Advances in Multidisciplinary Approach for Liver Cancer

Abstract

The collective effort of specialized individuals in every institution helps in contributing to the ultimate success. Malignant liver cells mimic similar actions of coordinated efforts through their unregulated multiplication subsequently resulting in multiorgan failure whence the third most common cause of cancer related mortality globally. Irrespective of the form of liver cancer in the patient, there are significant challenges to the patient, carers, and health professionals. Issues arise in line of decision making and implementation of the best management modality. Due to the complexity, and patient’s needs during metastatic processes, multidisciplinary input is a necessity for optimal outcomes. Complications arising from liver cancer tend to impair the patient’s functioning. To avert poor hastened outcomes for better prognosis, unique interventions should be from specialized professionals. Patients who are treated successfully may require rehabilitation therapy. In instances when liver cancer is incurable, the best quality of life should be maintained while on supportive chemotherapy with integration of palliative care.

1. Introduction

Liver cancer is one of the most common malignancies contributing to significant morbidity and mortality globally [1]. Histologically, it mainly exists in the forms of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA) although other forms of primary and secondary liver malignancies exist. Globally, HCC remains the most frequent histologic type of primary liver cancer [2, 3]. Development of each of the subtypes is linked to distinct risk factors. Hepatitis B Virus (HBV) and Hepatitis C virus (HCV) have been identified as key risk factors for development of HCC while parasites (Opisthorchis viverrini and Clonorchis sinensis) have been implicated for iCCA. However alcohol and non-alcoholic steatohepatitis could also increase the risk for liver cancer [4]. Despite the decrease in viral infections overtime, HCC due to non-alcoholic steatohepatitis is gradually increasing. Pathologically, liver cirrhosis has been a key step for liver carcinogenesis in most forms of HCC and iCCA. Cases have been documented across the globe mainly from Africa, Asia, and the Americas, among less developed and developed countries [1, 5]. Cases increase every year with males being more affected than females. The occurrence of liver cancer differs regionally often due to common predisposition; for example liver cirrhosis due to viruses (HBV and HCV) and excessive alcohol consumption was more in parts of Asia, Africa, and Europe, respectively [6].

Due to its aggressiveness, liver cancer remains complicated to treat and manage. This complexity mostly results in poor prognosis especially the overall recuperation following late diagnosis. Mortality due to liver cancer still remains significant even in developed nations with advanced medical care [7, 8]. Individual variations also exist in regard to metastatic process in patients. Estimates indicate that by 2030, almost all countries will have an increased number of individuals with liver cancer except Japan. This calls for a well-trained team of health professionals at all levels to optimize treatment and care [9].

Although there is improvement in the management of cancerous conditions globally, liver cancer in its different forms still remains a challenge. The possible reduction of HCC cases in resource-rich regions was achieved mainly through therapies like resection, ablation, and transplant in the early stages of liver cancer [10, 11]. Recent innovations in therapies for liver cancer including molecular targeted systemic therapies and immunotherapy are being used for intermediate and advanced stages of liver cancer. These interventions improve prognosis if integrated with multidisciplinary efforts [12]. Curative therapies in isolation do not offer the desired cure in all that affected; for example only below 13% can be cured by tumor ablation, surgical resection, and liver transplant [13]. Incorporating different dimensions of care for the patient with liver cancer becomes a vital necessity. Patient care and needs should be through a form of either a lens or prism with the patient at the center. These needs could be internalized or externalized. Interestingly, these needs and care concepts cannot be in a form of one bundle that fits all but rather individualized. Derangements in the different human domains could incidentally destabilize the recuperation process. These human domains could be physiological, psychological, social and spiritual. An imbalance in any human domain affects the overall wellbeing of the patient [14]. Borrowing from the concept of health which is not mere absence of infirmity but rather totality in overall wellbeing, care should seek to address all health problems affecting the patient. Approaches to offer such care to patients with liver cancer while considering their needs should be multidimensional with a specialized team.

2. Multidisciplinary team approach

So, which approach is multidisciplinary? Does it mean interdisciplinary? Does it mean interprofessional? What is transdisciplinary?

