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PubMed2004

Access to multidisciplinary cancer care: is it linked to the use of breast-conserving surgery with radiation for early-stage breast carcinoma?

BACKGROUND: Breast-conserving surgery (BCS) with radiation (BCSR) requires a multidisciplinary care approach between surgeons and radiation oncologists. METHODS: This retrospective cohort study examined the use of preoperative radiation oncology consultation and whether use of or distance to this care was associated with treatment choice among 1188 women age > or = 65 years who were diagnosed with local or regional breast carcinoma in Washington State in 1994 and 1995. Study outcomes included rates of BCSR; BCS alone; and mastectomy; and radiation therapy among women who underwent BCS. RESULTS: Only 29% of patients in the current study consulted with a radiation oncologist preoperatively, and less than half of the patients (46.6%) consulted with either a medical oncologist or a radiation oncologist. Among women who underwent either BCSR or mastectomy, the odds of undergoing BCSR among women who had a preoperative radiation oncology consultation were 6.7 times the odds of women who did not have the consultation (P < or = 0.001). Similarly, the odds of receiving radiation therapy among women who underwent BCS and had a preoperative radiation oncology consultation were 5 times the odds of women who did not have the consultation (P < 0.001). The 3.4% of women who lived > 50 miles from the radiation therapy center had the lowest BCSR rate (15.8%) and had the lowest radiation therapy rate among women who underwent BCS (54.5%), although these findings were not statistically significant in adjusted analyses. CONCLUSIONS: A preoperative visit with a radiation oncologist was associated strongly with BCSR use. More should be done to evaluate the role of multidisciplinary consultation in the decision to use BCSR.

Aged↗

PubMed2004

Establishing the multidisciplinary care of patients with cancer in the state of Delaware.

Delaware has the fifth highest cancer death rate in the U.S. As part of a comprehensive program to decrease the cancer mortality and incidence in the state, an infrastructure to establish the multidisciplinary care of patients with cancer was established. In May 2002, Christiana Care Health Services opened the Helen F. Graham Cancer Center to meet the specific need for coordinated and centralized comprehensive cancer care. This effort took the cooperation of many individuals in a community-based teaching hospital, the largest of six acute care hospitals in the state. These efforts have led to a 13% accrual rate to the Community Clinical Oncology Program funded by the National Cancer Institute. The effort also led to the establishment of multidisciplinary disease site centers with representation from the three major physician disciplines of surgery, medical oncology, and radiation oncology. In addition, translational research projects, a tissue procurement center, and genetic counseling and testing with the establishment of a high-risk family cancer registry and collaborative efforts with hospitals across the state were established. The current article reviewed the continued success of this program in the state of Delaware in the effort to reduce the cancer incidence and mortality.

Cancer Care Facilities↗

PubMed2007

Economic aspects of diabetic foot care in a multidisciplinary setting: a review.

BACKGROUND: To evaluate the economic aspects of diabetic foot care in a multidisciplinary setting. METHOD: A review of the English language literature, published from 1966 to November 2005. RESULTS: The results of available studies on the cost-of-illness of diabetic foot problems are difficult to compare. Nevertheless trends concerning excess of costs, protraction in time of costs, positive correlation to severity of ulcer and/or peripheral vascular disease, contribution of in-hospital stay and length of stay, and the patient's own contribution to total costs, are obvious. Only a few cost-effectiveness and cost-utility studies are available. Most use a Markov based model to predict outcome and show an acceptable result on long-term. CONCLUSIONS: Diabetic foot problems are frequent and are associated with high costs. A multidisciplinary approach to diabetic foot problems has proved to be cost saving with regard to cost of treatment itself. Nevertheless, it remained unclear if these savings could offset the overall costs involved in implementing this kind of approach. The few studies that address this issue specifically all show an acceptable cost-effectiveness, but often the profit will be evident after some years only, because long-term costs are involved. Based on these data, policymakers should foresee sufficient reimbursement for preventive and early curative measures, and not only for 'salvage manoeuvres'.

Cost of Illness↗

PubMed2007

GP concordance with advice for treatment following a multidisciplinary psychogeriatric assessment.

