An evaluation of treatment decisions at a colorectal cancer multi‐disciplinary team

Objective It is mandatory for treatment decisions for patients with colorectal cancer to be made within the context of a multi‐disciplinary team (MDT) meeting. It is currently uncertain, however, how to best evaluate the quality of MDT decision‐making. This study examined MDT decision‐making by studying whether MDT treatment decisions were implemented and investigated the reasons why some decisions changed after the meeting. Method Consecutive MDT treatment decisions were prospectively recorded. Implementation of decisions was studied by examining hospital records. Reasons for changes in MDT decisions were identified. Results In all, 201 consecutive treatment decisions were analysed, concerning 157 patients. Twenty decisions (10.0%, 95% confidence interval 6.3–15.2%) were not implemented. Looking at the reasons for nonimplementation, nine (40%) related to co‐morbidity, seven (35%) to patient choice, two changed in light of new clinical information, one doctor changed a decision and for one changed decision, no reason was apparent. When decisions changed, the final treatment was always more conservative than was originally planned and decisions were more likely to change for colon rather than rectal cancer (P = 0.024). Conclusion The vast majority of colorectal MDT decisions were implemented and when decisions changed, it mostly related to patient factors that had not been taken into account. Analysis of the implementation of team decisions is an informative process to monitor the quality of MDT decision‐making.     

The Central Urology Multidisciplinary Team – Is it Time to Change the Referral Criteria? An Audit of Practice in a District General Hospital in London

INTRODUCTION

All cancer patients are discussed in multidisciplinary team meetings (MDTs). Certain patients are referred to the Central MDT based on specific national criteria. We wanted to see whether the Central MDT aided in the decision-making process above that of the Local MDT alone.

PATIENTS AND METHODS

All MDT forms (local and central) for 2007 were retrospectively reviewed.

RESULTS

A total of 217 patients were reviewed at the Local MDT. Of these 217 cases, 102 (47.0%) cases were referred to the Central MDT and 15 of the 102 (14.7%) cases were awaiting investigations at the time of the Local MDT and were, therefore, excluded. For the prostate cancer cases (n = 67), the Central MDT did not change outright the Local MDT decision in any case, but in 6 of 67 (9.0%), advised/excluded patients from clinical trials. For bladder cancer cases (n = 19), 4 of 19 (21.0%) patients had their management changed by the Central MDT. The one kidney cancer case had its Local MDT decision changed by the Central MDT.

CONCLUSIONS

This audit suggests that the Central MDT plays a useful role in the decision-making process for bladder and kidney cancers, and helps determine eligibility for clinical trials in metastatic prostate cancer patients. Its value over the Local MDT alone in the decision-making process for non-metastatic prostate cancer is questionable.     

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目的通过分析北京肿瘤医院消化系统肿瘤多学科专家组(multidisciplinary team,MDT)治疗模式的开展情况,了解国内MDT模式的发展现状。方法回顾性分析2009-09-07至2010-11-29北京肿瘤医院消化道肿瘤MDT会议讨论的决策、决策执行情况和执行结果。统计学分析采用SPSS13.0。结果共407例病人进入MDT讨论。资料完整纳入研究304例(74.7%),胃癌、结直肠癌占74.5%,77例(25.3%)为初治病人。全部病例进行321人次讨论,决策中需要两种或两种以上治疗方法参与的有109个(34%),完全执行MDT决策199个(62%),其中达到MDT预期的191例(96%),部分执行者40例,达到预期15例(37.5%)。结论国内MDT治疗模式尚在起步阶段,多学科治疗理念的仍需进一步普及。     

The decision to operate: role of integrated computed tomography positron emission tomography in staging oesophageal and oesophagogastric junction cancer by the multidisciplinary team

