No One Stands Alone, No One Walks Alone

With the evolution of cancer care, patients now undergo varied modalities of treatment by various healthcare specialists. The burden on the patient begins with diagnosis, and worsens as they navigate the complex healthcare system, managing various procedures, diagnostic tests and doctor visitations.

 

At Tan Tock Seng Hospital, multidisciplinary cancer teams and clinics are created to lessen such a burden on patients, and enhance the efficiency and standards of care.  

Caring for newly diagnosed cancer patients is becoming an increasingly complex task. The practice of a lone practitioner or surgeon, utilising a single modality of treatment and managing various aspects of care is a thing of the past. Current treatment approaches involve the use of a variety of modalities, either sequentially or concurrently. Surgery, radiotherapy, chemotherapy, and interventional radiology are a few in this range of modalities employed. To assist in the delivery of care, input from various allied healthcare professionals are often needed. Separate clinic visits on different days are often required, adding on to the strain in the patient experience.

To a patient, the diagnosis of cancer comes as a burden. Having to navigate complexities and inefficiencies of the healthcare system is an additional burden patients should not shoulder. Having to keep track of the various procedures, diagnostic tests and doctor visits are often difficult enough. Having to understand the purpose of these various tests and their results, takes this challenge to another level.

Managing physicians who are involved in the care process face similar frustrations, having to collate the opinions of other specialists involved. Separate calls to radiologists, pathologists, radiation and medical oncologists for their opinions are needed, in order to formulate a complete care plan. Then comes the arduous task of coordinating different clinic visits for the doctors involved. Opinions between physicians may differ, leading to added confusion for patients.

The advent of a multidisciplinary team has helped ease this burden significantly, improving treatment efficiency and results of care, especially in complex cases. This is a team of healthcare professionals who work together on each cancer patient, working through a forum to go through their radiology and pathology results. Opinions of the various physicians and allied healthcare professionals are sought in a single meeting, with various viewpoints heard and discussed. State-ofthe- art treatment approaches and modern techniques from various international meetings are often discussed, to keep the various members updated.

Treatment recommendations are thus formulated in accordance to internationally recognised best practices and guidelines.

A care coordinator would then plan a course of action that would allow smooth treatment sequencing and delivery – cutting down on unnecessary hospital visits for patients. For more commonly occurring cancer types, multidisciplinary clinics have been developed for patients to see the different doctors involved on a single day, at a single location. This allows for different treatment options to be presented, discussed, and planned for in one sitting. This approach increasingly practised in major centres globally has shown improvements to patient care, with enhanced efficiency and standards of care.

Several multidisciplinary teams operate at Tan Tock Seng Hospital (TTSH), with different teams possessing different modes of treatment delivery and systems. Refinements are constantly made as new team members bring in newer techniques that can enhance care delivery. A few of the multidisciplinary cancer teams are illustrated below

Lung Cancer

 

Multidisciplinary Team The management of lung cancers can be very diverse. Locally advanced lung cancers can be treated by chemotherapy, concurrent or sequential chemoradiation, and radiotherapy alone. Surgery is included in selected cases. Our lung cancer tumour board meeting is conducted fortnightly, to determine how best to manage this diverse group of patients. Respiratory physicians, surgeons, radiation oncologists, medical oncologists, pathologists and radiologists are also involved.

Head and Neck Cancer

 

Multidisciplinary Team Included in this group of malignancies are nasopharyngeal cancers, squamous cell cancers of the various locations (including tongue, buccal cavity, larynx, pharynx, hypopharynx), thyroid cancers and salivary gland tumours. Management of this diverse group of malignancies differs greatly based on the tumour site and pathology subtype. For operable tumours, surgery is often carried out upfront.

Further adjuvant treatment is added in selected cases. Adjuvant treatment options include radiotherapy, chemo-radiation and radionuclide therapy in thyroid malignancies. For operable cases where the extent of surgery results in loss of speech or swallowing function, patients are often offered organ preservation methods by means of chemo-radiotherapy alone.

Otorhinolaryngology (ENT) surgeons, head and neck surgeons, radiation oncologists, medical oncologists, plastic surgeons, dental surgeons, speech therapists, dieticians, and pharmacists are often engaged in the decisionmaking process to formulate care plans for this diverse tumour type.

Breast Cancer

 

Multidisciplinary Team Breast cancer is the most common malignancy among women. Treatment options include upfront surgery with mastectomy or lumpectomy, with sentinel lymph node sampling or axillary clearance. Breast reconstruction can also be performed, either at the time of surgery or at a later date. Neoadjuvant chemotherapy is used, prior to surgery for selected cases. Following surgery, adjuvant chemotherapy, hormonal therapy and radiotherapy are added on in certain cases.

