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Multidisciplinary Care in Head and Neck Cancer

Insights From: Ezra Cohen, MD, UC San Diego Moores Cancer Center; Robert L. Ferris, MD, PhD, FACS, University of Pittsburgh Cancer Institute; Jared Weiss, MD, University of North Carolina School of Medicine
Published: Wednesday, Apr 20, 2016


Transcript:

Robert Ferris, MD, PhD, FACS:
Head and neck cancer is really a devastating disease affecting the organs of speech, swallowing, and breathing. So, because of the important cranial nerves and physiologic functions that head and neck tumors affect, this has been a disease where multimodality and multidisciplinary management has led to the best outcomes. Because our goal is not just to cure, it’s to retain a good quality of life and a good function, patients who can swallow. And one of the best things that we do as humans is to go out to dinner, and eat, and socialize. So, patients who are chronically feeding tube-dependent—even if they’re alive—may not have a quality of life in some situations where they are happy and pleased with the outcome. The multidisciplinary team’s role is not only to select the best treatment to optimize cure, it’s to assess the function. The multidisciplinary treatment team includes the surgeon, usually whose role is to bring the best staging so that we don’t under-stage and therefore under-treat; the medical oncologist; and the radiation oncologist. We don’t usually treat up front, locally advanced head and neck cancer with chemotherapy alone. That would be reserved for the palliative scenario.

The curative modality, other than surgery, is generally radiation, and that’s either radiation alone or in combination with chemotherapy. The multidisciplinary treatment team has some other very important members: the radiologists, who help us to interpret the imaging; the pathologists, who ensure that we have the right diagnosis and help to assess the prognostic factors; but also our nursing, our speech, and swallowing therapists, the whole team and often the folks who work on the social aspects of this disease. If we have a debilitating surgery—and there’s time in a nursing facility to get a patient back to a functional status—if they go through chemotherapy and radiation where they have visits every day for 6 or 7 weeks, there’s a great social impact. So, having some help navigating that for the patients and families is critical also.

Head and neck cancer is a multidisciplinary treatment team, and a multimodality therapy is really key to optimized treatment. Often, we have choices. We can treat a patient with surgery or radiation therapy, and what is best can often be arrived at through consensus, through data. Data is usually not owned or restricted to simply one modality. Certainly, the surgical team may know their literature better. The medical and radiation oncology team likewise know the nonsurgical literature. And yet, when you bring the group together with the patient at the center, that sometimes leads, in a healthy adversarial way, to arguing in favor of the best outcome, arriving at—in a collegial way—what we are going to ultimately recommend to the patient. Sometimes we’re at an impasse and we cannot select one over the other, and the patient chooses because each has their side effects and toxicities. So, a good functioning multidisciplinary team recognizes that we have a lack of data in some situations to prioritize one treatment over another.

In Pittsburgh, we have this active group that meets formally weekly, but we’re talking, and texting, and e-mailing, and calling many, many times over the course of the day. We use our multidisciplinary conference to go over the imaging together to arrive and agree on the staging, but also for clinical trial accruals. For folks in the community, it’s certainly harder, but I would recommend that they find individuals in the respective modalities and areas of expertise that they trust, that they get along with, because it’s not intended that this is an either/or situation and one set of doctors wins while the other loses. Unfortunately, there’s plenty of these patients. And ultimately, if we select the wrong treatment up front, we’re not doing a service to the patient and they’ll end up back in your office with a poor outcome. We try to recognize that and have the big picture in our multidisciplinary clinics. And, in the community, I would recommend that they go out of their way for the head and neck cancer patients to find the highest-volume care providers, people that have a lot of experience and an interest in this disease.

Jared Weiss, MD: The question was about coordination of care. This is absolutely critical in head and neck cancer. This may be the cancer type that most demands multidisciplinary care and, therefore, coordination of that multidisciplinary care. I think the thing that helps the most is having a group of practitioners that are used to treating patients together. In an academic center, this happens more or less automatically. But in the community, having a surgeon, a radiation oncologist, and a medical oncologist who are accustomed to working together and have regular modes lines of communication, is extremely helpful. From a practical standpoint, tumor boards are invaluable. Getting the medical oncologist, radiation oncologist, surgical oncologist, radiologist, pathologist, nutritionist, and speech-and-swallow therapist, who all care about head and neck cancer, in the same room at regular intervals to discuss each case is absolutely invaluable. And the final thing that can be exported is the use of a nurse navigator, nurses specialized in coordinating the care of these kinds of patients.

