10.59987/ads/2018.3.134-140
Introduction: Currently, the management of cancer, from the detection of clinical and radiographic characteristics to the final diagnosis and treatment, is becoming more complex. The Multidisciplinary Team Care (MDTC) approach has become the care model for cancer patients worldwide. The MDTC approach is a tool to improve the survival rate of cancer patients by providing them with the best treatment plan for the prevention and/or the treatment of adverse events.
Materials and methods: This paper describes the management algorithm of our MDTC called Mo-Max (Oral Medicine and Maxillofacial Surgery) at the Department of Oral and Maxillo-Facial Sciences, “Sapienza”, University of Rome.
Discussion and Conclusions: The efficacy of MDTC on oral cancer (OC) management in the literature is still elusive due to the absence of a consistent definition for MDTC, the complexity of the management of OC, the non-effective construction and nature of the multidisciplinary team and the poor communication between different cancer centres nationally and internationally. To date, the MoMax project has yielded good results in shortening the time of managing patients with OC and increasing good patient therapeutic compliance. Further research is needed to achieve a distinctive definition and principles of MDTC for OC patients and to analyse efficacy, costs and time delay.
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Annali di stomatologia
oro-pharyngeal cancer
A multidisciplinary team for the management of oral cancer: a project called MoMax
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A multidisciplinary team for the management of oral cancer: a project called MoMax
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                                                                                                   Original article



    A multidisciplinary team for the management of oral
    cancer: a project called MoMax




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    Umberto Romeo MD                                       distinctive definition and principles of MDTC for
    Gianluca Tenore DDS, PHD                               OC patients and to analyse efficacy, costs and
    Andrea Cassoni MD                                      time delay.




                                                                                           io
    Federica Rocchetti DMD, PHD
    Ahmed Mohsen DMD, PHD                                  Key Words: multidisciplinary team care, oral
    Giorgio Pompa MD                                       medicine and maxillofacial surgery, oral potential-




                                                                     az
    Valentino Valentini MD                                 ly malignant disorders, oro-pharyngeal cancer.
    Antonella Polimeni MD, DDS

                                                           Introduction




                                                                   rn
    Department of Oral and Maxillo-Facial Sciences,
    “Sapienza” University of Rome, Rome, Italy             The management route of cancer frequently requires
                                                           the contribution of many qualified health care
                                                           providers (1), which results in pushing the patients to




                                                        te
    Corresponding Author:                                  move among different specialists in order to be ade-
    Federica Rocchetti                                     quately treated. Thus, the achievement of efficient
    Department of Oral and Maxillo-Facial Sciences,        coordination between these specialists is the corner-
    “Sapienza” University of Rome
                                                      In   stone of providing a high and uniform level of special-
    Rome, Italy                                            ist care.
    Tel.: 320 2847201                                      The Multidisciplinary Team Care (MDTC) approach
    E-mail: federica.rocchetti@uniroma1.it                 has become the care model for cancer patients
                                                           worldwide (2) and recently has been extended to oral
                           ni

                                                           cancer (OC) and oral potentially malignant disorders
    Summary                                                (OPMD). MDTC can be achieved in many formats in
                                                           the present healthcare systems. These formats may
                         io


    Introduction: Currently, the management of can-        include a comprehensive patient treatment, a devel-
    cer, from the detection of clinical and radiograph-    opment of wide multidisciplinary cancer programmes,
    ic characteristics to the final diagnosis and treat-   a creation of multidisciplinary diagnosis and treat-
                       iz



    ment, is becoming more complex. The Multidisci-        ment protocols, and a formation of cancer collabora-
    plinary Team Care (MDTC) approach has become           tive services or multidisciplinary tumour conferences,
    the care model for cancer patients worldwide. The      which are known as tumour boards (1, 3).
          Ed




    MDTC approach is a tool to improve the survival        The advantages of MDTC may include psychological
    rate of cancer patients by providing them with the     benefits for patients, efficient treatment decisions by
    best treatment plan for the prevention and/or the      diverse specialists, improved clinical integration of
    treatment of adverse events.                           care for medical centres and healthcare providers,
    Materials and methods: This paper describes the        education for practitioners, caregivers and partners
    management algorithm of our MDTC called Mo-            and increased patient contribution in clinical trials (4).
 IC




