The Effect of a Multidisciplinary Thoracic Malignancy Conference on the Treatment of Patients With Esophageal Cancer

Transcription

1 The Effect of a Multidisciplinary Thoracic Malignancy Conference on the Treatment of Patients With Esophageal Cancer Richard K. Freeman, MD, Jaclyn M. Van Woerkom, RN, BSN, Amy Vyverberg, RN, BSN, and Anthony J. Ascioti, MD Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana Background. There is a paucity of data evaluating whether a multidisciplinary conference coordinating surgery, chemotherapy and radiation therapy translates into better patient care. This review compares the experiences of patients with esophageal cancer before and after the formation of a prospective, multidisciplinary thoracic malignancy conference (TMC). Methods. The records of patients with carcinoma of the esophagus at a tertiary care hospital were reviewed for completeness of staging, multidisciplinary evaluation before the initiation of therapy, time from pathologic diagnosis to treatment, multimodality therapy, and adherence to national treatment guidelines. Summary data were compared for patients treated before and after the TMC was initiated. Results. Between 2001 and 2007, 117 patients were treated before the initiation of the TMC and 138 patients within the TMC. The number of patients receiving, respectively, a complete staging evaluation (67% and 97%, p < ), multidisciplinary evaluation before therapy (72% and 98%, p < ), and adherence to National Comprehensive Cancer Network treatment guidelines (83% and 98%, p < ) all increased significantly, whereas mean days from diagnosis to treatment significantly decreased (27 and 16, respectively; p < ). Conclusions. A multidisciplinary TMC increased the percentage of patients receiving complete staging, a multidisciplinary evaluation, and adherence to nationally accepted care guidelines while decreasing the interval from diagnosis to treatment significantly. While the ultimate goal of treatment is to improve patient survival, the surrogate variables examined in this review indicate that patients with esophageal cancer benefit from being evaluated in a prospective, multidisciplinary manner. (Ann Thorac Surg 2011;92: ) 2011 by The Society of Thoracic Surgeons Multidisciplinary care conferences (MDCC) and clinics for patients with carcinoma of the esophagus involving physicians specializing in medical and radiation oncology, gastroenterology, thoracic surgery, radiology, and pathology are becoming more common as the staging and treatment of these patients has become more complex. We and others. have shown that there are measurable advantages to coordinating the care of patients with other forms of malignancy through such a mechanism [1 4]. However, there is a paucity of published information delineating any specific value-added features of such a conference for esophageal cancer patients. This investigation summarizes a comparison of patients with esophageal cancer treated before and after the establishment of a prospective, multidisciplinary thoracic malignancy care conference (TMC). Accepted for publication May 16, Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31 Feb 2, Address correspondence to Dr Freeman, 8433 Harcourt Rd, Indianapolis, IN 46260; rfreeman@corvascmds.com. Material and Methods All patients treated for carcinoma of the esophagus at a tertiary care medical center between January 2001 and December 2007 were identified using the institution s tumor registry. The institution s Institutional Review Board approved this protocol and waived individual patient consent for this investigation. A retrospective analysis of these patients records was then performed. Demographic data, completeness of staging, multidisciplinary evaluation before the initiation of therapy, time from pathologic diagnosis to treatment, and adherence to the National Comprehensive Cancer Network (NCCN) treatment guidelines in effect at the time of diagnosis were all assessed [5]. Two study groups were populated based on whether a patient had their care prospectively coordinated through the institution s multidisciplinary TMC or were diagnosed and treated before the conference s establishment. After the initiation of the TMC, it was the intention to present all newly diagnosed esophageal cancer patients at the conference. Presentation of the patient at a traditional, retrospective tumor board was not considered equivalent to the prospective TMC. Also excluded from this analysis were patients who refused all forms of treatment after their diagnosis by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 1240 FREEMAN ET AL Ann Thorac