OBJECTIVE: Our objective was to assess the role of fusion positron emission tomography-computed tomography (PET-CT) in staging patients for minimally invasive oesophagectomy (MIO) with potentially resectable disease from the perspective of a multidisciplinary team (MDT) deciding on operability with conventional staging investigations. METHODS: Fifty consecutive patients presenting with potentially operable oesophageal or oesophagogastric junctional tumours were staged with computed tomography (CT) and endoluminal ultrasound (EUS). The MDT categorised patients as group A (n=33; CT N0M0) or group B (n=17; CT N1/possible M1). All patients underwent FDG PET-CT. Patients with localised disease (at T3), including single level N1 disease on PET-CT, were deemed suitable for induction chemotherapy followed by surgery. RESULTS: PET-CT re-categorised 12% of patients as inoperable on grounds of distant metastases (four in group A, two in group B). Five patients did not proceed to resection for other reasons. Two had metastatic disease at thoracoscopy. Resection specimens (n=37) contained 24 nodes (median). Compared with pN status, positive predictive value of PET-CT was 40% and negative predictive value was 43%. The expected PET-CT N1 group had the highest mean number of involved nodes. Median survival for all patients (n=50) was 31.9 months for group A compared with 17.3 months for group B (not statistically significant). There was no significant difference between patients who were PET-CT N0 or N1 in survival or disease-free survival in patients undergoing surgery (n=37). CONCLUSIONS: PET-CT informs the MDT decision to operate in avoiding futile surgery in stage IV disease or widespread nodal disease. In this study, overall PET-CT N1 status has low positive and negative predictive value for overall pN status.     

多学科团队诊断与治疗模式在规范开展经肛全直肠系膜切除术中的应用价值

经肛全直肠系膜切除术(TaTME)是治疗低位直肠癌的一种新兴手术方式,其以远端直肠手术良好的视野显露和超低位保肛等优势得到认可和推广。目前国内外相关诊断与治疗指南均推荐直肠癌的治疗需要经多学科团队(MDT)讨论决定。MDT已成为直肠癌患者得到规范化治疗的制度性诊断与治疗模式。直肠癌TaTME手术适应证的选择依赖MDT模式下术前影像学检查精准分层、复发危险度判断。规范的MDT术前评估、多学科研讨作出决策是TaTME获得规范化实施和合理推广的保障。同时,TaTME作为一种可能改善直肠肿瘤疗效的手术方式,使部分患者在基于影像学检查准确分期的基础上免去术前放化疗,从而调整外科手术在MDT模式中的地位,为优化直肠癌整体疗效和卫生经济学做出贡献。     

Differences in multidisciplinary team assessment and treatment between patients with stage IV colon and rectal cancer

Objective  At diagnosis, 14–27% of patients with colorectal cancer (CRC) have distant metastases (stage IV) and a poor prognosis. Today, treatment decisions for CRC patients are often made at multidisciplinary team (MDT) conferences. The aim of this study was to evaluate the effects of development and implementation of MDT assessment and treatment in patients with stage IV colon cancer (CC) and rectal cancer (RC) in a large population.
Method  All 1449 patients who had stage IV CRC at the time of diagnosis and were registered in the regional quality registry of Stockholm from 1995 to 2004 were included. Patients with CC and RC were grouped according to treatment and their characteristics were analysed separately.
Results  In total, 1000 patients with CC and 449 patients with RC had stage IV disease. Of these, 689 (68.9%) CC patients and 352 (78.4%) RC patients were assessed by a MDT and the proportion increased over the study period ( P  < 0.001). Surgery for metastases was undertaken on 39 (3.9%) CC patients and 38 (8.5%) RC patients ( P  < 0.001). CRC patients selected for metastasis surgery had 37% 5-year survival when compared with 2% in patients who were not selected for metastasis surgery ( P  < 0.001).
Conclusion  Patients with CC were less often assessed by a MDT and less often had metastasis surgery than RC patients. The proportion of patients with CC and RC assessed by a MDT increased during the study period, as did the proportion who had surgery for metastases. MDT assessment opens up the opportunity for more aggressive treatment with better outcomes.     

