The Value of a Multi-disciplinary Breast Cancer Case Conference

Getting a treatment opinion from a qualified physician expert about a breast cancer diagnosis is very important. There are facilities, however, that take this consultative process a step further. They hold, on a routine basis, a multi-disciplinary case conference. The structure and process of such conferences can vary from facility to facility. Their intent and purpose usually are the same- to provide an opportunity for a group discussion about patients newly diagnosed so that consensus can be achieved.

Depending on the number physicians committed to breast cancer at a specific hospital, the size of the case conference can vary. In many cases there may only be one surgeon, one medical oncologist, and one radiation oncologist available for reviewing individual cases. Ideally, however, it is best to have several physicians from each specialty offering their expertise, thus ensuring that the patient is getting expert opinion from several physicians with experience and knowledge in the same specialty. In doing so the patient has the opinion of many rather than one from each discipline.

From a financial and time saving's perspective, this is a wonderful service to breast cancer patients. Rather than having the expense of seeing several surgical medical and radiation oncologists who specialize in breast cancer, they are afforded the opportunity of getting their opinion all at once. It provides an efficient way to expedite providing patients with the answers they need.

The Johns Hopkins Breast Center provides a multi-disciplinary approach to patient management and treatment planning for individual patients. The health care professionals who attend include most disciplines of the breast center. They are: three surgical oncologists, four medical oncologists, two radiation oncologists, two or more radiologists (mammography), two or more pathologists, a social worker, several nurses, and the education and outreach director. There are also two plastic surgeons who specialize in breast reconstruction available to offer input as well. Each of the members of the case conference review team specializes in breast cancer diagnosis and treatment. Residents and fellows also have the opportunity to attend as a learning experience.

At the Johns Hopkins case conference, the patient's actual mammograms and pathology slides are reviewed. The radiologist explains what is seen of the mammogram and other x-ray films such as ultrasound films or scintimammograms that the patient may have had done. The pathologist is able to display the slides by using a microscope connected to a large screen television so that everyone present can see what he sees through the microscope. The status of the margins, type of breast cancer, sizes of tumor, tumor growth rate, and other pathology issues are explained by the pathologist to the multi-disciplinary team.

The patients discussed are individuals who have been seen in the last week and a detailed discussion of the patient's clinical condition, diagnostic findings, and recommendations for optimal treatment are discussed and planned. This is an effective way to help ensure that the patient is being given individualized attention and care by utilizing maximum breast cancer knowledge, experience, and expertise by the breast center team.

Patients newly diagnosed are discussed as well as special patients with complex needs. The Breast Center has developed criteria for defining these special cases for team discussion. Examples are: patients who want breast conservation surgery that is contraindicated based on the size of the tumor and extent of the; non-compliant patients refusing treatment; patients who have developed recurrence of the disease; patients desiring prophylactic mastectomy; patients needing chemotherapy therapy prior to surgery. Follow up discussions of complex patients previously reviewed at a prior case conference are also discussed. This is an additional way of ensuring continuity of care and good quality of care.

Time is also devoted to reviewing cases where there is a disagreement between what the pathology results or mammography records reported from another facility and what Hopkins' pathologists and radiologists see on the same slides and films. These would be for patients seeking a second opinion at Hopkins or patients who have had their mammogram and/or biopsy performed elsewhere and wishes to have their breast cancer treatment performed at Johns Hopkins. These findings can be significant because it can totally alter the recommended treatment plan the patient was originally told elsewhere.

By reviewing large volumes of individual cases that meet specific criteria, many facilities offering multi-disciplinary conferences will identify patterns. These patterns in the outcomes of specific treatment plans, in mammography and pathology discrepancies, and other similarities among individual cases that can be used for educational purposes and treatment decision making in the future.

For facilities that are accredited by the American College of Surgeons for the Commission on Cancer as a designated comprehensive cancer center, multi-disciplinary case conferences are mandatory. Many hospitals are not certified by this most important process. These hospitals may have no oversight for the cancer care they are rendering which constantly compares them to national standards. Further even smaller hospitals may have ACS certification but the volume of cases treated may be so low that timely multi-disciplinary conferences are not always available. The survey process for being accredited by the ACS includes the review of case conference minutes, criteria for selecting cases for review, and evidence that the results were shared with the patients afterwards. If you are in doubt about your local hospital, check the ACS web site @ www.facs.org .

Patients newly diagnosed seeking treatment advice should inquire, no matter where they are going for their care, if the doctor they are seeing is a member of a multi-disciplinary case conference and asks if their specific case will be reviewed by such a panel of experts. Inquire who are members of the team who attends and what their backgrounds are related to diagnosing and treating breast cancer patients.

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