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2380
Multidisciplinary Breast Cancer Clinics
Do They Work?
Molly Gabel, M.D.1
Nathan E. Hilton, M.D.1
S. David Nathanson, M.D.2
BACKGROUND. In an attempt to improve the care they provide for their patients
with breast cancer, the authors’ institution developed a multidisciplinary breast
cancer clinic (MDBCC) to offer ‘‘one-stop shopping’’ consultation and support for
1
Department of Radiation Oncology, Henry
Ford Hospital, Detroit, Michigan.
2
Department of General Surgery, Henry Ford
Hospital, Detroit, Michigan.
newly diagnosed breast cancer patients.
METHODS. One hundred sixty-two patients, the control group for this study, were
evaluated at Henry Ford Hospital during the year prior to the opening of the
MDBCC. These patients, who were referred in the traditional sequential consultation manner, were compared with the first 177 patients seen during the first year
of the clinic’s operation. Retrospective chart reviews were conducted to assess
treatment timeliness, and anonymous questionnaires were used to assess patient
satisfaction.
RESULTS. The authors found that the MDBCC increased patient satisfaction by
encouraging involvement of patients’ families and friends and by helping patients
make treatment decisions (P õ 0.001). The time between diagnosis and the initiation of treatment was also significantly decreased (42.2 days vs. 29.6 days; P õ
0.0008).
CONCLUSIONS. Although planning and operating a multidisciplinary clinic is not a
new venture, to the best of the authors’ knowledge, they have provided the first
report demonstrating the benefits described above. Cancer 1997;79:2380–4.
q 1997 American Cancer Society.
KEYWORDS: breast neoplasms, integrated delivery of health care, patient satisfaction, patient education.
B
The authors wish to thank Tamir Ben-Menachem, M.D., for statistical support. They recognize, in fond memory, Angelos Kambouris,
M.D., without whom this clinic would not exist.
They also thank Sheryl Schlacht, R.N. B.S.N.
O.C.N. and Wanda Szymanski, R.N. B.S.N. for
their effort and enthusiasm in the development
and improvement of the clinic.
Address for reprints: S. David Nathanson, M.D.,
Department of General Surgery Henry Ford Hospital, 2799 West Grand Blvd., Detroit, Michigan.
Received November 27, 1996; revision received
February 6, 1997; accepted February 6, 1997.
reast cancer is a common disease requiring evaluation by many
physician specialists including radiologists, general and plastic
surgeons, medical and radiation oncologists, and pathologists. In
most large medical institutions, multidisciplinary breast cancer conferences promote interspecialty communication regarding newly diagnosed breast cancer patients. Such tumor boards are essential for
generating coordinated treatment plans.
Treatment options often appear to be overwhelming as patients
are faced with the formidable task of making timely, wise decisions
during this very frightening and stressful period in their lives. Furthermore, patients must schedule consultations with several specialists,
which often takes several weeks. In an effort to improve the service
provided for breast cancer patients, the authors began a multidisciplinary breast cancer clinic (MDBCC) in October 1994, in addition to
their weekly tumor board. The goals of this clinic were twofold: 1) to
facilitate prompt medical management, and 2) to provide a convenient, supportive, and educational environment for patients with
newly diagnosed breast cancer. The inception of this clinic was facilitated by departmental mandates that all newly diagnosed patients
q 1997 American Cancer Society
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W: Cancer
Multidisciplinary Breast Cancer Clinic/Gabel et al.
within the health care system of the Henry Ford Hospital should be offered consultation in the new clinic.
Feedback from participating physicians has been
favorable regarding the utility and efficiency of this
new clinic. However, the value of the clinic from the
patient’s perspective had not been specifically assessed. Accordingly, this study was undertaken to evaluate the clinic in reference to its intended goals.