Surg MULTIDISCIPLINARY ESOPHAGEAL CANCER CARE 2011;92: Table 1. Comparison of Patient Demographics and Outcomes Between Two Patient Groups With Esophageal Cancer MDCC MDCC p Value Age, mean years Range Histology Adeno 113 (97%) 132 (96%) 0.76 Squamous 4 (3%) 6 (4%) 0.76 Stage I 16 (14%) 19 (14%) 1.0 II 31 (26%) 39 (28%) 0.78 III 56 (49%) 65 (47%) 1.0 IV 14 (11%) 15 (11%) 0.84 Chemotherapy Neoadjuvant (T 3 /N 1 ) Adjuvant presented at the Thoracic Malignancy Conference; MDCC refers to patients presented at the conference; neoadjuvant refers to patients receiving chemotherapy before an intended esophagectomy (T 3 and/or N 1 ); and adjuvant refers to patients receiving chemotherapy after surgery and does not include patients receiving chemotherapy before surgery who had additional chemotherapy after therapy. Analysis of data was carried out using GraphPad Prism software 4.02 (San Diego, CA) for Windows (Microsoft, Redmond WA). Continuous data are expressed as the mean SD except where otherwise indicated. Differences between categorical variables were evaluated by Fisher s exact test. Differences between continuous variables were measured by the two-tailed Student t test or the Mann-Whitney test for nonnormally distributed data. A value of p less than 0.05 was considered significant. Definitions COMPETE STAGING EVALUATION. A minimum of computed tomography and positron emission tomography scans, esophagogastroduodenoscopy, bronchoscopy, complete blood count, electrolyte profile, endoscopic esophageal ultrasonography, biopsy confirmation of suspected metastatic disease, and further evaluation of any specific symptoms [5]. MULTIDISCIPLINARY EVALUATION BEFORE THE INITIATION OF THERAPY. At a minimum, an evaluation by a thoracic surgeon, gastroenterologist, radiation oncologist, and medical oncologist for patients with carcinoma of the esophagus. ADHERENCE TO NCCN GUIDELINES. Compliance with the NCCN guidelines for the staging and treatment of esophageal cancer in effect at the time of diagnosis. Patients who refused recommended studies or therapies were counted as being in compliance with the guidelines as long as documentation existed. Similarly, patients whose performance status or other factors prevented them from participating in a particular form of therapy indicated by the guidelines were not counted as deficiencies as long as alternative therapy was offered. DAYS FROM DIAGNOSIS TO TREATMENT. This interval was defined in days from the time of pathologic diagnosis until the initiation of any treatment (chemotherapy, radiation therapy, or surgery). Results Between January 2001 and December 2004, 129 patients were diagnosed with esophageal cancer at the study institution before the initiation of a TMC. Subsequently, 152 patients were diagnosed with carcinoma of the esophagus from January 2005 through December 2007 and were presented prospectively to a bimonthly care conference that included thoracic surgeons, medical and radiation oncologists, and gastroenterology and radiology physicians. Of these patients, 117 and 138 patients, respectively, met this investigation s entrance criteria and were included for analysis. Demographic data for the two groups are summarized in Table 1 and are comparable. Specifically, patient age, the distribution of tumor histology, and tumor stage did not differ significantly between the two groups. The number of patients who refused recommended therapy also did not differ between the two groups (not displayed). Significant differences between the two patient groups, however, can be demonstrated and are indicated in Table 2. Specifically, patients who received a complete staging evaluation utilizing appropriate imaging or invasive techniques before the initiation of treatment, patients who received a multidisciplinary evaluation defined as an assessment from a thoracic surgeon, gastroenterologist, medical, and radiation oncologist before treatment, and patients whose care could be documented to adhere to the NCCN practice guidelines were significantly more frequent among patients presented at the TMC. Patients who were presented at the TMC were also found to have Table 2. Comparison of Outcomes Between Two Patient Groups With Esophageal Cancer MDCC MDCC p Value Complete staging 78 (67%) 134 (97%) Multispecialty evaluation 84 (72%) 135 (98%) Diagnosis to treatment, mean days NCCN guidelines 97 (83%) 135 (98) Palliative care 18 (15)% 35 (25%) Hospice care 14 (12%) 29 (21%) Research registration 13 (11%) 27 (20%) presented at the Thoracic Malignancy Conference; MDCC refers to patients presented at the conference. NCCN National Comprehensive Cancer Network.

