Multidisciplinarityin cancer care

Paolo G. Casalipaolo.casali@istitutotumori.mi.it

Multidisciplinary cancer teams

action

n

y

action

clinical state

decision

Algorythms

uncertainty

atypical cases

pt preferences

complexity

R p<0.05

R p<0.05

Decision analysis

action

action

outcome

outcome

utility

action

action

outcome

outcome U1utility =U2

utility =U3

U1utility =U1P1

P2

EU = (P1*U1)+(P2*U2)

EU = (1*U3)

“Strategic” clinical decision

radiation & chemo

surgery

radiation & chemo

surgery

Tumor boards

Organization

Surg

Med

RT

TUM TUM TUM

Organization

Surg

Med

RT

TUM TUM TUM

Decision rule

Psycho-oncologists

…is a patient-physician shared decision!

The good clinical decision…

The reference physician

Extra medical time!

Frequent solid cancers

inc./100,000/y

GI 110Urological 84Breast 64Lung 56Gynecological 28

Rare solid cancers

inc./100,000/y

Head & neck 16Melanoma 14 Sarcoma 6CNS 6Endocrine 4Neuroendocrine 3Thoracic rare 2

Rare solid cancers

inc./100,000/y

Head & neck 10Rare GI 6 Sarcoma 6CNS 6Endocrine 4Neuroendocrine 3Rare male genital 3Rare female genital 2Rare urological 2Rare thoracic 2Skin rare 1

From the reference center...

…to the Reference network

Rare cancers…

childhood

Rare cancers…

hematologicalchildhood

Rare cancers…

childhoodhematological

adult solid tumors

Rare Tumours in EuropeCHALLENGES AND SOLUTIONS6 November 2008 - Brussels

Rare Tumours in EuropeCHALLENGES AND SOLUTIONS

www.rarecancers.eu

PR

VA

LC

VI TV

BG

LU

GR

PG

CN

AL

MI

Desio

LO

PV

Alzano LombardoC

O

Casalpusterlengo M

N

Orbassano

CandioloTO

Ivrea

Biella N

O Negrar

Aviano

TS

SS

Olbia

SondaloBZ

Taormina

TA

TN

TN

Treviglio

UD

VB

GE

FIPI

LIValdarno A

R

Empoli

CA

CT

AG

TP

ME

PA

BNN

A

CZ

RC

Tropea

Rionero in VultureP

Z

Altamura

Castellaneta

LE

BR

Manduria

S.G. Rotondo

BA

AN

PU

Lanciano

Penne

S.Omero (v.Vibrata)

AQ

PE

Cittàdella Pieve

Città di Castello

LT

FE

Forlì

BO

MO

Carpi

PC

RA

VC V

RPD

CB

IS

AO

RE

CR

GO

PO

Nocera Inf.

Alba

Asolo

BLSO

BS

CS

ROMA

TE

S.Severino Marche

chemotherapy

surgery

radiation

“logical” patient

“virtual” patient

“real” patient

Who is moving in a network?

pathologic diagnosismultidisciplinary strategic decision

surgeryhi-tech resources

virtual sharing!

rationalization!

Distant patient sharing

Teleconsulting…

McAleer JJA et al.Broadcast quality teleconferencing for oncology.The Oncologist 2001; 6: 459

GIST Synovial Sarcoma

Leiomyosarcoma Cellular Schwannoma

Extra medical time!

020406080

100

12 24 36 48 mos

Cost shift

healthsystem

REGIONE

LOMBARDIA

PHARMACIES

HEALTH & SOCIAL

ASSISTANCE

GENERAL

PRACTITIONERS

LOCAL HEALTH

CARE UNITS

CITIZENS

HOSPITALS

REGIONE

LOMBARDIA

FARMACIE

ASSI

MMG/PLS AZIENDE

SANITARIE LOCALI

CITTADINI

ENTI EROGATORI

< x >name = “value”

Patient discharge reportOutpatient clinic visit report

Patient discharge reportOutpatient clinic visit report

Patient cancer historyPatient non-cancer historyTreatment program in the current phase of diseaseTreatment donePatient state

< x >name = “value”

“ROL-doc”

Patient cancer historyPatient non-cancer historyTreatment program in the current phase of diseaseTreatment donePatient state

Patient cancer historyPatient non-cancer historyTreatment program in the current phase of diseaseTreatment donePatient state

diseases

tumors

Disease “phase”

Disease “phase”

localized metastasis terminaldisease (1st CT) (2nd CT) disease

Disease phases

localized metastasis terminaldisease (CT 1st l) (CT 2nd l) disease

Disease phases

localized metastasis terminaldisease (CT 1st l) (CT 2nd l) disease

clinical practiceguidelines

Clinical practice guidelines

Stadiazione

Metastasi

Exeresi> ampiaconserv.fattibile

Demolizione fattibile

Exeresiampia

Sarcoma t.molli tipico

adultoG2-3

M. avanzata

Resezioneradicale

Demolizione

>5 cm CT

Sì

Sì

Sì

Rifiutodemolizio

neSì No

Sì

No

No

No

Follow-upG2-3 NED

AccettaCT SìSì

No

No

>5 cm CT + RTAccettaCT SìSì

RTNo

No

M. locoreg.inoperabile

Exeresimarginale

fattibile

Sì

No

Virtual tissue banking

Data protection regulations!

The medical semantics!

In brief...Multidisciplinarity is imposed by the multimodal approach to most solid cancersMultidisciplinarity implies an integrated cooperation of specialists, not just their involvement one by oneIt is a challenge for cancer centers and physiciansIt will be more and more played within collaborative networksRare cancers are a priority for national and cross-nation networkingBut networking is spreading to manage cancer care in general also at a regional levelIn the end, multidisciplinarity within a hospital, or a comprehensive cancer center, or a network, or a health system, needs money, which will pay off, certainly in the society perspective

paolo.casali@istitutotumori.mi.it