Multidisciplinary approach derives from multidisciplinary teamwork. Although the terms multidisciplinary, interdisciplinary, and interprofessional appear similar, they have slight differences. They are often used interchangeably. Several authors have defined multidisciplinary teamwork. It has been described as a mechanism to ensure holistic patient care and service to patients throughout their disease trajectory across all levels of care [15, 16]. Relatedly, multidisciplinary team in oncology has been defined as “a cooperation between different specialized professionals involved in cancer care with the overarching goal of improving treatment efficiency and patient care”. Generally a multidisciplinary team entails collective specialized efforts and services toward a patient by members with different training to cater to the patient’s diverse needs with the aim of better patient outcomes. With multidisciplinary approach, a patient is assessed and managed individually by several professionals while maintaining their disciplinary boundaries according to the scope of practice. The role(s) of each professional may be either related or unrelated. The relationship between the multidisciplinary team and multidisciplinary approach is similar to that of the chain and the sprocket. A multidisciplinary team approach offers alternatives to team members to implement their roles in order to improve the quality of life of a patient with liver cancer. On the other hand, interdisciplinary approach was defined by [17] as willingness to share specialist knowledge and authority if the needs of the client can be met by other professional groups. There is emphasis on exchange between professional groups. Thus, interdisciplinary is often used interchangeably with interprofessional. During interdisciplinary team working, members share their individual assessments and develop a joint management plan. Transdisciplinary approach entails members of the team sharing roles to achieve common goals. Specialists could share their skills with other members of different specializations in the team. Being almost similar to delegation of tasks in health practice, it could result in task shifting; however, it enables the patient receive the required care in absence required specialist in the team. However, the skills being shared must be appropriate based on the level training and complexity of the of the skill. With this approach, there an individual in the team who should be accountable for the procedures and skills performed on the patient.

3. The team

A therapeutic collaboration among health professionals improves the overall delivery of patient-centered care and subsequent outcomes. Treatment and care are based on the level of the health facility and specialization among the health professionals [18]. Multidisciplinary teams refer to either a group or groups of health professionals from diverse disciplines who come together to provide comprehensive assessment and management for mutual benefit to the patient. The main link in this concept of management is provision of appropriate health services. The team members do not necessarily have to belong to one unit. There should be self-driven specialized input in-line with the patient condition to summate efforts for holistic management of patient. Although the patient has a confirmed diagnosis of liver cancer, different dimensions of both physical and psychological life are affected. This presents with complexity requiring multidisciplinary teamwork; for example, metastasis to distant organs in the body could require specialists of organs affected in the body together with spiritual, financial, and societal dimensions [19, 20].

Multidisciplinary system is comprised of intertwined single or several appointment(s) with a patient scheduled so that several health professionals of different training and skills are involved in each visit. Team members have different roles and specializations. They include nurses, medical doctors, psychologists, social workers, spiritual leaders, investigation experts, and trusted caregiver(s). Team members (Figure 1) may vary based on the needs of the patient and staging of liver cancer. Investigation experts may include laboratory team members and radio-imaging experts. In this regard, spirituality and religion should be viewed as distinct concepts. However, one helps achieve the other. It is important to note that an individual may not have a religion but attain spirituality. Religion could help one achieve spirituality. The healthcare professional does not need to impose own beliefs and perceptions on a patient in crisis due to liver cancer [21].

Figure 1.

Multidisciplinary health professional team members “The Multidisciplinary Wheel”.

Training about multidisciplinary approach of management is important in order to achieve optimal results. This could be curriculum based and in service training. Interprofessional education seeks to educate health professionals within their core specialization about all important aspects of the patient’s life. It helps health professionals realize the uniqueness of every patient encountered [22]. Liver cancer affects different aspects of life, which requires distinct specialized knowledge for management. In this training, every member learns to appreciate the need of other members who are empowered with decision making on the patient care plan. Inefficiency in management of liver cancer patients may arise not only from individual deficiency of knowledge and skills but also from inefficiency in the team [23]. A training program that utilizes case-based scenarios, simulations, critical thinking, analysis, communication skills, description of roles, and support should be established in health institutions caring for liver cancer patients. These programs should have a feasible framework that suits needs and gaps identified in the setting [24, 25]. This approach has been limited by lack of perceived value, tight schedules, lack of flexibility in the curriculum, poor attitude among health professionals, lack of awareness by key stakeholders, and limited resources for interprofessional training [22]. Efforts should be tailored at implementing and building a multidisciplinary team (Figure 1) while identifying barriers to the process and creating feasible solutions to such hurdles.

