There are often borderline situations in which the decision for an intervention or a chemotherapy treatment is not clear, nor clearly included in a protocol, and requires the participation of different opinions
Cancer care is a multidisciplinary process in nature. In other words, for the diagnosis and treatment of cancer, the intervention of various specialists is required, not only oncology professionals. Together they deal with the specific tumor pathology, participate in the definition of procedures and protocols and in the assessment and specific decision-making on each of the patients.
However, as stated by Dr. Miguel Hernández-Bronchud, specialist in medical oncology at Clínica Corachan and former member of the National Commission for the Specialty of Medical Oncology in the Ministry of Health and Education, and as such, co-author of the current MIR training program for Oncology specialists, “until a few years ago, systematized work together with colleagues from other specialties was not so common. Today, on the other hand, it is known that it is not possible to carry out truly multidisciplinary care work without the so-called Tumor Committees& rdquor;.
- “The need for the joint work of several specialists derives from the complexity of many of the oncological pathologies. And that each specialist provides complementary knowledge for the benefit of a specific patient,” explains Dr. Hernández-Bronchud.
As the Clínica Corachan specialist argues, “there are often borderline situations in which the decision for an intervention or a chemotherapy treatment is not clear, nor clearly included in a protocol, and requires the participation of different opinions& rdquor ;.
It specifies, for example, that “personalized aspects of a molecular or anatomo-pathological type; surgical or medical procedures (in which the patient has liver disease or a poor general condition) add nuances to decision-making, which thus becomes a complicated process plagued with uncertainties& rdquor ;.
The discussion of the case from all its points of view, with the contributions of each one of the members of the committee facilitates the care decision and at the same time provides reinforcement to each one of the participants.
In addition, as Dr. Miguel Hernández-Bronchud points out, “from a health resource management point of view, cancer work through Tumor Committees provides a more economical and rational use of said resources.
The simultaneous work of the different specialists allows the same medical time to be shared for the knowledge of the case and the decision-making that it entails & rdquor ;.
Thus, the Tumor Committees are at the same time a great benefit for patients, who will know their diagnosis in less time and the guidelines for their possible treatments will be much more precise, thanks to the 360º that talent contributes to the evaluation of their case. of different specialists at the same time.
The tumor committees are organized by pathologies. They integrate all the specialists involved in the care of a specific oncological pathology, in a regular meeting, usually weekly.
Working in committees promotes teamwork, the protocolization of oncological actions and the evaluation of the quality of care processes.
Work without multidisciplinary committees
For example, in the specific case of lung cancer -according to Dr. Hernández-Bronchud- the classic distribution of roles and tasks involved the pulmonology assessment of a lung mass (pathological chest x-ray referred by the primary care physician). , the request for additional imaging studies (thoraco-abdominal CT), followed by histological diagnostic studies (bronchoscopy, EBUS or PAAF), which led to making a therapeutic decision.
When the radiological findings were not clearly defining (in the case of lung cancer, there could be doubts about the invasion of the great vessels by the mass), it was necessary to carefully review the images of the case with the radiologist, first, followed by a consultation with the thoracic surgeon. to propose the decision of radical surgery.
If, after a few days or weeks, the latter finally dismissed the surgical intervention, returning the case to the requesting pulmonologist, he or she would request again –through a new interconsultation request– the evaluation of neoadjuvant chemotherapy for oncology. If, after this last evaluation, the best possible therapy was concomitant chemo-radiotherapy treatment, a new interconsultation had to be requested, this time with the radiotherapist, to include the case in said program.
It can easily be understood that such a cascade of successive evaluations entails various inconveniences and deficiencies that Hernández-Bronchud points out:
a) they overload the patient and their relatives who, in addition to acting as messengers carrying different flyers, have to make appointments and go to multiple consultations where they receive assessment.
b) increase the time interval from the suspicion of neoplasia to the start of specific cancer treatment.
c) as each specialist works on their own, there is no extra gain of information that only the simultaneous exchange of opinions provides, which can translate into clinical decisions that are not fully adjusted to the set of characteristics of the case.