Transcript Edited for Clarity
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Transcript:

Robert Ferris, MD, PhD, FACS:
Head and neck cancer is really a devastating disease affecting the organs of speech, swallowing, and breathing. So, because of the important cranial nerves and physiologic functions that head and neck tumors affect, this has been a disease where multimodality and multidisciplinary management has led to the best outcomes. Because our goal is not just to cure, it’s to retain a good quality of life and a good function, patients who can swallow. And one of the best things that we do as humans is to go out to dinner, and eat, and socialize. So, patients who are chronically feeding tube-dependent—even if they’re alive—may not have a quality of life in some situations where they are happy and pleased with the outcome. The multidisciplinary team’s role is not only to select the best treatment to optimize cure, it’s to assess the function. The multidisciplinary treatment team includes the surgeon, usually whose role is to bring the best staging so that we don’t under-stage and therefore under-treat; the medical oncologist; and the radiation oncologist. We don’t usually treat up front, locally advanced head and neck cancer with chemotherapy alone. That would be reserved for the palliative scenario.

The curative modality, other than surgery, is generally radiation, and that’s either radiation alone or in combination with chemotherapy. The multidisciplinary treatment team has some other very important members: the radiologists, who help us to interpret the imaging; the pathologists, who ensure that we have the right diagnosis and help to assess the prognostic factors; but also our nursing, our speech, and swallowing therapists, the whole team and often the folks who work on the social aspects of this disease. If we have a debilitating surgery—and there’s time in a nursing facility to get a patient back to a functional status—if they go through chemotherapy and radiation where they have visits every day for 6 or 7 weeks, there’s a great social impact. So, having some help navigating that for the patients and families is critical also.

Head and neck cancer is a multidisciplinary treatment team, and a multimodality therapy is really key to optimized treatment. Often, we have choices. We can treat a patient with surgery or radiation therapy, and what is best can often be arrived at through consensus, through data. Data is usually not owned or restricted to simply one modality. Certainly, the surgical team may know their literature better. The medical and radiation oncology team likewise know the nonsurgical literature. And yet, when you bring the group together with the patient at the center, that sometimes leads, in a healthy adversarial way, to arguing in favor of the best outcome, arriving at—in a collegial way—what we are going to ultimately recommend to the patient. Sometimes we’re at an impasse and we cannot select one over the other, and the patient chooses because each has their side effects and toxicities. So, a good functioning multidisciplinary team recognizes that we have a lack of data in some situations to prioritize one treatment over another.

In Pittsburgh, we have this active group that meets formally weekly, but we’re talking, and texting, and e-mailing, and calling many, many times over the course of the day. We use our multidisciplinary conference to go over the imaging together to arrive and agree on the staging, but also for clinical trial accruals. For folks in the community, it’s certainly harder, but I would recommend that they find individuals in the respective modalities and areas of expertise that they trust, that they get along with, because it’s not intended that this is an either/or situation and one set of doctors wins while the other loses. Unfortunately, there’s plenty of these patients. And ultimately, if we select the wrong treatment up front, we’re not doing a service to the patient and they’ll end up back in your office with a poor outcome. We try to recognize that and have the big picture in our multidisciplinary clinics. And, in the community, I would recommend that they go out of their way for the head and neck cancer patients to find the highest-volume care providers, people that have a lot of experience and an interest in this disease.

Jared Weiss, MD: The question was about coordination of care. This is absolutely critical in head and neck cancer. This may be the cancer type that most demands multidisciplinary care and, therefore, coordination of that multidisciplinary care. I think the thing that helps the most is having a group of practitioners that are used to treating patients together. In an academic center, this happens more or less automatically. But in the community, having a surgeon, a radiation oncologist, and a medical oncologist who are accustomed to working together and have regular modes lines of communication, is extremely helpful. From a practical standpoint, tumor boards are invaluable. Getting the medical oncologist, radiation oncologist, surgical oncologist, radiologist, pathologist, nutritionist, and speech-and-swallow therapist, who all care about head and neck cancer, in the same room at regular intervals to discuss each case is absolutely invaluable. And the final thing that can be exported is the use of a nurse navigator, nurses specialized in coordinating the care of these kinds of patients.

Transcript Edited for Clarity
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