46: Concepts on the Oncology Team
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Pediatric cancer is defined as a rare disease, representing less than 1 percent of all cancers diagnosed in the United States. Nevertheless, is a leading cause of death for children and adolescents.1 Over the past four decades, there has been a continuous, increase in the incidence of cancers occurring under the age of 15.2
The likelihood of surviving a diagnosis of childhood cancer depends on the country in which the child lives: in high-income countries, more than 80% of children with cancer are cured, but in many low-income countries less than 30% are cured.3 A high proportion of survivors of cancer, represents individuals at high risk of experiencing serious, disabling, and life-threatening acute, chronic, and late adverse effects of cancer and its therapy.4
Cancers that occur among those aged 0–17 reflect a heterogeneous group of diseases with unique biologic, genetic, and demographic features. Moreover, the classification and categorization of childhood cancers are continually evolving with the emergence of new knowledge relating to the molecular, pathologic, and prognostic characteristics of this diverse group of malignancies. Leukemias, lymphomas, and central nervous system cancers combined account for 70 percent of cancer cases in this age range.1
Multidisciplinary Care—What is Old is New Again
In order to effectively treat cancer in children, numerous different medical and healthcare professions are frequently required, risking poor communication and ineffective care coordination. These professionals involved in a patient's cancer care make up the oncology team, known as multidisciplinary team (MDT), defined as an integrated approach to health care in which medical and allied health care professionals jointly develop an individual treatment plan for each patient, taking into account all appropriate treatment options.
In cancer, the idea of a MDT is not new. In the past 50 years, tumor boards have existed in the United States. Yet, up until recently, enhancing patient care was less of a priority than education. A trend toward community-based cancer care in the United States throughout the 1980s sparked the creation of tumor boards, which facilitated information sharing among participating physicians and improved the standard of care.5
In many healthcare systems, multidisciplinary cancer care is still referred to as tumor boards, multidisciplinary cancer conferences, multidisciplinary case reviews, or multidisciplinary clinics. According to the population they serve, these MDTs and clinics generally focus on specific organs or tumors. These meetings are often held weekly at large hospitals; but, in smaller facilities, they may be held monthly or connected through videoconferencing to larger cancer centers for ongoing meetings.
Regular meetings have been endorsed as a means to achieve this, to ensure that all patients receive prompt diagnosis and treatment, that patient management is evidence-based, and that there is continuity of care. In Chile, a National Cancer Plan was published in 1988 and endorsed the multidisciplinary team model for the management of cancer patients.
MDT has been recognized as a crucial facilitator in the delivery of high-quality care and treatment for cancer patients. The focus of MDT meetings is on collaborative decision-making and treatment planning, where core team members from pertinent specialties attend the meetings to share their expertise and formulate group recommendations for patient management that are supported by the best available scientific evidence.
Studies in adult population has demonstrated that MDT choices improve adherence to evidence-based recommendations and lead to changes of cancer diagnosis and treatment regimens in new cancer cases.6 Furthermore, excellent patient satisfaction with the use of MDTs has been demonstrated.7
Evidence to Support the Role of Mdt
Although the evidence linking MDT approach to enhanced survival has not been clearly established, recent data seem to support the association between it and improved pediatric liver cancer survival in our country. Physicians in training have a great opportunity to discuss specific situations at meetings. Health-members communicate and share information, especially between hospital-based specialists and primary care doctors, to improve referral and ongoing care.
Medical oncologists, orthopedic oncologists, pediatric oncologists, head and neck surgeons, diagnostic and interventional radiologists, radiotherapists, pathologists, and nurses are typically the core components of the multidisciplinary cancer team.
Other members involved in the MDT are: 1. Palliative care physicians and nurses, currently referred to as supportive care team, their role is to prevent and treat symptoms and side effects of cancer and its treatment. 2. Oncology clinical pharmacist, experts in drug protocols, drug administration, dosage adjustment, interactions, and adverse effects. 3. Mental health professionals, such as psychiatrists, psychologists, and certified counselors. 4. Rehabilitation therapist, such as physical, occupational, speech, or recreational therapists. 5. Oncology social worker, connecting people with financial support resources and other practical resources. 6. Genetic counsellors a crucial component of modern cancer treatment planning, and family's cancer risk.
Depending on the tumor stream and the health service, the team's composition differs. In our country, the pediatric oncologist attends the conference with patient information and concerns. In US and European countries, this role relies in Nurse Practitioners or Physician assistants.
In accordance with the stage of cancer management, all healthcare professionals present their points of view, discussions are held, and recommendations are stated and documented in the patient's medical records. An appropriate member of the care team follows up on all recommendations with the patient's parents once the meeting is over.
