What started as tumor board conferences a decade ago has grown into a true multidisciplinary team approach to comprehensive breast care. ProHealth Care’s Center for Breast Care at Waukesha Memorial Hospital’s Regional Cancer Center in Waukesha, Wisconsin, is an interdisciplinary breast cancer clinic where patients can see multiple specialists in one visit. With the opening of the clinic, the various specialists involved in patient care can talk to each other about a patient in real time, not replacing tumor board conferences, but taking patient care to the next level.
“One of the things that are really hard for patients is the amount of information coming at them when they first are diagnosed with breast cancer, understanding what that all means. In addition, they hear about meeting a surgeon and the treatment the surgeon might offer, and that they might be meeting a radiation oncologist, and later even a medical oncologist. It is all these nebulous specialists they are hearing about out in their future,” explained Katherine M. Bayliss, MD, medical director of the Center for Breast Care. “Instead what we do is create this team of specialists that they can meet and sort of get their arms around upfront; they are real people. The patients can get an understanding upfront about the various roles the specialists play. They are also then connected with the other team members, such as the geneticist or others that offer supportive services.”
Building the approach
The Center for Breast Care instituted its comprehensive breast services in phases. At its beginning in 1995, the center served mainly as a screening/ diagnostic center, where patients received immediate results of their imaging. Also available since that time are two nurse care coordinators who “help navigate the patients in our health system, providing education and support from the time of abnormal mammogram and breast cancer diagnosis to follow-up care, including surgical visits and periodic phone checks. We link them with our community resources,” explained Michelle Willman, RN, BSN, OCN, CBCN, one of the nurse care coordinators.
In September 2009, an onsite breast surgeon was installed and the interdisciplinary clinic begun. To round out the staff, a group of surgeons is available to see patients, as are medical and radiation oncologists, specially trained radiologists and technologists dedicated to breast imaging, and pathologists specializing in breast cancer diagnosis. Support services are also offered, including a dietitian, a genetic counselor, a supportive care coordinator, a social worker, and a financial counselor.
The weekly conferences allow all the specialists to discuss as a group what is in the best interest of each patient. These discussions provide an avenue for all disciplines to interact and learn. Bayliss, a pathologist, gave this example: “Over time as you share these discussions and treatment plans, there is greater understanding of what each other’s roles are, what each other’s issues might be, what information I might have that might matter to physicians taking care of that specific patient or vice versa. The lines of communication become much better, and our understanding of what each person does and what the nuances are of the pieces that they need to know becomes more evident. From a pathology standpoint, I think that I have done a better job of presenting information for my colleagues who treat the patient because I have a better understanding of what they are up against. Conversely, I think that my clinical colleagues have come to better understand things that aren’t so black and white for us, things that can be challenging for us, how they can help us interpret a patient’s pathology specimen by providing us the right information.”
This holds true for the radiologists as well. “It gets us more involved. As breast imagers, we like to be more involved in patient care, and the weekly tumor conferences give us a way of making recommendations and lending expertise to their care,” said Jennifer T. Bergin, MD, a radiologist, who is the director of breast imaging.
Now that everyone can interact daily in the clinic, discussion has been turned up a notch. “Typically, we will discuss a patient in that week’s conference, for which we have gathered as much information that is available, then come up with a plan. Then, we may meet that patient later in the week, or even that same day. There may or may not be additional information available at that time, for example, the hormone receptor profile may have returned in the interim or radiographic data,” explained Peter Johnson, MD, a medical oncologist. “We will then incorporate that new information into the plan and see the patient at the clinic visit.”
It also offers each physician a chance to “know exactly what the surgeon was thinking or why something happened,” James C. Jones, MD, a radiation oncologist, told The Oncology Nurse-APN/PA. In addition, all team members “can express a concern, explaining why they would rather do this than that.”
And this interaction can involve specialists beyond just medical, surgical, and radiation oncologists. If a radiologist is needed, for example, when a patient comes from another healthcare system, then the radiologist is involved prior to the patient’s day of appointment, talking to the patient and the other care providers, explained Bergin.
“It is extremely rewarding, just being able to talk with the physicians and talk with the genetic counselors. Having that interaction is really rewarding and important, and having everybody in one place fosters that communication,” said Kelli K. Pettit, MD, a surgical oncologist. This face-to-face real-time interaction with colleagues during a patient visit not only provides the specialists an opportunity to understand what information the patients receive from the other physicians but also gives patients information about their treatment, according to Pettit.
Improving patient care
All this communication leads to enhanced patient outcomes. Over time the ongoing interaction between pathologists and surgeons has improved the ability to accurately assess margins, ensuring that the orientation of the specimen is optimized, and confidence that the tumor was completely excised, according to Bayliss.
Moreover, patient waiting times are kept short. Willman gave these examples: “If a patient needs a biopsy, the time from abnormal mammogram to biopsy may be as soon as same day to within 1 to 2 weeks per patient preference. The time to get to the surgeon appointment is 1 to 2 days. Many of our patients are having surgery within 1 to 2 weeks of their diagnosis. Once we have all the pathology, oncologist consults occur quickly.”
In addition, the Center for Breast Care offers a more holistic approach to patient care. To complement traditional oncology treatments, the center incorporates supportive oncology including dietary nutrition support, emotional support, and Reiki and relaxation therapy. For Pettit who finished her fellowship training in June 2009, “I probably offer my patients more of those healing therapies and talk to them more about the supportive aspects of our care as opposed to focusing just on the medicine aspect. Obviously, we talk about the surgery, we talk about chemotherapy. But I’ve also realized that most patients at some point during their treatment are looking for something else, something to make them feel empowered. I think that some of those other therapies, the nutrition, the Reiki therapy, the counseling, provide this for the patients.”
The team believes that the multidisciplinary aspect affords optimal care in general and that the clinic provides the best vehicle for that approach. “Having the multidisciplinary clinic after not having one for 16 years,” said Jones, “has been more beneficial than I might have imagined it would have been for communication and providing the best care for the cancer patients.” Johnson seconds that opinion: “We have had excellent feedback from patients about how they have come away from their visits quite gratified and reassured that they at that point have received a comprehensive assessment of their situation and a plan for dealing with it.”
The Center for Breast Care has not only received positive feedback from patients. It also has received recognition from peers. ProHealth Care’s Regional Cancer Center, of which the breast center is a part, has been awarded a contract to the National Cancer Institute Community Cancer Centers Program, making it one of 30 such community cancer centers in the nation.