Introduction

Multidisciplinary care teams are those that are composed of members from multiple different medical specialties working together to achieve the highest quality of care for the patient. Such teams are particularly needed in complex environments such as cancer hospitals, where the needs of the patients cross the boundaries of specialties. There are the providers of medical care, including medical oncologists, radiation oncologists, and surgeons; the ancillary care providers such as imaging, pathology, and laboratory medicine; and a host of supportive services including nutrition, rehabilitation services, and chaplaincy. In order for such a diverse group to work effectively together, communication and mutual understanding are critical.

Imaging plays a central role in the care of patients with cancer. Subsequent chapters deal with some of the specifics regarding the use of imaging in the multidisciplinary environment, such as tumor staging, lesion respectability, and treatment-related complications. Many clinical decisions are influenced by the results of imaging studies, and the radiologist must, therefore, be a central member of the multidisciplinary care team. The significant role of imaging can be seen in the continued growth in the numbers of scans performed each year, particularly in the advanced imaging studies such as x-ray computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography with x-ray CT (PET/CT).¹

One of the major challenges for radiologists in the multidisciplinary environment is that imaging intersects with nearly all aspects of patient care. Scans ordered by a radiation oncologist for the purpose of treatment planning may be interpreted with a different emphasis and perspective than scans ordered by a surgeon prior to planned curative resection or by a medical oncologist in anticipation of systemic chemotherapy. The radiologist needs to be aware of the clinical scenario in which the scan is being ordered and should have an understanding of the implications of the scan results for the patient. This level of expertise is gained through direct and frequent interaction with the other members of the care team.

Central to the role radiologists play in the management of patients with cancer is communication. Results need to be conveyed in an understandable and clinically relevant fashion, and preferably in a timely manner. The following sections describe the radiologist’s perspective on multidisciplinary cancer care and discuss ways to effectively communicate in such an environment.

Multidisciplinary Cancer Imaging: The Role of the Radiologist

The field of radiology has grown in complexity as the technology of imaging has advanced. Plain x-ray, fluoroscopy, and radionuclide scintigraphy have been a part of medical practice for many decades, whereas CT, MRI, ultrasound, and PET/CT are more recent additions to the field. Even within imaging modalities, techniques continue to evolve. CT studies are now often performed in a multiphasic fashion, using multispectral scanners. Clinical MRI is now performed on both 1.5- and 3.0-T systems, with an ever-increasing array of sequences and coils. New developments are always on the horizon, from higher–field strength MRI systems to novel tracers for PET/CT. Advances are not confined solely to the diagnostic arena, but are also seen in the fields of intervention and therapy.

This increase in the breadth and complexity of radiology and nuclear medicine has necessitated a shift in practice patterns at many sites. In order to effectively function in the multidisciplinary environment of an academic cancer hospital, radiologists have needed to specialize. Radiology specialization has traditionally been either by modality (e.g., ultrasound, CT) or by system (e.g., body imaging, neuroradiology, thoracic radiology). The clinical specialties, conversely, have trended toward specialization according to disease. At M. D. Anderson Cancer Center, there are multidisciplinary care teams devoted to the care of patients with various malignancies. Each care team is composed of multiple members from various disciplines, including surgery, medical oncology, and radiation therapy. In order to adapt to the multidisciplinary paradigm, imaging has had to adapt from the traditional modality-based and system-based approaches to a disease-oriented framework (Figure 1-1).

Figure 1-1 In the multidisciplinary cancer care environment, the emphasis in imaging shifts from modality-based practice to disease-based practice. CT, computed tomography; GI, gastrointestinal; GU, genitourinary; MRI, magnetic resonance imaging.

The challenge for the radiologist is that the diagnostic imaging within each of the multidisciplinary centers crosses the boundaries between traditional imaging specialties. To take an example, a woman with newly diagnosed, locally advanced breast cancer presents for workup (Figure 1-2). Breast imaging plays a central role in her evaluation, starting with mammography and moving to breast ultrasound and/or MRI as needed. Her pathologic diagnosis and tumor genetic markers will likely be established by a guided biopsy procedure. Further imaging workup of such a patient may include a contrast-enhanced CT of the chest and abdomen or a radionuclide bone scan for detection of osseous metastatic disease. The workup may stop there, but depending on many clinical factors such as signs and symptoms and serum tumor markers, additional imaging may be requested including PET/CT with fluoro-2-deoxy-D-glucose (FDG), or brain MRI.

