Introduction
Oncology should offer personalized management,
defined as "tailor made" treatment, which should be
based on multidisciplinary assessment[] focusing on
efficacy, feasibility, and cost/benefit but, at the same
time, considering the patient's age, clinical condition,
type of disease and personal needs. Nowadays, minimally
invasive procedures are increasingly used to
manage oncological patients; these procedures are especially
beneficial in elderly frail patients[] to avoid
overtreatment or age-related undertreatment.[] Different
non-surgical procedure types exist to treat localized
malignancies or oligometastatic diseases, which
can be collected under the name interventional oncology
(IO) and include interventional radiotherapy
(IRT) (brachytherapy), interventional radiology, interventional
endoscopy, and interventional chemotherapy.
IO is a new tool in cancer treatment and has the
potential to improve treatment results and benefits, as
well as to reduce complications in localized solid cancers
or selected oligometastatic diseases. Many IO procedures
could be proposed alternatively and only a detailed
case assessment and multidisciplinary evaluation
can result in the best personalized therapeutic choice.
An IO center should offer an opportunity in cancer
care and specifically, "interdisciplinary service for
diagnosis and treatment of cancer and cancer-related
problems using targeted (focal) minimally invasive procedures."[] Specialized multidisciplinary tumor
boards (MDTs), in this paper called "IO MDT board
(INTER-BOARD)," are interdisciplinary meetings in
which different specialists are directly involved in patient
management, overcoming the limits of a general
tumor board. This evaluation aims to discover and report
the influence of the INTER-BOARD in terms of
waiting time, medical procedure complications, and
average hospital stay.
Methods
As a consequence of a health care plan at Gemelli
University Hospital a dedicated pathway for IO patients
was defined (Fig. 1). From January 2018 all patients,
candidates to interventional procedures, were
discussed in the dedicated weekly multidisciplinary
meetings (INTER-BOARD). INTER-BOARD members
are radiation oncologists experienced in IRT, radiation
oncologists experienced in external beam focal
radiotherapy, interventional radiologists, interventional
endoscopists, geriatric-oncologists, and radiation
technicians. All patients were evaluated following
a multidisciplinary pre-hospitalization discussion to
intercept any condition that can influence the procedure
and to sign the informed consent. A retrospective
analysis was carried out using medical records of
patients managed at the INTER-BOARD from January 2018 to June 2019. The number of patients in each semester,
the median time between initial assessment
and admission to the hospital, the total number of procedures,
features, procedure types, side effects, length
of hospital stay, and complication rates were collected
and analyzed.
Fig 1: A dedicated pathway for interventional oncology patients.
Analysis of Data and Statistical Methods
Clinical data were progressively collected in a database
obtained by "SPEED" technology (connected with
COBRA/BOA[] informatics architecture), which is an
electronic institutional platform, that is an evolution of
the "SPIDER"S NET" system.[] Data processing was
carried out by two researcher (MI and PC). Patient
characteristics were represented as frequencies and
percentages. The statistical analysis was performed using
Microsoft Excel for macOS software.
Results
From January 01, 2018 to June 30, 2019, the INTER
BOARD discussed 438 consecutive patients. The mean
age was 64 years (range 27-92 years), with 203 procedures
performed in patients over 65 years and 49 over
80 years. The number of discussed patients was progressively
increased: 82 (18.7%) from January to June
2018, 120 (27.4%) from July to December 2018, and
236 (54.1%) from January to June 2019 (Fig. 2).
Fig 2: Number of patients discussed during INTERBOARD:
1st, 2nd semester 2018 and 1st semester
2019.
Patients with 33 cancer types were discussed (Fig.
3) and 22 different types of procedures were performed
(Fig. 4). The average waiting time from INTERBOARD
to pre-hospital admission assessment was 11 days, while the average interval from pre-hospital assessment
and admission was 11 days. The average waiting
time from INTER-BOARD to hospital admission
was 22 days. Urgent cases were managed in a fast-track
pathway guaranteeing procedures in optimal clinical
time. In selected urgent clinical cases the multidisciplinary
evaluation was performed ad hoc with a complete
laboratory and radiological assessment (when
required) directly performed at the ward. The overall
mean hospitalization time was 4 days. An analysis of
hospitalization time for semesters was performed.
With the improvement of the pathway and the pre-hospitalization
assessment, the mean hospitalization time
decreased progressively over time going from 5 days in
the first semester to 4 days in the second semester and
3 days in the last semester considered.
Fig 3: Types of evaluated tumors.
Fig 4: Types of performed procedures (The list of procedures
is reported in descending order).
The overall complication rate was 4%. The rate of
complications progressively decreased (16%, 5%, 3%,
respectively, for 1st, 2nd semester 2018 and 1st semester
2019) (Fig. 5). Figure 6 summarizes all observed complications.
