Introduction

Multidisciplinary care teams are those that are composed of members from multiple different medical specialties working together to achieve the highest quality of care for the patient. Such teams are particularly needed in complex environments such as cancer hospitals, where the needs of the patients cross the boundaries of specialties. There are the providers of medical care, including medical oncologists, radiation oncologists, and surgeons; the ancillary care providers such as imaging, pathology, and laboratory medicine; and a host of supportive services including nutrition, rehabilitation services, and chaplaincy. In order for such a diverse group to work effectively together, communication and mutual understanding are critical.

Imaging plays a central role in the care of patients with cancer. Subsequent chapters deal with some of the specifics regarding the use of imaging in the multidisciplinary environment, such as tumor staging, lesion respectability, and treatment-related complications. Many clinical decisions are influenced by the results of imaging studies, and the radiologist must, therefore, be a central member of the multidisciplinary care team. The significant role of imaging can be seen in the continued growth in the numbers of scans performed each year, particularly in the advanced imaging studies such as x-ray computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography with x-ray CT (PET/CT).¹

One of the major challenges for radiologists in the multidisciplinary environment is that imaging intersects with nearly all aspects of patient care. Scans ordered by a radiation oncologist for the purpose of treatment planning may be interpreted with a different emphasis and perspective than scans ordered by a surgeon prior to planned curative resection or by a medical oncologist in anticipation of systemic chemotherapy. The radiologist needs to be aware of the clinical scenario in which the scan is being ordered and should have an understanding of the implications of the scan results for the patient. This level of expertise is gained through direct and frequent interaction with the other members of the care team.

Central to the role radiologists play in the management of patients with cancer is communication. Results need to be conveyed in an understandable and clinically relevant fashion, and preferably in a timely manner. The following sections describe the radiologist’s perspective on multidisciplinary cancer care and discuss ways to effectively communicate in such an environment.

Multidisciplinary Cancer Imaging: The Role of the Radiologist

The field of radiology has grown in complexity as the technology of imaging has advanced. Plain x-ray, fluoroscopy, and radionuclide scintigraphy have been a part of medical practice for many decades, whereas CT, MRI, ultrasound, and PET/CT are more recent additions to the field. Even within imaging modalities, techniques continue to evolve. CT studies are now often performed in a multiphasic fashion, using multispectral scanners. Clinical MRI is now performed on both 1.5- and 3.0-T systems, with an ever-increasing array of sequences and coils. New developments are always on the horizon, from higher–field strength MRI systems to novel tracers for PET/CT. Advances are not confined solely to the diagnostic arena, but are also seen in the fields of intervention and therapy.

This increase in the breadth and complexity of radiology and nuclear medicine has necessitated a shift in practice patterns at many sites. In order to effectively function in the multidisciplinary environment of an academic cancer hospital, radiologists have needed to specialize. Radiology specialization has traditionally been either by modality (e.g., ultrasound, CT) or by system (e.g., body imaging, neuroradiology, thoracic radiology). The clinical specialties, conversely, have trended toward specialization according to disease. At M. D. Anderson Cancer Center, there are multidisciplinary care teams devoted to the care of patients with various malignancies. Each care team is composed of multiple members from various disciplines, including surgery, medical oncology, and radiation therapy. In order to adapt to the multidisciplinary paradigm, imaging has had to adapt from the traditional modality-based and system-based approaches to a disease-oriented framework (Figure 1-1).

Figure 1-1 In the multidisciplinary cancer care environment, the emphasis in imaging shifts from modality-based practice to disease-based practice. CT, computed tomography; GI, gastrointestinal; GU, genitourinary; MRI, magnetic resonance imaging.

The challenge for the radiologist is that the diagnostic imaging within each of the multidisciplinary centers crosses the boundaries between traditional imaging specialties. To take an example, a woman with newly diagnosed, locally advanced breast cancer presents for workup (Figure 1-2). Breast imaging plays a central role in her evaluation, starting with mammography and moving to breast ultrasound and/or MRI as needed. Her pathologic diagnosis and tumor genetic markers will likely be established by a guided biopsy procedure. Further imaging workup of such a patient may include a contrast-enhanced CT of the chest and abdomen or a radionuclide bone scan for detection of osseous metastatic disease. The workup may stop there, but depending on many clinical factors such as signs and symptoms and serum tumor markers, additional imaging may be requested including PET/CT with fluoro-2-deoxy-D-glucose (FDG), or brain MRI.

Figure 1-2 Imaging can play a role in all cycles of patient care. In this patient with a new breast lump, the diagnosis of breast cancer was first suspected on mammography (A) and MRI (B) and subsequently confirmed on ultrasound (C) with ultrasound-guided biopsy (D). E, A fluoro-2-deoxy-D-glucose (FDG)–positron-emission tomography/computed tomography (PET/CT) showed the primary tumor and axillary metastases, but also numerous osseous metastases. F, The patient subsequently received chemoradiation for stage IV disease. A follow-up FDG-PET/CT showed complete metabolic response of the primary tumor, nodal metastases, and osseous metastases, but a new hypermetabolic lesion in the liver. G, This lesion was confirmed and biopsied under ultrasound guidance, after which a limited hepatectomy was performed. H, Follow-up CT scan shows evolving postoperative changes and no evidence of recurrence.

All of these imaging studies will be taken into account in order to decide whether the patient should proceed to surgery, undergo neoadjuvant chemotherapy or chemoradiation, or undergo chemotherapy or radiotherapy either alone or in combination. Imaging may guide specific intervention not part of the overall treatment strategy, such as radiotherapy or surgical fixation of a bone metastasis with impending pathologic fracture. In this fairly straightforward example, there is potentially the need for imaging specialists in the fields of breast imaging, body imaging, nuclear medicine, and neuroradiology.

In response to this shift in clinical practice toward multidisciplinary care, radiology at M. D. Anderson Cancer Center has also moved toward a disease-based approach. This has required both a shift in traditional boundaries and a close cooperation between radiologists of different subspecialties. In many cases, one of the radiology subspecialties fits in well with one or more of the clinical care centers. For the patient described previously, undergoing workup and care by the breast cancer team, the breast imaging section plays a major role, interacting directly with the clinicians and offering guidance with regards to additional imaging. The thoracic imaging group provides the direct interface with the lung cancer, esophageal cancer, and mesothelioma teams. Within each of these sections, radiologists may develop areas of interest and become, for example, specialists in the imaging of pancreatic cancer or gynecologic malignancies.

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