STEP 3: Diagnosis, assessment and treatment planning
Step 3 outlines the process for confirming the diagnosis and planning subsequent treatment. The guiding principle is that interaction between appropriate multidisciplinary team members should determine the treatment plan.
Diagnostic work-up should include:
- history and examination
- staging: local – MRI, thallium or PET scans; systemic – bone scan, PET/CT, CT chest
- image-guided biopsy – percutaneous needle or open
- examination of tumour tissue by histological, immuno-histochemical, molecular pathological and cytogenetic methods, as appropriate
- lymph node biopsy (if functional imaging is positive or clinical examination suspicious).
The tumour should be staged on completion of investigations.
To confirm malignancy, and provide a histological diagnosis, biopsy should be performed after all imaging modalities have been completed and reviewed by the specialist. Image-guided needle core biopsy (NCB) is the preferred method, performed by a radiologist who is familiar with the issues of sarcoma biopsy in a specialist sarcoma unit setting with appropriate multidisciplinary input.
The histological diagnosis and determination of grade and subtype of sarcomas should be undertaken by an appropriately trained histopathologist. Histological diagnosis should be made according to the 2013 World Health Organization (WHO) classification (ESMO 2014b).
Timeframe for diagnosis
Timeframes should be informed by evidence-based guidelines (where they exist) while recognising that shorter timelines for appropriate consultations and treatment can reduce patient distress.
The following recommended timeframes are based on expert advice from the Sarcoma Working Group:2
- Complete all investigations within two weeks of first specialist assessment.
The responsibilities of the multidisciplinary team are to:
- nominate a team member to coordinate patient care and identify this person to the patient
- nominate a team member to be the lead clinician (the lead clinician may change over time depending on the stage of the care pathway and where care is being provided) and identify this person to the patient (if different from the care coordinator)
- develop and document an agreed treatment plan at the multidisciplinary team meeting (including consideration of clinical trial options)
- communicate/circulate the agreed multidisciplinary team treatment plan to relevant team members, including the patient’s general practitioner
- inform quality and safety improvements, collect data and benchmark outcomes.
The general or primary medical practitioner who made the referral is responsible for the patient until care is passed to another practitioner.
The general or primary medical practitioner may play a number of roles in all stages of the cancer pathway including diagnosis, referral, treatment and coordination and continuity of care as well as providing information and support to the patient and their family.
The care coordinator is responsible for ensuring there is continuity throughout the care process and coordination of all necessary care for a particular phase. The care coordinator may change over the course of the pathway.
The lead clinician is responsible for overseeing the activity of the team.
The multidisciplinary team should comprise the core disciplines that are integral to providing good care. Team membership will vary according to cancer type but should reflect both clinical and psychosocial aspects of care. Additional expertise or specialist services may be required for some patients (Department of Health 2007b).
Team members may include:
- a cancer nurse (with appropriate expertise)*
- a care coordinator (as determined by multidisciplinary team members)*
- a dietitian*
- a medical oncologist*
- a musculoskeletal radiologist*
- a paediatric surgeon*
- a pathologist*
- a radiation oncologist*
- a reconstructive surgeon*
- a social worker*
- a surgical oncologist*
- an expert in providing culturally appropriate care to Aboriginal and Torres Strait Islander patients (this may be an Aboriginal and Torres Strait Islander health worker, health practitioner or hospitality liaison officer)*
- an expert in the psychosocial care of AYA (with preference for a representative from a youth cancer service)*
- an orthopaedic oncologist*
- an orthotist/prosthetist*
- a clinical trials coordinator
- a fertility specialist
- a general practitioner
- a nuclear medicine specialist
- a palliative care specialist
- a pharmacist
- a physiotherapist and/or exercise physiologist
- a psychiatrist
- a psychologist
- a rehabilitation physician
- a speech therapist
- a thoracic surgeon.
- an occupational therapist
* Core members of the multidisciplinary team are expected to attend most multidisciplinary team meetings either in person or remotely.
All newly diagnosed patients should be discussed in a multidisciplinary team meeting before beginning treatment. The level of discussion may vary depending on clinical and psychosocial factors. Teams may agree standard treatment protocols for non-complex care facilitating patient ascertainment and associated data capture.
A treatment plan for each case should be discussed at the beginning of treatment to determine timing and the choice of surgical resection, surgical reconstruction and radiation therapy to minimise surgical-related and radiation therapy-related morbidity (Cancer Council Australia Sarcoma Guidelines Working Party 2014).
