10.14639/0392-100X-N2368
text/xml
1827-675X
2368
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Ester Orlandi
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
telemedicine
Implementing a virtual multidisciplinary clinical case discussion to manage rare and complex head and neck cancers: an expert-defined protocol proposal from the Italian Association of Head and Neck Oncology (AIOCC)
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Letters to the Editor-in-Chief
2023-02-27
2022-11-04
2023-02-28
2023-02-28
82-84
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Ester Orlandi
2023/02/27
10.14639/0392-100X-N2368
82
Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy; L.D. Locati, I. Herman, P. Bossi and E. Orlandi contributed equally to this work
1827-675X
telemedicine
en
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Implementing a virtual multidisciplinary clinical case discussion to manage rare and complex head and neck cancers: an expert-defined protocol proposal from the Italian Association of Head and Neck Oncology (AIOCC)
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ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:82-84; doi: 10.14639/0392-100X-N2368




Letter to the Editor


Implementing a virtual multidisciplinary clinical case
discussion to manage rare and complex head
and neck cancers: an expert-defined protocol
proposal from the Italian Association of Head
and Neck Oncology (AIOCC)
Discussione multidisciplinare virtuale per la gestione di casi clinici rari e complessi
dei tumori della testa e collo: una proposta di protocollo da parte degli esperti
dell’Associazione Italiana di Oncologia Cervico-Cefalica (AIOCC)
Laura D. Locati1,2*, Irene Herman3*, Marco Benazzo2,3, Pierluigi Bonomo4, Andrea Ferri5, Roberto Maroldi6,7,8,
Gabriele Molteni9, Paolo Bossi8,10*, Ester Orlandi11*
1
  Translational Oncology Unit, Maugeri Clinical Research Institutes IRCCS, Pavia, Italy; 2 University of Pavia; 3 Department of
Otolaryngology Head Neck Surgery IRCCS Policlinico San Matteo Foundation, Pavia, Italy; 4 Radiation Oncology, Azienda
Ospedaliero-Universitaria Careggi, Florence, Italy: 5 Maxillo-Facial Surgery Division, Head and Neck Department, University Hospital
of Parma, Parma, Italy; 6 Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, ASST-Spedali
Civili, Brescia, Italy; 7 AIOCC President; 8 University of Brescia; 9 Otolaryngology-Head and Neck Surgery Department, University
Hospital of Verona, Verona, Italy; 10 Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences
and Public Health, ASST-Spedali Civili, Brescia, Italy; 11 Radiation Oncology Clinical Department, National Center for Oncological
Hadrontherapy (CNAO), Pavia, Italy
*
  L.D. Locati, I. Herman, P. Bossi and E. Orlandi contributed equally to this work.


KEY WORDS: multidisciplinary, tumour board, head and neck cancers, telemedicine          Received: November 4, 2022
                                                                                         Accepted: November 18, 2022
PAROLE CHIAVE: multidisciplinarietà, tumour board, tumori della testa e collo,
telemedicina                                                                             Correspondence
                                                                                         Laura D. Locati
                                                                                         Department of Medical Oncology and Therapeutics,
Dear Editor,                                                                             University of Pavia, Palazzo Botta 10, 27100 Pavia,
Head and neck cancer (HNC) represents a heterogeneous group of neoplasms.                Italy
                                                                                         E-mail: lauradeborah.locati@unipv.it
These tumours may differ in location, pathogenesis, behavior, treatment, prog-
nosis, and effect on quality of life 1. According to the project RARECAREnet 2,
                                                                                           How to cite this article: Locati LD, Herman I,
HNCs include epithelial tumours of the nasal cavity and sinuses, nasopharynx,
                                                                                           Benazzo M, et al. Implementing a virtual multidis-
hypopharynx, larynx, oropharynx, oral cavity, lip, eye and its adnexa, middle              ciplinary clinical case discussion to manage rare
ear, major salivary glands and salivary-gland type tumours. Advanced skin                  and complex head and neck cancers: an expert-
                                                                                           defined protocol proposal from the Italian Asso-
cancer of HN area and complex thyroid cancers are also included for anatomi-
                                                                                           ciation of Head and Neck Oncology (AIOCC).
cal reasons. HNCs are rare since the incidence rate (IR) of each HNC subsite               Acta Otorhinolaryngol Ital 2023;43:82-84.
is < 6/100,000, although the IR varies with the highest value for larynx cancer            https://doi.org/10.14639/0392-100X-N2368
and the lowest for paranasal sinus and salivary gland cancers. Overall, HNC
                                                                                         © Società Italiana di Otorinolaringoiatria
is the sixth most common cancer worldwide with an annual incidence of ap-                e Chirurgia Cervico-Facciale
proximately 850,000 cases and a mortality rate estimated at 450,000 in 2018,
accounting for 3% of all cancers 3. It is typically diagnosed in patients over                          OPEN ACCESS
60 years of age with heavy use of alcohol and tobacco. In addition, cases of             This is an open access article distributed in accordance with
                                                                                         the CC-BY-NC-ND (Creative Commons Attribution-Non-
Human Papilloma Virus (HPV)-associated oropharyngeal cancer are being in-                Commercial-NoDerivatives 4.0 International) license. The
creasingly diagnosed worldwide, especially in younger individuals in the US              article can be used by giving appropriate credit and mentio-
                                                                                         ning the license, but only for non-commercial purposes and
and Europe 1. HNC is associated with considerable burden and costs due to                only in the original version. For further information: https://
the complexity of treatments and treatment-related toxicities and, despite the           creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                Virtual multidisciplinary discussion in head and neck cancer




