Development, Practice Patterns, and Early Clinical Outcomes of a Multidisciplinary Liver Cancer Clinic

Abstract

Multidisciplinary care has been associated with improved survival in patients with primary liver cancers. We report the practice patterns and real world clinical outcomes for patients presenting to the Johns Hopkins Hospital (JHH) multidisciplinary liver clinic (MDLC). We analyzed hepatocellular carcinoma (HCC, n = 100) and biliary tract cancer (BTC, n = 76) patients evaluated at the JHH MDLC in 2019. We describe the conduct of the clinic, consensus decisions for patient management based on stage categories, and describe treatment approaches and outcomes based on these categories. We describe subclassification of BCLC stage C into 2 parts, and subclassification of cholangiocarcinoma into 4 stages. A treatment consensus was finalized on the day of MDLC for the majority of patients (89% in HCC, 87% in BTC), with high adherence to MDLC recommendations (91% in HCC, 100% in BTC). Among patients presenting for a second opinion regarding management, 28% of HCC and 31% of BTC patients were given new therapeutic recommendations. For HCC patients, at a median follow up of 11.7 months (0.7-19.4 months), median OS was not reached in BCLC A and B patients. In BTC patients, at a median follow up of 14.2 months (0.9-21.1 months) the median OS was not reached in patients with resectable or borderline resectable disease, and was 11.9 months in patients with unresectable or metastatic disease. Coordinated expert multidisciplinary care is feasible for primary liver cancers with high adherence to recommendations and a change in treatment for a sizeable minority of patients.

Optimizing the Diagnosis and Biomarker Testing for Patients with Intrahepatic Cholangiocarcinoma: A Multidisciplinary Approach

“…The implementation of molecular tumor boards illustrates how to educate clinicians regarding the importance of biomarker testing [ 21 , 22 , 83 , 93 ]. Additionally, the application of precision medicine programs in community-based oncology practices is not only feasible but has been shown to improve survival and reduce healthcare costs [ 20 , 21 , 22 , 82 , 83 , 94 ]. Lastly, recent analysis shows the achievability of collaboration between academic and community oncologists to identify the most effective treatment options [ 83 , 84 , 95 ].…”

“…First, the team members should comprise all specialties appropriate for the cancer type. For iCCA, the hepatobiliary MDT generally includes gastroenterologists, radiologists (both diagnostic and interventional), pathologists, medical and surgical oncologists, and radiation oncologists, with each playing a critical role in patient care [ 19 , 20 ]. The team must be well-organized, efficient, have a good leadership structure, and be able to critically examine the quality and outcomes of MDT decisions [ 79 ].…”

“…However, in real-world clinical practice, the implementation of effective MDTs with precision medicine-focused communication may be difficult at both academic and community-based practices [ 21 , 82 , 83 ]. Available evidence indicates the clinical benefit of coordination between physicians in the community and academic settings for the treatment of patients with iCCA, [ 23 , 84 ], where improvements in diagnosis and treatment occur when a community physician seeks a second opinion from a specialized cancer clinic or academic center [ 20 , 85 ]. For example, single-day MTD liver clinics (MDLC) at an academic tertiary care cancer center that reviewed imaging and pathology results from outside providers led to a change in interpretations in 18 and 10% of cases, respectively [ 85 ].…”

“…For example, single-day MTD liver clinics (MDLC) at an academic tertiary care cancer center that reviewed imaging and pathology results from outside providers led to a change in interpretations in 18 and 10% of cases, respectively [ 85 ]. Moreover, of patients with BTCs who presented for a second opinion, 31% of patients received new treatment recommendations compared to the one proposed in the community setting [ 20 ] (Focus Box 5 ).…”

“…The barriers may include delays in CCA diagnosis, hurdles associated with tissue acquisition for biomarker testing, ineffective collaboration between the hepatobiliary multidisciplinary team (MDT), and lack of awareness of the importance of biomarker testing [ 14 , 15 , 16 , 17 , 18 ]. The integral role of an effective MDT for the diagnosis and optimal treatment of patients with cancer, including CCA, is essential in both the community and academic settings; however, challenges associated with optimal patient care remain, which highlight the need for improvement [ 19 , 20 , 21 , 22 , 23 ]. In particular, patients with metastatic CCA progress rapidly; thus, improved diagnosis, biomarker testing, and treatment options are needed in this setting.…”