System‐based factors influencing intraoperative decision‐making in rectal cancer by surgeons: an international assessment

Aim Sound surgical judgement is the goal of training and experience; however, system‐based factors may also colour selection of options by a surgeon. We analysed potential organizational characteristics that might influence rectal cancer decision‐making by an experienced surgeon. Method One hundred and seventy‐three international centres treating rectal cancer were invited to participate in a survey assessment of key treatment options for patients undergoing curative rectal‐cancer surgery. The key organizational characteristics were analysed using multivariate methods for association with intra‐operative surgical decision‐making. Results The response rate was 71% (123 centres). Sphincter‐saving surgery was more likely to be performed at university hospitals (OR = 3.63, P = 0.01) and by high‐caseload surgeons (OR = 2.77 P = 0.05). A diverting stoma was performed more frequently in departments with clinical audits (OR = 3.06, P = 0.02), and a diverting stoma with coloanal anastomosis was more likely in European centres (OR = 4.14, P = 0.004). One‐stage surgery was less likely where there was assessment by a multidisciplinary team (OR = 0.24, P = 0.02). Multivariate analysis showed that university hospital, clinical audit, European centre, multidisciplinary team and high caseload significantly impacted on surgical decision‐making. Conclusion Treatment variance of rectal cancer surgeons appears to be significantly influenced by organizational characteristics and complex team‐based decision‐making. System‐based factors may need to be considered as a source of outcome variation that may impact on quality metrics.     

Refocusing cancer multidisciplinary team meetings in the United Kingdom: comparing urology with other specialties

IntroductionMultidisciplinary team (MDT) meetings have been the gold standard of cancer care in the UK since the 1990s. We aimed to identify the views of urology cancer MDT members in the UK on improving the functioning of meetings and compare them with those of other specialties to manage the increasing demand on healthcare resources and enhance the care of complex cancer cases.MethodsWe analysed data from 2 national surveys distributed by Cancer Research UK focusing on the views of 2,294 and 1,258 MDT members about cancer MDT meetings.FindingsMost breast, colorectal, lung and urology cancer MDT members felt meetings could be improved in the following areas: time for meeting preparation in job plans, streamlining of patients, auditing meeting decisions and prioritising complex cases. Most urology respondents (87%) agreed some patients could be managed outside a full MDT discussion, but this was lower for other specialties (lung 78%, breast 75%, colorectal 64%).ConclusionsTo facilitate decisions on which patients require discussion in an MDT meeting, factors adding to case complexity across all tumour types were identified, including rare tumour type, cognitive impairment and previous treatment failure. This study confirms that urology MDT members are supportive of changing from reviewing all new cancer diagnoses to discussing complex cases but managing others with a more protocolised pathway. The mechanisms for how to do this and how to ensure the safety of patients require further clarification.     

Facilitators and Barriers to Teamworking and Patient Centeredness in Multidisciplinary Cancer Teams: Findings of a National Study

Background

Multidisciplinary teams (MDTs) are the standard means of making clinical decisions in surgical oncology. The aim of this study was to explore the views of MDT members regarding contribution to the MDT, representation of patients’ views, and dealing with disagreements in MDT meetings—issues that affect clinical decision making, but have not previously been addressed.

Methods

Responses to open questions from a 2009 national survey of MDT members about effective MDT working in the United Kingdom were analyzed for content. Emergent themes were identified and tabulated, and verbatim quotes were extracted to validate and illustrate themes.

Results

Free-text responses from 1,636 MDT members were analyzed. Key themes were: (1) the importance of nontechnical skills, organizational support, and good relationships between team members for effective teamworking; (2) recording of disagreements (potentially sharing them with patients) and the importance of patient-centered information in relation to team decision making; (3) the central role of clinical nurse specialists as the patient’s advocates, complementing the role of physicians in relation to patient centeredness.

Conclusions

Developing team members’ nontechnical skills and providing organizational support are necessary to help ensure that MDTs are delivering high-quality, patient-centered care. Recording dissent in decision making within the MDT is an important element, which should be defined further. The question of how best to represent the patient in MDT meetings also requires further exploration.     

Choosing where to have major surgery: who makes the decision?

