Radiation oncologist, Lizbeth Kenny from Queensland, Australia, showed the way to interventional oncologists at the ECIO meeting (25–28 April, Florence, Italy).
Kenny, medical director, Central Integrated Regional Cancer Service, Queensland Health and Clinical Lead, Queensland Health Imaging Program, told interventional oncologists, clearly, that if they want to be accepted as real clinicians in the field of cancer care, focusing on being excellent technicians is not enough: they need to improve their information gathering, they need to provide credible evidence with regard to the outcomes of their interventions, and they need to improve their understanding of tumour biology. The lecture was very well received and started a constructive debate that is likely to influence interventional radiological practice internationally.
“It is truly fair to say that there is hot competition for your title. Interventional oncology means different things to different people. In Australia, my colleagues—radiation oncologists and surgical oncologists and the like—also view themselves as interventional oncologists. Interventional oncology goes all the way from robotic surgery to brachytherapy, which uses radioactive seeds that give a high radiation dose to the tumour, in every cavity, organ and tissue. With radiation oncology we also ablate tissue in single very large doses with stereotactic radiosurgery. In my department, which uses very high-end equipment, we use radiation, photons, and electrons, to manipulate and provide very sophisticated, individualised doses of radiation treatment. So there is a lot of competition for your title,” she said.
Being an oncologist
Kenny told delegates that the word oncologist meant caring for people with cancer for prolonged periods of time. “The title ‘oncologist’ confers great responsibility—you have made your choice in your title, and an oncologist must absolutely understand the natural history of cancer in-depth, must understand what your colleagues, other oncologists do, and make shared decisions in a multidisciplinary team setting. Oncologists must clearly understand the need for integrated treatment in a highly planned, deliberate sequence. It is not possible to know everything about anything.
This holds true for all of us, and emphasises the need for collaboration between us. You need to collaborate with other interventional oncologists to collect and publish data, including patient centred factors such as quality of life. However, there is an utter requirement to be an expert technician in your field of specialty,” she said.
The benefits of multidisciplinary teams
Kenny stated that staging the patient’s cancer, mapping out and clearly documenting the extent of disease, and any other procedures require a team effort. When deciding on and documenting what treatments are available, all the options to be recommended must be looked at collaboratively in terms of the evidence base. The patient must be involved in making the choice, and the options chosen need to be documented and communicated to all involved.
“The patient should also be assessed for suitability in trial entry, and collaborative decisions should be made regarding appropriate support before, during, and after treatment. Multidisciplinary teams facilitate relationships between medical specialists, and between other professions involved in cancer care, including nursing and allied health. Teams like this require great respect and trust. They facilitate an understanding of what integration of treatment really means. At the end of the day, 30% of what we do in medicine is positively harmful, and multidisciplinary teams are a way of trying to reduce that. One of my key take-home messages is that just because you can, does not mean that you should. Multidisciplinary teams help to maintain good decision making,” she said.
Radiotherapy, chemotherapy and surgery
“It is critical for interventional oncologists to know and understand radiation oncologists, medical oncologists and surgeons. It is also critical to understand the need for timed integration when combinations of treatments are being used. The evidence base for radiation therapy is very high,” she noted.
Kenny made the point that interventional oncology is not for the casual player, and that technical competence needs to be high and measurable. She also pointed out that interventional oncology needed to ask certain key questions such as: What evidence do we really need? What training are we going to require? Where does the treatment fit in the scheme of things? How do we manage this with run-away expenditure in all developed countries?
“We need to stop trying to do everything to everyone and focus on what is good for patients. This will refocus the issue of putting the patient at the centre of care; today, the doctor is at the centre of care. You, as interventional oncologists, have the ability to change so much. It is key to identifying what interventional oncology brings that is equivalent to other cancer treatments, because you are likely to have less cost and potentially much less morbidity. But the issue around credibility is critical. The title oncologist is a privileged one and confers great responsibility—you must understand cancer, at least the ones you are going to be involved in treating, and you must understand your colleagues and make shared decisions. And if you do not have multidisciplinary teams, you must create them. Within the interventional oncology community you need to collaborate with your colleagues. Publish data that are important and create a quality framework within which to operate and measure what you are doing. One of the things that is really hard is trial design, because I do not see how the gold standard randomised controlled trial is easily applied in interventional oncology. CIRSE is ideally placed to be very engaged in these issues. Caring for patients is central, and collaboration is an utter given, but it is the difference between being a technician and an oncologist that is going to take interventional oncology to where it should be,” Kenny said.
Kenny spoke to Interventional News after the session:
As the director of Cancer Services for the Central Area Health Service in Queensland you have worked to redirect radiologists toward a central role in patient care. How can involving radiologists early in diagnosis and management help transform healthcare systems?
I think it is critical to involve diagnostic radiology in patient management. Far too often, other doctors involved in caring for patients do not have a very good idea of which imaging procedure to request. We often find that inappropriate imaging requests delay the correct diagnosis, or even lead to the wrong one, and might result in many unnecessary imaging investigations and a lot of unnecessary radiation exposure. If we had diagnostic radiologists involved from the very beginning, they could guide what the appropriate tests were to request. Rather than having radiology at everybody’s beck and call, it really does need to guide the diagnostic pathway, and it is only by having it upfront, being very visible and interacting actively with other specialities that this can be achieved.
