Multidisciplinary care for women with early breast cancer in the Australian context: what does it mean?

Multidisciplinary care is a team approach to the provision of healthcare by all relevant medical and allied health disciplines. In 1995, multidisciplinary care was recommended, by a House of Representatives inquiry, as a means of achieving best practice: “through their combined understanding . . ., all members of the team liaise and co-operate together and with the patient to diagnose, treat and manage the condition . . . to the highest possible standard of care”.1

For women with breast cancer, there is evidence that multidisciplinary care has the potential to reduce mortality, improve quality of life and reduce healthcare costs.2-4 In one US study, the initial treatment recommendations received by women during single or sequential consultations were compared with a second opinion provided by a multidisciplinary panel.5 For 43% of the women, the treatment recommended by the multidisciplinary panel differed from that recommended by the individual physicians and was more likely to accord with internationally accepted standards of “best practice”. Without multidisciplinary team input, treatment options for women with breast cancer may be limited to those that are within the field of expertise of the individual clinician, and psychosocial issues may not be considered.

There is no universally accepted model of multidisciplinary care. A number of cancer centres around the world have established multidisciplinary clinics that aim to deliver a “one-stop shop”, enabling women with newly diagnosed breast cancer to see appropriate specialists from various disciplines at the one clinic on the same day.5-8 Some cancer centres hold treatment planning meetings that include all relevant specialists as well as the woman herself. Other centres focus on providing information and psychosocial support, in a multidisciplinary setting, to women during their first postoperative consultation.9 In the United Kingdom, the restructuring of cancer services as outlined in the Calman–Hine Report supports the delivery of best care through designated Cancer Units.10 These units provide specialist diagnostic and therapeutic expertise, together with facilities for managing common cancers.

In Australia, multidisciplinary care is widely recommended as the preferred approach to managing breast cancer.1,11,12 In its Clinical practice guidelines for the management of early breast cancer, the National Health and Medical Research Council (NHMRC) recommends that women with breast cancer should have access to the full range of multidisciplinary treatment options,11 but does not define any particular model of multidisciplinary care or address ways in which it could be implemented.

The Australian healthcare system also faces the challenge of providing equity of care for women living in rural or remote locations. Up to 30% of Australian women diagnosed with breast cancer live in rural or remote areas,13 where there is often limited access to specialists (such as medical and radiation oncologists) and diagnostic, supportive and therapeutic services. Even in Darwin, a city of medium size, women do not have access to a specialist radiation oncology service — the nearest service is in Adelaide, over 3000 kilometres away.

The difficulty of providing multidisciplinary care in the Australian context is illustrated by the results of a survey14 of 150 surgeons about their opinions of the NHMRC’s clinical practice guidelines.11 While surgeons were generally positive about the guidelines, 44% of rural and 10% of urban surgeons disagreed with the recommendation that “women should ideally be treated by a specialist who treats a large number of similar patients and who has access to the full range of treatment options in a multidisciplinary setting”. Moreover, 34% of rural and 11% of urban surgeons felt it would be difficult to implement this recommendation in their practice.

Because of the diversity of healthcare service delivery settings and models of care in Australia, it is not appropriate to have a fixed approach to implementing multidisciplinary care. For example, the common approach in the United Kingdom of having all members of a multidisciplinary team attend weekly face-to-face meetings to discuss patient management would not always be feasible in Australia, where a surgeon may work 2500 kilometres away from a treatment centre, there may not be a dedicated breast pathologist, and there may not even be a clinic.

Subsequent to the House of Representatives inquiry,1 a National Multidisciplinary Care Demonstration Project15 was commenced in February 2000 to investigate the implementation of a flexible approach to providing multidisciplinary care for Australian women with breast cancer. A subgroup of the project steering committee was given the task of developing a set of principles of multidisciplinary care to guide the project.

An operational definition of multidisciplinary care in the Australian context was required. The working group examined common elements in overseas approaches to care3,4 and consulted consumer representatives, senior clinicians and allied health professionals involved in caring for women with breast cancer across Australia. The key elements of care, as identified from research and reports and informed by the experience and knowledge of Australian experts, were used to determine a set of principles of care provision (Box).

Rather than describing a specific model of care, the “Principles of multidisciplinary care” aim to accommodate a variety of delivery models and to enable clinicians to apply them according to the geographical, social and cultural context in which they work. For example, psychosocial care may be delivered in a variety of ways: by an on-site psychologist and breast nurse, by a travelling oncology nurse, or by a psychologist located many kilometres away (via teleconference).