Figure 1-2 Imaging can play a role in all cycles of patient care. In this patient with a new breast lump, the diagnosis of breast cancer was first suspected on mammography (A) and MRI (B) and subsequently confirmed on ultrasound (C) with ultrasound-guided biopsy (D). E, A fluoro-2-deoxy-D-glucose (FDG)–positron-emission tomography/computed tomography (PET/CT) showed the primary tumor and axillary metastases, but also numerous osseous metastases. F, The patient subsequently received chemoradiation for stage IV disease. A follow-up FDG-PET/CT showed complete metabolic response of the primary tumor, nodal metastases, and osseous metastases, but a new hypermetabolic lesion in the liver. G, This lesion was confirmed and biopsied under ultrasound guidance, after which a limited hepatectomy was performed. H, Follow-up CT scan shows evolving postoperative changes and no evidence of recurrence.

All of these imaging studies will be taken into account in order to decide whether the patient should proceed to surgery, undergo neoadjuvant chemotherapy or chemoradiation, or undergo chemotherapy or radiotherapy either alone or in combination. Imaging may guide specific intervention not part of the overall treatment strategy, such as radiotherapy or surgical fixation of a bone metastasis with impending pathologic fracture. In this fairly straightforward example, there is potentially the need for imaging specialists in the fields of breast imaging, body imaging, nuclear medicine, and neuroradiology.

In response to this shift in clinical practice toward multidisciplinary care, radiology at M. D. Anderson Cancer Center has also moved toward a disease-based approach. This has required both a shift in traditional boundaries and a close cooperation between radiologists of different subspecialties. In many cases, one of the radiology subspecialties fits in well with one or more of the clinical care centers. For the patient described previously, undergoing workup and care by the breast cancer team, the breast imaging section plays a major role, interacting directly with the clinicians and offering guidance with regards to additional imaging. The thoracic imaging group provides the direct interface with the lung cancer, esophageal cancer, and mesothelioma teams. Within each of these sections, radiologists may develop areas of interest and become, for example, specialists in the imaging of pancreatic cancer or gynecologic malignancies.

The radiologists associated with various disease-based care centers should be familiar with the role of imaging in the workup and management of their patients, including the role of imaging studies outside their traditional boundaries. One of the best examples of this model at M. D. Anderson Cancer Center is PET. PET scans were traditionally interpreted by nuclear medicine physicians. With the advent of PET/CT and the additional anatomic information provided by the CT component of the study, radiologists began to show greater and greater interest in the modality. Currently, many sites are performing PET/CT with intravenous and oral contrast, making the CT portion of the examination nearly identical to a traditional diagnostic-quality CT scan. PET/CT has developed into one of the central imaging strategies in the evaluation of patients with a variety of malignancies. At M. D. Anderson, radiologists from multiple subspecialties have undergone training in PET/CT under the guidance of nuclear medicine and are qualified to interpret scans independently. The section of PET/CT has, therefore, become a “virtual section,” with members from nuclear medicine, body imaging, thoracic imaging, musculoskeletal imaging, and neuroradiology.

The need for a broad fund of knowledge in a well-integrated multidisciplinary environment is balanced by the need for specialization. No one radiologist in an academic cancer center can be familiar enough with each and every imaging test to provide the level of expertise and consultation required. Radiology, therefore, also needs teams. The primary radiology section interfacing with a multidisciplinary care center serves as the anchor and a point of contact. The other sections provide backup and consultation as needed for particular patients. A bone scan performed in nuclear medicine using single-photon emission computed tomography (SPECT)/CT, for example, may show an unsuspected finding in the pancreas, and the advice of a member of the body imaging section may be requested to provide a differential diagnosis.

Cancer imaging in a multidisciplinary environment provides the opportunity to become directly involved in the decision-making processes of patient care and to learn about the role and relevance of imaging within the broad clinical picture. There are challenges in adapting from the traditional modality-based or region-based practice of imaging to a disease-based approach, but these challenges can be met with adaptation and communication.

The Value of Communication

Central to the role of the radiologist in the multidisciplinary environment is the ability to communicate effectively. This must occur in direct interactions with colleagues and through the written radiology report. Although verbal communication has many advantages, it is simply not feasible to personally discuss each and every case with the clinical team, and the written report is, therefore, the venue through which the information obtained from the scan is conveyed in the majority of cases. In order for this to be done effectively, careful attention should be given to reporting skills.