As an advocate of multidisciplinary cancer management, how can interventional radiology help improve the management of cancer?
I think that it is very likely that interventional oncology and interventional radiology techniques have got a tremendous amount to offer patients.
It is usual that for people with cancer, multiple treatment options will be possible. The treatment recommended can depend a good deal on whom they see and what expertise is available. So if they only see the surgeon, they are likely to get surgical treatment. Likewise, if the patient only sees a radiation oncologist, they are likely to be treated by radiation. By having everybody in the same room, you can look critically at what the options are, and what the personal cost to the patient is likely to be both in terms of curing that cancer, if cure is what you are looking for, and in terms of the morbidity and upset from the treatment you are offering both in the short- and long-term. This is where the evidence base for using interventional techniques really needs to be developed and incorporated into ordinary decision making. Interventional oncologists will have a tremendous amount to offer, but unless they are operating within that multidisciplinary team, the right choices of treatment may not be offered, or all choices of treatment may not be considered. So I view the multidisciplinary team as a critical enabler for interventional oncology.
What are the key clinical skills and competencies that interventional oncologists will need to acquire in order to become part of the mainstream in the treatment of cancer patients?
Societies like CIRSE in Europe and the Royal Colleges and other professional colleges have a very important role to play because they can help to set the curriculum. The curriculum will help describe the competencies that are required in terms of training. The second aspect is having a quality framework in which to operate and deliver care. CIRSE is perfectly placed in Europe to set the parameters, within a continuing professional development scenario, of a quality framework within a setting of multidisciplinary collaborations, making it possible to establish whether an appropriate benchmark is being achieved in practice.
There should be global collaboration with like societies on this, because many of the large radiation oncology and medical oncology trials are multinational. That is the only way that we have been able to acquire a large amount of information over a clinically relevant timeframe. A trial that takes over 20 years to accumulate enough patients is irrelevant. We need to devise methods to allow for rapid collection of the data required in order to compile the required evidence of benefit. Because this is a rapidly evolving field, working hand in hand with groups with expertise in trial design is likely to get you further very much more quickly.
Why is it important that interventional oncologists gain these skills you have outlined?
There is nothing worse than ablating the wrong piece of tissue or treating the wrong area. We know in radiation oncology that geographic miss is a major determinant of whether you are likely to achieve local cure. So making sure that you are hitting the right target and that you are ablating the right tissue and not causing unnecessary complications are very important parameters to assess. In radiation treatment, we can print out CT scans of our treatment planning; we cannot do that in interventional oncology, but we could potentially match the freezeball with the scans prior to treatment and know properly in a three-dimensional sense that we have treated the right area. How do we measure complications? We can do harm if we treat the wrong thing, or if we do not treat what you are aiming to treat. So having the skills, knowing what you have done and being able to audit what you have done is critical. That should be routine in interventional oncology. Amassing that sort of information in multiple centres would probably make a very large difference.
If an interventional oncology technique is equivalent to an open surgical procedure, then the difference in morbidity and personal costs and cost to the system is likely to be very substantial. So we are looking for measures not just for equivalence, but also cost to the person and to the system. The time will come when a major brake will be applied across an awful lot of what we do because we can no longer afford it. So getting away from the philosophy that “If we can do it, let’s do it” to “Is this patient going to benefit from it?” is critical and a hard decision for individual practitioners to make. Collectively, in a multidisciplinary setting, where we can really look at evidence that is available to guide us, we are far more likely to come to the right decision.
Certain areas of interventional radiology and radiation oncology are converging. What are the areas of common ground between these two disciplines?
Whenever you are looking at maximising local treatment and local cure, particularly in patients where local cure is hard to achieve, then the combination of treatments could be extremely beneficial. Primary cancers of the lung are worth considering; we still struggle to cure lung cancer. Looking at cancer types where it is hard to cure the primary tumour with non-surgical techniques would be important. In patients undergoing palliative treatment, there is a very great requirement to try and minimise symptoms from their cancer with as little cost to them as possible. This is where having interventional oncologists in the room when you are discussing such patients can become important. In fact, by having everybody around the table, you open up new possibilities, for instance of substitution, or combinations of treatments.
How can radiation oncology and interventional radiology collaborate for mutual benefit?
They are partners made in heaven. A number of the professional colleges train radiation oncologists, diagnostic radiologists and interventional radiologists. So in colleges such as the Royal College of Radiologists (RCR) and the Royal Australian and New Zealand College of Radiologists (RANZR), where this is ordinary practice, you have an enormous resource in the radiation oncology faculties in terms of knowledge of cancer and training in cancer management; for radiologists to become part of that would be a very straightforward procedure—a natural progression.
However, it would take a desire on behalf of both radiation oncology and diagnostic radiology to do so.
I do not think there has ever been a time when radiology and radiation oncology have been so close. We are both very dependent on each other, and with interventional oncology in particular, it is a very obvious partnership. So I think that the partnership is a fast-track to the knowledge that is required in terms of the natural history of cancer, options for treatment and understanding radiation treatment. I think that it is a fantastic way forward.
Liz Kenny will also speak on the topic at CIRSE 2012 in Lisbon on 18 September between 10.00 and 11.00am.
