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Monday, December 02, 2013

Patients are True Beneficiaries of the "Power of Partnership"

Sarah S. Donaldson, M.D.

Although challenges remain, radiologists who join with colleagues and patients to deliver the best healthcare possible are demonstrating the true "Power of Partnership" and the value of the specialty, said RSNA President Sarah S. Donaldson, M.D., during her President's Address on Sunday.

"It's my vision to have partnerships internally with other radiologists, externally with our colleagues outside of radiology and jointly with our patients, who are our most important partners," Dr. Donaldson said.

Pediatric cancer care is an example of multidisciplinary cooperation that has yielded successful results, said Dr. Donaldson, who subspecializes in pediatric radiotherapy. "Not long ago, childhood cancer was a fatal disease; in fact, data from the mid-1970s show that just over half of the afflicted children survived only five years," she said.

At that time, radiation oncology was primitive. Medical linear accelerators were in early development and the pediatric oncology discipline didn't exist. Before cross-sectional CT and MR imaging were available, radiologists used mainly plain films. "Then, radiologists were generalists," Dr. Donaldson said. "Our training programs were unified, and we were at the nexus of patient care."

Radiology expanded rapidly with advances in technology. Radiologists subspecialized and training programs separated as therapy split from diagnosis, Dr. Donaldson said. "The good news was that within radiation oncology, the new technology offered improved accuracy and understanding that allowed us to apply higher doses of radiation with improved cancer cure rates," she said.

Ironically, the very treatment that improved cancer cure rates created a new problem—radiation injury to normal tissues, challenging radiation oncologists to reduce toxicity while still achieving desired cure rates. "We had to rely on each other," Dr. Donaldson said of radiologists and radiation oncologists. "We cooperated, we collaborated and we developed research programs that created more precise therapy. Today, more than 80 percent of children with cancer are cured using multidisciplinary, risk-adapted therapy."

That experience, Dr. Donaldson said, taught her the extraordinary power of partnerships. "It's a time that requires us to focus on producing value not volume, and outcomes not output," she said.

In order to target a tumor, radiologists must integrate images from all imaging modalities, seeing tumors in every dimension and understanding how tumors move, their heterogeneity, their blood supply and their molecular pathways. Dr. Donaldson shared an image of a hepatic lesion in a patient with primary colorectal cancer. The abnormality was not well defined by CT and was deemed inappropriate for radiofrequency ablation. Instead, the facility's tumor board recommended stereotactic body radiotherapy, which required daily real-time image guidance and tumor tracking facilitated by fiducial markers implanted by interventional radiologists. At simulation, the team obtained PET-CT images to localize the lesion.

"Our gating techniques confirmed the tumor did not move with respiration, but the PET scan showed a larger hypermetabolic lesion than revealed by CT," she said. "Our nuclear medicine colleagues confirmed this and, on the basis of their consultation, we enlarged our treatment target volume.

"Without integrated multimodality imaging and close interaction with our imaging colleagues, we would have underestimated the true extent of the disease, which would have resulted in a marginal miss—and a marginal miss guarantees a local failure," Dr. Donaldson continued. "Instead, as partners, we controlled this disease, without hepatic toxicity."

As advanced imaging allows more tailored therapy, it will demand that medical professionals share more responsibility. At the same time radiologists must also find creative ways to become more visible, Dr. Donaldson said. "One way is to get out of the basement and out of the reading room by actively participating in clinics, tumor boards and multidisciplinary conferences. While it may be difficult to send a radiologist to every conference and tumor board, the fact is that we can't afford not to."

Most importantly, radiologists need to partner with their patients, she said. "Whether or not this environment is comfortable for us, we must acknowledge that patient-driven care is our new challenging reality."

Dr. Donaldson shared stories and photos of a few young patients with whom she became "buddies" during their cancer care, and told the audience how they stayed in touch with her through adulthood after they were cancer-free. "I'm truly optimistic that we can achieve these partnerships," Dr. Donaldson said. "But to do so, we have to meet critical challenges. We must modify our culture and then invest in the opportunities ahead."

Dr. Donaldson is the Catharine and Howard Avery Professor of Radiation Oncology at Stanford University School of Medicine in Stanford Calif. She also serves as the associate director of the radiation oncology residency program at Stanford Hospital and Clinics and is the chief of the radiation oncology service at Lucile Salter Packard Children's Hospital at Stanford.

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© 2013 RSNA. The RSNA 2013 Daily Bulletin is the official publication of the 99th Scientific Assembly and Annual Meeting of the Radiological Society of North America. Published Sunday, December 1 - Thursday, December 5.

The RSNA 2013 Daily Bulletin is owned and published by the Radiological Society of North America, Inc., 820 Jorie Blvd., Oak Brook, IL 60523.

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