This is the sixth in a series of columns on the doctor/cancer patient relationship by Seabrook resident Dr. Roy Sessions, MD, and Fellow of the American Council of Surgeons.
Although less frequently then in previous years, cancers today are sometimes managed by the “occasional cancer doctor”. However, today’s diagnostic and therapeutic “standard of care” is the cancer team that is associated with a cancer center; and within the team, a multidisciplinary approach is ideally used in which the territorial interests of the doctors are subordinated to that of the patient.
Not too long ago, cancer management was less standardized (if at all), and not infrequently a primary care doctor who diagnosed a tumor referred the patient directly to a surgeon, to a radiation therapist, or to a medical oncologist. Where the patient started in the referral system had a lot to do with what treatment was ultimately employed. This is not to say that the treatment that followed was necessarily wrong, but the process did not lend itself to cross-fertilization of ideas between specialties; and additionally, the game plan–i.e. the treatment strategy–was inconsistent. In cancer management, nothing trumps a game plan in importance. Compare this concept to starting a business with or without a business plan.
With that said, it should be noted that sometimes it’s impractical for a patient to be sent to a cancer center. In small town and rural America, this is not an infrequent problem, and on many such occasions, a patient will not or cannot go to a center, and the doctors have to scramble a bit. This logistical issue occurs less frequently as our approach to this disease has matured, and as more and more people accept the concept of the cancer center. Those doctors who have specialized training in oncology – whether surgical, medical, or radiation – have gradually come to congregate in communities large enough to house such centers.
In the United States, the American College of Surgeons has placed its stamp of approval on over 1500 regional cancer centers. These are not necessarily academic institutions, but they are site visited and must meet the criteria established by the College regarding standards in credentials, staging, and record keeping relative to results. More sophisticated accreditation results from the National Cancer Institute (NCI) branch of the National Institutes of Health (NIH) that has awarded certain special status to 65 cancer centers throughout the country. These are generally academic institutions in which there are post-graduate training programs, and where clinical trials and research (much of which is federally funding) are conducted. This is the gold standard. These centers are funded by the NIH/NCI and are so designated as centers of excellence.
For the reader’s convenience, I have included a list and the respective contact information of the NCI designated centers throughout the United States. [Click here to download a printable version of National Cancer Institute Designated Centers in the USA]. Because of the large number of centers approved by the American College of Surgeons, the reader is referred to the appropriate website for that information.
It’s a huge understatement to say that times have changed with regards to the diagnosis and management of cancer. Even during the last 30 years, dramatic advances have been made in the war against cancer – diagnostics, drugs, molecular and genetic engineering, deliverance methods of therapeutic nuclear energy, newer surgical tools, such as robotics and lasers – to cite but a few. The complexity of this new science- whether diagnosis, evaluation (staging), or treatment has far exceeded the capacity of any one person or specialty, and because of this, today’s gold standard in contemporary cancer care is based on a sophisticated, multi-disciplinary model in which different specialties design and implement an overall strategy (the game plan) best suited for the particular problem.
For example, in my particular area of interest – head and neck cancer – the typical team might consist of surgical oncologists, medical oncologists, radiation therapists, dental oncologists, head and neck radiologists, nurse practitioners, nutritionists, psycho-oncologists, social workers, physical therapists, speech and swallowing therapists, ethicists, and others. Not all of these people are involved in the care of each patient, but ideally the tumor conferences in which the patients are usually discussed should include the participation of this diverse talent pool. Out of such a conference, consensus standards are hammered out by means of argument, both data and anecdotal based, frequent disagreements and occasional bruised egos. Together the process and the product generally far exceed the value of the proverbial “second opinion”.
Of all of the recent changes that have occurred in the cancer world, this concept may be the most important. In such an endeavor, everyone contributes their respective expertise, and in the final analysis, the patient benefits from an objective game plan. Time consuming- yes; expensive – yes; but it is justifiably becoming the new standard. The seeming delays that result from all of this are mitigated by the fact that other than the emotional urgency of patient and family (understandably important), there is usually no hurry to get started. Time spent in preparation is more important. The planning should be such so as the timing of each stage should be predictable and consistent. On occasions, things don’t go as expected, and the team has to know how to scramble; however, that should be the exception rather than the norm.
Submitted by Roy B. Sessions, MD, FACS
Seabrook Island, SC