OBJECTIVE: To evaluate the concordance of General Practitioners (GPs) with advice for treatment after a multidisciplinary psychogeriatric assessment by the Diagnostic Observation Centre for PsychoGeriatric patients (DOC-PG). METHOD: Concordance checklists, listing the recommendations from the multidisciplinary team, were sent to the GPs in order to establish GP concordance. Regression models were used to study the associations between various patient and GP characteristics and level of concordance. Furthermore, results of a questionnaire (to identify the level of satisfaction regarding the services provided by the DOC-PG) were compared with the level of GP concordance. RESULTS: Based on 530 recommendations, the overall GP concordance rate amounted to 71%. The most common types of advice pertained to medication, GP follow-up/advice and referral. GP concordance with advice regarding admissions was the highest, followed by advice concerning the arrangement of daycare, home care and the adaptation of medication. GP concordance was lowest for referral recommendations to other specialties and recommendations regarding psychoeducation. Concordance was higher for patients who lived alone, for patients with fewer cognitive problems, when the number of recommendations did not exceed six and in group practices. Concordance was dependent on the type of advice. Satisfaction with DOC-PG did not correlate with the level of concordance. CONCLUSIONS: In general, GPs showed a high level of concordance with advice from the DOC-PG. Enhancement of GP concordance can be achieved by limiting the number of recommendations, giving detailed explanations about the purpose of recommendations and educating GPs by doing.

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PubMed2005

Multidisciplinary management of head and neck sarcomas.

BACKGROUND: Head and neck sarcomas are extremely rare. This article reviews the management and outcomes in a multidisciplinary clinic. METHODS: The records of 41 male and 19 female patients (mean age, 50 years) were reviewed. Forty percent underwent surgical resection only, 35% underwent surgery and adjuvant therapy, and 25% underwent radiotherapy and/or chemotherapy without surgery. Seventy-one percent had complete histologic clearance. RESULTS: The mean follow-up was 3 years and 10 months, with an overall 5-year survival rate of 60%. Completeness of surgical excision was highly significant in determining 5-year local control (p < .025), and the addition of adjuvant radiotherapy had a major effect on local control, but only if complete surgical clearance had been achieved (p < .025). As expected, patients with more aggressive tumors had a significantly poorer overall prognosis, and achieving local control led to an enhanced 5-year survival (p < .025). CONCLUSION: These tumors are best managed in multidisciplinary clinics, and the mainstay of treatment is wide local excision and planned postoperative adjuvant radiotherapy.

Adolescent↗

PubMed2006

The role of mental health professionals in multidisciplinary pain rehabilitation programs.

The traditional roles of psychologists and mental health therapists are challenged by the comprehensive treatment necessary for patients being treated in multidisciplinary pain rehabilitation programs (MPRPs). Mental health professionals within MPRPs provide direct clinical care but also guide the biopsychosocial model of pain management and cognitive-behavioral interventions for multiple disciplines. Illustrated by a case example of a patient who has complex chronic pain, this article discusses the biopsychosocial approach to pain treatment, structure of multidisciplinary care, major roles of mental health professionals in MPRPs, complexities of treating patients who have pain, and challenges in collaborating with multiple disciplines.

Chronic Disease↗

PubMed2006

Multidisciplinary International Conference on Gynecologic Cancer, Bologna, Italy, June 8-12, 2005.

The first "Multidisciplinary International Conference on Gynecologic Cancer" which was held in Bologna on June 8-12, 2005, addressed some of the most crucial topics in gynecologic oncology, presented the latest achievements and, at the same time, designed the guidelines for future developments in the field. The scientific program was intended not only to share and compare views and ideas among gynecologists but also with oncologists and researchers in basic science. The scientific committee strongly believed in the "multidisciplinary approach" towards medicine and particularly towards patients.

Crk-Associated Substrate Protein↗

PubMed1991

Intraoperative radiotherapy in the multidisciplinary treatment of bone sarcomas in children and adolescents.

From September 1984 to December 1989, 38 patients of pediatric age with localized bone sarcomas received intraoperative radiotherapy (IORT) as part of a multidisciplinary treatment program. The age ranged from 6 to 21 years. The tumor histologies were 22 osteosarcomas and 16 Ewing's sarcomas. Thirty-four had initial primary disease (90%) and 4 were treated for local recurrence (10%). IORT was used on 32 untreated patients and in 6 previously treated with external beam radiotherapy (EBR). The IORT field included the surgically exposed tumor bed area. Single radiation doses ranging from 10 to 20 Gy were delivered, using 6-20 MeV electron beams. The median follow-up time for the entire group is 25 months (2-65+ months). The projected 5-year disease-free and overall survival rates are 65% and 69%, respectively. One patient developed a local recurrence in each histological group: one chondroblastic osteosarcoma and one cervical Ewing's sarcoma. Six patients died from metastatic progression: 3 initially recurrent tumors and three primary disease cases. Severe neuropathy and soft tissue necrosis were seen in some patients as IORT related complications. IORT is a feasible technique to be integrated in multidisciplinary programs that may promote local control in pediatric and adolescent patients with bone sarcomas. Peripheral nerves are dose-limiting tissue structures for IORT.

