SF 4a - Image-guided interventions in oncology: the pieces of the jigsaw
1. To explain the importance of quality assurance in image-guided interventions in oncology and their effect on treatment outcomes.
2. To describe how developments in functional imaging are affecting clinical practice in oncology.
3. To summarise the current evidence regarding the treatment of cancer patients by interventional radiologists and explain the methods being employed to obtain the relevant data.
Establishing a program that includes continuous assessment of clinical outcomes ensures patient safety and increases the quality of the services. It is thus important to organise an accurate auditing system that will allow the identification and minimisation of risks and the maintenance of a low incidence of complications. Several safety practices can substantially reduce errors and medical complications and provide an optimal standard of care to patients. Imaging in oncology has dramatically evolved with the inclusion of functional information of the underlying process. A better understanding of which tumoural areas still remain active after therapy ensures the obtaining of accurate information that may improve the targeting of percutaneous biopsies or the direct guidance of selective therapies. If interventional radiologists are willing to be a robust pillar in the management of cancer patients they must be part of multidisciplinary teams, acquire skill in clinical responsibilities and obtain solid support, based in evidence, for the procedures they perform. For obtaining such conditions, interventional radiologists must have dedicated programs of training, must improve their social visibility and must conduct research and clinical trials.
1. To summarise the main developments in molecular imaging.
2. To highlight the importance of image fusion in the diagnosis and treatment of cancer.
3. To explain how functional imaging is changing oncological practice.
Molecular and functional imaging has become an integral step in the evaluation of cancer patients. Most primary tumours are now biopsied under image-guidance to determine the best therapeutic strategy. However, the standard image-guided biopsy entails sampling a small portion of a tumour. Tumours are notoriously heterogeneous so that a small amount of tissue may not adequately represent the most aggressive component. Serial biopsies to account for variable expression of molecular targets throughout the tumour (tumour heterogeneity) are typically not practical. To optimize tissue sampling, molecular imaging can provide a more complete insight into living tumours. The ability of PET/CT to demonstrate malignancies, which are not visible on anatomic images, increases the number of biopsy requests based on foci of tracer uptake. In addition, some neoplasms may demonstrate non-uniform tracer uptake and can be mostly necrotic or contain metabolically active tumour cells in only a small portion of the total mass. Whenever no PET tracers are available, SPECT/CT may be used as well for image guidance. Image fusion with MR can also be used to target biopsies toward areas with restricted diffusion. Lastly, dynamic contrast enhancement studies using MRI, CT or ultrasound nicely demonstrate foci of microvascular anomalies suitable for biopsy.
1. To explain the methods of gathering evidence in practical disciplines.
2. To outline the evidence base for image-guided interventions in oncology.
3. To outline the main current trials and registries in image-guided interventions in oncology.
Medicine, in some instances more than other fields, undergoes a constant development process, making guidelines and standard operative procedures an important tool for the medical community. This is especially true in oncology, a discipline for which multidisciplinarity and combined therapies are essential for treatment success or better outcomes. Principles of clinical guidelines are based on current scientific knowledge with participants coming from different medical societies and on the consensus of medical experts, sometimes called good clinical practice. Furthermore, high-quality guidelines are necessary not only for a structured knowledge transfer, but they also find their place in the structures of the health system, being more and more a reference for discussions with reimbursement institutes and insurances. At least, evidence-based guidelines serve as a basis for creating and updating of disease management programs and to define quality indicators that will be used for the certification process of comprehensive cancer centres. If one refers to the number of papers, lectures and conferences focused on interventional radiology, we are forced to admit that the interventional oncology is taking a large place in interventional radiology. Over the last 30 years, interventional oncology has not only developed palliative monotherapies but could also obtain curative treatment for selected patients with renal, hepatic or pulmonal cancers.
1. To explain the importance of clinical practice in image-guided interventions in oncology.
2. To describe how interventional radiologists can practice as clinicians rather than technicians.
3. To outline the curriculum being developed for image-guided interventions in oncology.
Interventional radiologists working in the field of cancer care have an excellent understanding of imaging and a diversity of interventional skills. However, they lack formal training in oncology and have a relatively poor understanding of chemotherapy and radiotherapy. Furthermore, their relative lack of sub-specialisation in interventional oncology is a disadvantage when communicating with other disciplines. It is very important to consider the patient and not the image. Talking to the patient, establishing his/her general state of physical and psychological health and their family and domestic circumstances is very important. In addition, the interventional oncologist should understand the disease and should be familiar with treatment alternatives other than those offered by interventional radiology. Sub-specialisation in interventional oncology is likely to increase and has substantial advantages because it provides a clear path for referrals and makes it easier for interventional oncologists to participate fully at multidisciplinary meetings. Participation at multidisciplinary meetings is very important because interaction with other disciplines improves decision-making and reduces the risk of error. Interventional oncologists should practise as clinicians at every stage in the patient pathway. Delegation of care to other disciplines can lead to inadequate consideration of the indications for and limitations of interventional radiological treatment, is wasteful of resources and is frustrating and unkind to patients. Practising as a clinician makes it easier for the interventional radiologist to prepare the patient appropriately, obtain true informed consent and ensure adequate follow-up.
1. To highlight the importance of quality assurance in image-guided interventions in oncology.
2. To explain how quality assurance affects clinical outcomes in cancer care.
3. To summarise the content and practical implications of the framework developed for quality assurance in image-guided interventions in oncology.
In acknowledgement of the overwhelming importance of standards of practice and their ultimate incorporation into a quality assurance programme, CIRSE has developed a set of practice standards for interventional oncology. The framework is based on the Australian and New Zealand Radiation Oncology Practice Standards and they follow the entire care pathway for patients undergoing interventional cancer procedures. They will support safe quality care for patients and will also act as a basis on which interventional oncologists can work with facilities to improve the infrastructure and processes required for their teams to practise effectively. There are 14 standards, broadly divided into three areas, and each follows a standard format: facility management (7 standards), treatment planning and delivery (3 standards), safety and quality management (4 standards). There is a consistent format for each standard, as follows: i. each standard refers to a corresponding goal or outcome, ii. criteria describe the key processes required to attain that goal, iii. a commentary provides information which outlines how a criterion applies in everyday practice and iv. the required evidence that documents the records that the facility should be able to provide to demonstrate compliance with the standards. These draft standards have been piloted in a number of interventional oncology units during the second half of 2016. Upon completion, CIRSE will incorporate the standards into a quality assurance and credentialing programme.