The five Principles emphasise the importance of the team approach, good communication, having access to the full range of therapies, maintaining standards of care, and involving the patient in decision-making. The implementation of each Principle aims to achieve particular outcomes (Box), but the means by which these outcomes are achieved are flexible, depending on local services, needs and skills. Moreover, each outcome is measurable.

1. Team. This Principle identifies the core disciplines integral to providing good care. In addition to specialist providers, the general practitioner is included as a core team member, and may play a number of roles in all stages of the disease process, including diagnosis, referral, treatment, coordination of care, continuity of care, and provision of information and support to the woman and her family. Also included in the core team is a supportive care provider (eg, a specialist breast nurse, oncology nurse or social worker) who deals with the psychosocial aspects of care. In areas where specialist services (eg, in psychiatry, psychology or genetics) are not available locally, referral links with such services should be established.

2. Communication. It is important that all team members be available for regular interactive case-conferencing to develop a management plan. However, it is recognised that there are a number of ways in which this may be facilitated.

3. Access to full range of therapies. Women should not be disadvantaged by geographical remoteness or small size of their local healthcare service in having access to the full range of treatment options, including access to clinical trials. The development of collaborative links between smaller rural hospitals and large urban teaching hospitals and other service providers is vital to providing best care. For example, referral links for specialist services such as plastic surgery, lymphoedema therapy and genetics could be established.

4. Standards of care. Management should be in accord with nationally agreed standards12 and should be supported by professional development activities, such as participation in the Royal Australasian College of Surgeons Breast Audit. Treatment decisions should not be based on inadequate information.

5. Involvement of the woman. Women should be involved in discussions about their care and should receive timely and appropriate information from clinicians. In Australia, consumer information about breast cancer has been developed in parallel with clinical practice guidelines to facilitate women’s involvement in decision-making about their care.16 The diversity of culture and language among Australian citizens must be recognised, and support mechanisms, such as interpreter services and links with local Aboriginal healthcare workers, need to be put in place to facilitate information transfer. It is important that psychosocial care also be provided.17

A recent, unpublished study of clinicians’ perceptions about the provision of multidisciplinary care services in Australia provides preliminary validation of the Principles (Zorbas H, Rainbird K, Redman S, Luxford K. “Multidisciplinary care: Australian hospitals can talk the talk but do they walk the walk?”). The study asked 60 clinicians from a representative sample of hospitals across Australia about their level of agreement with the key components of multidisciplinary care as proposed in the Principles. Ninety-five per cent or more of the clinicians agreed that the principles of communication, full therapeutic range, standards of care and involvement of the woman were essential or preferable for the provision of multidisciplinary care.

The House of Representatives inquiry concluded that for many women with breast cancer the management and treatment process was fragmented and uncoordinated.1 Nevertheless, several local Australian studies have shown that aspects of “best practice”, involving multidisciplinary care, are attainable for women with breast cancer irrespective of location or practice setting.18-20 For instance, one study found that a multidisciplinary approach to developing a treatment plan could be achieved in a rural setting by consulting city colleagues on a case-by-case basis.18 However, it is not known how widespread such strategies are in rural and remote Australia.

The extent to which the “Principles of multidisciplinary care” could be applied as an operational definition in the Australian context is being explored through the National Multidisciplinary Care Demonstration Project.15 The project involves three multifacility collaborations located in Queensland, New South Wales and Victoria. Each collaboration has proposed strategies that they could implement to improve care in accordance with the Principles. For example, in one collaboration the challenge of geographical remoteness has led to the use of telemedicine for multidis-ciplinary case-conferencing. In another, a breast-care nurse has been appointed to act as a focal point for women being treated at several facilities within the collaboration, ensuring the women receive continuity of care and that issues of psychosocial support are considered by the multidisciplinary team.

The project is investigating the cost, acceptability and impact on patterns of care of implementing multidisciplinary care strategies. The results will be used to make recommendations about implementing multidisciplinary care in Australia and are anticipated to help improve the coordination of treatment received by women with breast cancer, irrespective of location. The long-term benefits in terms of patient outcomes from this process could be assessed in the future.

This flexible, principle-based approach to multidiscip-linary care is, to our knowledge, unique. Moreover, the Principles would be readily applicable to other healthcare systems and other cancers and chronic diseases.21