Selected Podcast

Benefits of Multi-Disciplinary Care for Colorectal Cancer Patients

Ravikumar Paluri, MD, Rojymon Jacob, MD, and Greg Kennedy, MD, join the segment in this panel discussion on the benefits of multi-disciplinary care for Colorectal Cancer patients, and when to refer to the specialists at UAB Medicine.
Benefits of Multi-Disciplinary Care for Colorectal Cancer Patients
Featured Speaker:
Ravikumar Paluri, MD | Rojymon Jacob, MD | Greg Kennedy, MD
Dr. Ravikumar Paluri, MD is an oncologist in Birmingham, Alabama. He is affiliated with University of Alabama Hospital.

Learn more about Ravikumar Paluri, MD 

Rojymon Jacob, MD is an Assistant Professor, Radiation Oncology, University of Alabama School of Medicine.

Learn more about Rojymon Jacob, MD 

Greg Kennedy, MD is currently the John H. Blue Chair of General Surgery and the Director of Gastrointestinal Surgery and the University of Alabama in Birmingham.

Learn more about Greg Kennedy, MD


Release Date:      October 31, 2018

Expiration Date:  October 31, 2021

Disclosure Information:

Dr. Jacob has the following financial relationships with commercial interests:


  • Payment for Development of Educational Presentations - Varian SBRT Course

  • Payment for Lectures, including service on Speakers Bureaus - Medtronics, Varian

  • Dr. Paluri has the following financial relationships with commercial interests:


  • Consulting Fee - Ipsen, Amgen

  • Payment for Lectures, including service on Speakers Bureaus - Alabama Cancer Congress

  • Drs. Jacob and Paluri does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers have any relevant financial relationships to disclose.

    There is no commercial support for this activity.

    Transcription:

    UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

    Melanie Cole (Host): Welcome. Our topic today are the benefits of multidisciplinary care for colorectal cancer patients. Joining me in this panel discussion today, are my guests Dr. Ravikumar Paluri. He’s a hematologist, medical oncologist. Dr. Rojymon Jacob. He’s a radiation oncologist and Dr. Greg Kennedy, he’s a colorectal surgeon and they are all at UAB Medicine. Gentlemen I’d like to start with Dr. Kennedy. Explain a little bit about the incidence of colorectal cancer and what are you seeing among providers as far as awareness and speaking with their patients about colonoscopy and informing their patients of what they need to know?

    Greg Kennedy, MD (Guest): Yeah, well first, thank you Melanie for having us on. We are really honored to be here today just to talk about the program. The incidence of colorectal cancer overall has been declining for the past several decades. But it still remains the third most common cancer in both males and females here in the United States. As far as how we are addressing it in clinic, I do think that providers are more likely to talk about screening for their patients. Of course, the screening starts at age 50, perhaps earlier with the recent guidelines coming from the American Cancer Society for screening to start at 45. And what’s the best screening tool still being a colonoscopy. I do think that with our increased focus on screening, the incidence of colorectal cancer has been decreasing annually for the past several decades actually. Now that’s of course, has to be tempered a little bit by saying it’s decreasing in whites; however, the African American population unfortunately still remains relatively flat or increasing slightly. So, we do have some disparities yet to address in our screening as well.

    Melanie: Dr. Jacob as people hear about colonoscopies and we have done shows on that, so we don’t need to get into some of the diagnostic criteria for colonoscopy. Tell us about some of the benefits of multidisciplinary care because in this segment today, I have a radiation oncologist, a hematologist medical oncologist and a colorectal surgeon. Tell us a little bit about how this multidisciplinary care works together if somebody is diagnosed with colorectal cancer.

    Rojymon Jacob, MD (Guest): Thank you Melanie. So, as Dr. Kennedy mentioned, colorectal cancer is a very major part of our current practice in oncology. It’s a very common cancer. It’s treated using three major specialties of namely surgery, radiation and chemotherapy and this is a multidisciplinary approach where all these three specialists come together. Traditionally, once the patient is diagnosed, they are seen by all these multiple physicians and specialists over a course of several days in different clinics and oftentimes it takes days or weeks to formulate a plan of care for these patients. So, what the multidisciplinary colorectal clinic does is have all these specialists in a single setting where patients can be seen by the surgeon, the radiation oncologist and the medical oncologist all in one visit so that by the end of their appointment, patients can go with a recommendation for whatever treatment that they need. And oftentimes, the treatment involves care with chemotherapy and radiation as well as surgery. So, multidisciplinary care for colorectal cancer is paramount because these patients not only need local, regional therapy in the form of radiation and surgery, but they also oftentimes need systemic treatment because these cancers have the ability to travel through the bloodstream or lymphatics to far flung areas such as the liver or lungs.