    Max (Oral Medicine and Maxillofacial Surgery) at       The MDTC approach is a tool to improve the survival
    the Department of Oral and Maxillo-Facial Sci-         rate of cancer patients through providing them with
    ences, “Sapienza”, University of Rome.                 the best treatment plan together with the prevention
    Discussion and Conclusions: The efficacy of            or treatment of adverse events (5). The team compo-
C




    MDTC on oral cancer (OC) management in the lit-        sition varies according to the cancer site and institu-
    erature is still elusive due to the absence of a       tion (1, 3).
    consistent definition for MDTC, the complexity of      The literature agrees that the MDTC approach for OC
    the management of OC, the non-effective con-           should include a core team consisting of oral patholo-
©




    struction and nature of the multidisciplinary team     gists, general dentists, maxillofacial surgeons, oncol-
    and the poor communication between different           ogists, radiotherapists, radiologist and anatomy-
    cancer centres nationally and internationally. To      pathologists. If necessary, the patient can be referred
    date, the MoMax project has yielded good results       to other specialists, such as speech therapists, dieti-
    in shortening the time of managing patients with       cians or psychologists. In fact, most of the patients
    OC and increasing good patient therapeutic com-        affected by OPMD or OC undergo an oral pathologist
    pliance. Further research is needed to achieve a       and/or maxillo-facial surgeons at a late stage, when

    134                                                                       Annali di Stomatologia 2018;IX (3):134-140
    A multidisciplinary team for the management of oral cancer: a project called MoMax


    their lesions become symptomatic, which may lead to          Materials and methods
    an important negative influence on the diagnosis and
    the prognosis of the pathology. For OC, the delay in         MoMax Clinical Pathway
    patient management is basically related to three main        MoMax was created and implemented at the Depart-
    factors: patient delay, professional delay and treat-        ment of Oral and Maxillo Facial Sciences, at “Sapien-




                                                                                                  li
    ment delay. The consequence of increased waiting             za” University of Rome in June 2014. The MoMax
    time is tumour growth, clinical upstaging, deteriorated      core team is formed by oral pathologists, prosthodon-




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    prognosis and worsening of the quality of remaining          tists, dental hygienists and maxillofacial surgeons
    life. The MDT serves as a point of reference for the         who meet once a week in the same surgery to treat
    patients, accompanying them from diagnosis to treat-         patients. Furthermore, once a week, the core team
    ment.                                                        meets with radiotherapists, oncologists, otorhino-
    We are going to report the management algorithm              laryngologists, an anatomy-pathologist and a radiolo-




                                                                                              io
    (Fig. 1) for OC in a specialist multidisciplinary team       gist to discuss the patients at Head-Neck Tumour
    called MoMax (Oral Medicine and Maxillo Facial Sur-          Board (HNTB) in order to plan the best personalized
    geon) to facilitate daily clinical decision-making of all    treatment for each patient (Fig. 2).




                                                                            az
    health-care specialists involved, in order to reduce         The MoMax group takes care of patients from the di-
    patient waiting time and to guarantee the most effec-        agnosis to the treatment through cytological exams
    tive therapy and benefits from this type of approach.        (brush and oropharyngeal swabs), histological exams




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    Figure 1. Clinical pathways algorithm of MoMax project.


    Annali di Stomatologia 2018;IX (3):134-140                                                                    135
    U. Romeo et al.




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    Figure 2. Head and Neck Tumour Board organization.




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    (scalpel and laser biopsy), pharmacological thera-        tal history in an unified clinical chart of all the referred
    pies, maxillofacial surgery and prosthetic rehabilita-    patients (Fig. 3).
    tions.                                                    Specifically, the choice of the second level X-ray ex-
    The MoMax project consists of 3 pathways: preven-
                                                     In       amination depends on the anatomical localisation of
    tion, diagnosis and treatment. These pathways run         the tumour: in the case of lesions close to the bone,
    through 4 steps. The first step is established through    such as the alveolar bone or gingivobuccal bone, it is
    carrying out a full clinical examination in conjunction   preferable to perform a contrast-enhanced and non-
    with the recommended investigations (brush biopsy,        enhanced computed tomography (CT) scan of the
                             ni

    oropharyngeal swabs, excisional and incisional biop-      maxillo-facial area, jaw and neck. For areas not di-
    sies and X-rays) after recording the medical and den-     rectly connected to the bone (i.e., the tongue and the
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    Figure 3. Chart of MoMax project.


