Multidisciplinary care

An oncologist may play a critical role in a patient’s mBC treatment, but 59% of women with breast cancer state that their lives have changed in a negative way and that oncologists are not addressing the psychosocial aspects of the disease (Mayer et al., 2010). A multidisciplinary team (MDT) approach can help overcome these issues and is necessary if patients are to receive optimal care (Wanchoo et al., 2017). It has been stated that MDTs provide ‘consistent, continuous, co-ordinated, and cost-effective care to the patient’ (Fleissig et al., 2006) and there is evidence to suggest that decisions made by an MDT are more likely to align with evidence-based guidelines (Sainsbury et al., 1995; Chang et al., 2001; Vinod et al., 2010; Saini et al., 2012). Furthermore, introduction of multidisciplinary care has been shown to significantly improve outcomes such as mortality. Comparison of two regions in Scotland, one with- and one without multidisciplinary care, showed a significant improvement in breast cancer mortality following introduction of an MDT approach (Kesson et al., 2012).

However, the implementation of MDTs for breast cancer care appears to differ around the world (Figure 7) (Saini et al., 2012).

MDTs in breast cancer care. Percentage of respondents who stated that MDTs are a mandatory part of breast cancer care in their country.

Figure 7: MDTs in breast cancer care. Percentage of respondents who stated that MDTs are a mandatory part of breast cancer care in their country (Saini et al., 2012).

Geographical differences in the use of MDTs in breast cancer care is not limited to their mandatory nature. In Europe, 90% of respondents stated that the MDT met weekly to discuss patients, however, only 50% of respondents in Asia said they met this regularly (Saini et al., 2012).

It has been recommended that the MDT should consist of a surgical oncologist, radiologist, medical oncologist, pathologist, clinical nurse specialist and palliative care specialist (Abdulrahman, 2011). In the USA, the National Institutes of Health recommends the introduction of a palliative care specialist into the MDT as early as possible in the case of mBC. This is so they can prevent or manage symptoms and side effects as well as any psychological, social, or spiritual issues that arise (National Cancer Institute, 2017).

The role of clinical nurse specialists in breast cancer care should also not be underestimated. Patient surveys reveal that access to a clinical nurse specialist improved the patient experience and satisfaction with the service provided (Hardie & Leary, 2010). In addition to face-to-face meetings, many nurses provide ongoing care and support via phone consultations. In one study over a 28-day period, two clinical nurse specialists received 229 phone contacts, which resulted in 1,282 interventions that could be clustered into four areas: (1) providing information (29%), (2) managing symptoms (26%), (3) psychological/social issues (33%), (4) and other issues (Warren et al., 2012).

While a typical MDT structure has been described, certain patient populations may require additional input. Around 10–30% of patients with mBC are diagnosed with brain metastases and the rates are increasing due to an ageing population, improved detection of subclinical disease and better control of systemic disease (Gil-Gil et al., 2014). To address the specific needs of this patient population, The University of North Carolina at Chapel Hill created a breast cancer brain metastasis clinic to provide the multidisciplinary care needed in this setting. This clinic builds on the typical MDT to include a neurosurgeon enabling timely access to neurosurgical interventions should they be needed (McKee et al., 2016).