Multidisciplinarity
in cancer care


     Paolo G. Casali
     paolo.casali@istitutotumori.mi.it
Multidisciplinary cancer teams
Algorythms


         clinical state




                          y
             decision         action


              ...
complexity

              atypical cases




uncertainty

                pt preferences
R   p<0.05
R   p<0.05
Decision analysis


                  outcome
                            utility

        action


                  outc...
outcome          U
EU = (P1*U1)+(P2*U2)                       1
                                 utility = U1
            ...
“Strategic” clinical decision
surgery




radiation & chemo
surgery




radiation & chemo
Tumor boards
Organization


          TUM   TUM   TUM


   Surg

   Med

    RT
Organization


          TUM   TUM   TUM


   Surg

   Med

    RT
Decision rule
Psycho-oncologists
The good clinical decision…




  …is a patient-physician shared decision!
The reference physician
Extra medical time!
Frequent solid cancers
                        inc.
                     /100,000/y

     GI                  110
     Uro...
Rare solid cancers
                         inc.
                      /100,000/y

     Head & neck         16
     Melano...
Rare solid cancers
                              inc.
                           /100,000/y

     Head & neck             ...
From the reference center...
…to the Reference network
Rare cancers…




     childhood
Rare cancers…




                 hematological
     childhood
Rare cancers…




                           adult solid tumors
                 hematological
     childhood
Rare Tumours in Europe
CHALLENGES AND SOLUTIONS
6 November 2008 - Brussels
www.rarecancers.eu
BZ
                                            Sondalo
                                                                   ...
surgery


                         radiation

chemotherapy
“logical” patient




     “virtual” patient




         “real” patient
Who is moving in a network?
virtual sharing!

pathologic diagnosis
multidisciplinary strategic decision


surgery
hi-tech resources

                 ...
Distant patient sharing
Teleconsulting…




           McAleer JJA et al.
           Broadcast quality teleconferencing for oncology.
           T...
GIST             Synovial Sarcoma




Leiomyosarcoma   Cellular Schwannoma
Extra medical time!
100
 80
 60
40
20
 0
      12   24   36   48   mos
Cost shift




             health
             system
REGIONE
                  LOMBARDIA




FARMACIE
PHARMACIES                         ENTI EROGATORI
                       ...
<x>
       name = “value”




Patient discharge report
Outpatient clinic visit report
Patient discharge report
Outpatient clinic visit report
Patient cancer history
Patient non-cancer history
Treatment program in the
current phase of disease
Treatment done
Patient...
“ROL-doc”




                                <x>
                                name = “value”




            Patient c...
Patient cancer history
Patient non-cancer history
Treatment program in the
current phase of disease
Treatment done
Patient...
Disease “phase”



diseases




tumors
Disease “phase”




        localized   metastasis              terminal
         disease     (1st CT)    (2nd   CT) disea...
Disease phases




        localized   metastasis                 terminal
         disease     (CT 1st l)   (CT 2nd   l) ...
Disease phases


                    clinical practice
                       guidelines




        localized   metastasi...
Clinical practice guidelines




                        Sarcoma t.
                        molli tipico
                 ...
Virtual tissue banking
Data protection regulations!
The medical semantics!
In brief...
   Multidisciplinarity is imposed by the multimodal
   approach to most solid cancers
   Multidisciplinarity i...
paolo.casali@istitutotumori.mi.it
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers
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Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers

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Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers. Casali P. Technical Conference: Multidisciplinary Care in Cancer as a model of health care quality (Madrid: Ministry of Health and Social Policy, 2010)

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Multidisciplinary care: a perspective from diagnosis and treatment of rare cancers

