Biomed Imaging Interv J 2006; 2(2):e31
© 2006 Biomedical Imaging and
LETTER TO THE EDITOR
Delivering cancer services: a multi-disciplinary approach
LM Tho*,1, MRCP,
DWY Wong2, MRCP, FRCR
1 Cell-Cycle and Checkpoint Laboratory, Beatson
Institute for Cancer Research, Glasgow, United Kingdom
2 Department of Clinical Oncology, Birmingham Cancer Centre,
Birmingham, United Kingdom
The article by Lim  on the development
of oncology services in Malaysia was both insightful and comprehensive.
It is interesting to read that cancer services are growing from
strength to strength, with a national cancer institute planned.
The field of oncology has been transformed over the last few
decades with a proliferation in technological advances and a
revolution occurring in molecular medicine. Interestingly, the
thinking surrounding cancer service delivery has also been changing.
Cancer care is increasingly being delivered within a multidisciplinary
team environment, involving a host of highly skilled professionals.
As oncologists, despite our unique skills in the diagnosis and
treatment of cancer  we are, but a cog
(albeit a necessary one), in a big wheel that is required to
manage this complex disease. Therefore, it is arguable that
oncology might actually be considered a multi-disciplinary specialty.
Every oncology department relies on a team of highly trained
radiographers, physicists, pharmacists, nurses, and support
staff for everyday functioning. With the resurgence of radiation
research and development, intensity modulated and image guided
radiotherapy  being prime examples, our
reliance on our physicist and radiographer colleagues has never
been greater. This includes all aspects of radiotherapy delivery,
machine commissioning, quality assurance, treatment planning,
and research. It has also been recognized that cancer centres
benefit from taking an active role in public education and outreach,
as this often leads to drastic improvements in patient satisfaction
and overall perceptions.
The concept of teamwork extends far beyond our own departments.
One of our inseparable partners is radiology, which has evolved
into a vast and multifaceted discipline. Different forms of
imaging are used during a patient’s clinical course to
diagnose, stage, plan, deliver intervention, and detect recurrence.
Standard workhorses such as plain radiography and computed tomography
(CT) are invaluable, but more specialized imaging is also important,
including magnetic resonance imaging for detecting spinal cord
lesions or imaging pelvic anatomy, bone scans for detecting
skeletal metastases, and radiofrequency ablation for treating
liver metastases. Even the most subtle of radiological features
may predict a patient’s outcome, for example, the presence
of rectal tumour found within 1 mm of the mesorectal fascia
on a T2 weighted MRI scan could signify a substantial increase
in the chance of local recurrence and warrant aggressive downstaging
by preoperative chemoradiotherapy .
An emergent technology is CT-positron emission tomography
(CT-PET). It offers undeniably superior imaging quality and
evidence of its efficacy is emerging for various tumour sites
[5, 6]. In addition, it
is creating vast opportunities for in vivo imaging research,
which is revolutionising the way drug trials are being designed
(e.g., non-invasive pharmacokinetic and pharmacodynamic studies
) and the way molecular research is conducted.
These benefits must be balanced by the cost of providing this
service. Not only does it incur an initial set-up cost of at
least £4 million/MYR 25.5 million (scanner and cyclotron)
and annual running costs of at least £1.2 million/MYR
7.5 million , but requires the support
of specialist radiopharmacists, physicists, and radiologists.
Clearly, the best value for money would be for a multidisciplinary
team to fully utilise this technology.
Another specialty that we work closely with is pathology.
Good pathological examination enables the right diagnosis to
be made and, consequently, the right treatment to be delivered.
This is especially critical when dealing with curable conditions.
For each tumour type, different tumour characteristics can serve
as either prognostic factors (to predict disease behaviour,
e.g., recurrence rates, overall survival) or predictive factors
(to predict tumour responses to anti-cancer therapy). For example,
in breast cancer, the presence of lymph node involvement, lymphovascular
space invasion, and a high tumour grade confers a poor prognosis,
while hormone receptor or HER-2 receptor status would predict
for a response to anti-oestrogen therapy or trastuzumab (Herceptin®),
respectively . Such routine analysis often
requires the support of highly specialised facilities and staff.
Furthermore, new techniques are constantly being developed,
eg., multi-gene and multi-protein analysis using gene-array
and protein-array platforms , and this
requires continued collaboration to evaluate and apply these
Another key player in oncology is undoubtedly the surgeon.