TABLE 1
Time to Treatment Determination
Stage
Local therapy utilized
Defined start date
0
Observation
Radiation
Mastectomy
Mastectomy
Radiation
Mastectomy
Neoadjuvant chemotherapy
Excisional biopsy
First day of radiation therapy
Surgery date
Surgery date
First day of radiation therapy
Surgery date
First day of chemotherapy
I–II
III–IV
MATERIALS AND METHODS
The Clinic
Patients diagnosed with breast cancer are referred to
the MDBCC. When the pathology report yields cancer
of the breast, the Pathology Department notifies the
MDBCC nursing coordinator, who in turn schedules
the patient for MDBCC consultation. The nursing coordinator also acquires pertinent reports and mammograms so that these studies are available for review
by the physicians.
The multidisciplinary clinic begins with a morning
conference attended by specialists from surgery, radiation oncology, medical oncology, radiology, and pathology. Each patient is discussed with mutual input
as mammography films and pathology specimens are
reviewed in detail. Treatment recommendations then
are proposed and discussed among the group.
During the multidisciplinary conference, patients
and their support groups attend a separate 45-minute
educational seminar outlining important aspects of
breast cancer diagnosis and treatment. Topics discussed include breast anatomy, breast cancer staging,
therapeutic surgical techniques, and rationale for chemotherapy and for hormone therapy. Each patient is
then offered a same-day evaluation by a breast surgeon, a medical oncologist, a radiation oncologist, and
if needed, a plastic surgeon. In turn, each consultant
performs a physical examination after obtaining a
medical, social, and family history. The recommendations of the tumor board are then disclosed while discussion ensues with emphasis on side effects, survival,
local control, and cosmetic outcome. Nursing staff and
social workers are available for patient consultation
and education. In addition, volunteers from the inhouse patient support program, who are specially
trained for cancer patient education, are available if
needed. On leaving the clinic, the patients are provided with literature designed to reinforce information
addressed during the clinic visit. Preoperative testing
and definitive surgery scheduling are also completed
prior to the patient’s departure from the clinic.
The Study
Two patient groups were compared. Each of the
groups was analyzed according to timeliness of treat-
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2381
ment and patient satisfaction, as determined by retrospective chart review and by patient questionnaires,
respectively. The control group included all patients
diagnosed with breast cancer at Henry Ford Hospital
during the year prior to the clinic’s inception (n Å
162). The MDBCC group was comprised of all patients
seen during the first year of the MDBCC’s operation
(n Å 177). Patients excluded from the study were male
patients (n Å 2) and those who were lost to follow-up
(n Å 3). Patients who sought the MDBCC only for a
second opinion (n Å 8) were included in the patient
satisfaction segment of the study, but were excluded
from the objective analysis because their therapy was
to be dictated elsewhere.
The timeliness of treatment was measured as the
time in days between diagnosis (by fine-needle biopsy
or by excisional tissue biopsy) and the start of definitive local therapy. Because modes of therapy differ
according to the stage of disease and patient preference, the timeliness of treatment varied accordingly,
as illustrated in Table 1. For those patients choosing
mastectomy, the treatment date was the date of the
surgery; for patients undergoing radiation therapy, the
treatment start date was the first day of radiation (after
appropriate surgical procedure, healing period, and
radiation treatment planning). For a minority of patients who had advanced disease, the start of treatment was defined as the date of the first course of
neoadjuvant chemotherapy administration. Finally,
despite counseling, some patients chose lumpectomy
as the only form of treatment. In this last group, the
date of therapy was defined as the date of excisional
biopsy, which in some cases was both the diagnostic
and the therapeutic procedure. Patient groups were
evaluated according to disease stage, type of treatment
rendered, and the time from diagnosis to treatment.
Statistical analysis was performed via the Wilcoxon’s
rank sum test. The authors did not collect data regarding patients receiving adjuvant chemotherapy or hormonal therapy because the purpose of the current
study was to quantify the time elapsed before the start
W: Cancer
2382
CANCER June 15, 1997 / Volume 79 / Number 12
TABLE 2
Clinical Stage Distribution of Control and MDBCC Groups
Clinical stage
Control (%)
MDBCC (%)
Control (no.)
MDBCC (no.)
