Multidisciplinary Team Approach Considering Patient Values
STEP 1 — Gather Information
Collect confirmed diagnosis of Cushing’s syndrome (elevated UFC, late‑night salivary cortisol, or abnormal dexamethasone suppression test), review prior treatments and surgical outcomes, assess patient’s values, preferences, and goals of care, and document comorbidities and psychosocial factors. → Proceed to rule in/out need for multidisciplinary discussion.
STEP 2 — Rule In / Rule Out
Rule in if the patient has persistent or recurrent hypercortisolism after initial surgery, is being considered for second‑line therapies (medical therapy, bilateral adrenalectomy, radiotherapy), or has complex comorbidities/preferences that affect treatment choice; rule out if the patient is a straightforward surgical candidate with expected remission and no conflicting values. → If ruled in, move to classification; if ruled out, proceed with standard treatment pathway.
STEP 3 — Classify or Stratify
Classify the patient into one of three pathways based on disease etiology, prior treatment, and patient preference: (1) Surgical candidate (repeat transsphenoidal surgery or adrenalectomy), (2) Medical therapy candidate (steroidogenesis inhibitors, glucocorticoid receptor antagonist, etc.), (3) Radiation/radiosurgery candidate (for corticotroph tumor control). Document patient’s stated priorities (e.g., avoiding lifelong steroids, minimizing hospital visits, preserving fertility). → Determine the preferred pathway and prepare for multidisciplinary discussion.
STEP 4 — Decide
Convene a multidisciplinary team (endocrinologist, neurosurgeon or ENT surgeon, adrenal surgeon, radiation oncologist, nurse educator, and optionally a psychologist or social worker) to review the classification, present treatment options, discuss risks/benefits aligned with patient values, and reach a shared decision on the definitive plan. → Arrange patient education session, obtain informed consent, and schedule the chosen intervention.
Clinical Guardrails / Mimics / Pitfalls
Do not delay definitive treatment while awaiting perfect consensus; do not assume the patient prefers the most aggressive option without exploring quality‑of‑life concerns; do not overlook psychosocial barriers (e.g., depression, financial toxicity) that may affect adherence; do not proceed with medical therapy without confirming patient willingness for long‑term medication and monitoring; do not omit the experienced endocrinologist from the team, as their input is critical for biochemical monitoring and comorbidity management.
Concrete Clinical Example
A 48‑year‑man with recurrent Cushing’s disease after two transsphenoidal surgeries has persistent hypercortisolism (UFC 3× ULN). He values avoiding lifelong glucocorticoid dependence and wishes to minimize hospital visits. The multidisciplinary team discusses repeat surgery (high morbidity risk), bilateral adrenalectomy (requires lifelong steroids), and pasireotide medical therapy (requires injections). After education about each option’s impact on his lifestyle, he chooses bilateral adrenalectomy, and the team schedules laparoscopic adrenalectomy with preoperative endocrine optimization.
Source: Treatment of Cushing’s Syndrome: An Endocrine Society Clinical Practice Guideline, Nieman et al., 2015, DOI: 10.1210/jc.2015-1818