    Ravikumar Paluri, MD (Guest): So, the multidisciplinary GI clinic at UAB is a very terrific new program and actually an improvement that we were all like excited about. And the primary goal is mainly to – the patient experience for which the patients with the cancer of the lower GI tract, the colon, rectum and anal cancers are the cancers we see typically in this clinic. And the best cancer care is delivered by here – the team of doctors and not by just an individual doctor. So, what we learned from our patients from listening to them over the course of the past several years is one of the most stressful and most difficult part of the treatment once they are diagnosed with the cancer is trying to organize appointments and keep track of all the doctor visits. So, we have a dedicated nurse coordinator who coordinates for them and streamlines instead of having multiple office visits, especially for those patients who are coming from the long distances. The multidisciplinary approach will make it less overwhelming for them so, that they have this one-day shopping experience rather than a long drawn out process over multiple visits. Sometimes even multiple weeks. So, you are bypassing all of that time and essentially providing them the individualized care within a short interval of time. And it also, helps with patient-centered discussion and it fosters an open discussion to come up with a personalized solution for the particular patient. And it also serves as a good platform to discuss about if these patients are candidates for minimally invasive surgeries or if they are candidates for clinical trials as appropriate. And also, knowing that all of us work as a team, sometimes this comforts the patient as well.

    Melanie: I would think it certainly does. Dr. Kennedy tell us – expand a little bit more on what Dr. Paluri was saying as far as the management of the several aspects of care and improved coordination between providers. Besides the three of you, and now we know there is a nurse navigator; who else might be involved in shepherding this patient around?

    Dr. Kennedy: Yeah, well in shepherding the patient around, Melanie it’s going to be primarily the nurse navigator, however, who else might be involved in the care of the patient when they come to the multidisciplinary clinic; in addition to seeing the three of us, and by the three of us, what I really mean is a radiation oncologist, a medical oncologist and a colorectal surgeon. The three of us work in the clinic, but we work with a team and there are several colorectal surgeons who participate, a couple of different medical oncologists, a couple of different radiation oncologists. So, we are absolutely a team and the three of us are here representing that team today. All of them are outstanding. This is a fantastic team that I think we have been able to put together.

    So, the patient will certainly see one of the members, the three members of the team from the different specialties. In addition, the patient may be needing genetics counseling. We will arrange that, and we will shepherd them to the genetics counselor. They may have some issues after treatment or during treatment with various symptoms, symptom management. They may need a nutritionist for example, heaven forbid a physical therapist for pelvic floor retraining, etc. Things like that. Those are certainly all things that are available to our patients and we are able to arrange those types of visits even in the multidisciplinary clinic. So, I think those are the types of capabilities this multidisciplinary approach though provides our patients because we all come from different specialties and have our focus on different aspects of the patient. Where Dr. Paluri might be focused on the medical treatment and some of the symptoms of the medical treatment, Dr. Jacob might be focused on the radiation and some of the symptom management of the radiation and where I’m focused on the surgery and the management of the surgical complications and management of the symptoms that are a direct result of some of the surgical interventions. So, it allows the three of us to come together and look at those even after surgery for example, after the treatment has been completed say is there something we are missing, and can we help the patient with this aspect through getting physical therapy or nutrition or whomever involved in the care.

    Melanie: Dr. Jacob are there some limitations as a radiation oncologist and I’m going to ask this question to Dr. Paluri as well, to many specialties being involved? So, if the patient is moving from chemotherapy, from medical oncology into radiation or vice versa; how are you all working together and keeping track and speak about adherence for management of all of these specialties.

    Dr. Jacob: So, the three specialties that I mentioned have to work in unison to take care of the patient. And it has always been the case that regardless of whether we have a multidisciplinary clinic or not; these three specialties have to act in unison with a great deal of coordination. So, it’s been often challenging because the unified patient care requires involvement from multiple personnel, like clinical nurse specialists and radiation therapists so it is not just that there are just the three doctors talking to each other. So, we have always taken the help of coordinators so that a patient who goes through radiation can for example get concurrent chemotherapy, start chemotherapy on the same date, be monitored for chemotherapy and radiation side effects simultaneously. So, all this has been going on even before the multidisciplinary clinic started but it has often been challenging. The fact that we have a clinic now has made the process a lot easier because we have a unified coordination and a care system which makes things a lot easier. Now, going forward, we are hoping that we will be involving more specialists into the multidisciplinary team in the multidisciplinary clinic which will make the coordination even more seamless.