Unknown
Stage 0
Stage I
Stage II
Stage III
Stage IV
Total
2
17
39
28
12
1
2
24
30
28
12
3
4
28
64
46
19
2
163
4
43
54
50
22
5
178
MDBCC: multidisciplinary breast cancer clinic.
TABLE 3
Therapy Distribution of Control and MDBCC Groups
Intervention
Control (%)
MDBCC (%)
Control (no.)
MDBCC (no.)
Observation
Mastectomy
Radiation
Chemotherapy
Total
6
51
39
4
11
47
31
11
10
83
63
7
163
19
84
54
20
177
MDBCC: multidisciplinary breast cancer clinic.
of treatment, which, in the vast majority of cases, was
local therapy.
To assess patient satisfaction, questionnaires were
mailed to all patients in both the control (pre-MDBCC)
group and the MDBCC group. Patient anonymity was
ensured. Response rates were 67% and 44% for the
control and the MDBCC groups, respectively. Statistical analysis of the responses was performed utilizing
the chi-square method with Yates correction.
RESULTS
Characteristics of the two patient groups are summarized in Tables 2 and 3. The majority of patients were
diagnosed with early stage breast cancer (Stage 0 – II).
There was a statistically significant difference in treatment type between the two groups (P Å 0.02) in that
there were more patients who either received neoadjuvant chemotherapy or who underwent lumpectomy
alone in the MDBCC group. There was not a significant
difference between the groups regarding mastectomy
versus breast conservation.
Timeliness of Treatment
There was a statistically significant difference (P õ
0.0008) in the mean time from diagnosis to treatment
between the control group (42.4 days) and the MDBCC
group (29.6 days) (Fig. 1) Note that the multidiscipli-
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nary clinic group had a greater proportion of patients
who underwent lumpectomy alone. In many cases,
this implies a time interval from diagnosis to treatment
of 0 days. To exclude bias possibly introduced by this
incongruity, the authors tested the groups after exclusion of the ‘‘lumpectomy alone’’ patients. Their results
remained significant (P õ 0.001).
Patient Satisfaction
Two questions on the patient satisfaction questionnaire yielded significantly different responses when
comparing results from the control group with those of
the MDBCC group (P õ 0.001) (Table 4). The MDBCC
group responded more favorably in that the MDBCC
both encouraged support group involvement and
helped participants make a treatment decision.
DISCUSSION
The MDBCC was initially designed in an effort to provide supportive, coordinated and convenient care for
newly diagnosed patients. The results of the current
study have shown that patients are pleased with this
clinic model and that more timely care is provided.
Although the clinic discussed in the current study is
not unique, there is a paucity of literature on this subject. Rare articles address psychologic and/or logistical
problems encountered by patients, yet to the authors’
W: Cancer
Multidisciplinary Breast Cancer Clinic/Gabel et al.
2383
TABLE 4
Anonymous Questionnaire Responses
Control (n Å 108)
MDBCC (n Å 78)
Question
Yes
(%)
No
(%)
No Answer
(%)
Yes
(%)
No
(%)
No Answer
(%)
P value x2 with Yates
correction
Were family or friends encouraged to attend?
Did the consultation help you make a treatment decision?
Did nurses sufficiently answer questions?
Did the surgeon spend adequate time with you?
Did the radiation oncologist spend adequate time with you?
Did the medical oncologist spend adequate time with you?
58
62
86
87
70
82
39
30
14
13
9
11
3
8
0
0
21
7
87
80
83
88
86
74
9
7
7
4
2
5
4
13
10
8
12
21
õ0.001
õ0.001
NS
NS
NS
NS
MDBCC: multidisciplinary breast cancer clinic; NS: not significant.
FIGURE 1. Mean days from diagnosis to treatment as shown by group.