Currently, the health costs related to increasingly
complex patients make the sustainability of health systems
difficult. In this scenario, a multidisciplinary and
multidimensional approach in the IO tumor board has
as its main advantage the treatments personalization. A
"tailor-made" treatment, the constant multidisciplinary
case management and the presence in the evaluations
of an oncogeriatric assessment of the complexity, allows
more targeted and punctual interventions which in clinical
terms corresponds to a reduction of the phenomena
of under and overtreatment, reduction of the patient's
hospital stay with reduction of the indirect effects (risk
of delirium, enticement, loss of performance, and infections),
improvement of patient compliance and impact on the quality of life. In terms of health economics, a reduction
in hospitalization associated with a reduced risk
of adverse events corresponds to a reduction in direct
and indirect health costs.
Fig 5: Percentage of hospitalizations with a complication:
1st, 2nd semester 2018 and 1st semester 2019.
Fig 6: Complications observed in treated patients (Data
are reported in percentages).
Discussion
Over 18 months, 438 consecutive patients were evaluated
at the INTER-BOARD, with a progressive increase
in the number of performed procedures. The INTERBOARD
and a dedicated pathway for oncological patients
optimized oncological procedures, especially in
the field of interventional medicine; thus, progressively
more specialists requested patient assessment and
treatment at the IO center.
During INTER-BOARD meetings, specialists discussed
the advantages and disadvantages of several potential
procedures. These consensus procedures resulted
in personalized treatment with tailored solutions.
More specifically, in our cohort an impressive number
of elderly patients was assessed and treated as a result
of personalized management, aiming to avoid underand
overtreatment. Among the optimized oncological
procedures is for example radiotherapy, which offers
IRT (brachytherapy; IRT) or electro-chemotherapy as prognoa
local treatment.[] IRT represents the optimal method
to apply a high radiation dose according to biological
needs within the target volume including a rapid
dose fall-off in adjacent organs at risk. Furthermore,
relatively short treatment times and good functional
outcomes are typical.[]
Electrochemotherapy is a relatively new local tumor
therapy. An electric field is generated in a tumor region
between a set of electrodes. This electric field makes the
cell membranes permeable to large molecules for a short
time, thereby allowing anticancer drugs to enter cells.
At the same time, different focal treatments for
example percutaneous or intra-arterial locoregional
procedures are performed by interventional radiologists.
Percutaneous locoregional treatments are mainly
represented by radiofrequency ablation or microwave
ablation, and cryoablation, which uses thermal energy
to heat (radiofrequency, microwaves) or focally cool
(cryoablation) tissues to cytotoxic levels (more than
60°C or <-40°C). Ablation technology has evolved rapidly
during the past decades, with substantial technical
and procedural improvements, which helped to improve
clinical outcomes and safety profiles by creating
larger areas of ablation, attempting to more precisely
control the area of ablation, ensuring the safety of the
procedure, and achieving greater long-term success.
Intra-arterial procedures are mainly represented
by trans-arterial chemoembolization or embolization
trans-arterial radio-embolization, in which devascularization/
ischemia of tumors is associated with a selective
and locoregional delivery of high chemotherapy
drugs or internal radiotherapy (with radioactive isotopes
e.g. yttrium-90 (Y90)-tagged glass or resin microspheres)
dose to the cancer.[-]
Both, IRT and interventional radiology can be curative,
converting patients from palliative to treatable
status, or purely palliative. Furthermore, ancillary procedures,
such as biopsy, fiducial marker placement, venous/
vascular access, drainage, fluid management, and
other procedures, are essential in cancer care, which
are usually performed to permit other procedures or
to treat complications. Regarding the role of specialists,
the endoscopist can offer diagnostic procedures or
ablative treatments using an endoscopic approach.
The role of geriatric oncologists is mandatory to
evaluate patients" physical and cognitive performance,
to choose the best therapeutic approach, and to avoid
under- and overtreatment. Moreover, a geriatrician facilitates
the identification of frail patients according to
international guidelines, which is especially in times
fearing coronavirus infection important.[-]
The most frequently treated cancer, accounting for
54% of all cancers treated, were endometrial and cervical
cancers. This can be explained by the fact that
our center is a hub of excellence for gynecological
cancers. Thus, the most frequent procedures were IRT
(47.9%). Furthermore, the INTER-BOARD assessed
also non-cancer patients (patients with keloid) and
perform procedures that responded to non-cancer
disease (treatment late toxicity), such as actinic proctitis
(Endoscopic Argon Plasma Coagulation). Many
researchers have tried to establish a relationship between
waiting times and outcomes in the management
of cancer patients. Most of these studies use
waiting time until treatment initiation as a quality
indicator. Using waiting time as a reference indicator
allows us to improve access to treatments and to optimize
treatments themselves.
Several studies suggested that discussed cases at
an MDT were more likely to receive appropriate staging[-] and neo-adjuvant/adjuvant treatment compared
to cases, which were not evaluated at an MDT.
[-] A justification for this condition is represented
by the hypothesis that the presence of more specialists,
discussing a clinical case, allows a better and more precise
cancer staging.[] Moreover, the formulation of
the best treatment plan is facilitated by the presence of
several specialists discussing the advantages and disadvantages
of each procedure applied to the patient
in question.[] Thus, multidisciplinary approaches
are the best way to deliver complex cancer care to patients.[] Both diagnostic capabilities and therapeutic
options can be easily discussed to ensure the best
treatment for each patient. All this can also lead to a
non-standard treatment plan that adheres to existing
guidelines and fulfills the needs of the individual patient.
