Guest Editorial

Multimodal cancer care research

N. MacDonald , MD *

*Department of Oncology, Faculty of Medicine, McGill University, Montreal, QC.



Research models must more closely take into account the interdependence of social, behavioral, psychological, organ system and cellular molecular mechanisms of disease.

— Norman Anderson1

Today, most oncologists would agree that Anderson’s statement is common sense and subscribe to its expressed wisdom2,3. And yet most cancer centres are not set up to apply this wisdom to patients with advanced cancer, even the patients with serious multisystem problems. To do so requires access to interprofessional teams, ideally from first diagnosis. Palliative care is based on teams that address all dimensions of illness, but most still concentrate on end-of-life care; they provide comprehensive care only to a modest degree to patients and families early in the course of illness.

Oncologists commonly work in nurse–physician dyads; nurses are partners offering consistent ongoing patient follow-up. That approach, while laudable, cannot supply a full envelope of care. To do so requires adoption of the “multimodal team care” concept put forward by Fearon4. Following those principles, I use the term “multimodal” to mean care offered by a core team made up of nurses, physicians, physical and occupational therapists, social workers, and dietitians working as co-equals. They see patients and families at the same visit and formulate an articulated care plan. This core team may expand as needed to meet specific patient needs. Their care is continuous, not episodic; it is not characterized by isolated consults unto themselves.

An adage holds that “the beginning of wisdom lies in calling things by their right name.” Without clarity, fine endeavours may fail in a morass of misunderstanding. “Multimodal care” meets the criteria for a rehabilitation team just as for a palliative care team5,6. Multimodal teamwork is also an exercise in prevention: “When sorrows come, they come not single spies, But in battalions”7. Indeed, symptoms feed on each other, and if not addressed early and well, may produce a crescendo of suffering and accelerate disease. An intertwining of approaches, perhaps regarded by many as separate entities, should therefore be seen as a common front.

It is unsurprising that many aspects of quality of life improve for patients working with multimodal teams, as documented by Gagnon et al. 8 and Chasen et al. 9 in this issue of Current Oncology. Improvement of this kind has consistently been demonstrated in palliative care programs, and the multimodal teams being spoken of are, in reality, based on palliative care principles. But is there a biologic rationale for their potential success in controlling symptoms and possibly improving the results of drug therapy and patient survival alike? I think that there is.

Tumour immune response is undoubtedly a two-edged sword. As advanced cancer progresses and metastasizes, the immune reaction engendered turns traitorous. The tapestry of cytokine and chemokine production stimulates tumour growth, angiogenesis, tissue invasion, and metastasis1012. This aberrant chronic inflammatory state increases symptom frequency and severity, most notably the anorexia–cachexia syndrome13,14, and clearly connotes a grim prognosis for survival15.

Exercise, some dietary components, and psychosocial intervention have anti-inflammatory effects1621. It can be hypothesized that adding sophisticated dietary counselling, follow-up exercise and self-help routines, and psychosocial interventions might not just increase appetite and help patients “feel good,” but might also ameliorate the chronic inflammatory state and thus decrease cancer symptoms and inhibit tumour progress. Sound social and biologic rationales therefore underpin the idea of combining conventional anticancer therapies with multimodal team care from first diagnosis.

Only baby steps toward proving these hypotheses have been taken. The two papers in this issue—and the few other studies from teams dealing with cachectic cancer patients—have, in total, enlisted fewer than 500 patients in nonrandomized trials. But if the Anderson concept is accepted as correct, as seems to be the case, and if a plausible biologic rationale supports comprehensive team activity, then surely we should advance research initiatives in this sphere—a task that, by long experience, is understood not to be easy for a range of reasons:

I think that there may be ways to address those issues, including these:

Multimodal care is based on common sense; it will enjoy community support and understanding (“Why weren’t you doing this all the time?”), it has a biologic rationale, and in one expression or another, is lauded by our cancer societies. Still, a wide gap exists between recognition and application. The hope is that the research published in this issue of Current Oncology will help in some small way to narrow the gap. I think that an informed public would expect us to do so.


The author has no financial conflicts of interest to declare.


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14. MacDonald N. Chronic inflammatory states: their relationship to cancer prognosis and symptoms. J R Coll Physicians Edinb 2011;41:246–53.
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15. McMillan DC. The systemic inflammation-based Glasgow Prognostic Score: a decade of experience in patients with cancer. Cancer Treat Rev 2013;39:534–40.

16. Galland L. Diet and inflammation. Nutr Clin Pract 2010;25:634–40.
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18. Lenk K, Schuler G, Adams V. Skeletal muscle wasting in cachexia and sarcopenia: molecular pathophysiology and impact of exercise training. J Cachexia Sarcopenia Muscle 2010;1:9–21.

19. Antoni MH. Psychosocial intervention effects on adaptation, disease course and biobehavioral processes in cancer. Brain Behav Immun 2013;30(suppl):S88–98.

20. Betof AS, Dewhirst MW, Jones LW. Effects and potential mechanisms of exercise training on cancer progression: a translational perspective. Brain Behav Immun 2013;30(suppl):S75–87.

21. Green McDonald P, O’Connell M, Lutgendorf SK. Psychoneuroimmunology and cancer: a decade of discovery, paradigm shifts, and methodological innovations. Brain Behav Immun 2013;30(suppl):S1–9.
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Correspondence to: Neil MacDonald, Palliative Care Program, Élisabeth Bruyère Hospital, Ottawa, Ontario K1N 5C8. E-mail:

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Current Oncology , VOLUME 20 , NUMBER 6 , DECEMBER 2013