Adolescent↗

PubMed2005

Credentialing of nuclear medicine physicians, surgeons, and pathologists as a multidisciplinary team for selective sentinel lymphadenectomy.

There are several possible applications of the sentinel lymph node (SLN) concept with different technological aspects such as individualized surgical management of solid tumors, multidisciplinary treatments, and novel therapeutic approaches. To achieve these clinical applications, multidisciplinary teamwork with surgeons, nuclear medicine physicians, and pathologists would be critically required. Interdisciplinary issues should be resolved in order to develop optimal standard procedures of SLN dissection for various solid tumors.

Credentialing↗

PubMed1985

Treatment of retinoblastoma and choroidal melanoma. A multidisciplinary approach.

Retinoblastoma and choroidal melanoma are two malignant ocular tumours that still give rise to discussions about diagnosis, natural history with respect to metastasis an choice of treatment. The therapeutic problems are best solved within a multidisciplinary oncology team in which the ophthalmologist, ophthalmopathologist and the general pathologist play an important role. In most institutes for ophthalmology a patient with a tumour in or in the region of the eye, is first seen by a specialist for eye diseases, who is also a surgeon in this field. In general the ophthalmologist decides on the diagnosis, the treatment and the follow-up without consulting other specialists in oncology. This solely ophthalmological approach can harbour a potential danger for the patient. Decisions on treatment made in a multidisciplinary team of specialists trained in oncological principles are responsible for the best results. Surgery combined with radiotherapy and chemotherapy can be a better choice than surgery alone, but even when surgery alone seems the best treatment, the discussion with the members of an oncological team can be of importance for the surgeon. The natural history of the tumour which includes the growth patterns, the growth rate and the tendency to metastasize may influence the choice of the surgical procedure; surgical intervention might be more or less extensive than previously foreseen. Dr. W.A. Manschot, professor in ophthalmic pathology, rightly advocates the contribution of the ophthalmopathologist to such an oncological team, because such a person has acquired knowledge in histopathology of the ocular tumours and experience in evaluating international literature in this field, the results of the treatment of groups of patients with the same tumour and publishing the statistically verified conclusions.(ABSTRACT TRUNCATED AT 250 WORDS)

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PubMed1993

The effect of coordinated, multidisciplinary ambulatory care on service use, charges, quality of care and patient satisfaction in the elderly.

This study evaluated a multidisciplinary care center, the Pike Market Clinic (PMC), whose physicians provide and coordinate inpatient and outpatient care for downtown low-income elderly in Seattle. We interviewed users of PMC and their near-neighbors with a 206 item questionnaire to compare their medical and social service use, quality of care, and satisfaction. We then estimated mean annual charges/person for inpatient, outpatient and emergency room services in the two groups. Demographic and health status characteristics were similar in the two groups. PMC patients made significantly more annual visits than neighbors to their primary physicians. Visits to non-primary physicians occurred at the same rate in both groups, but PMC patients were referred more often by their primary physicians. Both emergency room and inpatient use were higher in the neighbor group. Social services were used at the same rate by PMC patients and neighbors. Various indices suggested that quality of care and satisfaction were comparable or superior among PMC patients. Using utilization data, we estimated that neighbors generated charges over $1000/person/year greater than PMC patients. Coordination by PMC providers rather than the availability of multidisciplinary services may be largely responsible for utilization differences between PMC patients and their neighbors.

Aged↗

PubMed1996

Computed tomography vs clinical and multidisciplinary procedures for early evaluation of severe abdomen and chest trauma--a cost analysis approach.