3 Ann Thorac Surg FREEMAN ET AL 2011;92: MULTIDISCIPLINARY ESOPHAGEAL CANCER CARE Table 3. Comparison of Surgery Between Two Patient Groups With Esophageal Cancer MDCC MDCC p Value Endoscopic mucosal resection 3 (3%) 13 (9%) Surgical resection Curative intent Transhiatal esophagectomy 2 3 Laparotomy/thoracotomy R R ntherapeutic Operative mortality 3 (4.2%) 4 (4.9%) 1.0 presented at the Thoracic Malignancy Conference; MDCC refers to patients presented at the conference; curative intent indicates patients undergoing esophagectomy with the intention of resecting all disease; laparotomy/thoracotomy indicates esophagectomy through laparotomy and right thoracotomy; R 0 refers to patients in whom all disease was resected with all margins free of tumor, R 1 refers to microscopically positive margin at the time of resection; and nontherapeutic indicates patients who underwent surgery with curative intent but were found to have unresectable disease. a significantly shorter mean interval from the initial pathologic diagnosis to the initiation of treatment when compared with patients diagnosed before the establishment of the conference. Other differences between the two groups were also recognized. Specifically, the percentage of endoscopic mucosal resection of T 1 cancers in eligible patients was greater when care was coordinated through a TMC. This finding was attributed directly to the conference s ability to produce a discussion between physicians regarding patients who could be managed without esophagectomy with early stage esophageal cancer. Two other differences were identified that approached but did not reach statistical significance between the two patient groups. Patients receiving palliative or hospice care were more frequent among patients presented at the TMC. Similarly, a higher percentage of patients presented at the conference were enrolled in local, national, or international research protocols than patients treated before the conference was established. However, the percentage of patients with T 3 or N 1 esophageal cancer who underwent neoadjuvant (preoperative) chemotherapy or chemoradiation therapy did not differ between the two groups nor did the percentage of patients undergoing surgery with curative intent after neoadjuvant chemotherapy or chemoradiation therapy (Table 3). Similarly, the number of patients undergoing a complete surgical resection (R 0 ) did not differ significantly between the two groups nor did operative mortality. There was also not a significant difference in the number of patients undergoing a nontherapeutic surgical procedure. After esophagectomy with curative intent, no difference in the percentage of patients treated with adjuvant therapy, when indicated, was seen as well. Comment 1241 Patients with many forms of solid organ malignancy now undergo more than one form of treatment. Owing to the continued poor survival of patients with locally advanced carcinoma of the esophagus, clinicians have increasingly considered multimodality therapy, including a combination of surgery, systemic chemotherapy, and external beam radiotherapy. As thoracic surgeons, medical and radiation oncologists, and other physicians and nonphysicians become involved in the care of such patients, developing a treatment plan that encompasses the expertise of all these providers becomes complex. Without proper coordination, the unintended results for patients can be excessive imaging studies, inaccurate staging assignment, significant delay or interruption of treatment, lack of consideration of all surgical and nonsurgical treatment or palliative options, and excessive or inadequate follow-up care. Success in coordinating the care of patients with other malignancies requiring complex care has been reported. Baldwin and colleagues [2] and Fairchild and associates [3] found measurable benefits in the care of patients with breast cancer including higher rates of breast conservation, multimodality therapy, and pain management. Pawlik and coworkers [4] similarly found improvements in the care of patients with pancreatic cancer. Specifically, their investigation found that a significant change in a patient s treatment occurred in 25% of cases with the application of a coordinated multidisciplinary approach. The treatment of patients with another intrathoracic malignancy using a coordinated, multidisciplinary approach has also been shown to have some advantages. Leo and associates [6] summarized the outcomes of 344 patients presented at a multidisciplinary lung cancer treatment conference over a 1-year period. They found that the conference produced a high rate of acceptance of a recommended treatment by patients and their primary physicians and resulted in a median time to treatment of 16 days for chemotherapy and 27 days for radiation. Unfortunately, their study did not have the benefit of a control group, did not assess the adequacy of staging or adherence to any standardized treatment guidelines, and did not attempt to analyze patients receiving multimodality treatment including neoadjuvant therapy and surgery. The study did identify a trend for an increase in survival in patients treated using a MDCC that did not reach statistical significance. Riedel and associates [7] also compared historical cohorts of patients with lung cancer treated during a multidisciplinary thoracic oncology clinic and after it closed at a single center between 1999 and They failed to find a significant improvement in the timeliness of care patients received who were cared for in the TMC. They identified potential confounders in their study as the lack of a thoracic surgeon in the clinic and the continuation of a multidisciplinary care conference after the multidisciplinary clinic closed.

