Multidisciplinarity and quality of cancer care Zorica Tomasevic, MD,PhD Medical Oncologist, Visiting Professor of Belgrade Medical Faculty SEE Meeting on Western Balkan Regional Network for Radiotherapy and Oncology 7 th and 8 th September 2018. Podgorica Montenegro

Cancer: ~200 types (including leukaemia, lymphomas) Different : etiology, (genetic mutations), incidence, prevention, gender predisposition, geographic predisposition, racial differences; heredity, natural prognosis; recognizable molecular targets (treatment targets); treatment options (drugs with specific toxicity profile );

MTD cancer specific MTD members should be experts in specific cancer types Expertise is linked to specific education and experience Experience is linked to time…(and certain age)

Multidisciplinarity is essential: Multidisciplinary tumor boards (MTD) Surgeon (breast, abdominal, thoracic, gynaecology oncology, ORL& maxillofacial, neurosurgeon, plastic/reconstructive… ) Medical oncologist (breast, gynaecological, gastrointestinal, lungs, ORL, haematology ,CNS…) Radiotherapist (breast, gynaecological, gastrointestinal, lungs, ORL, haematology ,CNS…) Diagnostician (RTG,CT,MRI, US, PETCT ) Pathologist (at least on call) Molecular biology specialist Interventional radiologist Nurses (also specific education … nurse practitioners) Neuro oncologist Palliative care specialist Psychologist… Dietitians , nutrition specialist Specialist in cancer rehabilitation … Expanding need for other professional medical profiles in the era of patient centralized cancer care

Implementation of treatment recommendations : comprehensive cancer centres, dedicated specialized units Countries have been concentrating expertise for certain tumour types in dedicated centres, or units, (such as for childhood and rare cancers), and most compreherehensive cancer centres have teams for the main cancer types. Established universal, dedicated units only for breast cancer, (European declarations,2016) ECCO’s essential requirements expert group suggest: all tumour types to adopt the principles of such dedicated care with breast cancer to be delivered in specialist multidisciplinary centres.

European CanCer Organisation Through its 24 Member Societies - representing over 150 000 professionals - ECCO is the only multidisciplinary organisation that connects and responds to all stakeholders in oncology Europe-wide. ECCO is a not-for-profit federation that exists to uphold the right of all European cancer patients to the best possible treatment and care, promoting interaction between all organisations involved in cancer at European level. It does this by creating awareness of patients’ needs and wishes, encouraging progressive thinking in cancer policy, training and education and promoting European cancer research, prevention, diagnosis, treatment and care through the organisation of international multidisciplinary meetings.

ECCO essential requirements for quality cancer care (ERQCC) : checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific tumour type Key facts of various ,malignancies, diagnostic and treatment requirements SURVIVAL IS DEPENDANT ON CONTRY OF RESIDENCE!!! ORGANIZATION OF CANCER CARE INFLUENCES SURVIVAL!! ACSESS TO CLINICAL TRIALS VERY IMPORTANT!!!

ECCO essential requirements for quality of cancer care; checklist Cancer care pathway Timeline of care MTD dedicated to specific malignancy Audit performance measurement, quality assurance, quality of care, (annualy). Professional education, enrollment in clinical trials and delivery of patient information

CRC example : Factors that influence outcome: Health care system organization: Waiting time to diagnosis and provision of optimal treatment can explain about third differences in cancer survival Cancer national plans, promotion of guidelines and professional training and quality control measures, can explain a quarter of survival differences 2nd most frequent cancer in F and 3rd in M Might be prevented (screening, polyp and adenoma excision, dietary physical activity modifications…) 2nd cause of death in EU ~447.000 new cases/yr. ~ 215.000 deaths/ yr. 1.2 mill survivors (prevalence) Prognosis variable and dependant not only upon tumour biology

CRC example :optimal time from symptoms to diagnosis and treatment (~10% of asymptomatic pts detected by screening) Primary care practitioners are the usual referrers of those with suspected CRC and need timely access to hospital specialists and typically a diagnosis is established by endoscopy. maximum time for an appointment to check suspected symptoms of all cancers is 2 weeks (England and Wales) suspected CRC identified through faecal occult screening programmes is referred in the same time (2 weeks). In the Netherlands, the maximum time for an appointment when a malignancy is suspected is 1 week. ECCO expert group strongly recommends that countries ensure that waiting time are below these times as is the case in several European countries that make urgent referrals within 48 h.