OBJECTIVE: To compare contrast computed tomography (CT) for evaluating abdominal and vascular chest injuries after emergency room resuscitation with multidisciplinary management based on bedside procedure (BP), e.g., peritoneal lavage, abdomen ultrasonography urography and, if indicated, CT and/or aortography or transesophageal echocardiography. DESIGN: Randomized study. SETTING: Emergency, critical care and radiology departments in a trauma center. PATIENTS: The study was performed in 103 severe blunt trauma patients with a revised trauma index < 8, admitted over a 16 month period and divided into group (G1, n = 52, CT management) and group 2 (G2, n = 51, BP management). INTERVENTIONS: A relative direct cost scale used in our trauma center was applied, and cost units (U) were assigned to each diagnostic test for cost-minimization analysis (abdomen ultrasonograph = 7.5 U, peritoneal lavage = 8 U, urography = 9 U, computed tomography = 9 U, transesophageal echocardiography = 13.5 U, and aortography = 15 U). One unit is approximately equivalent to $43.7. RESULTS: Injury severity score (ISS) was 31.7 +/- 15.4 in G1 and 33.8 +/- 18.3 in G2. Sensitivity for CT was 90.4% (G1) vs 72.5% for BP (G2) in abdomen (P < 0.01) and 60% in chest for evaluating mediastinal hematoma etiology (G1). As Table 2 shows, G1 needed 59 tests for evaluating injuries (1.1 +/- 0.3 tests patient) while G2 required 81 tests (1.68 +/- 0.8 tests/patient) (P < 0.01). The total relative cost was 538 U for G1, 7.04 +/- 2.2 U cost/injury and 10.3 +/- 3.3 U/evaluation of trauma vs 698 U for G2, 9.84 +/- 5.03 U cost/injury and 13.68 +/- 8.5 U/evaluation (P < 0.05). CONCLUSIONS: This cost-minimization study suggests that CT is a more cost-effective method for the post-emergency room resuscitation evaluation of severe abdominal blunt trauma than the multidisciplinary BP. Chest CT is a screening method for mediastinal hematoma but not for etiology.

Abdominal Injuries↗

PubMed1988

Multidisciplinary treatment for resectable pancreatic cancer.

Since November 1983, a multidisciplinary protocol for the treatment of pancreatic carcinoma has been used for eight patients at the National Cancer Center Hospital. This therapy includes an extended pancreatic resection, intra-operative irradiation with 3,000 rad of electrons using a microton, and an intra-operative hepatic arterial or portal infusion of mitomycin C, 10 mg. Furthermore, post-operative chemotherapy with mitomycin C (10 mg to 10 mg x 3) is added by Seldinger's method or intravenously (i.v.). The post-operative course was uneventful in all eight patients. Although the number of patients treated is small, the one-year survival rate was 86%. This rate is markedly better than the 28% after conventional radical pancreatectomy from 1962 to 1983. According to our experience, pancreatic carcinoma is unlikely to be cured by only radical operative procedures. A multidisciplinary treatment protocol as an adjunct to radical surgery appears necessary for a good prognosis of this disease.

Aged↗

PubMed2000

Multidisciplinary approach to selective sentinel lymph node mapping in breast cancer.

Although the role of axillary lymph node dissection is controversial with respect to survival benefits, its role as a staging procedure has been well established since nodal involvement is the most reliable prognostic indicator for patients with breast cancer. Selective sentinel lymph node (SLN) dissection is gaining acceptance as a useful staging procedure because it is minimally invasive and spares approximately 70-80% of the patients a more extensive axillary lymph node dissection. The evolving techniques for selective SLN dissection using blue dye and radiotracer methods are reviewed in this article. Based on the classic definition of the breast lymphatic drainage and recently published articles addressing the issue of peritumoral and intradermal injections, a possible new and simplified approach using intradermal injection may identify the axillary SLN more quickly and reliably. This article emphasizes the importance of a multidisciplinary approach in the identification of SLNs by preoperative lymphoscintigraphy performed by expert nuclear medicine physicians, the intraoperative mapping and harvesting of SLNs by well trained surgeons and the meticulous examination of SLNs by experienced pathologists. Therefore, to achieve the highest rate of accuracy regarding SLN status, it is imperative that a multidisciplinary team with close communication and cooperation be formed. The clinical significance of SLNs will be determined by results from follow-up and clinical trials.

Breast Neoplasms↗

PubMed2004

[The multidisciplinary approach to reconstructive surgery of the extremities-considerations for trauma and orthopedic surgery].

Interdisciplinary reconstructive surgery of the extremities involves a variety of indications ranging from IIIB/C open fractures with major segmental loss of bone and soft tissue, to arterial vessel injury necessitating vascular repair, and to biological, plastic reconstruction following resection of musculoskeletal tumors. The multidisciplinary approach involving trauma/orthopedic surgery combined with vascular, plastic, and neuro- resp. microsurgery has significantly increased the rate of limb-sparing operations and improved morbidity, function, quality of life, and long-term oncological outcome. The multidisciplinary treatment of both complex trauma and malignant bone/soft tissue sarcoma of the extremity is an integral task of surgical trauma and tumor centers. Close interactive communication between the individual surgical disciplines has decisively influenced prognosis and is the precondition for priority-adapted therapeutic strategies.