    136                                                                          Annali di Stomatologia 2018;IX (3):134-140
    A multidisciplinary team for the management of oral cancer: a project called MoMax


    floor of the mouth) it is preferable to perform a mag-       Discussion and conclusions
    netic resonance imaging (MRI) of the maxillo-facial
    area, jaw and neck with and without contrast. A high-        OC represents the sixth most common cancer in the
    definition chest X-ray is always required to evaluate        world (8). In Italy, cancer registries reveal that OC
    the presence of distant metastases.                          represents approximately 3% of all cancers in males




                                                                                                   li
    In the case of early oral cancer (T1, according to           and 1% in females (9). OC represents approximately
    UICC TNM staging system) with a thickness less than          85% of all head and neck cancers and is traditionally




                                                                                                 na
    8 mm, both the CT and MRI lack of specificity and            defined as a Squamous Cell Carcinoma, because
    sensitivity, and in case of the presence of dental           90% of these cancers are histologically originated
    amalgam reconstructions that can cause artefacts, an         from the squamous cells of the oral cavity (8).
    intraoral ultrasound (US) with a very small transduc-        OC is a preventable disease. The multifactorial na-
    er, such as a toothbrush, is performed. This examina-        ture of OC results in a complex interaction between




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    tion allows identifying the size and the vascularity of      genetics, the environment and behavioural factors
    the cancer, the tumour depth and the tumour thick-           (i.e. tobacco and alcohol) (8). Less common risk fac-
    ness in order to eventually plan, pre-operatively, the       tors include human papilloma virus and chronic mu-




                                                                            az
    requirement of neck-dissection. Furthermore, in this         cosal trauma (Fig. 4).
    first step, trained dental hygienists assist smoking pa-     OPMDs have been introduced in the literature and
    tients to quit tobacco use by providing information          describe the precancerous lesions of the oral mucosa
    and supporting them with questionnaires and with the         in recent years (10). These lesions include oral leu-




                                                                          rn
    “5A” intervention model (6).                                 coplakia, oral erythroplakia, palatal lesions in reverse
    The second step is the selection and the submission          smokers, oral submucous fibrosis, actinic keratosis,
    of the cases to the Head-Neck Tumour Board in order          oral lichen planus and discoid lupus erythaematosus
    to achieve the most effective and suitable treatment         (11). Oral leucoplakia, oral submucous fibrosis and




                                                        te
    plan. This submission is performed through the oral          oral erythroplakia have the highest malignant trans-
    presentation of the cases with the use of photos, CT,        formation rates. Atrophic and erosive subtypes of oral
    MRI and US imaging.                                          lichen planus also have the greater malignant trans-
                                                      In
    The third step is the application of the Tumour Board-       formation rate compared to other subtypes. The aeti-
    recommended treatment plan: surgery, radiation ther-         ology is not fully understood for most OPMDs (10).
    apy (RT) or chemotherapy (ChT). Patients scheduled           OPMDs can be considered as risk indicators of likely
    to receive radio and or chemotherapy that involves           future malignancies in the oral mucosa (11) (Fig. 5).
                               ni
    the mandible, maxilla or salivary glands are referred        Therefore, one of the prevention methods for OC that
    to MoMax for a comprehensive dental consultation,            can be effective is the early diagnosis and manage-
    assessment and clearance before therapy begins in            ment of these disorders.
    order to treat, eventually, dental infections. Patients      Only half of newly diagnosed OC patients has more
                             io


    are also informed of the adverse events of these             than 5-year survival rate (12). The low survival rate
    treatments such as mucositis and osteoradionecrosis          and poor prognosis of OC were commonly a result of
    and are motivated to establish a good standard of            late diagnosis rather than being hard to diagnose.
                           iz



    oral hygiene (7). One of the means of prevention of          Thus, early diagnosis and treatment remains the key
    the adverse events of radiotherapy are the delivery of       of improving the survival rate (8).
    fluoro-prophylaxis masks to patients, to limit the de-       The late diagnosis of OC is due to three factors: pa-
           Ed