CRC example : Inequalities (survival) Countries in Eastern and Central Europe have the lowest survival rates for CRC. In the Eurocare-5 study the highest 5-year survival for colon cancer was found for patients in Belgium, Germany and Iceland (62%) and lowest for patients in Latvia (43%) (but lower survival than the 57% European aver- age was also observed for patients in Denmark (54%) and Croatia (50%)). For rectal cancer, the highest survival was for patients in Belgium and Switzerland (63%) and lowest for those in Latvia (36%), but low survival was also observed for Croatia (49%) and Slovenia (50%). Ferlay et al., 2013a

CRC example :Centre, necessary specialities, doctors experience Number of procedures per hospital: ~50-100 CRC operations, ~20 liver resection, local recurrence excision, peritoneal interventions) Gastroenterology (endoscopic) Pathology (all pts) Radiology/imaging (all pts for proper staging) Surgery (~80-90% pts needs surgery: et least 2 experienced surgeons) Medical oncologist (all pts Stage III/IV needs treatments) Radiotherapy Interventional radiology Nursing (in some countries nurses are educated for endoscopy) Follow up plans Survivorship support…

CRC: Research and clinical trial, recommendations Continuous medical education Clinical research Centres treating CRC must have clinical research programmes The MDT must assess all new patients for eligibility to take part in clinical trials at the centre or in research networks CRC, centres should have at least 10% of all patients included in research projects Clinical trials represents benefit for patients, hospitals, health care system (no costs at all!) Clinical trials are great opportunity for selected patients, who can be treated immediately with future drugs. For clinical trials experienced hospital staff but also experienced ,well organized CRO support is MUST!

Treatment proposal/decision is complex issue Guidelines (what should be done) Guidelines might be implementable, OR NOT… …dependant on health system organisation and … policy makers, awareness & money dedicated to cancer care = country income Can oncologist contribute ? Rationalized treatment and diagnostic decision* (significant amount of money could be saved and redirected to new treatment options) Choose wisely: what should not be done! *especially in follow up of asymptomatic pts

ASCO don’t do: Don’t use colony stimulating white cells stimulating factor for primary preventions of febrile neutropenia for pts with less than 20% risk for this complication (exception : higher risk due to age, medical history, or disease characteristics) Don’t give patients starting on a chemotherapy that has a low or moderate risk of causing nausea and vomiting anti-emetic drugs intended for use with a regimen that has a high risk of causing nausea and vomiting. Don’t use combination chemotherapy instead of monotherapy when treating patients with metastatic breast cancer, unless patients need a rapid response to relieve tumour related symptoms! Avoid PET,CT scanning in follow up for cancer recurrence in asymptomatic pts who finished initial treatment unless there is a high level evidence that it might change outcome! Don’t use cancer directed therapy for solid tumour pts with: low PS (3 or 4),who do not benefit from prior evidence based interventions, not eligible for clinical trials , and no strong evidence supporting the clinical value of further treatment. Don’t perform PET,CT and radionuclide bone scans in the staging of early prostate cancer at low risk for metastases. Don’t perform PET,CT and radionuclide bone scans in the staging of early breast cancer at low risk for metastases Don’t perform surveillance testing (biomarkers) or imaging (PET,CT, radionuclide tests) in asymptomatic individuals iwho have been treated for breast cancer in curative intent. 1 2 7 8

ASCO don’t do: Don’t perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live less than 10 years. Don’t use targeted therapy intended to use against a specific genetic alteration unless a patients tumour cells have a specific biomarker that predicts and effective response to the targeted therapy 9 10