  1. 1. Multidisciplinarity in cancer care Paolo G. Casali paolo.casali@istitutotumori.mi.it
  2. 2. Multidisciplinary cancer teams
  3. 3. Algorythms clinical state y decision action n action
  4. 4. complexity atypical cases uncertainty pt preferences
  5. 5. R p<0.05
  6. 6. R p<0.05
  7. 7. Decision analysis outcome utility action outcome action
  8. 8. outcome U EU = (P1*U1)+(P2*U2) 1 utility = U1 P1 action outcome U 1 utility = U2 P2 action utility = U3 EU = (1*U3)
  9. 9. “Strategic” clinical decision
  10. 10. surgery radiation & chemo
  11. 11. surgery radiation & chemo
  12. 12. Tumor boards
  13. 13. Organization TUM TUM TUM Surg Med RT
  14. 14. Organization TUM TUM TUM Surg Med RT
  15. 15. Decision rule
  16. 16. Psycho-oncologists
  17. 17. The good clinical decision… …is a patient-physician shared decision!
  18. 18. The reference physician
  19. 19. Extra medical time!
  20. 20. Frequent solid cancers inc. /100,000/y GI 110 Urological 84 Breast 64 Lung 56 Gynecological 28
  21. 21. Rare solid cancers inc. /100,000/y Head & neck 16 Melanoma 14 Sarcoma 6 CNS 6 Endocrine 4 Neuroendocrine 3 Thoracic rare 2
  22. 22. Rare solid cancers inc. /100,000/y Head & neck 10 Rare GI 6 Sarcoma 6 CNS 6 Endocrine 4 Neuroendocrine 3 Rare male genital 3 Rare female genital 2 Rare urological 2 Rare thoracic 2 Skin rare 1
  23. 23. From the reference center...
  24. 24. …to the Reference network
  25. 25. Rare cancers… childhood
  26. 26. Rare cancers… hematological childhood
  27. 27. Rare cancers… adult solid tumors hematological childhood
  28. 28. Rare Tumours in Europe CHALLENGES AND SOLUTIONS 6 November 2008 - Brussels
  29. 29. www.rarecancers.eu
  30. 30. BZ Sondalo BL S Aviano V O TN U A B L Alzano As D G O V C C Lombardo Biel olo O A O T la Des B N B T S io G Neg VI O S V V Trevig rar M P Orbassa Ivr C I lio V no ea LO Casalpuster R D lengo C Candiolo T A PV M O R N L PC Al b Car F P pi E a R R C E M N G O E B R O A Forl ì P P O U PI L U EmpolFI A i N LI Valdar no A Citt R à di S.Severino Cast Marche ello P Città G della S.Omero G T (v.Vibrat Pieve E Pen a) R T N ne PE A Q Lancia no RO MA S.G. Rotondo C B IS L T B Olbi N Altam B a N Rioner ura A A o B Nocer R S a Inf. in Castellan S Vulture P eta Mandu T Z A ria L E CA C S C Z Trop ea M R E C T P P A Taorm ina C T A G
  31. 31. surgery radiation chemotherapy
  32. 32. “logical” patient “virtual” patient “real” patient
  33. 33. Who is moving in a network?
  34. 34. virtual sharing! pathologic diagnosis multidisciplinary strategic decision surgery hi-tech resources rationalization!
  35. 35. Distant patient sharing
  36. 36. Teleconsulting… McAleer JJA et al. Broadcast quality teleconferencing for oncology. The Oncologist 2001; 6: 459
  37. 37. GIST Synovial Sarcoma Leiomyosarcoma Cellular Schwannoma
  38. 38. Extra medical time!
  39. 39. 100 80 60 40 20 0 12 24 36 48 mos
  40. 40. Cost shift health system
  41. 41. REGIONE LOMBARDIA FARMACIE PHARMACIES ENTI EROGATORI HOSPITALS CITTADINI CITIZENS GENERAL AZIENDE HEALTH LOCAL MMG/PLS PRACTITIONERS SANITARIE LOCALI CARE UNITS HEALTH & SOCIAL ASSI ASSISTANCE
  42. 42. <x> name = “value” Patient discharge report Outpatient clinic visit report
  43. 43. Patient discharge report Outpatient clinic visit report
  44. 44. Patient cancer history Patient non-cancer history Treatment program in the current phase of disease Treatment done Patient state
  45. 45. “ROL-doc” <x> name = “value” Patient cancer history Patient non-cancer history Treatment program in the current phase of disease Treatment done Patient state
  46. 46. Patient cancer history Patient non-cancer history Treatment program in the current phase of disease Treatment done Patient state
  47. 47. Disease “phase” diseases tumors
  48. 48. Disease “phase” localized metastasis terminal disease (1st CT) (2nd CT) disease
  49. 49. Disease phases localized metastasis terminal disease (CT 1st l) (CT 2nd l) disease
  50. 50. Disease phases clinical practice guidelines localized metastasis terminal disease (CT 1st l) (CT 2nd l) disease
  51. 51. Clinical practice guidelines Sarcoma t. molli tipico adulto G2-3 Stadiazione Metastasi Sì M. avanzata No RT No No Accetta Exeresi >5 cm Sì Sì CT + RT CT Exeresi Sì ampia > ampia conserv. fattibile Sì Accetta Resezione >5 cm Sì Sì CT radicale CT No Exeresi Sì marginale No fattibile No No Rifiuto Demolizio Sì demolizio No Demolizione ne fattibile ne No M. locoreg. Sì inoperabile Follow-up G2-3 NED
  52. 52. Virtual tissue banking
  53. 53. Data protection regulations!
  54. 54. The medical semantics!
  55. 55. In brief... Multidisciplinarity is imposed by the multimodal approach to most solid cancers Multidisciplinarity implies an integrated cooperation of specialists, not just their involvement one by one It is a challenge for cancer centers and physicians It will be more and more played within collaborative networks Rare cancers are a priority for national and cross- nation networking But networking is spreading to manage cancer care in general also at a regional level In 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
  56. 56. paolo.casali@istitutotumori.mi.it
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