    Dr. Paluri: The communication between medical oncology and the radiation oncology and also with the GI surgery and nowadays it is literally more straightforward because we have our impact messaging system. Sometimes we talk over the phone and there is no day that passes without me talking to either radiation oncologist which is more common in terms of the patient’s care or with the surgeon. So, we have very little time in talking over the phone in regarding the coordination of the care. And also, our supporting staff that includes our nurse practitioners and our nurses who pretty much know the same supporting staff with the other disciplines say radiation oncology or the surgery, so everyone will be on the same page for any patient related matters.

    Melanie: Dr. Paluri, sticking with you for a minute; do you have any predictors of treatment response based on these many specialties in your new multidisciplinary care clinic? How do you evaluate the impact because not every hospital system in the country is doing this? So, what strategies are you using to see how this program works on outcomes?

    Dr. Paluri: That’s a great question. So, to begin with, this multidisciplinary approach as we just discussed offers many benefits to both patients and also to the providers. So, that includes evidence-based decision making and shorter time to treatment and increased patient satisfaction. And at this time, our metrics are shorter times to treatment. We haven’t objectified that one yet. And the patient satisfaction scores. And I have seen patients comment or have been discussed with the patients, the patients comments were they were very happy with the current approach where they will get – they go home after the come to the clinic with a clear plan and with the follow ups everything and also the time from the treatment – let’s say the patient was diagnosed with a cancer and he’s coming from an outside state or from an outside provider; when the C is on the clinic and if the patient needs a surgery and I have seen Dr. Kennedy operate on that patient within a week. And this would not have been possible outside of the multidisciplinary clinic where the time from the diagnosis to the time definitive treatment is longer compared to the multidisciplinary approach and this was even reported in some studies, previously. And so, the – I would say the metrics are going to be the shorter time to the treatment and patient satisfaction scores.

    Melanie: Wow, that’s fascinating. Dr. Kennedy how about the survivorship period and the management of the several aspects of care? Whether you are talking about prevention or new cancer diagnoses, surveillance for recurrence. Speak about how the survivorship is included in this clinic.

    Dr. Kennedy: Yeah. Survivorship is certainly a critically important part of the cancer management. So, after the patient is treated, there is a number of things that we need to think about and it comes along with some of the symptom management I was alluding to earlier. Symptoms as a result of the treatment that they have gone through as well as some of the prevention. We know that an aspirin for example will help prevent recurrent polyps and perhaps decrease rates of recurrent cancer. We know that specific tests should be ordered to screen patients for development of new cancer or recurrence and other tests really shouldn’t be ordered. So, it really is important to have that coordinated care. Now to be completely honest with you Melanie, we are at a point where we haven’t really gotten into the survivorship piece as part of this multidisciplinary clinic. It’s a relatively new initiative for us only started in March of this year. This is certainly something that we are looking forward to adding in 2019, however, is really adding the survivorship piece to the multidisciplinary clinic. So, thanks for bringing that up.

    Dr. Jacob: One other point that I wanted to bring up with regard to possible endpoint to this whole interval is in the context of UAB’s commitment to clinical research. You know this is a major – ours is a major academic institution and we are committed to clinical research in a big way. So, the multidisciplinary clinic provides a setting for identifying patients who are eligible for cutting edge research and all of our physicians and nurses and nurse practitioners are all committed to supporting clinical research. We are personally involved in a lot of clinical trial protocols and there are new concepts that we discuss and there are new ideas that we have come up with which we would be testing shortly in our patients and these are all clinical ideas which should for example tests highly technically skilled organ preserving surgery, or very high precision radiation therapy protocols or highly patient specific systemic treatment protocols. So, the multidisciplinary clinic also provides the perfect setting for clinical research and I think we will – I personally and I’m sure all my colleagues agree with me that putting patients on clinical research would also be a very major end point to testing the efficiency of multidisciplinary clinic.

    Melanie: Dr. Jacob is part of this multidisciplinary care to more effectively inform the patients about the treatments? As we talk about the ability now to really include research and survivorship; what are you seeing that the patients are feeling from this clinic?

    Dr. Jacob: So, as Dr. Paluri alluded to earlier, we have not formally scored our patient satisfaction. But all the feedback that we have received so far is that patients are absolutely delighted for the fact that it’s a very efficient way of providing care. Patients are delighted that their appointment times are very short because the patients get to see all three. The patients get to come to clinic within a week. Number two, they get to see all specialists in one day. They are provided with the opportunity to undergo special imaging studies on the same day as they are scheduled to come to clinic. And most importantly, by the end of the day, when they walk out of the clinic; they have a treatment plan ready for them. And they find that extremely satisfying.

