Insights From: Catherine T. Frenette, MD, Scripps Green Hospital; Darren S. Sigal, MD, Scripps Green Hospital
Darren S. Sigal, MD: Dr. Frenette, treating liver cancer is such a complicated issue because you’re treating the disease, the tumor, and the liver. There are various ways of treating this cancer, different subspecialists. Can you talk to me about a multidisciplinary team approach in liver cancer diagnosis and therapy—what members, what subspecialists are important to be part of this team?
Catherine T. Frenette, MD: So, the multidisciplinary treatment and teams for management of liver cancer is incredibly important. There have been multiple studies that have looked at this and have shown that people who use a multidisciplinary team, and patients who go through that multidisciplinary team, have an earlier, more accurate diagnosis, better treatment options, and better overall survival, and really, this is now the standard of care for treatment of liver cancer.
So, a multidisciplinary team can really be done in multiple different ways. The way that we do it, we have a tumor board that meets on a routine basis. We discuss patients always at diagnosis and often when we’re bringing them back for more treatment. A multidisciplinary team needs to include a hepatologist for the liver, an oncologist for the cancer, radiologists—both diagnostic and interventional—for pathology if there are biopsies or for resection, and hepatobiliary or transplant surgeons to talk about surgical treatments. Radiation oncology may be an option. We also have a nurse navigator who can help, and the goal is to give the patients the opportunity to have all of these different specialists, who have an input in their care without them having to go from office to office to office to office. And really, that cuts down on the time spent in the offices, as well as the delay in treatment.
There was actually an interesting study that I saw that looked at the number of specialists that people saw before treatment, and the more specialists that someone had to see before they ultimately went to treatment resulted in a significant delay from diagnosis to treatment, as long as 6 months in some cases. So, really, the MDT, or the multidisciplinary team, cuts that time down and tries to get people on the appropriate track right away. When we’re presenting someone, we’ll discuss them at initial diagnosis to make sure that the staging is appropriate. Are the number of lesions that are on the report what’s actually there? Is there vascular invasion that wasn’t realized? Is there more advanced disease that we didn’t realize in terms of their liver?
Our surgeons are there, and oftentimes, based on what I tell them as far as the liver function, what their platelet count is, they determine if this is a sign of portal hypertension. And really reviewing the imaging on the screen, they can tell me if they think this guy is a surgical candidate or a transplant candidate or not. And if they can look at this cancer and say, “This is not resectable,” I’ve just saved that patient a visit to the surgeon. So really, that’s the goal, and really, that has been known as standard of care now for lots of different cancers. I’m sure you have the MDT in multiple other cancers as well that you have to attend. So, this is really where the treatment should be.
Darren S. Sigal, MD: Once you see a patient be presented at the MDT and they go through treatment, do they come back and get re-reviewed?
Catherine T. Frenette, MD: They do, depending on what their treatment response is and how complicated it is. For instance, for somebody who is being started on systemic treatment, if based on their follow-up scans, they’re doing fine for 6 months but then something changes—maybe their tumor has a response, maybe now they’ve actually, with this systemic treatment, been downstaged into resection candidacy—so, we may re-review them for that. Or, for someone who had a chemoembolization and on their initial scan, it looks like a complete response, they feel good, and their labs look good, I might not review that patient again at tumor board. But with their next scan that shows some active disease, I’ll bring them back again to talk about what’s the right treatment for this patient.