latest advances in the management (e.g. transoral surgical        larger ones, contributing to increase enrolment in clinical
approaches, intensity modulated radiation therapy, proton         trials. In addition, other several advantages can be foreseen,
therapy, immune checkpoint inhibitors), survival has not          e.g. reduction of the time spent for travelling for the patient
significantly improved. For all these reasons, diagnosis and      but even for the physician; overcoming geographical bar-
treatment of HNC must be tailored to the individual patient       riers; creation of clinical networks. The need to establish
and disease. A highly specialised multidisciplinary team          a vMDT on a national basis to discuss the most complex
(MDT) is required in order to assure the best outcome and         cases of HNC, including patients with rare tumours (e.g.
avoid or adequately treat any side effects through specific       those involving the salivary glands; nasopharynx; paranasal
coordinated skills and communication across disciplines,          sinuses or unknown primaries) is stronger than ever. Rare
considering that treatment differs according to tumour type       or complex HNCs present numerous challenges in diagno-
(e.g. squamous cell carcinoma vs adenocarcinoma), as well         sis and management, which include the scarce confidence
as stage of disease (e.g. I-II vs III-IV), anatomical site (e.g   in treating especially by community hospitals given the rar-
oral cavity vs larynx/hypopharynx), and surgical accessibil-      ity of the disease, complexity of treatment approaches, and
ity (e.g. open approach vs transoral surgery) 1. Indeed, data     high mortality rates. Notwithstanding the potential bene-
from the literature reported that a MDT-based approach is         fits, some pitfalls of virtual meetings have been pointed out,
advantageous for HNC patients, improving diagnostic and           which include deficits in engagement, teamworking, train-
staging accuracy, reducing the interval time between diag-        ing in remote settings 8, delay in receiving supporting infor-
nosis and the beginning of therapy and, most importantly,         mation such as imaging and pathology slides and the cost
is associated with higher survival rates 4. In particular, a      of virtual informatics infrastructure. In addition, where an
change in diagnostic and therapeutic approaches in up to          MDT in presence dispenses opportunities for group educa-
60% of cases has been reported with MDT management,               tion, increases interdisciplinary research collaboration and
especially for rare tumours such as those affecting para-         promotes collective professional fulfillment, we still know
nasal sinuses, nasopharynx and salivary glands 5. In addi-        little about the impact of a vMDT, especially for HNC. In
tion, most HNC patients arrived at the MDT evaluation for         a recent report, during videoconference (VC) meetings, be-
a second opinion, once primary treatment has been already         haviour tended to become more formal and the different
delivered 5. This means that, in case of an incorrect primary     disciplines may merely state their views, which does not
approach, the possibility to regain control of the disease        help to formulate an optimal treatment plan for the patient.
and to cure the patient is extremely small. For all these rea-    However, if the teams met each other physically at least
sons, a multidisciplinary approach according to evidence-         once a year and received VC training, this consolidated
based guidelines is considered mandatory to provide the           feelings of solidarity and VC communication between the
best diagnostic workup and define the optimal individual          teams improved 9.
treatment strategy. Despite the benefits of MDT, it must          In Italy there is still a lack of structured protocols for vMDT
be noted that this approach requires considerable time, ef-       for HNC patients and no such telemedicine infrastructure ex-
fort and financial resources and is usually more frequent in      ists. In order to define a vMDT protocol for patients with
highly organised and high-volume centers. Literature data         HNC, with emphasis on rare and complex cases, a working
on clinical research suggest that patients treated in high-       group of experts from the Italian Association of Head and
accrual centers report better treatment outcomes compared         Neck Oncology (AIOCC) proposed a structured protocol to
to patients treated in low-volume centres. It is now well ac-     be implemented on a national level. The primary aim of this
cepted that high-volume facilities should manage patients         project is to investigate the feasibility of multidisciplinary
with HNC, especially in those with the rarest cancers 6. In       clinical case discussion at the national level. Secondary ob-
considering solutions to overcome barriers to better care of      jectives include the assessment of adherence to MDT rec-
HNC patients and in healthcare access and utilisation, time-      ommendations according to AIOCC pathways and AIOM
ly access to comprehensive oncology consultation can be           (Italian Association of Medical Oncology) guidelines; per-
improved by applying the principles of telemedicine to cre-       centage of cases managed according to MDT recommenda-
ate a virtual MDT (vMDT). The utility of telemedicine has         tions; time to treatment initiation; patient’s satisfaction; phy-
also become increasingly apparent during the COVID-19             sician’s satisfaction etc. “Complex” HN cases are defined as
pandemic, which led to completely new ways of managing            all squamous cell cancer (SCC) requiring a multimodality
patients remotely through vMDTs 7. Telemedicine can also          approach, e.g. stage III-IV (all HN subsites) according to
be used to connect university and community hospitals to          AJCC VIII edition; loco-regional relapse after multimodal-
accelerate dispersal of information of recent research, and       ity treatment; oligometastatic cases and all cases that in the
it can also permit smaller centres to share resources with        opinion of a “local” MDT require additional discussion of