Advantages of working with committees
A clear example of the gain obtained thanks to the joint work of specialists in a committee is the improvement of access to anatomopathological information.
Instead of waiting for an appointment in consultation to receive and assess the result of a biopsy or puncture, or an oncological surgical intervention, the specialist simply requests an assessment of the case in a session of the Tumor Committee. In this, the pathologist will provide the pertinent information (often stimulated precisely by the commitment to have to comment on the data).
The simultaneous evaluation of the case in a committee and the simultaneous making of citations in different services or units allows time to be shortened. In this way, hospital bureaucracy is simplified, in addition to gathering clinical consensus and updates, while consolidating team relationships, beyond the natural borders of each service.
In addition, the possible absence of some service in smaller centers can be compensated by connecting with specialists from another center or from the referral hospital. These will be made to participate in the committees.
In general, and to the extent that cancer management becomes more complicated and involves the interaction of multiple specialists throughout the care process, it becomes more necessary to establish forums for evaluation, discussion, and organization of cases, precisely what represents the Committee on Tumors.
Functions of the Tumor Committee
a) The main function is clinical advice in case management: diagnostic and/or therapeutic decision. Any doctor is assisted in making decisions by fellow specialists from the center with the simple request for evaluation of a case. Moreover, in the same process the transfer of the patient between specialties takes place according to the decision of the committee.
b) Organization of patient flows. Ideally, the committee should have a secretariat that is in charge of organizing the care according to the decisions made. It would be, for example, making an appointment with the patient for a consultation or scheduling her visit to carry out an imaging study.
Sessions and participants
The Tumor Committee is organized by different sessions for each of the various tumors (breast, lung, urological and digestive tumors, etc.). Each of the sessions is assigned to a day and time of the week.
The committee is made up of physicians who systematically participate in the assessment of cases of tumor pathology. They are usually one or two doctors per service.
The inclusion of a case in the tumor committee is requested by the doctor, any of the center, who requires the evaluation of a clinical case.
In the committee there is the figure of the secretary, who can be administrative staff, who organizes and coordinates the tasks related to the committee session, clinical documentation (electronic and on paper) and healthcare actions.
In each session of the committee there are usually 10 to 20 professionals from medical oncology and radiation therapy oncology, specialized surgery, radiodiagnosis, pathology, laboratory, nursing, and specialist psychologist, among other specialists.
During the session, all the cases presented are evaluated in detail and successively. The secretary takes note of the attendees at the session and who leads it. The person in charge of the session takes notes about the comments made on each case by the different members. In addition, he systematically collects the decision made and the care plan.
Among the possible decisions that the committee can take are, for example:
- Radical/diagnostic surgery.
- Chemotherapy.
- Radiotherapy.
- Other cancer treatments.
- Follow-up without active treatment.
- Complete studies.
- Subsequent reassessment in committee.
It is frequent that after the deliberations it is concluded that it is advisable to carry out an additional study before making a final decision.
Additional (or already protocolized) molecular tests are common, allowing the personalized indication of new therapies against specific molecular targets (for example, mutations in oncogenes in lung or breast cancer) or immunohistochemical markers that suggest the use of immunotherapies instead or in conjunction with chemotherapy. In that case the decisions would be to complete studies and subsequent reevaluation in committee.
The care plan will establish a timely appointment for the patient in consultation or the scheduling of their surgical intervention or pre-surgical or neoadjuvant treatment, such as certain types of chemotherapy, immunotherapy or hormone therapy.
In support of oncology professionals, the Spanish Society of Medical Oncology (SEOM) publishes every year Clinical Guidelines that have been prepared with the collaboration of National Cancer Research Cooperative Groups.
Specifically, Dr. Miguel Hernández-Bronchud participated in the drafting of the White Paper on Spanish Oncology, which regulated the first tumor committees, and in the Pla Oncològic i Consell Assessor of the Department of Health of the Generalitat de Catalunya.