First and foremost, any radiologic report should answer the clinical question. Scans are ordered with a particular question in mind, from the general (“what is the patient’s disease status following treatment?”) to the specific (“what is the cause of the abdominal fullness felt on abdominal examination?”). Effective reports directly answer these questions, in either the positive or the negative. In order for this to happen, the radiologist must understand the clinical question being asked. Sometimes, this information is contained in the scan order, but at other times, it may be necessary to probe the patient’s history in order to find the rationale for the scan in question.

In the setting of multidisciplinary cancer care, the challenge for the radiologist is to fully understand the clinical questions for different disease types. The information relevant to the care of patients with different types of malignancies can be quite diverse. As an example (Figure 1-3), patient A has newly diagnosed esophageal cancer, verified by endoscopic biopsy. Patient B has newly diagnosed large B-cell lymphoma, diagnosed by a retroperitoneal lymph node biopsy of a known retroperitoneal mass. Both patients undergo FDG-PET/CT, and each is found to have a hypermetabolic nodal mass in the left para-aortic space of the retroperitoneum below the celiac trunk. In patient B, in which this additional node is almost certainly a manifestation of retroperitoneal lymphoma, it has little additional significance because it does not change the stage of the patient’s disease. In patient A, this node is, however, a critical finding, changing management from chemoradiation and potentially curative surgery to palliative chemotherapy or chemoradiation. An identical finding in these two patients has markedly different significance in terms of the fundamental clinical question of tumor stage and appropriate therapy and the reporting should reflect this.

Figure 1-3 Similar imaging findings may have very different significance depending on the clinical scenario. A, In a patient with newly diagnosed esophageal cancer, CT shows a suspicious lymph node in the left retroperitoneum (arrow), subsequently biopsied and shown to be due to metastatic disease. This node significantly altered patient management from neoadjuvant chemoradiation followed by surgery to palliative chemotherapy. B, In a patient with newly diagnosed non-Hodgkin’s lymphoma, a similar node is seen in the left retroperitoneum (arrowhead) on CT. In this case, the presence of this node had no impact on management because many larger nodes were seen throughout the abdomen and pelvis.

Answering the clinical question, therefore, becomes a matter of, first, understanding the disease process enough to appreciate the relative importance of various radiologic findings and, then, of reporting those findings in an effective manner. A helpful framework for high-quality radiology reporting is the eight Cs of effective reporting (Table 1-1). This framework was initially put forward by Armas² as six Cs, and expanded to eight Cs by Reiner and colleagues.³ The eight Cs are Correctness, Completeness, Consistency, Communication, Clarity, Confidence, Concision, and Consultation. These are useful measures of effective reporting, particularly in the setting of a multidisciplinary cancer care system.

Table 1-1 The Eight Cs of Effective Radiology Reporting

From Reiner BI, Knight N, Siegel EL. Radiology reporting, past, present, and future: the radiologist’s perspective. J Am Coll Radiol. 2007;4:313-319.

Correctness is perhaps the most basic of these concepts, but at the same time, it is not as absolute as it seems. Everyone strives for the correct diagnosis in radiology reporting, yet given the complexities of imaging, it is not always possible to arrive at the correct diagnosis. In fact, there are situations in which the best scan interpretation may not contain the correct diagnosis. For example, a patient with prior non–small cell lung cancer presents with a new slowly enlarging speculated pulmonary nodule. The report of the chest CT appropriately suggests metastatic disease, and a percutaneous biopsy is performed. The biopsy shows inflammatory reaction and fungal elements, and a diagnosis of Nocardia infection is made. In this case, the CT report was not “correct” in the sense of making the appropriate diagnosis; however, the workup generated by the CT report was appropriate, and the diagnosis of fungal infection was made allowing for treatment with antibiotics. The emphasis might, therefore, better be placed on interpreting studies in the correct fashion (i.e., up to the standards of good medical practice) rather than focusing on the correct diagnosis.⁴

Completeness and consistency are related parameters. Completeness is defined as containing all the parts and elements necessary for a high-quality report, and consistency implies structure to the report, applied over time. Both of these elements can be achieved through the use of reporting templates or standardized reporting. A representative guideline for reporting of PET/CT scans is provided by the Society of Nuclear Medicine’s PET Center of Excellence, outlining the components of an effective PET/CT report in oncology.⁵ Other guidelines and templates exist for other imaging modalities.

Communication is the core of quality in the field of imaging. The best images obtained on the newest scanner and interpreted by the best-trained radiologist can be clinically useless if the results are not effectively communicated to the referring clinician. Often, the written report is the only interface between the radiologist and the clinician. Special care must, therefore, be given to the structuring of the report to ensure the message is delivered in an appropriate fashion. The final four Cs can be seen as tools to achieve that effective communication.

