神经肿瘤的多学科联合治疗

Glioblastoma: Outcome 2016
Newly diagnosed patients
RT/TMZ
Adjuvant 5-day TMZ cycles
All
# 833
PFS (mths) 8.2
OS (mths) 17.7
MGMT methylated
0 6 10 18 26 34 42 50 MGMT unmethylated
Koekkoek JA J NO 120:589, 2014 Walbert T J NO 117:217, 2014 Ford E Neuro-Oncol 14:392, 2012
Glioblastoma: Tenets of Patient Care
1. Optimized outcome for GBM patients requires multidisciplinary expertise and collaboration.
Field, KM J Clin Neurosci 17:1130-35, 2010
Does A Multidisciplinary Team Approach Make a Difference for Brain Tumor Patients?
Back et al. Ann Acad Med Sing 36:347-51, 2007
Brain Tumor Patient: Heavy Symptom Burden
Cognitive decline Behavioral changes Aphasia Immobility Headache Seizures Incontinence Psychosocial toll on caregivers - Up to 40%: depression
- Improve education/teaching opportunities
Does Multidisciplinary Team Conference Improve Patient Care?
Complexity of Case
Likelihood of Treatment Change
How Multidisciplinary Team (MDT) Works In Neuro-Oncology
2016 Chinese Society of Neuro-Oncology/SNO Joint Meeting Guangzhou, China March 19, 2016
David A. Reardon, MD Clinical Director Center for Neuro-Oncology Dana-Farber Cancer Institute david_reardon@dfci.harvard.edu
Levels of Function
1. 2. Regular meetings to review cases (i.e. Tumor Board/Case Conference) Regional/geographic centers of excellence to coordinate optimal care
Overview
• Review the critical need of multidisciplinary team for the care of neuro-oncology patients • Review the importance of palliative care support for brain cancer patients
- # MDT Case Conferences: 259
- # patients reviewed: 1516 - 91% of MDT conference recommendations were implemented
Lutterbach Onkologie 28:22, 2005
Role of Multidisciplinary Team Meetings
Multidisciplinary Team 百度文库MDT)
Definition: A group of people of different health care disciplines which meets together at a given time (whether physically in one place or by video/teleconference) to discuss a given patient, and who are each able to contribute independently to the diagnostic and treatment decisions about the patient.
2. Goal of treatment: Balance improving survival with maximizing quality of life. 3. “We have treatments that can help; no one has treatments that work durably.”
Multidisciplinary Team to Optimize GBM Patient Care
Patient & Family
Medical/Surgical - Neurosurgery - Neuro-oncology - Radiation Oncology - Nursing - Rehabilitative Medicine (physical therapy/ occupational therapy/ speech therapy) - Neurology (epilepsy) - Nutrition - Endocrine - Palliative Care - General medicine
Patient Care Continuum and Multidisciplinary Team Collaboration
Robin AM J NO 119:465-72, 2014
Multidisciplinary Team Meeting (Tumor Board): Fridays 2:30pm
6-PFS (%)
9 9 11.4 14.7
Median OS (weeks)
26 22 25.1 24.8
Bevacizumab5
1Lamborn
1
85
43
37
KR et al. Neuro-Oncol 10:162, 2008; 2Ballman KV et al. Neuro-Oncol 9:29, 2007; 3Wu et al Neuro-Oncol 12:164,2010; 4Gorlia et al. Eur J Ca 48:1176,2012 5Friedman et al. J Clin Oncol 27:4733, 2009
New Patient Referral (newly diagnosed and recurrent patients)
Clinical presentation/status
Imaging
Goals: 1. Interdisciplinary communication 2. Generate treatment plan 3. Consider possible clinical trials 4. Ensure proper clinic scheduling
Does A Multidisciplinary Team Approach Make a Difference for Brain Tumor Patients?
Back et al. Ann Acad Med Sing 36:347-51, 2007
Does A Multidisciplinary Team Approach Make a Difference for Brain Tumor Patients?
Meta-analysis 37 publications (Lamb et al Ann Surg Oncol 18:2116, 2011)
2-52% of cases changed treatment based on MDT conference recommendation
Impact of Multidisciplinary Team Conference in Neuro-Oncology: Limited Data in Literature
Multidisciplinary Team Conference Goals
- Increase efficiency and accuracy of diagnosis
- Increase delivery of evidence based care - Improve patient/caregiver support - Increase clinical trial recruitment
Psychosocial - Social work - Psychiatry (affect/behavior) - Psychology (cognition) - Integrative medicine Other - Neuropathology - Neuroimaging - Pharmacy - Research Staff
Multidisciplinary Team to Optimize GBM Patient Care
Patient & Family
Medical/Surgical - Neurosurgery - Neuro-oncology - Radiation Oncology - Nursing - Rehabilitative Medicine (physical therapy/ occupational therapy/ speech therapy) - Neurology (epilepsy) - Nutrition - Endocrine - Palliative Care - General medicine
245
517
10.5
7.8
23.2
16.0
Weeks
Gilbert MR JCO 31:4085, 2013.
Recurrent patients Source
NABTC1 NCCTG2 NCCTG + NABTC3 EORTC4
# Trials
8 16 27 8
# Patients
291 345 816 300
Psychosocial - Social work - Psychiatry (affect/behavior) - Psychology (cognition) - Integrative medicine Other - Neuropathology - Neuroimaging - Pharmacy - Research Staff
Back et al. Ann Acad Med Sing 36:347-51, 2007
Multidisciplinary Team Conference Hurdles
Too little time Excessive caseload Low attendance Poor leadership Insufficient communication/team work Low decision making Lack of dedicated prep time Inadequate facilities Inadequate nursing/patient advocacy input Medicolegal considerations
Pathology/molecular genetics Attendees: neurosurgery, neuro-oncology, radiation oncology, neuro-imaging, neuropathology, residents, fellows, students Practical considerations -Weekly; 60-90 minutes - 10-20 cases reviewed per meeting