The results of all relevant tests and imaging should be available for the multidisciplinary team discussion. The care coordinator or treating clinician should also present information about the patient’s concerns, preferences and social circumstances (Department of Health 2007c).
All patients with sarcoma should be offered the opportunity to participate in a clinical trial or clinical research if appropriate (Field et al. 2013).
Cross-referral between clinical trials centres should be encouraged to facilitate participation.
- Australasian Sarcoma Study Group is a national cooperative cancer clinical research group. It coordinates large-scale multi-centred sarcoma trials.
- Australian Cancer Trials is a national clinical trials database. It provides information on the latest clinical trials in cancer care, including trials that are recruiting new participants. For more information visit Australian Cancer Trials.
Cancer prehabilitation uses a multidisciplinary approach combining exercise, nutrition and psychological strategies to prepare patients for the challenges of cancer treatment such as surgery, chemotherapy and radiation therapy.
Evidence indicates that prehabilitating newly diagnosed patients with cancer before starting treatment can be beneficial. This may include conducting a physical and psychological assessment to establish a baseline function level, identifying impairments and providing targeted interventions to improve the patient’s health, thereby reducing the incidence and severity of current and future impairments related to cancer and its treatment (Silver & Baima 2013).
The process of prehabilitation for this complex group should be highly integrated with the treating surgical/medical team. Patients requiring amputation will benefit from preamputation counselling and comprehensive preoperative pain management to reduce the risk of phantom pain.
Medications should be reviewed at this point to ensure optimisation and to improve adherence to medicines used for comorbid conditions.
Screening with a validated screening tool (for example, the National Comprehensive Cancer Network Distress Thermometer and Problem Checklist), assessment and referral to appropriate health professionals or organisations is required to meet the identified needs of an individual, their carer and family.
In addition to the other common issues outlined in the Appendix, specific needs that may arise at this time include the following.
Physical
- Change in functional abilities – patients may benefit from referral to occupational therapy, physiotherapy and/or exercise physiology.
- Patient may need treatment for other physical symptoms such as pain, fatigue and musculoskeletal dysfunction.
- Patients require ongoing nutritional screening, assessment and management. Reduced oral intake and/or swallowing difficulties and weight loss require referral to a dietitian and speech pathologist (for swallowing difficulties).
Psychological
- Patients may require help with psychological and emotional distress while adjusting to the diagnosis, treatment phobias, existential concerns, stress, difficulties making treatment decisions, anxiety/depression, psychosexual issues such as potential loss of fertility, loss of previous life roles and interpersonal problems.
Social/practical
- Patients may need support to attend appointments.
- Provide guidance about financial and employment issues (such as loss of income and having to deal with travel and accommodation requirements for rural patients and caring arrangements for other family members).
Information
- Discuss fertility options with the patient and/or family (where appropriate) before beginning treatment.
- Provide appropriate information for people from culturally and linguistically diverse backgrounds.
Spiritual needs
- Patients and their families should have access to spiritual support that is appropriate to their needs throughout the cancer journey.
The lead clinician should:
- establish if the patient has a regular or preferred general practitioner
- provide contact details of a key contact for the patient
- discuss a timeframe for diagnosis and treatment with the patient and carer
- discuss the option of fertility preservation (referral to a fertility service for counselling and evaluation of options may be appropriate)
- discuss the benefits of multidisciplinary care and make the patient aware that their health information will be available to the team for discussion at the multidisciplinary team meeting
- offer individualised sarcoma information that meets the needs of the patient and carer (this may involve advice from health professionals as well as written and visual resources)
- offer advice on how to access information and support from websites, community and national cancer services and support groups for both patients and carers
- refer the patient to the What to Expect – Sarcoma (bone and soft tissue tumours) guide.
- use a professionally trained interpreter to communicate with people from culturally or linguistically diverse backgrounds including Aboriginal and Torres Strait Islander people.
The lead clinician should:
- ensure regular and timely (within a week) communication with the person’s general practitioner regarding the treatment plan and recommendations from multidisciplinary team meetings
- notify the general practitioner and family/carer if the person does not attend clinic appointments
- gather information from the general practitioner including their perspective on the person (psychological issues, social issues and comorbidities) and locally available support services
- help develop a chronic disease and mental healthcare plan as required
- discuss shared care arrangements (with general practitioners and/or regional cancer specialists)
- invite the general practitioner to participate in multidisciplinary team meetings (consider using video- or teleconferencing).
