3.4 Treatment planning

3.4 Treatment planning

Because of the urgency and complexity of treatment, every clinical haematology unit should have predefined, peer-reviewed treatment models of care that have been endorsed by the multidisciplinary team. Assessment of the premorbid state is an essential component of the treatment planning process.

Prevention and management of infections in AML include the following:

  • All patients should undergo screening for infections at high risk of reactivation or transmission before beginning treatment.
  • Some infections are determined by epidemiological risk of exposure and history of recent travel and/or extended habitation in high-risk countries.
  • Minimum requirements would include cytomegalovirus, hepatitis B, hepatitis C and HIV screening. Other tests such as for tuberculosis, strongyloides serology, and screening for multidrug-resistant pathogens as per institutional policy, should be considered.
  • Patients with antibiotic allergy labels should have suspected allergies reassessed where possible.
  • All institutions should have empiric sepsis guidelines/pathways that include appropriate recommendations for the initial management of neutropenic fever. Specialists in infectious diseases may be required for advice about duration and appropriate antibiotics based on pathogens isolated and patient factors (allergy, renal impairment).
  • Vaccination status should be assessed for all patients. Vaccination with influenza and Streptococcus pneumoniae can recommence after three months if in complete remission.
  • Prophylaxis guidelines for fungal and viral infections should accord with published national guidelines.

A number of factors should be considered at this stage:

  • the patient’s overall condition, life expectancy, personal preferences and decision- making capacity
  • discussing the multidisciplinary team approach to care with the patient
  • appropriate and timely referral to an MDM
  • pregnancy and fertility
  • support with travel and accommodation
  • teleconferencing or videoconferencing as required.

Induction treatment is often required before a full MDM ratifies details of the ongoing management plan (which should include full details of the response assessment). Most patients will receive their initial treatment as inpatients, allowing their initial multidisciplinary treatment planning to be established on the ward. For patients undergoing induction chemotherapy, presentation to, and consideration within, an MDM is most important once the outcome of the induction therapy is known. At this point, a review of the patient is required to inform further management and supportive care needs.

For patients not eligible for induction chemotherapy, or where uncertainty of the approach exists, a review at an MDM should occur as soon as practicable (before definitive treatment), to establish the recommended treatment plan and all aspects of supportive care, including early preparation for the post-treatment phase.

The level of discussion may vary, depending on the patient’s clinical and supportive care factors. Some patients with non-complex cancers may not be discussed by a multidisciplinary team; instead the team may have treatment plan protocols that will be applied if the patient’s case (cancer) meets the criteria. If patients are not discussed at an MDM, they should at least be named on the agenda for noting. The proposed treatment must be recorded in the patient’s medical record and should be recorded in an MDM database where one exists.

Teams may agree on standard treatment protocols for non-complex care, facilitating patient review (by exception) and associated data capture.

Results of all relevant tests and access to images should be available for the MDM. Information about the patient’s concerns, preferences and social and cultural circumstances should also be available.

The multidisciplinary team requires administrative support in developing the agenda for the meeting, for collating patient information and to ensure appropriate expertise around the table to create an effective treatment plan for the patient. The MDM has a chair and multiple lead clinicians. Each patient case will be presented by a lead clinician (usually someone who has seen the patient before the MDM). In public hospital settings, the registrar or clinical fellow may take this role. A member of the team records the outcomes of the discussion and treatment plan in the patient history and ensures these details are communicated to the patient’s general practitioner. The team should consider the patient’s values, beliefs and cultural needs as appropriate to ensure the treatment plan is in line with these. There may be early consideration of post-treatment pathways at this point – for example, shared follow-up care.

The multidisciplinary team should be composed of the core disciplines that are integral to providing good care. Team membership should reflect both clinical and supportive care aspects of care. Pathology expertise is essential.

See ‘About this OCP’ for a list of team members who may be included in the multidisciplinary team for AML.

Core members of the multidisciplinary team are expected to attend most MDMs either in person or remotely via virtual mechanisms. Additional expertise or specialist services may be required for some patients. An Aboriginal and Torres Strait Islander cultural expert should be considered for all patients who identify as Aboriginal or Torres Strait Islander.

The general practitioner who made the referral is responsible for the patient until care is passed to another practitioner who is directly involved in planning the patient’s care.

The general practitioner may play a number of roles in all stages of the cancer pathway including diagnosis, referral, treatment, shared follow-up care, post-treatment surveillance, coordination and continuity of care, as well as managing existing health issues and providing information and support to the patient, their family and carer.

A nominated contact person from the multidisciplinary team may be assigned responsibility for coordinating care in this phase. Care coordinators are responsible for ensuring there is continuity throughout the care process and coordination of all necessary care for a particular phase (COSA 2015). The care coordinator may change over the course of the pathway.

The lead clinician is responsible for overseeing the activity of the team and for implementing treatment within the multidisciplinary setting.