Solid circles: mean days for control group (pre-MDBCC), solid triangles:
mean days for the multidisciplinary breast cancer clinic group (MDBCC).
knowledge none to date communicate definite ideas
for improvement.1,2
Some important points relative to the patient survey should be noted. Approximately 21% of patients
in the control group provided ‘‘no answer’’ to the
questionnaire item related to their radiation oncologist, suggesting that these patients may not have been
evaluated by a radiation oncologist. Also, 21% of the
MDBCC group responded ‘‘no answer’’ when questioned about their medical oncologist. This was likely
a result of a higher percentage of ductal cancer in situ
patients seen in the MDBCC, thus reflecting that such
patients may not require routine thorough evaluation
by a medical oncologist.
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Timely access to care was improved by instituting
the MDBCC. The 6-week diagnosis to treatment interval observed in the control group may by representative of practices utilizing separately scheduled specialist referrals. The inefficiencies of the classic practice
of separate consultations for newly diagnosed breast
cancer patients have previously been delineated.3
Likewise, the management of breast cancer is not immune to inherent delays between treatment steps. Table 5 illustrates probable minimal time necessary for
each of these steps, not accounting for patient, physician, operating room, or radiology scheduling difficulties. According to this schema, the minimal time
that a patient would have to wait to undergo a mastectomy is approximately 2 weeks. Similarly, a patient
undergoing breast-conserving treatment must wait at
least 4 weeks before beginning treatment. The elapsed
time of 29.6 days in the current study is encouraging
when one considers that it approaches the minimal
elapse time as surmised in Table 5.
The reduction in therapy delay is due to at least
two factors. First, the authors’ same-day consultation
system allows for efficient evaluation by attendant
specialists. Second, patients are quickly referred to the
clinic after diagnosis. Importantly, the nursing coordinator sees that each patient diagnosed with breast
cancer in the Henry Ford Health Care System is referred to the next weekly MDBCC. Therefore, rapid
referral is a significant key to the clinic’s success in
minimizing treatment delay. The resultant effect on
future disease status is undetermined. Nevertheless,
the MDBCC is providing at the least a psychologic
benefit to its participants.
Patient satisfaction from participation in the
MDBCC was enhanced over that of nonparticipants.
This is due to seven observations that the authors believe are essential for a successful MDBCC: 1) there is a
dedicated nursing coordinator who gives each patient
W: Cancer
2384
CANCER June 15, 1997 / Volume 79 / Number 12
TABLE 5
Proposed Minimal Time Requirements in the Management of Breast Cancer
Interval
Time in days
Reason for delay
Definitive diagnosis to MDBCC
Appointment
MDBCC appointment to definitive surgery
2–8
Patient notification
Time until next weekly clinic
Further diagnostic tests
Adequate time for patient to process information and
to make treatment decision
Wound healing
Radiation simulation and treatment planning
Definitive surgery to start of radiation
therapy or of adjuvant chemotherapy
7
14
MDBCC: multidisciplinary breast cancer clinic.
personal attention from the time of initial diagnosis
to final therapy; 2) there is a minimal wait from diagnosis to MDBCC evaluation and to treatment; 3) all
relevant data (history, physical examination, pathology, and mammography) is available for discussion at
the MDBCC physician’s interspecialty conference; 4)
there is optimal intercommunication among attendant specialists; 5) an educational seminar provides
patients with basic knowledge about breast cancer; 6)
the specialists express a unified therapy plan during
the individual patient evaluations; and 7) the patient’s
support group (family or friends) is encouraged to attend the MDBCC with the patient.
As noted, patients feel better informed to make a
treatment decision from attending the MDBCC when
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compared with non-MDBCC consultation. This is
likely due to the latter three factors listed above. Of
paramount importance is that the success of the
MDBCC is highly dependent on employing a sincere
and competent nursing coordinator.
REFERENCES
1.
2.
3.
McFall SL, Warnecke RB, Kalunzy AD, Aitken M, Ford L.
Physician and practice characteristics associated with judgments about breast cancer treatment. Med Care 1994;32(2):
106–7.
Dest VM, Fisher M, Breast cancer: dreaded diagnosis, complicated care. RN 1994;June:48–54.
Zavertnik JJ, McCoy CB, Robinson DS, Love N. Cost-effective
management of breast cancer. Cancer 1992;69(7 Suppl):
1979–84.
W: Cancer
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