4 1242 FREEMAN ET AL Ann Thorac Surg MULTIDISCIPLINARY ESOPHAGEAL CANCER CARE 2011;92: Our group subsequently reported a comparison of patients with lung cancer treated before and after the establishment of a TMC [1]. We were able to demonstrate a significant increase in the percentage of patients receiving a complete staging evaluation, a multidisciplinary evaluation before the initiation of treatment and adherence to national care guidelines. Also recognized was a shorter time interval from diagnosis to treatment. Based on the previous discussion, it would seem intuitive that a prospective MDCC would benefit patients with esophageal cancer as well. However, despite the United Kingdom Department of Health recommending such an approach for patients with esophageal cancer in 2001, few published data exist as to whether such an approach produces a meaningful difference in the way patients with esophageal cancer are treated [8]. Davies and coworkers [8] in a report of 118 patients with a newly diagnosed gastric or esophageal cancer were able to show that a MDCC resulted in a more accurate clinical staging of patients who were to undergo surgery. Their investigation did not incorporate an external control group and did not analyze the gastric and esophageal cancer patients separately. Stephens and colleagues [9] subsequently demonstrated a decrease in nontherapeutic surgical procedures in patients with esophageal cancer whose care was coordinated through a multidisciplinary clinic, also implying improved clinical staging. They also found a lower operative mortality and an improved 5-year survival in patients whose care was coordinated through a MDCC. Their study did use a historical control group. However, their findings are confounded by the use of general surgeons in the control group and thoracic surgery specialists in the multidisciplinary care group. This investigation compares two groups of patients with esophageal cancer treated by the same physicians at a tertiary care hospital either before or after the establishment of a prospective MDCC. Our findings would appear to support the idea that patients with carcinoma of the esophagus do realize tangible benefits from having their care coordinated through such a conference. These included a more complete staging evaluation, more frequent multidisciplinary evaluation before the initiation of treatment, increased adherence to national care guidelines, and a shorter interval from diagnosis to treatment. An increase in the percentage of eligible patients undergoing endoscopic mucosal resection was also recognized. Furthermore, although a direct comparison was not made, such a conference appears to produce these beneficial effects without the need to see patients in a multidisciplinary clinic setting with its inherent complexities. Some unanticipated findings were also recognized from this study. Patients receiving palliative or hospice care were more frequent among patients presented at the TMC. Advanced stage esophageal cancer patients can have significant quality of life issues, which we found were managed more comprehensively by the MDCC. Similarly, a higher percentage of patients presented at the conference were enrolled in local, national, or international research protocols than patients treated before the conference was established. Although this study is unique in its design and subject, it does have some limitations. This investigation represents a single institution s experience. Furthermore, the cohort of patients treated before the establishment of the care conference was assessed retrospectively, which prevented the inclusion of quality of life and patient satisfaction assessments. While the benefits realized appear to be significant, the authors also realize that the ultimate goal in assessing the care of patients with esophageal cancer is to improve survival, which is not quantifiable at present between the patient groups. In conclusion, this investigation found compelling evidence that a prospective MDCC improved the timeliness and quality of care received by patients with esophageal cancer. Additional benefits of such a conference may include increased accrual to research protocols, more frequent use of palliative and hospice care, and less invasive endoscopic therapy when appropriate. Based on these results, future investigation of the effects of an MDCC on malignancies as well as any impact such a conference may have on resource utilization, patient satisfaction, overall survival, and quality of life are warranted. References 1. Freeman RK, Van Woerkom J, Vyverberg A, Ascioti AJ. The effect of a multidisciplinary thoracic malignancy conference on the treatment of patients with lung cancer. Eur J Cardiothorac Surg 2010;38: Baldwin LM, Taplin SH, Friedman H, Moe R. Access to multidisciplinary cancer care: is it linked to the use of breast conserving surgery with radiation for early stage breast carcinoma? Cancer 2004;100: Fairchild A, Pituskin E, Rose B, et al. The rapid access palliative radiotherapy program: blueprint for initiation of a one-stop multidisciplinary bone metastases clinic. Support Care Cancer 2009;17: Pawlik TM, Laheru D, Hruban RH, et al. Evaluating the impact of a single-day multidisciplinary clinic on the management of pancreatic cancer. Ann Surg Oncol 2008;15: National Comprehensive Cancer Network Guidelines for the treatment of esophageal cancer. Available at: nccn.org/professionals/physician_gls/f_guidelines.asp#site. 6. Leo F, Venissac N, Poudenx M, Otto J. Multidisciplinary management of lung cancer: how to test its efficacy? J Thorac Oncol 2007;2: Riedel RF, Wang X, McCormack M, et al. Impact of a multidisciplinary thoracic oncology clinic on the timeliness of care. J Thorac Oncol 2006;1: Davies AR, Deans DA, Penman I, et al. The multidisciplinary team meeting provides staging accuracy and treatment selection for gastro-esophageal cancer. Dis Esophagus 2006;19: Stephens MR, Lewis WG, Brewster AE, et al. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Dis Esophagus 2006;19:

