The one- and two-day initial visits that have become a hallmark of University of Colorado Hospital’s gastrointestinal cancer care are as good for diagnostic accuracy and appropriate treatment as they are for patient convenience and speed of service.
That’s according to a University of Colorado School of Medicine team that considered 1,747 patients involved in four GI multidisciplinary clinics (MDCs) from late 2012 through December 2015. They found MDCs changed the diagnoses of referred patients 27 percent of the time and altered patients’ recommended treatments 28 percent of the time.
The numbers jibe with previous studies that sought to quantify the effects of having diverse experts gather to decide on the course of a patient’s care, says Cheryl Meguid, DNP, the director of Multidisciplinary Program Development at CU and a nurse practitioner who has helped to lead the University of Colorado Cancer Center’s Multidisciplinary Pancreas and Biliary Clinic since it launched in October 2012.
“We knew it was significant and enough to make an impact,” said Meguid, the lead author of the new study published in the Annals of Surgical Oncology.
The authors, from the CU departments of Surgery, Radiation Oncology and Medical Oncology, represented four GI MDCs: pancreas and biliary; esophageal and gastric, launched in August 2013; liver and neuroendocrine, launched in April 2014; and colorectal, launched in February 2015. All but the esophageal and gastric MDC distill into a single day patients’ initial assessments, labs, scans, meetings with dietitians and social workers, consensus expert diagnoses and face-to-face meetings with the physicians who will lead their care. The esophageal and gastric MDC takes two days to allow time for an endoscopic evaluation the day before the multidisciplinary review.
The pancreas and biliary clinic has had the biggest impact, the data show, with 38 percent of patients leaving with a different diagnosis and 35 percent with a different treatment recommendation than they arrived with. The changes are also significant for the other clinics:
- Patients with liver and neuroendocrine tumors saw their diagnoses change 22 percent of the time and their treatment recommendations change 27 percent of the time.
- Patients with esophageal and gastric cancers had their diagnoses changed 13 percent of the time and treatment recommendations 20 percent of the time.
- Patients with colorectal cancer had their diagnoses changed 16 percent of the time and treatment recommendations 13 percent of the time.
Those figures don’t count the more than 6 percent of cases in which the MDC’s experts found problems unrelated to the cancer diagnosis. Such “incidental findings” included adrenal nodules, breast nodules, enlarged prostates, colorectal thickening, pulmonary emboli and benign cysts.
Spared the knife
Why did diagnoses changed more often with pancreatic and biliary cancer patients than with those with, say, colorectal cancer? It boils down to the challenges associated with the cancers themselves and the expertise demanded in their care, Meguid says.
For example, few institutions perform the necessary multidetector CT scan, which determines whether a pancreatic tumor involves the blood vessels. Such involvement means a tumor deemed to be operable may not be – or it may be necessary to do chemotherapy and/or radiation therapy to shrink the tumor before doing surgery. In addition, few outside institutions include chest CT scans in the initial pancreatic cancer workup, despite 10 percent of pancreatic cancers metastasizing to the lungs only. This may move a patient’s cancer stage to stage 4, at which point surgery isn’t a good option.
As a result, nearly 54 percent of the changes in diagnoses among pancreatic and biliary cancer patients involved reclassifying referring providers’ assessments from resectable (removable via surgery) to borderline/locally advanced; another 43 percent of diagnoses were changed to metastatic. Only about 3 percent of the time did a referring provider’s diagnosis that a pancreatic cancer was inoperable end up being overturned in the MDC.
In short, in addition to crafting better care pathways, the MDC spares patients surgeries that would have failed to remove all the cancer, Meguid and colleagues found.
One or 20
Richard Schulick, MD, MBA, chairman of CU’s Department of Surgery and a specialist in complex GI cancer procedures, championed the MDC approach at UCH and coauthored the paper. He says the new data further underscore the value MDCs provide to patients.
“Think about it – do you want one doctor deciding what the plan of attack should be, or do you want 20 experts?” Schulick said. “Instead of one doc focusing on surgery, one on radiation oncology, and one on chemo, you want them all arguing and debating what pathway should be the right one.”
The centerpiece of a GI multidisciplinary clinic is a noon meeting involving as many as 40 or 50 physicians, nurses, medical residents and others. It brings together medical oncologists, radiation oncologists, and cancer surgeons as well as gastroenterologists, pathologists and radiologists; in the case of liver cancer patients, transplant surgeons and interventional radiologists are also there. In addition to the four GI MDCs covered in the new study, there are also three other cancer MDCs devoted to breast cancer, thoracic oncology and sarcomas.
The work starts long before noon. The MDCs each have a dedicated advanced care practitioner (either a nurse practitioner or a physician assistant) who serves as a patient’s primary point of contact. Typically, patients go from referral to MDC within a week. By the time the patient arrives in the morning, the MDC coordinator has assembled a clinical history, established a patient’s probable care pathway, and set a schedule.
Patients start with radiology and labs, a health assessment and physical. There are meetings with support services, free within the UCH cancer center, such as dieticians and social workers, and then a lunch break, during which, in a Cancer Center conference room, the assembled specialist physicians consider cases and establish plans of care. Patients then meet with the appropriate physicians (if surgery is the first step, a surgical oncologist; if chemotherapy, a medical oncologist, as examples). Patients leave the cancer center knowing exactly where their care is headed.
“My single best healthcare experience EVER,” wrote one patient. “Having been in the healthcare world for more than 20 years, I sometimes get a bit jaded. An experience like today’s restores my belief that true personalized medicine does exist.”
Compare that to the old approach – still too often the status quo – in which patients must schedule separate appointments over a period of weeks with a succession of cancer specialists who may or may not be communicating. At an academic medical center such as UCH, where up to 18 percent of cancer patients come from out of state, it led to uncertainty compounded by inconvenience.
Such MDCs remain the exception, Schulick said, because few hospitals have the requisite depth of expertise.
“Even top-notch academic medical centers can’t all do this,” Schulick said. “It takes being top-notch, but it also takes the willpower and the discipline to say, ‘This is important, it’s a priority, and it’s the right thing for the patient.’”
The authors of the Annals of Surgical Oncology paper, The Multidisciplinary Approach to GI Cancer Results in Change of Diagnosis and Management of Patients. Multidisciplinary Care Impacts Diagnosis and Management of Patients, include:
Cheryl Meguid, DNP, ACNP
Richard Schulick, MD, MBA, FACS
Tracey Schefter, MD
Christopher Lieu, MD
Megan Boniface, PA-C
Nicole Williams, AGNP
Jon Vogel, MD, FACS
Csaba Gajdos, MD, FACS
Martin McCarter, MD, FACS
Barish Edil, MD, FACS