Clarity means that the opinion of the radiologist is clearly stated in the report. In the arena of oncologic imaging, this may mean definitively categorizing into one of the four criteria outlined in the World Health Organization (WHO) and RECIST (Response Evaluation Criteria In Solid Tumors) criteria^6–8: complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD). Clarity does not necessarily imply a single diagnosis because many radiologic findings require an organized and logically ordered differential diagnosis. Further clarity can be achieved with the addition of next-steps, if appropriate.

Confidence is a measure of how much faith the radiologist has in his or her conclusions. Again, it is entirely appropriate to give a differential diagnosis when imaging findings are not conclusive for a single process (as is often the case). A warning sign of low confidence is the overuse of qualifiers such as “likely,” “possible,” and “cannot exclude.” When such words are used frequently in reports, it waters down the message and leaves the clinician lacking in guidance as to how to manage the patient.

Concision means brevity; it is desirable in radiology reports for several reasons. First, from a pragmatic and economical standpoint, many practices pay for dictation by the word or by the line, so there can be significant cost savings associated with shortening the length of reports. Second, concision tends to lead to clarity, in that, in order to achieve it, care must be given to the choice of wording and how the message is to be spelled out. Finally, most clinicians are busy and may skim over lengthy reports in order to pull out the “bottom line,” leaving room for misinterpretation. When possible, it is best to distill the findings from imaging studies into a series of short, declarative sentences. This may not always be possible, particularly with complex modalities such as PET/CT and complex clinical scenarios, but should be striven for.

Consultation is where all of the Cs are pulled together. Radiologists are members of the multidisciplinary team and should view themselves as imaging consultants, rendering advice and opinion as to the significance of imaging findings in the care of each patient. The role of consultant should be maintained whether presenting cases at a tumor board or when reading cases at the workstation. It is here that the knowledge of the clinical scenarios and questions becomes paramount. Effective consultation sometimes requires anticipation of what questions may arise in a patient’s care and proactively answering those questions in the report, including both pertinent positive findings and pertinent negative findings. One of the phrases that is often used in radiology reporting can undermine the role of consultant: “clinical correlation is recommended.” When used in the context of a differential diagnosis in which there are certain signs and/or symptoms that may confirm the diagnosis, the use of the phrase may be appropriate. For example, in a patient whose CT shows inflammatory changes surrounding the sigmoid colon, a report reading “These changes may represent acute diverticulitis, correlate clinically” gives guidance and direction. In other settings, however, its use can be vague and may lead to confusion. In a patient with a subcentimeter pulmonary nodule, a report reading “This nodule could be inflammatory or malignant, correlate clinically” provides no guidance or advice, because no sign, symptom, or laboratory test will significantly change the likelihood of malignancy. If follow-up scanning is indicated to determine the stability of the nodule, this should be stated. If the findings are more concerning and the nodule is amenable to biopsy, this information should be conveyed.

Participation

The eight Cs described previously are helpful tools in the construction of effective and useful radiology reports. Many of the studies that are interpreted are acted upon based on that report without further interaction by the radiologist. However, in the true multidisciplinary care environment, keeping in mind the role of the radiologist as imaging consultant, person-to-person interaction is a requirement. This can range from phone consultation to participation in tumor boards or other multidisciplinary conferences. Despite best efforts to appreciate and answer the clinical questions, it is not always possible to fully understand or anticipate the information required by the clinician in a particular patient’s care. Even at centers in which the radiologist has access to the patient’s medical record and clinic notes, the most recent notes may not be available at the time of dictation, indicating the precise reason the examination was performed.

Personal consultation with clinicians is highly beneficial to the practice of radiology, and the benefits flow in both directions. Through discussions with the surgeons, medical oncologists, and radiation oncologists, the radiologist expands her or his knowledge of the medical field, improving their quality of interpretation and reporting for future patients. The clinician, by understanding more about the strengths and weaknesses of imaging studies, will improve his or her appropriate utilization of the modalities. Finally, the personal interactions ensure that the radiologist is viewed as a colleague, a member of the multidisciplinary team.

Summary

The practice of oncologic imaging in the multidisciplinary setting presents challenges for the radiologist. By the nature of the disease, therapies, and imaging technologies, there is a high degree of complexity in the imaging of the patients. Adherence to the eight Cs of effective reporting can help ensure effective communication, and an understanding of the diseases and therapeutic options aids in the crafting of a clinically relevant report. Finally, the radiologist must be an active and participating member of the multidisciplinary team, providing insight and perspective on the value and limitations of imaging in the care of patients with malignancy.