5 Ann Thorac Surg FREEMAN ET AL 2011;92: MULTIDISCIPLINARY ESOPHAGEAL CANCER CARE DISCUSSION DR MARK KRASNA (Baltimore, MD): Rich, that was an excellent presentation, and congratulations on following up from your prior work on lung cancer and multidisciplinary care. Actually, I m particularly impressed that even those patients who did not get multidisciplinary care got combined-modality therapy. I m curious to hear how you were successful in achieving this. I have two specific questions and then just a final comment. Can you tell us whether there was participation of both private practice thoracic surgeons and other physicians or were all the physicians who took part in the multidisciplinary conference employed physicians? I think it s very helpful to understand how you can get people together, as we ve discussed. Finally, you do mention it in your last slide, so you almost preempted my question, obviously there is not an exact simile between the clinic and a conference. At our institution, as you know, we do a multidisciplinary clinic where we actually see all the esophageal cancer patients together. What do you anticipate might be the added benefit of doing the multidisciplinary clinic? My last comment is just for the rest of the group. As you know, we currently will be participating in an NCI grant actually looking at multidisciplinary care in a prospective fashion. Thank you. I enjoyed your paper. DR FREEMAN: Thank you, Mark. Just to elaborate a little bit, Dr Krasna is the lead primary investigator for a multiinstitutional trial sponsored by the NCI to look at these questions, which we are lucky enough to be a part of. Mark, all of our oncology physicians right now are private practice physicians. This was a private practice model and they come and they participate. One of the questions was, is this worth the effort. That s why we looked at this. The idea of a clinic certainly makes intuitive sense, and what little literature is out there might suggest that there is not a lot of benefit. I see Dr D Amico and he may answer this question because they did some research on this a few years ago, but it was interesting to us to see that we did get a significant benefit without having the clinic, which can be very inefficient for physicians. Your other comment was about chemotherapy. I think we had a pretty good arrangement with the medical and radiation oncologists. I was happy to see that people received the therapy most of us think is correct. DR THOMAS A. D AMICO (Durham, NC): Dr Freeman, this is going to be a terrific addition to the literature. It s long overdue, and I really appreciate that you did it. My question is specific, though, about NCCN guidelines and concordance and discordance with NCCN recommendations. Even in the non-patients, the 83% concordance is quite good. It s not as good as the 98% concordance in the other group, but the guidelines have so many different decision-making nodes that it is difficult to do better than that. Can you be specific about what were the more common ways that the treatment was discordant with the NCCN guidelines in the non-patients? DR FREEMAN: That s an excellent question. In fact, I think if we could have a crystal ball, what we might see is that it was better documented after the MDC conference. In the chart reviews that I participated in, we couldn t always document that things were done along the pathway, even though we hoped that they were, and those counted against us. So it may be a little bit of an artifact of retrospective versus somewhat of a prospective approach. It is complicated, you re right, and the guidelines changed during this period of time, as you know, since you re on that committee, but we felt like we were able to be more specific in the patients who were through the MDC that we had followed them carefully. DR D AMICO: Thanks. Great paper DR DANIEL MILLER (Atlanta, GA): Dr Freeman, that was excellent presentation. I was very impressed by the amount of early-stage disease that you brought to that conference. You had a significant number of EMRs that were performed, usually we don t see those patients presented at a multidisciplinary conference. I applaud you. How did that occur? Was it because the gastrointestinal physicians were present or was it from a different mechanism? DR FREEMAN: I think two mechanisms. One, we see a lot of reflux and Barrett s. The other answer is that all patients with an esophageal cancer are presented in conference now so we may see more of them as surgeons than we did before the conference was initiated. DR MILLER: Also, I just got a text from my daughter, who is a nursing student at University of Alabama, that ObamaCare was overturned today as being unconstitutional by a federal judge in 24 states. So for now, I think you can continue to have your multidisciplinary conferences.