery and lowerrates of false-negative breast biopsieshave been observed when performedin higher volume and more specializedsettings.[4,5] However, differences inthe important end points of recurrenceand survival have not been shown.

Conclusions

Many studies are now being performedto assess center-based or specializedcare delivery models, and it ispossible that improvement in hard outcomesand the mechanisms by whichthese occur will be better understood inthe future. Dr. Rabinowitz is to be commendedfor highlighting the basic underpinningsof multidisciplinary careand for pointing out the areas in whichimprovements can be currently documented.Most importantly, an array ofoptions is discussed, rather than a singleformula. Even small movementstoward multimodality care can be implementedin most practices. Althoughwe cannot say at this time that patientswill live longer with this approach, itdoes appear to improve the communicationof options, satisfaction with care,and quality of life of patients-and possiblyof care providers as well.

Disclosures:

The author has no significantfinancial interest or other relationshipwith the manufacturers of any products or providersof any service mentioned in this article.

References:

1.

Smith TJ, Davidson NE, Schapira DV, et al:American Society of Clinical Oncology 1998 updateof recommended breast cancer surveillanceguidelines. J Clin Oncol 17:1080-1082, 1999.

2.

Silverstein MJ, Lagios MD, Groshen S, etal: The influence of margin width on local controlof ductal carcinoma in situ of the breast. NEngl J Med 340:1455-1461, 1999.

3.

Fisher B, Dignam J, Wolmark N, et al:Lumpectomy and radiation therapy for the treatmentof intraductal breast cancer: Findings fromNational Surgical Adjuvant Breast and BowelProject B-17. J Clin Oncol 16:441-452, 1998.

4.

Chang JH, Vines E, Bertsch H, et al: Theimpact of a multidisciplinary breast cancer centeron recommendations for patient management.The University of Pennsylvania experience.Cancer 19:1231-1237, 2001.

5.

Smith-Bindman R, Chu PW, MigliorettiDL, et al: Comparison of screening mammographyin the United States and the United Kingdom.JAMA 290:2129-2137, 2003.