A Brief Discussion of the ‘Individual’ vs the ‘Evolving Team’ in the Cancer Care Arena

This commentary begins with a personal reflection. During my first night as an internal medicine intern at the world-famous Bellevue Hospital in New York, New York–yes, the institution referred to by Dustin Hoffman in Midnight Cowboy when he says, “Just get me on a bus. You ain’t sendin’ me to Bellevue”)–I was called by the night nursing staff to see a patient on the large medical ward I was covering whose condition appeared to be rapidly deteriorating. Unsure of how to proceed, I called the covering senior resident to ask his advice and to this day I will never forget his words to me, which provide a focus to this commentary: “Doctor, the decisions and actions you take now will determine the fate of this patient.”

These words served as an important teaching moment, and of course I was given the help I needed. But this event, so early in my career, also emphasized to me the profound individual responsibility associated with being a physician.

While the feelings of personal responsibility for patient welfare among clinicians, in general, and oncologists, in particular, may not have changed over many decades, it is well recognized that the actual delivery of optimal care has undergone substantial evolution.

Of course, oncologic care has essentially always been a team effort, even if it was the individual doctor who was identified as being responsible for the outcome. For example, surgeons need assistants in the operating room, anesthesiologists, nurses, associated technical staff, and effective post-operative care to safely undertake procedures and insure a successful outcome.

But over time the standard oncologic care plan in multiple clinical domains has borne witness to major change, from the decision-making and oversight responsibilities of a single physician to a multi-disciplinary team approach. Today, with recognized exceptions, care of patients with cancer begins with discussions among relevant modalities, even within individual specialties. A colorectal surgeon may confer with a liver surgeon regarding the optimal approach to management of a rectal primary and an isolated metastatic lesion in the liver. A breast surgeon may discuss the optimal approach to breast reconstruction with a plastic surgeon colleague. Required surgical interventions may occur sequentially, or with several surgeons participating in a single definitive operative procedure.

The approach to diagnosis and primary management has shifted over time to include an oncologic team, with optimal care determined based on the unique characteristics associated with the cancer itself (e.g., size, location) and the individual patient (e.g., comorbidities). A biopsy of a solid tumor mass may be obtained by a more traditional surgical approach, or through less invasive efforts of an interventional radiologist.

After a diagnosis has been pathologically confirmed to be a solid tumor malignancy, documented or suspected to originate from a specific site, the initial therapeutic strategy may be systemic therapy (“neoadjuvant”), rather than surgical resection. However, in most settings this surgery is simply delayed and when undertaken, is anticipated to result in a higher probability of complete surgical resection as well as cause less normal tissue damage.

And to complete this evolutionary story, surgery is increasingly being employed not only as management of local/regional disease but also to remove metastatic lesions as a planned component of a comprehensive multimodality management plan. Finally, at the same time, revolutionary developments in antineoplastic therapeutics have begun to challenge the need for any surgical interventions in certain well-defined clinical settings.¹

Even the above noted rather substantial changes in how optimal care is currently delivered fails to fully capture the magnitude of the transformation. Consider, for example, the increasing importance of precision molecular medicine, both somatic and germline, in disease management. This strategy requires expertise from internal health system and/or external resources in the conduct of the testing itself, interpretation of the results, and discussions with patients (and possibly their families).

This evolution has altered the traditional relationship between clinical pathology and the patient’s care team, as essential information now extends far beyond a surgical pathology report and conventional blood tests evaluating normal or abnormal organ function (e.g., hematologic parameters, liver, renal function tests). Tumor-based single-gene, small- and large-panel molecular testing are now routine in cancer management, with a variety of liquid tumor biopsies increasingly utilized as a component of the standard of care. And more recent data have demonstrated the utility associated with molecular monitoring with circulating tumor DNA.² The clinical laboratory has evolved to become an increasingly relevant component of innovative individualized cancer care. 

There is perhaps no area of cancer management that has undergone more change than that of genetic counselors.³ In an earlier era, before the widespread availability of molecular germline testing, genetic counselors who worked within the cancer arena were focused on the limited data available through a family history (assuming such data were obtained in a busy medical practice) to evaluate and make recommendations regarding risk.

Not surprisingly, the need for these services was modest. However, with the virtual explosion in germline testing, evolving evidence for the relevance of documented and potentially pathologic variants that increase cancer risk, data demonstrating the benefits of specific antineoplastic therapeutics in the presence of particular molecular abnormalities (e.g., PARP inhibitors), as well as the value of prophylactic measures to prevent cancer (e.g., mastectomy, oophorectomy with BRCA1 or BRCA2 mutations), the need for well-trained and experienced genetic counselors has sky rocketed (and will only increase in the future).

We next must add to the “team” the evolving role of palliative medicine within the cancer care continuum. In the not-so-distant past, this subspecialty remained restricted to the end-of-life care setting. Similar to how oncologic management was delivered in the past, palliative medicine has been viewed not as an essential component of curative or life-extending care, but rather as an approach to be sequentially employed following the decision to discontinue the delivery of such care. Today, accumulating evidence-based data have demonstrated the favorable effect of a robust palliative care/symptom management effort (e.g., pain control, psychosocial and nutrition support and intervention) working directly beside the surgeons, radiation and medical oncologists.

Finally, in this all-to-brief discussion of the multidisciplinary team approach to cancer management it is essential to acknowledge other critical members, including oncology pharmacists, inpatient hospitalists working with patients with cancer, advanced practice nurses and physician assistants, psychologists, social workers, financial counselors, and experts in the evolving field of integrative medicine, all of whom contribute immensely to assist patients through the recognized complexities of their cancer journey.

Yes, the provision of optimal oncology care is now very firmly a “team effort,” and a patient’s fate no longer resides in the hands of a single physician (regardless of where they received their training).

References

1. Cercek A, Foote MB, Rousseau B, et al. Nonoperative management of mismatch repair-deficient tumors. N Engl J Med. 2025;392(23):2297-2308. doi:10.1056/NEJMoa2404512
2. Powles T, Kann AG, Castellano D, et al. ctDNA-guided adjuvant atezolizumab in muscle-invasive bladder cancer. N Engl J Med. 2025;393(24):2395-2408. doi:10.1056/NEJMoa2511885
3. Schienda J, Stopfer J. Cancer genetic counseling–current practice and future challenges.Cold Spring Harb Perspect Med. 2020;10(6):a036541. doi:10.1101/cshperspect.a036541
4. El-Jawahri A, LeBlanc TW, Kavanaugh A, et al. Multisite randomized trial of inpatient palliative care intervention for patients undergoing hematopoietic stem cell transplantation. J Clin Oncol. 2025;43(24):2700-2711. doi:10.1200/JCO-25-00378