Every new cancer case at Gibbs Cancer Center & Research Institute in Spartanburg, S.C., is presented at a multidisciplinary clinic before treatment decisions are made.
Nine multidisciplinary clinics are convened each week. The breast cancer clinic generally has the largest volume, with more than a dozen cases to discuss, followed by the gastrointestinal cancer clinic. Other clinics focus on lung cancer, hematologic cancers, melanoma, and other specific diseases.
At each clinic, medical oncologists, radiation oncologists, surgeons, pathologists, imagers, social workers, and others evaluate the treatment options for patients who have received an initial diagnosis within the past week. “We usually fill up the room,” said James D. Bearden, III, MD, the center's associate director. “We may have 50 to 75 folks attending who in some way touch the treatment of that particular malignancy.”
Gibbs began developing multidisciplinary clinics nearly eight years ago as a requirement for participation in the NCI Community Cancer Centers Program. Previously, cases had been presented as “show-and-tells” to a tumor board after the surgeon had decided how to proceed and often after radiation or chemotherapy had been started.
“By the time we talked about it, treatment decisions had been made—perhaps with all three disciplines involved, but perhaps not,” he said. “It was hard to turn the ship initially to get all the cases presented prospectively.”
Starting with breast cancer, radiologists were asked to present to the multidisciplinary clinic all mammograms that had led to a biopsy to substantiate an abnormality, he explained. The presentations are mandatory whether the surgeon or other treating physicians attend. However, physicians are incentivized to participate: unless they attend at least 50 percent of the breast clinics and attended at least one major continuing education meeting specific to their discipline each year, they would receive any unassigned cases.
All cases presented, he continued, have four decision points:
* Treatment must comply with guidelines published by NCCN, MD Anderson Cancer Center, or the American Society of Clinical Oncology;
* All clinic participants must agree that the tumor has been appropriately staged;
* Patients are offered a clinical trial, if available; and
* A treatment plan is entered into the patient's medical record—“The physician in charge has the choice about whether to adhere to the recommendations of the conference, but I don't think many doctors would drift off the recommendations made by their peers in a multidisciplinary clinic.”
Multidisciplinary Matrix Scores
Bearden uses the NCCCP “matrix of multidisciplinary care” to assess how Gibbs stacks up, which involves the following:
Case planning: All cases are reviewed prospectively and clinics occur weekly, but patients do not encounter care at the conference. “That's the direction we are going in,” he said, explaining that the cancer center exam rooms need to be reconfigured to allow this. Gibbs Score: 4 on a 5-point scale
Physician engagement: Physicians are engaged in quality improvements and strategic direction. They have financial and operational authority for the multidisciplinary clinic, but a non-physician administrator is designated to handle financial and operational matters. Gibbs Score: 4-5
Care coordination: Gibbs has navigators specific to each discipline, and also employs a social worker and a masters-level geneticist. “And, we have psychosocial support as well as the survivorship staff members and a palliative care team. All those disciplines are required to attend and have their say. Knowing a patient's social situation is important so we know what their psychological pressures may be at home.” Gibbs Score: 5
Infrastructure: All services are offered at the cancer center facility, and an oncology information management system allows all oncologists and surgeons to access and add to the notes about a patient's treatment. Gibbs Score: 5
Financial integration: Each physician bills patients separately, and there is no facility fee. Gibbs Score: 1
Clinical trials: All patients are evaluated for clinical trials during the multidisciplinary clinic. In recent years, at least 12 percent of patients treated at Gibbs—and up to 26 percent in some years—have been on clinical trials. “But we can do better, and we are really pushing this hard,” he said. “It's the best way to practice medicine.” Gibbs Score: 5
Medical records: All treating physicians, including primary care physicians, have access to patients' electronic medical records, but records are not fully integrated because software programs that capture both chemotherapy and radiation oncology data are not available. “We're able to access everything in the hospital and everything in the outpatient area, but it's just not one medical record,” he said. Gibbs Score: NA