Multidisciplinary care for women with early breast cancer in the Australian context

To the Editor: Zorbas et al1 have highlighted both the complexities and resource intensiveness of multidisciplinary care for women with early-stage breast cancer. The same arguments exist in advanced disease, where input from many disciplines is the norm. However, there is no evidence that such a process improves outcomes in the Australian setting. The references the authors draw upon relate to regions in which breast cancer outcomes have historically been poor. Evidence from Australian studies suggests higher standards of care and appropriate changes over time. 2,3,4

The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of early breast cancer5 provide an evidence-based strategy for managing the disease. Enshrined within them is the concept that many different treatment approaches are equivalent and that patient preferences are important. Patient input into multidisciplinary case conferences is frequently minimal. Case conferences can be confusing for patients, and it may not be clear to them who is their doctor. Many clinics include a breast nurse, who commonly acts as a patient advocate. Zorbas and colleagues note the different models of multidisciplinary care, but the minimum approach required to achieve good outcomes has not been established.

It is not surprising that 34% of rural surgeons find it difficult to implement a service in which all women have access to a full range of treatment options in a multidisciplinary setting. There is no evidence, however, that their patients are more unhappy or that management outcomes are inferior. Similarly, the guidelines correctly promote the importance of psychosocial support for patients, but the suggestion that this can be better achieved by a psychologist via teleconferencing rather than by the patient’s general practitioner is purely speculative.

None of the multidisciplinary models suggested by Zorbas et al addresses the management of patients at relapse, and yet data and clinical experience indicate this is the time of greatest stress for patients, 6 a time when input from a number of specialties — medical care, radiation oncology, palliative care — is the norm.

Multidisciplinary care appears to be beneficial regardless of the stage of disease. However, the execution of some of the models is resource-intensive. We need to evaluate not only whether the objectives of the NHMRC guidelines are met, but whether patient satisfaction and participation are enhanced, survival outcomes are improved and care through all stages of the disease is optimal. Currently, by such measures, multidisciplinary care has not been shown to be superior to a small number of well-directed, evidence-based selective consultations.