TTSH runs a weekly tumour board meeting, which is followed closely by a multidisciplinary clinic where patients are seen by various physicians during a single session. The team members include the breast surgeon, plastic surgeon (involved in breast reconstruction), radiation oncologist, medical oncologist, breast care nurse, radiologist and pathologist to ensure best possible treatment results.

Urological Tumour

 

Multidisciplinary Team The urological tumour board convenes monthly. Malignancies reviewed include prostate cancers, invasive bladder cancers and kidney cancers. Options for the treatment of localised prostate cancer include surgery, radiotherapy, hormonal therapy and observation. Decisions are made on the patient’s clinical, biopsy and radiological findings.

For invasive bladder cancers, treatment options include surgery and chemo-radiotherapy. Neoadjuvant and adjuvant chemotherapy options are discussed in certain instances. Multidisciplinary input is often needed in arriving at treatment recommendations.

Gastrointestinal Multidisciplinary Team

 

Esophageal, gastric and colonic and rectal tumours are included in this large group of malignancies. Our TTSH team holds weekly meetings to look into this common cancer group. Treatment options for this large group are relatively diverse, ranging from neoadjuvant chemotherapy, neoadjuvant chemo-radiotherapy, primary chemo-radiotherapy, surgery, adjuvant chemotherapy and adjuvant chemoradiotherapy. TTSH runs a twice-monthly multidisciplinary clinic, where patients needing combination chemotherapy and radiotherapy before or after surgery, are seen at a single setting.

Hepatobiliary Cancer Multidisciplinary Team

 

Liver, pancreas and biliary tract malignancies are discussed by this team. Common liver malignancies include hepatocellular cancers (HCC) and cholangiocarcinomas. For HCCs, treatment modalities include surgery, local ablative therapies such as transarterial chemoembilisation (TACE), liver transplantation and selective internal radiotherapy treatment (SIRT).

The role of a skilled interventional radiologist is paramount in the selection of the various modalities available. The management of bile duct malignancies and pancreatic malignancies typically involves upfront surgery for operable cases and chemo-radiotherapy for inoperable cases.

As more research is done to improve the treatment of cancer patients, greater teamwork is required between the various members of the multidisciplinary healthcare team. At TTSH, such teams work closely with the ultimate goal of delivering care with greater precision and efficiency.

Common team members of a multidisciplinary cancer care team include:

  • Surgeon
  • Medical oncologist
  • Radiation oncologist
  • Diagnostic radiologist
  • Interventional radiologist
  • Pathologist
  • Nursing specialists
  • Dietician
  • Speech therapist
  • Medical social worker

J.O.I.N.T. Movement to Enhance Oncology Care in TTSH

Joint Oncology INnovation Taskforce (JOINT) was established in 2012 and led by Adjunct Assistant Professor Chong Yew Lam, Divisional Chairman of Surgery with a multidisciplinary team of healthcare professionals at Tan Tock Seng Hospital (TTSH).

Recognising that the care of cancer patients is increasingly complex, JOINT is created to address these complexities, improve work processes and research to enhance cancer care efficiencies, and improve service delivery for a better patient experience.

This oncology integrated care cluster was established with three key thrusts:

  • Personalised Medicine - JOINT looks at the utility of cancer tests – that specific and targeted treatments go to the right patients at the right time. JOINT hopes to contribute to research capabilities for personalised medicine.
  • Care and Counselling – Cancer patients experience a lot of anxiety when they transit through the hospital. JOINT hopes to identify ways to address the emotional needs of our patients. JOINT plans to start by enhancing the awareness of patient anxieties among our staff, so that they can be better equipped to manage the simpler problems and escalate the complex cases to the specialist.
  • Multidisciplinary One-Stop Cancer Clinics – JOINT aims to enhance the patient care experience by creating one-stop clinics, where patients could be arranged to see different disciplines in one visit. One such example is the TTSH Gastrointestinal Cancer Centre (TGICC) operating from Outpatient Clinic 5A.

    TGICC is a multidisciplinary collaboration that is run by three main disciplines, namely medical oncology, radiation oncology as well as general surgery. In TGICC, waiting time is cut short as patients who require oncology care could see three disciplines in one visit. This will help to fast forward the treatment plan for our patients. Our clinicians can also benefit from giving patients a unified human voice to improve treatment outcomes and overall experience.
 

 


Dr Yeo Wee Lee is a Consultant of the Medical Oncology Department at Tan Tock Seng Hospital and the Johns Hopkins Singapore International Medical Centre. He graduated from the National University of Singapore and went on to receive his specialist training in medical oncology at the National University Hospital. He spent a year pursuing lung cancer research at Harvard Medical School. His sub-specialty interests are in head and neck, thoracic and gastrointestinal malignancies.