A century ago, a physician was typically seen as a lone man with a doctor’s bag visiting 1 patient’s home after another. He was expected to be a “jack of all trades,” providing symptomatic management to patients who were mostly illiterate and had very little medical knowledge. Being a physician meant lots of sacrifice, with very little compensation.
Today, medicine has become a highly specialized field. Over the last few decades, there seems to be a race to see just how specialized particular disciplines can become. For example, a general physician can choose to specialize in surgery, after which he can choose to specialize in orthopedic surgery, and after which he can choose to specialize in hand orthopedic surgery.
The highly specialized landscape of medicine means that there are a large number of physicians who are experts in their own fields but know little about how other disciplines operate. I have personally witnessed this in medical practice: some specialists have dedicated so many years entrenched in their own discipline that even simple procedures from other specialties elude them.
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Multidisciplinary Teamwork in Cholangiocarcinoma
The remedy for this problem is multidisciplinary teamwork. This is especially true in the field of oncology, in which the needs of patients are varied, spanning both medical and nonmedical areas of concern.
In Digestive Diseases, Khaled and colleagues conducted a review to understand the current state of multidisciplinary cooperation in cholangiocarcinoma. Cholangiocarcinoma is 1 of the rarest cancers in the world, accounting for less than 1% of human cancers. Its prevalence varies according to geographical location, but it is particularly high in South East Asia due to endemic liver fluke infections.
Read more about cholangiocarcinoma etiology
Surgical resection is the only curative option for cholangiocarcinoma. The objectives for surgery are clear: tumor-free resection margins, locoregional lymphadenectomy, and ensuring that a sufficient future liver remnant remains.
In resectable cholangiocarcinoma, surgeons form an integral part of the multidisciplinary management team. (It is important to note that most patients present at later stages of the disease in which surgical resection is impossible.)
Prior to surgery, surgeons typically complete a thorough preoperative diagnostic workup, involving various imaging studies. The type of surgery depends very much on where the tumor is anatomically located. In some cases, surgeons may decide that patients are eligible for liver transplantation, although the evidence for this approach is weak at best. Current guidelines dictate that patients should have stable disease at least 6 months prior to liver transplantation.
For patients with unresectable cholangiocarcinoma, systemic treatment is the mainstay therapy. The goal of systemic therapy is to extend survival, minimize cancer-related symptoms, and maintain a sufficient quality of life.
Oncologists typically prescribe gemcitabine/cisplatin as the first-line treatment for advanced cholangiocarcinoma. Studies indicate that this combination of drugs improve overall survival better than gemcitabine treatment alone. Currently, researchers are looking at triple-agent combinations in order to further improve outcomes. Current trials are assessing the use of nab-paclitaxel as an add-on therapy to the current gemcitabine/cisplatin model.
Patients with cholangiocarcinoma often have significant psychological distress as they contend with their diagnosis and the prospect of death. Hence, the involvement of mental health services in a multidisciplinary setting is essential.
“Patients may be troubled with both the disease and the negative effects of [cholangiocarcinoma] treatment affecting their physical, psychological, and unmet needs in terms of health-related quality of life,” Sangruangake and colleagues wrote in the Asian Pacific Journal of Cancer Prevention.
When it comes to addressing the psychological needs of patients with cholangiocarcinoma, it is important to recognize that caregivers are often under tremendous stress as well. Studies indicate that a larger caregiver burden was associated with lower functionality on the part of the patient, and that patients experience higher degrees of depression and anxiety when their caregivers are struggling to cope.
Another source of psychological stress among patients is simply the lack of understanding about their disease and its typical progression, something that can be easily remedied by ensuring that patients possess an adequate understanding of their condition during consultation meetings. A realistic appraisal of their condition gives patients the confidence to make informed decisions about their choice of treatment.
Read more about cholangiocarcinoma treatment
When discussing psychological care, it is important that we address the needs of a unique group of patients: cancer survivors. Studies indicate that cancer survivors undergo tremendous anxiety and distress during their treatment period, and that these feelings can linger long after the cancer has been cured. Psychologists have also described a phenomenon in which patients experience significant anxiety any time they have a follow-up involving a scan; this has been colloquially termed “scanxiety.” This is due to fears of cancer recurrence, whether they are justified or not.
In conclusion, the multidisciplinary management of patients with cholangiocarcinoma must encompass a wide spectrum of disciplines in order to ensure that the patient’s needs are addressed from every angle. Ultimately, our goal is for the patient to live with the best quality of life possible under their specific circumstances. We are most adept at achieving this when we put our heads together.
References
Ben Khaled N, Jacob S, Rössler D, et al. Current state of multidisciplinary treatment in cholangiocarcinoma. Dig Dis. Published online October 25, 2021. doi:10.1159/000520346
Sangruangake M, Summart U, Songthamwat M, Sangchart B. The relationship between unmet need, physical symptoms, psychological well-being and health-related quality of life in cholangiocarcinoma survivors. Asian Pac J Cancer Prev. Published online August 1, 2022. doi:10.31557/APJCP.2022.23.8.2821
