3.4 Treatment planning

3.4 Treatment planning

A number of factors should be considered at this stage:

  • the patient’s overall condition, life expectancy, decision-making capacity and results from a geriatric assessment if appropriate in those over the age of 70 years
  • patient preferences and aims of treatment
  • psychosocial screening/evaluation and support
  • discussing the multidisciplinary team approach to care with the patient
  • ensuring a breast care nurse is part of the multidisciplinary team
  • appropriate and timely referral to an MDM
  • considering if an interpreter is required
  • pregnancy and fertility options, contraception and prevention of chemotherapy-induced menopause
  • financial and social aspects
  • support with travel and accommodation
  • teleconferencing or videoconferencing as required.

Discussion at an MDM is a core component of quality care (ASCO & ESMO 2006). All patients with a new diagnosis of breast cancer should be referred to an MDM for discussion. Ideally, the multidisciplinary team should discuss all newly diagnosed patients with breast cancer prior to surgery or neoadjuvant chemotherapy. Results of all relevant tests and imaging should be available for the MDM. To assist with the burden of demand, sites may streamline and prioritise the MDM discussion using agreed protocols. Patients should be offered a referral to a breast cancer nurse within seven days of a definitive diagnosis.

Patients may be discussed at several time points during their diagnosis and treatment. This can ensure patients are identified who may benefit from neoadjuvant systemic therapy, where surgical decisions are complex and in planning of reconstructive surgery and sequencing of therapies, or for relevant clinical trials.

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.

When developing treatment recommendations for each patient, MDM participants ensure:

  • the tumour has been adequately staged
  • all appropriate treatment modalities are considered
  • psychosocial and medical comorbidities that may influence treatment decisions are considered
  • the patient’s treatment preferences are known and considered
  • clinical trial eligibility, availability and participation are considered
  • relevant optimal care pathway timeframes are considered.

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.

MDMs should aim to develop and agree by consensus an individualised treatment plan for each patient discussed. At times when there is a divergence of opinion about a patient’s management or equivalent options, these differing opinions should be discussed with the patient to enable them to make an informed decision. Patients should be given time to discuss treatment options with others before making this decision.

MDM recommendations should be communicated in a timely manner to the patient and referring doctor/general practitioner with formal documentation. Further details regarding MDM requirements can be found via the Victorian cancer multidisciplinary team meeting quality framework.

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 and radiology expertise are essential.

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

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 such as breast cancer patients during pregnancy. 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 (usually a breast care nurse) 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.