- Email: [email protected]
The origins of multidisciplinary cancer care
Available online at www.sciencedirect.com
Gynecologic Oncology 110 (2008) S2 – S3 www.elsevier.com/locate/ygyno
The origins of multidisciplinary cancer care
Fig. 1. Examples of anatomic diagram stamps and examination finding drawings developed to record multidisciplinary patient evaluations at the planning clinic. These visual cues were incorporated into the patient record providing detailed summaries of clinical tumor features over time.
Looking back on my 24-year career in gynecologic oncology, I came to realize that the history of cervical cancer treatment provided one of the earliest examples where different specialists came together to manage complex cancers. The partnership of Felix Rutledge and Gilbert Fletcher at The University of Texas M.D. Anderson Cancer Center firmly established the basis for many of the multispecialty treatment plans that we view as routine today. During the 1950s and 1960s, they brought personal expertise in pelvic surgery and radiotherapy together to define treatment standards for women with all stages of cervix cancer. They established the concept of the “planning clinic” where cervical cancer patients were jointly examined by surgical and radiotherapy teams to define extent of disease doi:10.1016/j.ygyno.2008.05.035
and arrive at a therapy plan. They produced tools to record examination findings and monitor progress over time (Fig. 1). Their landmark publications provide the back drop for much of what we currently accept as obvious. Evaluation of the clinical outcome of over 1300 women (Table 1) with stages I and II cervical cancer clearly demonstrated that central failure correlated with tumor volume [1]. And, as megavoltage equipment became available, greater energy irradiation provided better tumor control than kilovoltage treatment (Table 2). A detailed analysis of women with all stages of disease confirmed the importance of tumor volume as a critical prognostic variable [2]. Treatment failures were attributed to either massive disease or suboptimal dosing [3]. Dr. Rutledge provided and taught meticulous surgical technique using radical hysterectomy as the primary treatment
The origins of multidisciplinary cancer care
S3
Table 1 All patients with central recurrent disease [either alone or in combination with other sites] stages I and II carcinoma of the cervix Stage
Kilovoltage (1948–1954)
Megavoltage (1954–1963)
Total
I (471 patients) II (870 patients)
2/64 (3%) 20/252 (8%)
6/407 (1.5%) 30/618 (4.5%)
8/471 (1.9%) 50/870 (5.6%)
Reprinted from Durrance et al, Am J Roentgenol Radium Ther Nucl Med 1969, p. 832.
approach for women with early cancer. He was also instrumental in refining and promoting improvements in total pelvic exenteration as an option of last resort for women with central failure [4]. He developed, adopted, or popularized the “omental lid” as a method of enhancing healing in the pelvic cavity; ileal conduit as the urinary diversion technique of choice; and gracilis myocutaneous flap reconstruction of the vagina to foster sexual rehabilitation. In an era without a specialized ICU, blood component therapy, invasive monitoring, or a skilled rehabilitation team, his team obtained outstanding surgical outcomes (Fig. 2). Lymph node failure, particularly in the para-aortic region, was another early focus of the M.D. Anderson group. Patients with para-aortic metastases regularly died because their disease extended beyond the resection margins of surgery or outside of the pelvic radiotherapy fields. Initial analyses demonstrated that the risk of para-aortic disease correlated with primary tumor stage and volume as well as the presence of pelvic node metastases. Pretreatment lymphadenectomy in combination with extended field irradiation was examined as an option for node positive women [5]. Unfortunately, the use of radiotherapy following extensive surgical resection produced an unacceptable incidence of small and large bowel morbidity and significant mortality. Lymphangiography was subsequently employed in an effort to identify nodal metastasis without extensive surgery. Before the use of computed tomography and magnetic resonance, this was an opportunity to “see” nodal size and architecture. Early reports demonstrated a good correlation between a “positive” lymphangiogram and lymph node metastasis [6]. However, the high false negative rate, special expertise required to perform and interpret studies, and availability of other technology led to the abandonment of the technique. As a result of the structure established by our institution's pioneers, the Gynecologic Oncology Center now includes Table 2 Central active disease alone or concomitant in other sites appearing within five years megavoltage series34 September 1954–December 1963 Stage
g
I IIA IIB IIIA IIIB IV
Total number of patients treated
Patients with central active disease
734
12 (1.5%)
291 324 275 81
15 (5.0%) 24 (7.5%) 49 (17.0%) 32 (39.0%)
Reprinted from Fletcher 1971, p. 232.
