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Grand Rounds

All together now

By Burton Eisenberg, M.D.

Cancer is not a single disease. Even a specific type of cancer is really many diseases based on different molecular signatures. Only multiple specialists, all working in concert to deliver the best possible care, can address the complexity that is inherent in certain types of cancers. Academic medical centers are well suited to provide this kind of expert and integrated care, which is not readily available in community settings.

Dartmouth's Norris Cotton Cancer Center has been developing this type of integrated care for several years and extended such services in February 2006 with the opening of our Interdisciplinary Breast Cancer Clinic. This clinic is a significant expansion of our Comprehensive Breast Program, which helps to guide patients through the care process, provides them with educational information, and connects them to DHMC's Center for Shared Decision- Making to learn about relevant treatment options. The Interdisciplinary Clinic goes a step further and now makes it possible for providers across a range of disciplines to see patients, administer care, and interact with each other in order to share information and coordinate treatment for each patient. This model is becoming more common around the country in other National Cancer Institute (NCI)-designated comprehensive cancer centers like Dartmouth's.

Array: Clinical decision-making in breast cancer revolves around a complex set of issues: a growing array of sophisticated diagnostic procedures; a range of significant treatment options in surgery, radiation, and chemotherapy; many judgments about the order in which those treatments are best given; and rapid changes in the science and technology shaping the treatment of breast cancer. It's easy to see how much more effective we can be in caring for patients if there is a collective thought process that involves all the experts, and the patient, in making those decisions.

In our Interdisciplinary Breast Cancer Clinic, a breast-cancer patient can address the gamut of her concerns with a number of experts who meet with her and each other at the same time. Whether providing a second opinion, a treatment plan, or ongoing therapy, the

It's easy to see how much more effective we can be in caring for patients if there is a collective thought process that involves all the experts, and the patient, in making those decisions.

interdisciplinary clinic model focuses on giving the patient the whole picture. This meets her needs instead of conforming to a myriad of doctors' schedules. It's a different way of practicing medicine.

Take the example of a young woman with newly discovered breast cancer. Fortunately her cancer is relatively small, but she is very motivated to get aggressive therapy. At the same time, she is concerned about all kinds of other issues, including her body image, her young children, and her concern about not knowing exactly what the future holds for her.

In the Interdisciplinary Breast Cancer Clinic, we address these kinds of issues during the patient's first visit, when she meets with the nurse coordinator, a breast-care social worker, and the shared decision-making support service. Our process begins with discussion, education, and information-sharing to ensure that the young woman as well as her numerous providers will have all the necessary information to make carefully considered, appropriate medical decisions.

On her next visit, the young woman will be evaluated by a surgical oncologist,

who may discuss with her a range of procedures, such as breast preservation surgery and outpatient evaluation of her lymph nodes. After consultation with the radiation oncologist, the surgeon may suggest partial-breast radiation therapy as an alternative to whole-breast irradiation.

Support: In successive visits during her treatment, the young woman can choose to schedule appointments with different physicians on the same day. If her biopsy reveals a need for postoperative chemotherapy, a medical oncologist will be involved in her care. She also may see additional providers, such as the clinical research associate, who will work with her if she enrolls in a clinical trial; the physical therapist, who may help ward off problems with lymphedema; and the breast-care social worker, who will provide support for transportation, child care, or any number of issues that may arise over time.

This system of highly integrated care is not something the young woman is apt to find in many other settings. Elsewhere, specialist visits are likely to be separate and in different locations. There may be a lack of timely communication among physicians, too. At times, the young woman may feel like it's her responsibility to carry information from one doctor to the next and from one appointment to the next, often in a language she doesn't completely understand.

Integrated: The Interdisciplinary Breast Cancer Clinic—with its emphasis on multidisciplinary scheduling, coordination, and integrated management of an individual's particular cancer—is an example of what overall cancer care at Norris Cotton Cancer Center is expected to look like in the future. As an NCI-designated cancer center, we need to continue to develop and provide innovative, technologically appropriate advances and therapies for patients with malignancies. At the same time, we need to engage in ongoing self-evaluation of what it is that we are doing and how well we are doing it. Reevaluating how we deliver cancer care is a natural progression in the overall growth and development of the entire Medical Center and its role in the advancement and delivery of high-quality, evidence-based, patient-centered, patient-friendly care to its region and beyond.

The "Grand Rounds" essay concerns a topic of interest to the Dartmouth medical faculty. Eisenberg is a professor of surgical oncology at DMS and the deputy director of Dartmouth's Norris Cotton Cancer Center. He joined the Dartmouth faculty in 2003.

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