HYPOTHESIS: Efforts are under way to distribute hospital performance data directly to patients to inform their decisions about where to go for major surgery, but patients are not always involved in making the decision of where they will have surgery. DESIGN: Telephone interviews. PARTICIPANTS: Five hundred ten randomly selected Medicare patients who had undergone 1 of 5 elective high-risk operations approximately 3 years earlier: abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resections for bladder (n = 119), lung (n = 128), or stomach (n = 64) cancer. Main Outcome Measure Proportion of patients who responded that their physician was the main decision maker of where they would have surgery. RESULTS: Thirty-one percent of patients said their physician was the main decision maker about where the patient would have surgery (42% said they decided equally with their physician, 22% said they were the main decision maker, and 5% said their family helped make the decision for them). This proportion was similar across patient age, income, and educational attainment. Men were more likely to say the physician was the main decision maker (34% vs 24%; P = .02), as were patients in poor to fair health compared with those in good to excellent health (37% vs 28%; P = .05). The physician was significantly more likely to be the main decision maker for cardiovascular operations compared with cancer operations (39% vs 26%; P = .001). CONCLUSION: Although most patients participated in the decision of where they would have major surgery, one third said the decision was made mainly by their physician.     

A survey of UK peri‐operative medicine: pre‐operative care

The majority of UK hospitals now have a Local Lead for Peri‐operative Medicine (n = 115). They were asked to take part in an online survey to identify provision and practice of pre‐operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%). Our results demonstrate strengths in provision of shared decision‐making clinics. Fifty‐seven (65%, 95%CI 55.8–75.4%) had clinics for high‐risk surgical patients. However, 80 (93%, 70.2–87.2%) expressed a desire for support and training in shared decision‐making. We asked about management of pre‐operative anaemia, and identified that 69 (80%, 71.5–88.1%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively. A need for peri‐operative support in managing frailty and cognitive impairment was identified, as few (24%, 6.5–34.5%) respondents indicated that they had access to specific interventions. Respondents were asked to rank their ‘top five’ priority topics in Peri‐operative Medicine from a list of 22. These were: shared decision‐making; peri‐operative team development; frailty screening and its management; postoperative morbidity prediction; and primary care collaboration. We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.     

Pilot trial of a computerized decision aid for breast cancer prevention

This study sought to evaluate a shared decision-making aid for breast cancer prevention care designed to help women make appropriate prevention decisions by presenting information about risk in context. The decision aid was implemented in a high-risk breast cancer prevention program and pilot-tested in a randomized clinical trial comparing standard consultations to use of the decision aid. Physicians completed training with the decision aid prior to enrollment. Thirty participants enrolled (15 per group) and completed measures of clinical feasibility and effectiveness prior to, immediately after, and at 9 months after their consultations. The decision aid was feasible to use during the consultations as measured by consultation duration, user satisfaction, patient knowledge, and decisional conflict. The mean consultation duration was not significantly different between groups (24 minutes for intervention group versus 21 minutes for control group, p = 0.42). The majority found the decision aid acceptable and useful and would recommend it to others. Both groups showed an improvement in breast cancer prevention knowledge postvisit, which was significant in the intervention group (p = 0.01) but not the control group (p = 0.13). However, the knowledge scores returned to baseline at follow-up in both groups. Decision preference for patients who chose chemoprevention post consultations remained constant at follow-up for the intervention group, but not for the control group. The decision framework provides access to key information during consultations and facilitates the integration of emerging biomarkers in this setting. Initial results suggest that the decision aid is feasible for use in the consultation room. The tendency for the decision choices and knowledge scores to return to baseline at follow-up suggests the need for initial and ongoing prevention decision support.     

多学科协作诊治模式的会诊流程探讨(一)

目的探索结直肠肿瘤多学科协作(MDT)诊治模式的会诊流程。方法通过对MDT方式的认识与探索,并与传统会诊进行对比,结合我国特大型公立医院的特点,探讨具有自身特点的MDT模式会诊流程。结果总结分析了MDT模式会诊流程的优点和传统会诊的不足,用MDT整体模式的创新思想描述了MDT会诊流程的目的与特点,并简要描述了在结直肠肿瘤MDT中会诊流程的运用现状。结论MDT会诊流程的建立已经表现出有别于传统的特点,并且可能是未来会诊模式演变的方向,但尚需要进一步研究予以临床支持。     

From diagnosis of colorectal cancer to diagnosis of Lynch syndrome: The RM Partners quality improvement project

Aim

The UK National Institute for Health and Care Excellence guideline DG27 recommends universal testing for Lynch syndrome (LS) in all newly diagnosed colorectal cancer (CRC) patients. However, DG27 guideline implementation varies significantly by geography. This quality improvement project (QIP) was developed to measure variation and deliver an effective diagnostic pathway from diagnosis of CRC to diagnosis of LS within the RM Partners (RMP) West London cancer alliance.

