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
• additional tests to calculate the relevant prognostic scores for each low-grade lymphoma
• evaluation of relevant organ function based on history, clinical examination and, where appropriate, laboratory or imaging investigations (cardiac, respiratory, renal, hepatic)
• autoimmune screens (these are sometimes warranted in MZL, specifically autoimmune haemolytic anaemia)
• tests for occult infections (e.g. HIV, hepatitis B and C, tuberculosis) that may be affected by therapy or pose a risk of reactivation due to the immunosuppressive effects of For MZL, site-specific infectious disease testing should be performed.

The multidisciplinary team should meet to discuss newly diagnosed patients before definitive treatment so that a treatment plan can be recommended and there can be early preparation for the post-treatment phase. The level of discussion may vary, depending on the patient’s clinical and supportive care factors. The proposed treatment must be recorded in the patient’s medical record and should be recorded in an MDM database where one exists.

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.

Specifically in low-grade lymphomas, ‘watch and wait’, the dynamic observation of asymptomatic disease, can lead to significant anxiety. The patient’s anxiety can be alleviated with education from the treating specialist and counselling from a psychologist with experience in lymphoma.

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

• assistance for dealing with psychological and emotional distress while adjusting to the diagnosis; treatment phobias; existential concerns; stress; difficulties making treatment decisions; anxiety or depression or both; psychosexual issues such as potential loss of fertility and premature menopause; history of sexual abuse; and interpersonal problems
• management of physical symptoms such as pain and fatigue (Australian Adult Cancer Pain Management Guideline Working Party 2019)
• malnutrition or undernutrition, identified using a validated nutrition screening tool such as the MST (note that many patients with a high BMI [obese patients] may also be malnourished [WHO 2018])
• support for families or carers who are distressed with the patient’s cancer diagnosis
• support for families/relatives who may be distressed after learning of a genetically linked cancer diagnosis
• specific spiritual needs that may benefit from the involvement of pastoral/spiritual care. Additionally, palliative care may be required at this

For more information on supportive care and needs that may arise for different population groups, see Appendices A, B and C.

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 Appendix E for a list of team members who may be included in the multidisciplinary team for low-grade lymphomas.

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.