Fig. 2. 90-day operative mortality for 296 women undergoing pelvic exenteration between 1955 and 1976. Reprinted from Rutledge et al, Am J Obstet Gynecol 1977, p. 887.
physicians from gynecologic oncology, medical oncology, radiation oncology, pathology and diagnostic imaging. It also brings together nurses, pharmacists, social workers and support staff who have special experience in the management of women with gynecologic tumors and treatment complications. More recently, emphasis has been placed on research integration and support for clinical trials participation, tissue and serum acquisition, and translational laboratory projects. And so, what originally began as an effort to bring different physicians together around a patient's plan of care has now expanded to also incorporate subspecialty expertise in other services such as pathology and diagnostic imaging. The current concept of multidisciplinary care also includes disease-focused supportive services in social work, wound/ostomy care, nursing care, drug therapy, insurance coverage and patient education. Conflict of interest statement The author has no conflicts of interest to declare.
References [1] Durrance FY, Fletcher GH, Rutledge F. Analysis of central recurrent disease in Stages I and II squamous cell carcinomas of the cervix on intact uterus. Am J Roentgenol Radium Ther Nucl Med 1969;106:831–8. [2] Fletcher GH. Cancer of the uterine cervix Janeway Lecture, 1970. Am J Roentgenol Radium Ther Nucl Med 1971;111:225–42. [3] Jampolis S, Andras EJ, Fletcher GH. Analysis of sites and causes of failures of irradiation in invasive squamous cell carcinoma of the intact uterine cervix. Radiol 1975;115:681–5. [4] Rutledge FN, Smith JP, Wharton JT, O’Quinn AG. Pelvic exenteration: analysis of 296 patients. Am J Obstet Gynecol 1977;129:881–92. [5] Wharton JT, Jones III HW, Day TG, Rutledge FN, Fletcher GH. Preirradiation celiotomy and extended field irradiation for invasive carcinoma of the cervix. Obste Gynecol 1977;49:333–8. [6] Piver MS, Wallace S, Castro JR. The accuracy of lymphangiography in carcinoma of the uterine cervix. Am J Roentgenol Radium Ther Nucl Med 1971;111:278–83.
Thomas W. Burke Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA E-mail address: [email protected]. 23 May 2008
Gynecologic Oncology 110 (2008) S2 – S3 www.elsevier.com/locate/ygyno
The origins of multidisciplinary cancer care
Fig. 1. Examples of anatomic diagram stamps and examination finding drawings developed to record multidisciplinary patient evaluations at the planning clinic. These visual cues were incorporated into the patient record providing detailed summaries of clinical tumor features over time.
Looking back on my 24-year career in gynecologic oncology, I came to realize that the history of cervical cancer treatment provided one of the earliest examples where different specialists came together to manage complex cancers. The partnership of Felix Rutledge and Gilbert Fletcher at The University of Texas M.D. Anderson Cancer Center firmly established the basis for many of the multispecialty treatment plans that we view as routine today. During the 1950s and 1960s, they brought personal expertise in pelvic surgery and radiotherapy together to define treatment standards for women with all stages of cervix cancer. They established the concept of the “planning clinic” where cervical cancer patients were jointly examined by surgical and radiotherapy teams to define extent of disease doi:10.1016/j.ygyno.2008.05.035
and arrive at a therapy plan. They produced tools to record examination findings and monitor progress over time (Fig. 1). Their landmark publications provide the back drop for much of what we currently accept as obvious. Evaluation of the clinical outcome of over 1300 women (Table 1) with stages I and II cervical cancer clearly demonstrated that central failure correlated with tumor volume [1]. And, as megavoltage equipment became available, greater energy irradiation provided better tumor control than kilovoltage treatment (Table 2). A detailed analysis of women with all stages of disease confirmed the importance of tumor volume as a critical prognostic variable [2]. Treatment failures were attributed to either massive disease or suboptimal dosing [3]. Dr. Rutledge provided and taught meticulous surgical technique using radical hysterectomy as the primary treatment
The origins of multidisciplinary cancer care
S3
Table 1 All patients with central recurrent disease [either alone or in combination with other sites] stages I and II carcinoma of the cervix Stage
Kilovoltage (1948–1954)
Megavoltage (1954–1963)
Total
I (471 patients) II (870 patients)
2/64 (3%) 20/252 (8%)
6/407 (1.5%) 30/618 (4.5%)
8/471 (1.9%) 50/870 (5.6%)
Reprinted from Durrance et al, Am J Roentgenol Radium Ther Nucl Med 1969, p. 832.