Amputation, Surgical↗

PubMed2002

Teaching pharmacology within a multidisciplinary organ system-based medical curriculum.

We have described how the pharmacology of agents that act on the central nervous system (CNS) and endocrine system were incorporated into a case-based, multidisciplinary, integrated sophomore medical curriculum at Southern Illinois University School of Medicine (SIUSM). Faculty members from the Departments of Pharmacology, Pathology, Internal Medicine, Psychiatry, and Neurology were major participants in the CNS block, and faculty with primary expertise in radiology, epidemiology, and immunology also participated. Integrated sessions involving the entire class were organized around brief patient cases, which were given to the students in advance of the session. During the sessions, each patient case was presented by a physician or pathologist who briefly described symptoms, history, physical findings, differential diagnosis, and the classification of the subtypes of the particular class of disorder. The pathophysiology of the disease was discussed, and the pharmacology of agents to be considered for therapy was presented in the context of the Pharmacology Mental Algorithm, a systematic and rational approach to drug therapy. The session was completed by a clinician who added further clinically relevant information, which was followed by a question-and-answer period involving all faculty participants. The CNS block was presented over a 1-month period and included standardized patients and real patients who consistently exhibited specific disease findings, and these patient-oriented sessions were followed with small group tutorial sessions. Single discipline large-group sessions were also used to present material that is introductory or unique to a particular discipline. Student knowledge was assessed, using integrated evaluations based on case vignettes with multiple-choice questions provided by each discipline. The goal of the examination was to evaluate knowledge base in the discipline areas and its application to clinical problem-solving. A practical evaluation of each student's patient examination skills in CNS was also performed by clinicians. Feedback from the students on the organ system activities was obtained using a questionnaire. Development of these sessions required leadership and a considerable amount of time to organize, improve, and update sessions. The integrated approach largely eliminated the use of conflicting terminology and redundancy of material common with separate presentations on the same subject by different disciplines. The multidisciplinary, case-based sessions were perceived to be instructive, valuable learning experiences, based on formal and informal student and faculty feedback.

Adolescent↗

PubMed2001

Paediatric pelvic imaging: improvement in gonad shield placement by multidisciplinary audit.

BACKGROUND: In 1996, there were local reports of poor gonad protection for paediatric pelvic radiographs. OBJECTIVES: To investigate the nature of the problem and make necessary improvements. MATERIALS AND METHODS: A retrospective audit of 218 paediatric pelvic radiographs was undertaken in 1997. Each radiograph was assessed for the presence of a gonad shield, appropriateness of the device and its position. A multidisciplinary team was formed with representation from radiology, radiography, orthopaedics and medical physics to investigate ways of improving technique and reducing patient dose. These included radiographer training and the introduction of digital fluoroscopy as an alternative imaging technique in follow-up patients. There were further rounds of data collection in 1998 and 1999. RESULTS: In round 1, a gonad shield was present in 77.9 % of boys' films and 76 % of girls' films where one should have been, increasing to 85.2 % and 85.4 % respectively by round 3 of the audit (P < 0.05). Only 31.6 % of boys' devices and 21.9 % of girls' devices were correctly positioned in round 1, increasing to 78.3 % and 94.3 %, respectively, by round 3 of the audit (P < 0.05). After round 1, no inappropriate devices were used. CONCLUSION: Audit was an effective tool in gaining the resources needed to improve technique and reduce radiation exposure in children. The multidisciplinary approach was vital in the success of this project.

Child, Preschool↗

PubMed2003

Challenging cases in thyroid cancer: a multidisciplinary approach.

Recurrent thyroid cancer can present many complex management problems. Unfortunately, recurrent thyroid cancer is often refractory to radioiodine therapy. The proper use of external beam irradiation and surgical interventions can provide regional control of localized recurrences. Because of the complex nature of these patients, a multidisciplinary team approach to management which includes specialists in thyroid medicine and surgery, head and neck radiotherapy, and nuclear medicine often is required to provide individualized, optimal multimodality treatment recommendations. In this article we review a multidisciplinary team approach to a patient with widespread, radioiodine-refractory bone metastases from follicular thyroid cancer and to a patient with unresectable central neck recurrence of papillary thyroid cancer.

Aged↗