When implementing MDT work, a number of significant obstacles could arise, including a lack of time, staff resources, and small caseloads. Issues with hierarchical structures and unequal involvement in decision-making should also be addressed. To prevent marginalization of team members and bad decision-making, effective meetings should be complemented by effective leadership. The team must come to an agreement of mutual respect for one other's beliefs, valuing different opinions and the encouragement of constructive discussion, representing the patient's views and psychological aspects of care.
Although the necessity of inter-professional contact is universally acknowledged, there are differing opinions regarding the relative benefits of formal multidisciplinary meetings vs unofficial gatherings of practitioners when the need arises.
There is scarce information in the literature about the impact in survival of MDT meetings, and although, they are already widely accepted as the norm in many healthcare systems, making unlikely to have randomized control studies about it, some clinicians have expressed concern about the negative effects these meetings may have on trainees who attend these meetings in a purely passive capacity.8 Concerns are also expressed over the patients' diminishing role in these meetings and the possibility that their preferences and viewpoints may not be completely represented, without giving patients the chance to fully consider all of their available options.
Role for Clinical Decision Support Systems
Is there a role for clinical decision support systems (CDSS) in pediatric oncology care? CDSS can be defined as ‘‘systems that are designed to be a direct aid to clinical decision-making in which the characteristics of an individual patient are matched to a computerized clinical knowledge base, and patient-specific assessments or recommendations are then presented to the clinician(s) and/or the patient for a decision’’.9
Electronic medical records (EMRs), could help cancer MDT with organizational and administrative issues like planning, data gathering, presentation, and uniform documentation of decisions. Yet, using a CDSS, supports patient-centered, evidence-based decision-making, assessing all patient data in real time, including comorbidities, and provide alerts, reminders, and management recommendations, producing patient-specific real time recommendations.10
It is important to emphasize that CDSS typically just recommend the best management plan, outlining the medical reasoning and pertinent supporting documents and research; the MDT members are, of course, ultimately responsible for making the decision.
Moreover, the CDSS allows health caregivers and student doctors to process cases, and they can compare their own conclusions to the suggestions and supporting data.
Also, a CDS system's patient-friendly module can give patients access to and explanations of clinical recommendations in the proper manner, assisting them in understanding the rationale behind therapies being recommended and enabling them make better-informed decisions.
As conclusion, cancer care has come a long way, from a one-medical doctor decision-making, to forums where interesting cases where presented, to MDT meetings for collaborative day-to-day management of cancer patients.
New research should be directed to investigate better methods to support these heavily loaded but key care planning meetings. An advanced decision-support-technology promise for a transparent operational system supporting the decision making of MDTs worldwide.11
- Steliarova-Foucher E, Colombet M, Ries LAG, Hesseling P, Moreno F, Shin HY. Stiller CA, editors. International incidence of childhood cancer. 2017; Iii (electronic version). DOI: 10.1002/ijc.2910420408.
- Accis. Brill’s New Pauly 1991; 9 (9): 159–1169. DOI: 10.1163/1574-9347_bnp_e101580.
- Siegel RL, Miller KD, Statistics JAC. Cancer Statistics, 2020. 2020; 70 (1): 7–30. DOI: 10.3322/caac.21590.
- Gibson TM, Mostoufi-Moab S, Stratton KL, Leisenring WM, Barnea D, Chow EJ, et al.. Temporal patterns in the risk of chronic health conditions in survivors of childhood cancer diagnosed. 1970; 9 (12): 590–1601.
- Gross GE. The Role of the Tumor Board In a Community Hospital. CA Cancer J Clin 1987; 37 (2): 88–92. DOI: 10.3322/canjclin.37.2.88.
- Coory M, Gkolia P, Yang IA. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer. 2008;60:14-21. . DOI: 10.1016/j.lungcan.2008.01.008.
- Vinod SK, Sighom MA, Delaney GP. Do multidisciplinary meetings follow guideline-based care? J Oncol Practice. 2010; 6: 76–281. DOI: 10.1200/jop.2010.000019.
- Sim PG, Greenes R, Haynes R, Kaplan B, Lehmann H. Clinical decision support systems for the practice of evidence-based medicine. J Am Med Inform Assoc, 8 (6) (2001. DOI: 10.1136/jamia.2001.0080527.
- Fox J, Patkar V, Chronakis I, Begent R. From practice guidelines to clinical decision support: closing the loop. Journal of the Royal Society of Medicine. 2009; 02 (11): 64–473.
- Sutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ Digit Med 2020; 3 (1). DOI: 10.1038/s41746-020-0221-y.
Ultima atualização: 2023-04-10 07:36