In this continuum of care, the patient is at the center of care, being the most important person in the team. Like a fulcrum, the progression of events revolves around his/her overall well-being and satisfaction. This requires routine evaluation in the quality of care offered to the patient. A member in the multidisciplinary team preferably the primary care practitioner or advanced nurse should help coordinate this care.

4. Why multidisciplinary team approach?

The main aim of a multidisciplinary team is to provide optimal coordinated patient care and management. As such, the team requires good leadership [26, 27]. Multidisciplinary team approach is effective for individuals with complex care needs and long-term debilitating conditions in liver cancer. Multidisciplinary approach has been associated with improved overall survival of patients with liver cancer. This not only improves the quality of life but also lower mortality burden despite requiring more medical resources compared to conventional cancer management.

There are higher chances of receiving appropriate care for patients under multidisciplinary care compared to those under conventional cancer management [28].

During the terminal stages of liver cancer, maintenance of meaningful life is best achieved through basic activities of daily living and physical and cognitive function [29, 30]. This is mostly achievable through multidisciplinary team approach, which still remains a distant dream in several nations globally especially the developing nations. Even in the developed world, minority groups of elderly patients under palliative care face exclusion when it comes to access to multidisciplinary specialists mostly due to being mentally handicapped. Table 1 includes a summary of distinct roles by multidisciplinary team members.

Health profession	Roles
Primary care practitioner	Surveillance of all forms of liver cancer
Hepatologist	Treatment of all of liver-associated disorders, liver transplant
Endocrinologist	Identification of high-risk patients for liver cancer
Nurses	Multifaceted roles to improve care
Pharmacists	Guidance on medications, drug interactions, optimizing treatment
Pathologist	Confirm the diagnosis of liver cancer, staging, and its subtype.
Radiologist	Perform imaging studies, interventional radiology, and radiotherapy when preferred
Oncologist	Specialist in treatment of cancer like surgical oncologist, medical oncologist.
Dietitian	Guide the patient on dietary modification and lifestyle
Physiotherapist	Offer physical therapy to help regain strength, physical function thereby improve the level of independence in activities of daily living.
Occupational therapist	Help patients overcome effects of treatment such as chemotherapy and keep engaged mentally to improve their cognition and functionality.
Social worker	Resource mobilization, explaining diagnosis and management plan, liaising with healthcare team, support caregivers.
Spiritual/religious leader	Provide a calm environment, coping mechanism for positive living while undergoing treatment. Techniques such as meditation, counseling sessions, prayers sessions, encouragement, and mindfulness could be used.
Palliative care specialists	Care to improve quality of life, prolong during terminal stages of liver cancer.
Psychiatrist	Prevention, early detection, and treatment of psychiatric illnesses.
Others like peers, carers	Social support network, help with household activities, help with activities of daily living like washing and bathing, monitor for side effects, assist in administration of medications, organize and keep medical records, schedule appointments.

Table 1.

The multidisciplinary team in the management of a patient with liver cancer.

5. Factors that influence multidisciplinary team working

Multidisciplinary team approach can be challenging for the team members especially if certain parameters are not fullfilled. Several research studies [31] have reported a number of factors influencing team work among team members in health facilities. They were categorized into 7, which included; preparation, health professional attendance, caregiver attendance, schedule, meeting, discipline, administrative support, cases and streamlining. The health institution’s input should cultivate a culture to enable a belief about the benefits of multidisciplinary team discussion, technology, required skills, motivation to provide the required quality care, and collegiality among health professionals [32]. Other notable factors include communication techniques, presence of multidisciplinary models, health system with policies that support multidisciplinary team approach, and patient-related information [33, 34].

6. Multidisciplinary approach in the management of cancer

To achieve optimal benefits of multidisciplinary team work, certain models could be used. This enables discussion of complex cases with appropriate actions. The discussion to guide proper decision making and informed management could range from patients with suspected liver cancer, confirmed liver cancer and those on treatment. The model advocated for could be developed either in national or international guidelines. Modification could be done with expert consultation to integrate the local needs and emerging demands of liver cancer patients being cared for. Modification could also consider the resource demands, availability, and limitations. Increased workload due to increasing cases of liver with few health professionals could make efforts of multidisciplinary approach futile [35, 36]. The following models are crucial for multidisciplinary team working for liver cancer patients.