approach for women with early cancer. He was also instrumental in refining and promoting improvements in total pelvic exenteration as an option of last resort for women with central failure [4]. He developed, adopted, or popularized the “omental lid” as a method of enhancing healing in the pelvic cavity; ileal conduit as the urinary diversion technique of choice; and gracilis myocutaneous flap reconstruction of the vagina to foster sexual rehabilitation. In an era without a specialized ICU, blood component therapy, invasive monitoring, or a skilled rehabilitation team, his team obtained outstanding surgical outcomes (Fig. 2). Lymph node failure, particularly in the para-aortic region, was another early focus of the M.D. Anderson group. Patients with para-aortic metastases regularly died because their disease extended beyond the resection margins of surgery or outside of the pelvic radiotherapy fields. Initial analyses demonstrated that the risk of para-aortic disease correlated with primary tumor stage and volume as well as the presence of pelvic node metastases. Pretreatment lymphadenectomy in combination with extended field irradiation was examined as an option for node positive women [5]. Unfortunately, the use of radiotherapy following extensive surgical resection produced an unacceptable incidence of small and large bowel morbidity and significant mortality. Lymphangiography was subsequently employed in an effort to identify nodal metastasis without extensive surgery. Before the use of computed tomography and magnetic resonance, this was an opportunity to “see” nodal size and architecture. Early reports demonstrated a good correlation between a “positive” lymphangiogram and lymph node metastasis [6]. However, the high false negative rate, special expertise required to perform and interpret studies, and availability of other technology led to the abandonment of the technique. As a result of the structure established by our institution's pioneers, the Gynecologic Oncology Center now includes Table 2 Central active disease alone or concomitant in other sites appearing within five years megavoltage series34 September 1954–December 1963 Stage
g
I IIA IIB IIIA IIIB IV
Total number of patients treated
Patients with central active disease
734
12 (1.5%)
291 324 275 81
15 (5.0%) 24 (7.5%) 49 (17.0%) 32 (39.0%)
Reprinted from Fletcher 1971, p. 232.
Fig. 2. 90-day operative mortality for 296 women undergoing pelvic exenteration between 1955 and 1976. Reprinted from Rutledge et al, Am J Obstet Gynecol 1977, p. 887.
physicians from gynecologic oncology, medical oncology, radiation oncology, pathology and diagnostic imaging. It also brings together nurses, pharmacists, social workers and support staff who have special experience in the management of women with gynecologic tumors and treatment complications. More recently, emphasis has been placed on research integration and support for clinical trials participation, tissue and serum acquisition, and translational laboratory projects. And so, what originally began as an effort to bring different physicians together around a patient's plan of care has now expanded to also incorporate subspecialty expertise in other services such as pathology and diagnostic imaging. The current concept of multidisciplinary care also includes disease-focused supportive services in social work, wound/ostomy care, nursing care, drug therapy, insurance coverage and patient education. Conflict of interest statement The author has no conflicts of interest to declare.
References [1] Durrance FY, Fletcher GH, Rutledge F. Analysis of central recurrent disease in Stages I and II squamous cell carcinomas of the cervix on intact uterus. Am J Roentgenol Radium Ther Nucl Med 1969;106:831–8. [2] Fletcher GH. Cancer of the uterine cervix Janeway Lecture, 1970. Am J Roentgenol Radium Ther Nucl Med 1971;111:225–42. [3] Jampolis S, Andras EJ, Fletcher GH. Analysis of sites and causes of failures of irradiation in invasive squamous cell carcinoma of the intact uterine cervix. Radiol 1975;115:681–5. [4] Rutledge FN, Smith JP, Wharton JT, O’Quinn AG. Pelvic exenteration: analysis of 296 patients. Am J Obstet Gynecol 1977;129:881–92. [5] Wharton JT, Jones III HW, Day TG, Rutledge FN, Fletcher GH. Preirradiation celiotomy and extended field irradiation for invasive carcinoma of the cervix. Obste Gynecol 1977;49:333–8. [6] Piver MS, Wallace S, Castro JR. The accuracy of lymphangiography in carcinoma of the uterine cervix. Am J Roentgenol Radium Ther Nucl Med 1971;111:278–83.
Thomas W. Burke Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA E-mail address: [email protected]. 23 May 2008