MDTs are thought to optimize patient outcomes
and improve care performance, but it is a challenge
that requires organizational and behavior changes. It
is advisory that competent health managers who can
improve effective teamwork within their organizations,
lead these changes.
This approach offers the potential to achieve prolonged
survival in patients who, in the past, would
have only received palliative measures. For this reason,
clinical guidelines have already begun to incorporate
focal treatment techniques.[] Oligometastatic status
refers to a clinical stage in which patients present
a limited number of metastases in a single organ or in
few organs. These lesions may be more indolent than
those typically observed in patients with multiple metastases.
Oligometastatic patients have a better prognosis with adequate treatment. Surgery has traditionally
been the main treatment option, but, in many cases,
these metastatic lesions are unresectable, or the patient
is considered inoperable, or the long postoperative recovery
period may require an unacceptable delay in the
initiation of systemic therapy. As a result, less invasive
treatments such as radiotherapy are often necessary.
Technological advances of the past decades permitted
high focal ablative doses with great precision to various
sites. An important advantage of these high-dose
treatments is that they require fewer fractions; thus, the
treatment duration is shorter than with conventional
fractionation or usual hypofractionation schedules.
INTER-BOARD meetings play a multifactorial role
in bridging the gap between expert consensus panels
and selection of the most appropriate care and optimize
patient care by identifying all available options.
For this reason, IO centers could have an important
role for out-patient and in patient services, in education,
as well as in clinical research.[-]
Stereotactic radiosurgery and stereotactic body
radiation therapy are considered safe, with minimal
treatment-related toxicity, only requiring a brief interruption
of systemic therapy. The results of several heterogeneous
randomized studies with predominantly
small cohorts, as well as the analysis of prospective
and retrospective studies, indicate that local ablative
therapy in oligometastatic patients can improve the
progression-free survival and the overall survival in a
variety of tumor entities compared to systemic treatment
alone. The best available evidence is on nonsmall-
cell lung cancer and colorectal cancer.[] Indeed,
in recent years, it was demonstrated that local
treatments (either radiotherapy or surgery) improve
the progression-free survival and the overall survival
in patients with oligometastatic non-small cell lung
cancer at diagnosis and in those who respond to the
initial systemic therapy. However, the association of locoregional
interventional treatments and the abscopal
effect was only addressed in few studies. The concept
of abscopal effect is currently gaining importance in
modern oncology; as the link between focal irradiation
and triggering of immuno-mediated systemic antitumor
effects is getting clearer.[]
Although the results obtained are encouraging
and suggest that a dedicated pathway for oncological
patients can improve and optimize the treatment procedure,
this study has some limitations: it is a retrospective
analysis and due to the features with which the
analysis and evaluations were conducted, efficacy data
are absent.
Another limitation is represented by the fact that
our patient population doesn"t include all patients
treated in our Institution with interventional locoregional
treatments. In detail, INTER-BOARD is focalized
on a selective subgroup of patients with a potential
indication for locoregional treatments; however, it
is not exclusive as other patients, not included in our
evaluation, daily receive interventional locoregional
treatments following indications from different multidisciplinary
organ-specific tumor boards, well-active
in our Institution. However, this limitation didn't affect
our aim, to focused to register all patients treated in
our institution but how a MTB could improve patient
management.
Conclusion
IO represents one of the fastest-growing areas of interventional
medicine and has become an essential part
of comprehensive cancer care. Specialized MDT, such
as the INTER-BOARD, play a multifactorial role to
bridge the gap between expert consensus panels and
appropriate care choice. MDTs can optimize patient
care through identification of all available options, offer
cross-specialty knowledge translation, provide the best
evidence and continual updates on innovation among
all stakeholders, ensure a low complication rate, and
reduce waiting/hospitalization times. The results of our
work shows how an IO center is fundamental to offer
the best oncological treatments and to carry out a real
personalization of treatments.
Peer-review: Externally peer-reviewed.
Conflict of Interest: All authors declared no conflict of interest.
Ethics Committee Approval: Ethics Committee Approval
was waived due to the retrospective nature of the study and
the anonymized data reported.
Financial Support: This study has received no financial
support.
Authorship contributions: Concept - R.I., L.T.; Design
- V.L., F.C.; Supervision - V.V., A.R., G.K., R.M., M.A.G.;
Funding ? None; Materials - None; Data collection and/or
processing - F.A., A.L.; Data analysis and/or interpretation -
F.A., A.L.; Literature search - M.I., P.C.; Writing - M.I., B.F.,
P.C., A.C., G.C.; Critical review - R.I., B.F., P.C., M.I., V.L.,
A.C., F.A., A.L., F.C., F.M., G.C., A.R., G.K., M.A.G., R.M.,
V.V., L.T.
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