Dr Santiago González-Moreno
Medical Director and Head of Surgical Oncology, MD Anderson Cancer Center, Madrid, Spain; President Elect, European Society of Surgical Oncology (ESSO).
Cancer is a multidimensional and multifactorial reality. Starting at its very biological roots, the cancer cell needs the conjunction of different molecular and genetic events only to exist and more so to progress into a detectable and threatening disease, as elegantly expressed by Hanahan and Weinberg1 in their acclaimed paper “The Hallmarks of Cancer”. At the clinical level, the diagnosis and therapeutic management of cancer is a mirror image of the complexity and diversity of the disease at the biological level. Targeting only one of the various elements involved in cancer inception and promotion, even when it could leave us with a false sense of transient success, is not enough to eradicate the disease. Biology once again shows us the clues of reality at other levels.
We cannot treat or even talk about cancer without a reliable tissue diagnosis (and in more and more cases coupled with an accurate molecular or genetic characterisation) provided by an expert pathologist after examination of a representative tumour specimen, provided by a surgical specialist or an interventional medical discipline. System-based or general medical specialists may have played an important role in the initial clinical assessment of those patients presenting with signs and symptoms and have started the diagnostic process. Experts in diagnostic imaging will provide us with some keys for the disease diagnosis, as well as important information about its extension and staging. Finally, only the conjunction and fine coordination of clinical cancer specialists, each of them experts in a field within the varied cancer therapy armamentarium, will provide the best treatment plan. At the same time, allied specialists including nutritionists, specialised nurses, and psychologists will likewise provide expert care that cannot be ignored, helping the patients cope with the disease process and live through the effects of prescribed treatments. Only the harmonisation and integration of all these actions, sometimes sequentially, sometimes concurrently, will result in the best care for our patient, who is and should remain the very centre of our efforts.
A clinical oncologist is a cancer specialist by definition. With a basic common body of knowledge needed to understand the biological bases of the disease we deal with and its diverse clinical scenarios, from molecular biology to the end of life, the medical, surgical, or radiation oncologist contribute with the different therapies they master (systemic therapy, surgery, or ionising radiation) to the common goal. Each one of them is aware of the interaction between the therapy they provide and that is provided by others, as they should have basic understanding of all of them. Each one of them individually will never arrive to the same results. Therefore, expertise in cancer care or cancer knowledge or a pre-eminent role in cancer management cannot be claimed by just one specialty without ignoring the true nature and reality of this disease.
Every cancer patient deserves that his or her case is discussed at a multidisciplinary conference where all the specialists involved in his/her cancer diagnosis and management are present. Each one of them is there to provide the key diagnostic, staging, and treatment-related elements that will result in the elaboration of an upfront personalised therapeutic plan and timeline where surgery and/or systemic therapy and/or radiation therapy will be combined in one of the possible different ways for an optimal outcome of that patient’s disease according to the current knowledge.
It is possible that beyond amazing technical and medical advances, the advent of multidisciplinary cancer care that integrates them all should be considered as the revolution in cancer management that evolved over the last quarter of the past century. This is the premier and basic gold standard in cancer therapy, beyond (but of course aware of) acclaimed clinical practice guidelines or personalised evidence-based medicine, and it is here to stay. In a time of vertiginous changes in the oncology landscape at all levels, of industry-driven research, and governments call for cost-efficiency and cost-containment in healthcare, it is now our responsibility to nurture and hold on tight to patient-centered multidisciplinarity, beware and escape from temptations to underestimate it or ignore it, and take it to the next level. If we fail to do so we will be ignoring the very biological nature of the disease we treat and claim expertise in. And we will fail in our ultimate goal to eradicate or at least have cancer under our control one day.
1. Hanahan D, Weinberg RA. The hallmarks of cancer. Cell. 2000;100(1):57-70.