The American Society of Clinical Oncology (ASCO) maintains that a multidisciplinary team (MDT) is the cornerstone of quality care, yet despite incentives and interest, little is known about how teams affect cancer delivery. At the 2016 Cancer Survivorship Symposium, Linda A. Jacobs, PhD, CRNP, described the process necessary to develop and implement multidisciplinary survivorship care into practice while identifying barriers to providing care.
“The ideal cancer care team should be providing care from diagnosis through the end of life,” said Dr Jacobs, Clinical Professor of Nursing and Director for the Development of Cancer Survivorship Clinical Programs, Research and Educational Initiatives, at the Abramson Cancer Center of the University of Pennsylvania. “Diagnosis and treatment, primary care, survivorship care, palliative care, and hospice should all be part of this package.”
As Dr Jacobs reported, the goals of medical team-based care are clear—to reduce mortality, improve patient management, improve quality, and improve value—and are accomplished through the cooperation of a team comprised of surgeons, radiation therapists, medical oncologists, nurse practitioners, and physician assistants.
“The demand for teams has grown in parallel with healthcare reform and the public’s expectations for improved quality and value,” said Dr Jacobs, who also noted the establishment of the patient-centered medical home and accountable care organizations as drivers of the MDT model.
What Makes Teamwork Effective?
Despite this demand, questions remain about the structural and hierarchical components of the ideal MDT.
“When we talk about multidisciplinary cancer care teams,” said Dr Jacobs, “I think it’s important to discuss MDT clinical decision-making. How does the team really work together?”
In 2011, a systematic review of quality-of-care management decisions by MDTs looked at clinical, technical, and social factors that affect the quality of clinical decision-making. Analysis determined that social factors affect management decision by cancer MDTs.
“In all of these studies,” said Dr Jacobs, “team decisions were made by physicians; nursing personnel did not have an active role on the teams, and patient preferences were not discussed. It’s clear that leadership skills training and systematic input from nursing personnel are needed.”
Significant work has been done to develop these reports, said Dr Jacobs, who cited the Institute of Medicine’s “From Cancer Patient to Survivor” (2006),
ASCO’s “Future of the Oncologist Workforce” (2006), and the Institute of Medicine’s “Oncology Workforce Report” (2009).
“There’s been progress since those meetings,” she said, “with an emphasis on changing traditional models, and integrating and expanding the role of advanced practice providers within collaborative/team-based care models.”
That being said, the operational elements of teamwork in cancer care have not been studied adequately.
“Studies continue to focus on the role of the oncologists versus primary care physician in survivorship care so we know what is preferred by patients,” said Dr Jacobs. “How teams affect cancer care delivery and, more importantly, the role that team members play in providing care need to be assessed.”
Ideal Components of Survivorship Care
According to Dr Jacobs, a model program would feature individualized risk-based follow-up that included the following: medical risk assessment; management of long-term and late effects; assessment of psychological, behavioral, and social functioning; lifestyle modification of unhealthy habits; and care coordination, either consultative or ongoing care.
“The teamwork should be occurring with all different oncology providers—primary care providers as well as specialty care providers,” said Dr Jacobs. “Patients should be referred when they need to go to endocrine, cardiology, counseling, or physical therapy.”
“For institutions that have an advanced practice provider or a nurse navigator,” she added, “those roles can be critical in guiding the patient through this process of referrals.”
More Questions Than Answers
Given the diversity of practice settings, Dr Jacobs stressed that a one-size-fits-all model fits no one, and yet, the community should still strive for consensus about what care should include. In addition, there are payment issues to consider, as well as the aforementioned lack of evidence on the impact of different models.
But perhaps the biggest barrier to multidisciplinary care is the limited oncology workforce. “It’s more eminent than not that we do something about it,” said Dr Jacobs, who concluded with more questions than answers.
“Who should provide care, what should survivorship care encompass, and when should survivorship-focused visits occur?” she asked. “We need adequate surveillance guidelines that everyone can follow.”