    velopment of decay due to xerostomia.                        tient delay, professional delay and treatment delay.
    The fourth step includes the controls, follow-up and         Patient delay can largely be attributed to the un-
    modification of treatment plan by the multidisciplinary      awareness of the signs and symptoms of disease and
    team if needed. For the following year, at the end of        oral symptoms being rarely attributed to cancer and
    radiotherapy, patients undergo professional oral hy-         frequently interpreted as minor oral conditions. A lack
    giene sessions and controls every three months in or-        of understanding of the clinical presentation of these
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    der to maintain a good level of oral hygiene and to          diseases and confidence on the part of health profes-
    avoid the onset of periodontitis or caries. Further-         sionals has been suggested as a barrier for suspect-
    more, during this stage, patients can be rehabilitated       ing cancer and dealing promptly with an appropriate
    with traditional prosthesis or implants to maintain          referral or arranging a follow-up visit (13). The diag-
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    function and aesthetics.                                     nosis of oral and pharyngeal cancers at their early
    Regarding patient management time, in the case of            stage can be easily achieved through clinical exami-
    clinically suspicious lesions, many times we proceed         nation (9).
    to biopsy immediately or maximum in a week. In the           Villa et al. conducted a study to investigate patients’
©




    case of pre-radio and/or pre-chemotherapy dental             knowledge regarding OC risk factors and to explore
    consultation, we proceed with the necessary treat-           communication between clinicians and patients at-
    ments such as teeth extractions in a maximum of 10           tending dental departments within Italian university
    days, excluding the biological tissue healing time af-       hospitals by sending out 2200 questionnaires (14).
    ter the surgery.                                             The results revealed the majority (approximately
                                                                 94%) of individuals had knowledge of the clinical
                                                                 signs associated with OC; this knowledge was more

    Annali di Stomatologia 2018;IX (3):134-140                                                                       137
    U. Romeo et al.


                                                                                      Figure 4. Intraoral aspect of
                                                                                      verrucous carcinoma of the
                                                                                      buccal mucosa.




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    improved in individuals who had a family history of     receiving counselling about OC from their physicians
    OC compared to individuals with no family history       or dentists (14). In this study, most smokers knew
                            ni
    (11). Furthermore, the Authors noticed that the pa-     that smoking was a risk factor for OC (87%) and yet
    tients’ knowledge did not appear to be provided by      continued to smoke (14).
    clinicians, as less than 15% of participants reported   Colella G et al. (9) performed an epidemiological in-
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                                                                              Figure 5. Intraoral aspect of lichen
                                                                              planus of the buccal mucosa.

    138                                                                      Annali di Stomatologia 2018;IX (3):134-140
    A multidisciplinary team for the management of oral cancer: a project called MoMax


    vestigation in Italy to examine the dental health care       myriad of psychosocial factors necessitate the opti-
    providers’ knowledge of OC prevention and detection.         mization of patient care with a systematic approach
    The results were greatly surprising that only one-third      based on MDTC (16, 17). Nutritional and swallowing
    can correctly recognize the most common form of OC           evaluation, dental evaluations and treatments, and
    and early OC lesions. The Authors stated that these          pain management are mandatory before, during, and




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    values were considerably lower than those observed           after concomitant treatment.
    in recent surveys in other countries (6). Different          Finding evidence of the relation between the MDTC




                                                                                                        na
    studies (9) reported that a lower risk of death in can-      and patient outcomes, even with this controversy, is
    cer patients has been achieved by treating them in           the key for exerting more time and finances to sup-
    hospitals or by physicians serving high numbers of           port this approach (1). Our MoMax project, to this
    patients, as both provide multidisciplinary knowledge        day, has been giving good results with the short man-
    and management to the patients, which are needed             aging time of patients and good patient therapeutic




                                                                                                      io
    to solve the complexity of OC diagnosis and manage-          adhesion. Further research with larger cohorts of pa-
    ment. Given that a goal of MDTs is to improve patient        tients is needed to assess whether our MDTC may
    care, it would be important to demonstrate that pro-         positively influence the general patients’ survival rate




                                                                             az
    viding care within the MDT structure does not nega-          and their quality of life.
    tively affect waiting times.
    Patil, et al. demonstrated retrospectively that the im-
    plementation of MDTC at University of Cincinnati Vet-        Acknowledgements




                                                                           rn
    eran’s Administration Hospital (Cincinnati, Ohio, Unit-
    ed States) reduced the time from initial consultation        The Authors thank Dr. Di Carlo, Dr. Brauner, Dr. Bat-
    to being seen in the otolaryngology clinic from 27.5 to      tisti and Dr.ssa Montori for performing clinical assi-
    16.5 days (P<0.0001), and the time from the positive         stance.




                                                        te
    biopsy to the beginning of the treatment decreased
    from 35 to 27 days (P=0.04) (15).
    Our time management, compared to the literature, is          References
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