Capability model: This determines whether an individual could accomplish an assigned task in both theory and practice. It explores the competences of an individual to guide. Professions in the team bring together their unique skills. Competencies vary according to their experience and qualifications.

Care management: also referred to as case management. This model aims at helping patients survive and optimize their adjustment to the community. Case management contains distinct models including clinical case management, strengths model, intensive case management model, brokerage model, assertive community treatment model, and rehabilitatation models. Each model contains different specialists with an overall leader and coordinator. Brokerage mainly involves coordinating services often with non-clinically trained individuals. As such, the other models (clinical case management, strength, intensive case, assertive community treatment and rehabilitation) are useful in multidisciplinary team work [37, 38, 39].

With recent advances in laparoscopic liver resection, surgical resection remains the mainstay for HCC for several decades. It can be considered for patients with non-metastatic disease and normal underlying liver function. Patients with compensated cirrhosis with no evidence of portal hypertension could also benefit from this therapy. Resection must also be performed in a way that maximizes recovery while minimizing post-operative complications and adverse outcomes [7, 40]. To optimize outcomes, multidisciplinary approach and models should be utilized. The perioperative process should involve members of different specializations and training. This slightly differs from the traditional method of management focused on the surgical, medical, and chemotherapeutic interventions where the ultimate decision rested upon the lead physician. Preparation of the patient in the preoperative phase entails all members of the multidisciplinary team. With a coordinator, regular meetings are organized with the patient and significant others. Thorough explanation ultimately keeps both the patient and carers in the know. An informed patient is an expert patient who can cooperate and work toward own better life. Roles of the patient under multidisciplinary care aim at respect, shared decision making and patient empowerment. Efforts should focus on building their understanding while integrating their expectations [41, 42]. Team work must be carried out throughout phases of perioperative care (preoperative, intraoperative, and post-operative). A number of liver resection procedures can be employed in management of liver cancer with promising results. These procedures include non-anatomical resection, segmentectomy, bi-segmentectomy, major resection, and extended major resection. However, some rules must be respected: the future liver remnant (FLR) must have an adequate afferent and efferent blood supply, and biliary drainage. Furthermore, the volume of FLR must be sufficient to maintain a liver function during the postoperative period [43].

Adjuvant therapy after HCC resection in early stages holds promising potential as it may eradicate residual cancer cells and prevent secondary liver carcinogenesis. Several adjuvant strategies have been tested in clinical trials, including systemic and intra-arterial chemotherapy, intra-arterial radiolabeled lipiodol, TACE (trans-arterial chemoembolization), acyclic retinoids, interferon, adoptive immunotherapy, autologous tumor vaccine, and, more recently, sorafenib [7]. Postoperative adjuvant chemotherapy helps reduce or eliminate cancerous cells whence increase chances of survival. Use of adjuvant chemotherapy may be limited in some patients with adverse events like adverse reactions to sorafenib. Management of these adverse reactions requires expert consultation including physicians and pharmacists often necessitating permanent discontinuation [44, 45]. Risks and benefits should be weighed while using adjuvant chemotherapy. Decision from this analytical approach should emerge from a technical informed point of view preferably with use of models (Figure 2). Adjuvant chemotherapy should not be an option if the risks for its use in the patient outweigh the benefits. Evaluating the risks and benefits of each adjuvant therapeutic agent could help ascertain the overall prognosis. With higher overall survival, the patient could be maintained on appropriate therapy [46, 47]. Medications should be titrated to obtain the maximum therapeutic dose while minimizing its toxicity. Patients should be routinely monitored for both side effects and adverse events. Health professionals should be trained to monitor and identify significant pathophysiological deviations due to therapy. Liver transplantation (LT), which is usually indicated for patients with poor liver function, has also become safer following advances in perioperative management. Currently, efforts are being made to further expand the indications for liver transplant. Tumor characteristics, including serum alpha-fetoprotein, the presence of microvascular invasion, tumor grade or differentiation, and largest tumor size, are among the most important predictors of recurrence after liver transplant. Bridging therapy to downstage the tumor before LT is also proposed with atezolizumab plus bevacizumab resulting in a better progression-free survival than sorafenib [48].

Figure 2.

Risk-benefit model for use of post-operative chemotherapeutic agents.