Modern surgical oncology practices, for example, total mesorectal
resection in rectal cancer, maximal debulking in ovarian cancer,
and nephrectomies in renal cancers have radically improved survival
outcomes. The correct interplay between chemotherapy, radiotherapy,
and surgery is critical, and one of the best ways of ensuring
optimal sequencing and minimizing delays is to build close working
partnerships amongst professionals in these specialties. In
the general care of the cancer patient, clinical oncologists
often rely on input from their fellow specialists. This can
be in the form of support of the critically ill patient (intensive
care/anaesthetists), management of malignancy induced surgical
complications, e.g., bowel perforation or obstruction (surgeons),
or stabilisation of pathological fractures (orthopaedics), managing
infectious or other medical complications (physicians), blood
product support for patients undergoing chemotherapy (blood
bank/haematologists), and pain management and end-of life care
The final area that relies on collaborative effort is oncology
research. Clinical trial units rely heavily on the support of
research nurses, data managers, and statisticians. Translational
research and drug development requires close cooperation between
clinicians and scientists and, increasingly, from industry.
Good research tends to flourish where a critical mass of people
are able to generate ideas and lend expertise. Many cancer centres
have realised this and have sought to provide closer interactions
between specialties by developing joint clinics and multidisciplinary
meetings and seminars. For the various specialties involved,
a degree of sub-specialization is required to ensure familiarity
with the specifics of oncological practice. This can sometimes
require housing cancer treatment centres, research institutes,
and regional teaching hospitals in close physical proximity
to one another. National initiatives have also recognised the
need for a multidisciplinary approach. Within the world-famous
US National Cancer Institute (NCI), designated cancer centres
are “encouraged to stimulate collaborative research involving
more than one field of study” .
In a visionary move, the NCI has established the Cancer Biomedical
Informatics Grid , which aims to enable
global communication and resource sharing throughout it vast
network of centres. The nascent UK equivalent, the National
Cancer Research Institute (NCRI) Informatics Initiative, is
similarly promoting the integration of basic science and clinical
It is clear that a multidisciplinary approach in treating
cancer patients facilitates improvements in patient care and
outcomes. Therefore, it is vital that we continue to forge strong
links with colleagues from all specialties, particularly when
faced with increasing complexities in the treatment of this
Lim G. Clinical oncology in Malaysia: 1914 to present. Biomed Imaging Interv J 2006;2:e18.
Tho LM, Featherstone C, Reed NS. Training in Clinical Oncology. BMJ (Careers) 2005;330:113-5.
Xing L, Thorndyke B, Schreibmann E, et al. Overview of image-guided radiation therapy. Med Dosim 2006;31(2):91-112.
Brown G. Thin section MRI in multidisciplinary pre-operative decision making for patients with rectal cancer. Br J Radiol 2005;78 Spec No 2:S117-27.
Ukena D, Hellwig D. Value of FDG PET in the management of NSCLC. Lung Cancer 2004;45 Suppl 2:S75-8.
Huddart RA. Use of FDG-PET in testicular tumours. Clin Oncol (R Coll Radiol) 2003;15(3):123-7.
Workman P, Aboagye EO, Chung YL, et al. Minimally invasive pharmacokinetic and pharmacodynamic technologies in hypothesis-testing clinical trials of innovative therapies. J Natl Cancer Inst 2006;98(9):580-98.
Price P, Laking G. How should we introduce clinical PET in the UK? The oncologists need to have a view. Clin Oncol (R Coll Radiol) 2004;16(3):172-5.
Hayes DF. Prognostic and predictive factors revisited. Breast 2005;14(6):493-9.
MacBeath G. Protein microarrays and proteomics. Nat Genet 2002;32 Suppl:526-32.
The National Cancer Institute Cancer Centers Program [Web Page]. 19 April 2006; Available at http://www.cancer.gov/cancertopics/factsheet/NCI/cancer-centers.
von Eschenbach AC. A vision for the National Cancer Program in the United States. Nat Rev Cancer 2004;4(10):820-8.
The National Cancer Research Institute (NCRI) Informatics Initiative, United Kingdom [Web Page]. Available at http://www.cancerinformatics.org.uk.
Received 22 May 2006; accepted 15 June 2006
Cell Cycle and Checkpoint Laboratory, Beatson Institute for Cancer Research, Glasgow, Switchback Road, Bearsden, Glasgow G61 1BD, United Kingdom. Tel: 0141 330 3953 (ext. 3974); E-mail: firstname.lastname@example.org (Lye-Mun Tho)
Please cite as: Tho LM, Wong DWY, Delivering cancer services: a multi-disciplinary approach, Biomed Imaging Interv J 2006;2(2):e31
This article has been viewed 3579 times.