                                                                                                                                        83
L.D. Locati et al.




“secondary” level through a telemedicine approach. Stage I      Funding
and II are considered “complex” in case of high-risk patho-     This research did not receive any specific grant from fund-
logical features (i.e. close margins; R1 or R2 surgery; peri-   ing agencies in the public, commercial, or not-for-profit
neural and/or perivascular spread). Nasopharynx, paranasal      sectors.
sinuses, salivary gland cancers and unknown primaries have
been included in the “rare” HNC group. Complex skin can-        Author contributions
cer (advanced SCC and basocellular cancer) of HN area and       LDL and EO conceived and designed the study; LDL, IH,
advanced thyroid carcinomas with aggressive behaviour will      PB, EO, MB, AF, RM, GM, PB discussed the contents and
also be included in vMDT discussion. For the first aim, the     commented on the manuscript.
AIOCC board identified, among its members, a group of ex-
perts in HNC management in each of the specialties con-
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Conflict of interest statement                                       bjoms.2021.05.015
LDL received conference honoraria/advisory board fees           9
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from: Lilly, MSD, EISAI, Sunpharma, Roche, Bayer,                    oconferencing between a head-and-neck cancer center and its part-
Merck Serono, Sanofi-Regeneron, Istituto Gentili Srl, New            ner hospital add value to their patient care and decision-making? A
                                                                     mixed-method evaluation. BMJ Open 2019;9:e028609. https://doi.
Bridge; PB received conference honoraria/advisory board
                                                                     org/10.1136/bmjopen-2018-028609
fees from: Merck, Sanofi-Regeneron, MSD, Sunpharma,             10
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Angelini, Bristol-Myers Squibb, GSK, Nestlè.                         Society. PDTA. htpps://www.aiocc.it/documenti/pdta/. Accessed No-
The other authors declare no conflict of interest.                   vember 3, 2022




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