Computer-based technologies through models of electronic Health (eHealth), for example telemedicine, telenursing, and patient reminder applications, can be a focal point for integrating treatment and care for patients with liver cancer [49]. Several interventions to optimize patient health have been achieved through messaging applications between patients and the healthcare providers. It is much easier to share electronic data about the patient for expert consultation among team members. Websites with key liver cancer patient information for example lifestyle, dietary restrictions and booking appointments can play a crucial role in improving the quality of care, and life among patients with liver cancer [49, 50, 51, 52]. Models using telehealth for post-operative patients following liver transplant have been recommended for their ability to improve clinical outcomes [53, 54, 55]. Telehealth is also vital in areas with poor access to liver cancer specialty. Telehealth platforms often enable patients open up to express their needs while on therapy in and out of the treatment center. The multidisciplinary team members could also monitor the patient’s clinical and psychological status by sharing signs and symptoms from the patient to healthcare providers [56, 57, 58].

Risk-benefits models may be adjusted to suit the best patient’s needs at the point of diagnosis, and thereafter in the course of management. Chemotherapeutic agents may not be used if they worsen the clinical status of the patient and hasten poor prognosis. A conflict may exist on important needs coexisting at the same time. Those are the scenarios when judgment is guided through expert opinion from members of the multidisciplinary team. The Maslow’s hierarchy of needs could be considered to guide their decision.

7. Ethical considerations

Confirmation of liver cancer affects the psychological status of every patient diagnosed. This results in denial that can affect decisions that will be considered thereafter. Therapeutic modalities like chemotherapy and surgery are often viewed as an added burden by patients. Therefore from the patient’s perspective, explanations about procedure by the interventionist (surgeon, radiologist, oncologist) are often not understood. Clarity that could be added by other multidisciplinary team members such as the nurses and social workers improves the overall acceptance of therapy [59]. Multidisciplinary team working is a partnership with the goal of improving the patient outcomes when faced with liver cancer. The collaboration among professionals is mainly on mutual agreements and rarely involves legal binding except adhering to the scope of practice. A legal framework solely for guiding multidisciplinary teamwork still lacks in many health institutions. Even when they exist, they are in few health institutions in developed countries [60]. Multidisciplinary team members are often not aware of their medico-legal obligations. This puts several professionals involved in care of liver cancer patients in uncertainity especially those newly integrated in this form of patient care [61]. Key ethical issues identified in multidisciplinary team meetings include duty of care, privacy during meetings, consent of patients, expression of conflicting views, and professional liability. In practice policies should be formulated to guide on the common ethical issues in multidisciplinary team working [61, 62, 63].

8. Conflict management during multidisciplinary teamwork

Despite the importance of multidisciplinary teamwork in the management of liver cancer, it often result in conflicts among team members resulting in stress. Ultimately a stressed and strained workforce affects the quality of care offered to patients with liver cancer. [64, 65, 66, 67], like the saying “When the elephants fight, the grass suffers the consequences”. Although the conflicts may not involve actual fights, disagreements in the management plan alone do not benefit the patient. A pre-existing plan for identification of conflicts and their subsequent management should be provided for guidance. Interventions including training on leadership, teamwork, team building, and role training have been used as strategies to prevent conflicts in hospitals and specialized healthcare settings [68, 69]. Whenever faced with conflicts among multidisciplinary team members, evidence based interventions should be used to resolve disputes. Measures to de-escalate tensions, include use of the concept of mindfulness, emotional intelligence, workplace reporting system, effective communication with mediation from friends, and stress management [70, 71].

9. Conclusion

Multidisciplinary team work is necessary for better management of patients with liver cancer. It is crucial to integrate a multidimensional form of care where both physician and non-physician professionals’ expertise is considered vital with a patient being the centre of focus. Team members need to acknowledge and appreciate distinct roles of each member and how it contributes significantly to improved quality of life of the patient. Regular trainings ultimately improve the functionality of the multidisciplinary team while reducing chances of conflicts, and poor patient care. Modification of multidisciplinary approach models and techniques to fit the needs of a setup should be routinely done for optimal clinical outcomes of patients with liver cancer.

Acknowledgments

We acknowledge Mountains of the Moon University for providing a conducive environment to prepare this chapter.

Conflict of interest

All authors declare no conflict of interest.