    Dr. Kennedy: Medicine has changed pretty drastically I believe in the last even ten years. We’ve moved from a really physician and surgeon-centric view to a patient-centric view. So, the idea that a patient comes to my clinic as a surgeon and I send the patient to the radiation oncologist who then sends the patient to the medical oncologist is very efficient for me. So, it’s very much a physician centered approach. What we are trying to do with this multidisciplinary approach and I think what Dr. Jacob has said is that we’ve really now taken this patient-centered approach where we recognize that perhaps it’s not the most efficient way for us, the three of us, the physicians to see patients, but it is the most efficient for the patient. Come, see all three doctors that are potentially going to be involved in their care on that one day. And that’s really the goal here is really to provide this service to the patient and even if it means that perhaps I’m there in one day and there are ten patients and I only have to see five of them as the surgeon, but I’m there for those five patients and I might spend four hours to see those five patients. But that’s okay because it’s really about the patient that’s in front of us. I think that’s what we are all committed to. The whole team is committed to that approach.

    Melanie: That’s a great point. And led me into this last question Dr. Kennedy was it helps the patients obviously, because it gives them kind of a one-stop shop, but for you providers and for your whole team, is that benefit something that you see possibly growing around the country. So, I would like you to wrap it up for us Dr. Kennedy and I’m going to ask you each to kind of give your last thoughts on this. But, Dr. Kennedy starting with you, what you would like other providers to know about referring to this new multidisciplinary clinic, why you feel that it’s so cutting-edge and advanced and helpful to the patients as well.

    Dr. Kennedy: Yeah. Well I think that the most important thing that I’d like to say to the other providers are that because the patient is seen by us, doesn’t mean the patient has to be treated by us. We’re here to provide second opinions as well. So, I don’t want people to think – I don’t want providers in the community to think that we’re trying to take all the patients to UAB. That’s not at all the point. We believe strongly that patients are best treated in their communities and perhaps what they need at times is a reinforcement that what the doctors in their community are doing is providing the highest quality of care available. A referral to this clinic, this multidisciplinary clinic simply may reinforce what the providers in the community are already doing. And that allows the patients to then go back to their community, get the treatment that their providers have prescribed and see that the providers are actually providing the same care that they would get at UAB. That’s really the important part for us or one piece of it here. Certainly, want to take care of patients but we also want to help providers in the community take care of patients.

    Melanie: Dr. Paluri, on to you. What would you like to send the message what would you like people to take from this episode, this segment about the multidisciplinary care involved in colorectal cancer?

    Dr. Paluri: So, the UAB multidisciplinary colorectal cancer clinic and as Dr. Kennedy mentioned, it is the dedicated one-stop care for the lower GI cancers. And this approach is primarily a patient centered, so this essential to deliver optimal patient care and this is considered to be one of the key elements of high-quality care. And the aims that are being accomplished are to provide comprehensive evaluation and provide individualized treatment plans and this happens after incorporating all the resources such as the resources that available in a tertiary center like ours for diagnosis, treatment and research.

    Melanie: Dr. Jacob, last word to you. What would you like the listeners to take away from this segment and what a fascinating segment it is? What a remarkable center you have all set up and I know it’s going to be beneficial for the patients. So, Dr. Jacob last word to you.

    Dr. Jacob: Thank you Melanie. I want to echo both Dr. Kennedy’s and Dr. Paluri’s sentiments. This multidisciplinary clinic is solely meant to be helpful to the patient and to the referring physicians in periphery where we like patients to go back and get their treatment as much as possible. And that would be I would say 90% of our patients seen in the clinic. The clinic also in the off chance that patients need more specialized care; be it due to their advanced nature of cancer or their rarity of disease; we also want it to be the setting where we can provide a cutting-edge technology and also research which can only be offered in a very highly specialized tertiary clinic like ours. So, this not only provides the opportunity to provide a second opinion for patients, but also gives the opportunity for them to have the option of maybe partaking in a clinical trial which may not be possible in the community setting.

    Melanie: Thank you so much, gentlemen. What an absolutely wonderful segment. Thank you for sharing your expertise, explaining the benefits of multidisciplinary care for not only colorectal cancer in this case, but really how it might work around the spectrum and for all types of cancer and thank you for all the great work that you’re doing. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You’re listening to UAB Med Cast. For more information on resources available at UAB Medicine you can go to www.uabmedicine.org/physician, that’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.