Method

RM Partners includes a population of 4 million people and incorporates nine CRC multidisciplinary teams (MDTs), overseen by a Pathway Group, and three regional genetic services, managing approximately 1500 new CRC cases annually. A responsible LS champion was nominated within each MDT. A regional project manager and nurse practitioner were appointed to support the LS champions, to develop online training packages and patient consultation workshops. MDTs were supported to develop an ‘in-house’ mainstreaming service to offer genetic testing in their routine oncology clinics. Baseline data were collected through completion of the LS pathway audit of the testing pathway in 30 consecutive CRC patients from each CRC MDT, with measurement of each step of the testing pathway. Areas for improvement in each MDT were identified, delivered by the local champion and supported by the project team.

Results

Overall, QIP measurables improved following the intervention. The Wilcoxon signed rank test revealed significant differences with strong effect sizes on the percentile of CRC cases undergoing mismatch repair (MMR) testing in endoscopic biopsies (p = 0.008), further testing with either methylation or BRAF V600E (p = 0/03) and in effective referral for genetic testing (from 10% to 74%; p = 0.02). During the QIP new mainstreaming services were developed, alongside the implementation of systematic and robust testing pathways. These pathways were tailored to the needs of each CRC team to ensure that patients with a diagnosis of CRC had access to testing for LS. Online training packages were produced which remain freely accessible for CRC teams across the UK.

Conclusion

The LS project was completed by April 2022. We have implemented a systematic approach with workforce transformation to facilitate identification and ‘mainstreamed’ genetic diagnosis of LS. This work has contributed to the development of a National LS Transformation Project in England which recommends local leadership within cancer teams to ensure delivery of diagnosis of LS and integration of genomics into clinical practice.     

Multidisciplinary Cancer Team Meeting Structure and Treatment Decisions: A Prospective Correlational Study

Background

Anecdotally, organizational factors appear to have an effect on the quality of decision-making in the multidisciplinary team (MDT) meeting. We assess the effect of the number of team-members present, number and order of cases, and the timing of meetings on the process of decision-making in MDT meetings.

Methods

Between December 2009 and January 2010, data were prospectively collected on treatment decisions, meeting characteristics, quality of information, and teamworking for all cases discussed at a London-based MDT meeting. Variables measured using a validated assessment tool (MDT MODe) and correlational analyses were performed.

Results

Treatment decisions were reached in 254 of 298 (85 %) cases. Cases toward the end of meetings were associated with lower rates of decision-making, information quality, and teamworking (r = ?0.15 to ?0.37). Increased number of cases per meeting and team members in attendance were associated with better information and teamworking (r = 0.29–0.43). More time per case was associated with improved teamworking (r = 0.16). A positive correlation was obtained between ability to reach decisions and improved information and teamworking (r = 0.36–0.54; all P ≤ 0.001).

Conclusions

Organizational factors related to the structure of the MDT meeting are associated with variation in the likelihood of reaching a treatment decision. Further research is required to establish causation and to modify such factors in order to improve the quality of cancer care.     

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肝转移是结直肠癌病人诊治中常见的情况,很大程度上决定了病人的预后。结直肠癌肝转移的治疗需要综合外科、化疗科、放疗科、影像科、病理科、介入科等多学科的意见。针对该方面的多学科综合治疗协作组(MDT)模式已经在临床上得到了广泛的开展,然而其运作流程尚无统一的共识和规范。明确参与人员资质、合理选择讨论对象、规范MDT流程制度、保持MDT的先进性对于结直肠癌MDT更好的开展意义重大。MDT的规范化实施将为结直肠癌肝转移病人的诊治提供有力保障。     

The Charlson comorbidity score: a superior comorbidity assessment tool for the prostate cancer multidisciplinary meeting

INTRODUCTION: Multidisciplinary team (MDT) meetings use precise prognostic factors to select treatment options for patients with prostate cancer. Comorbidity is judged subjectively. Recent publications favour the Charlson comorbidity score (CS) for the use in the management of prostate cancer. We assess the feasibility of using the CS by our MDT in planning the treatment of patients with prostate cancer. PATIENTS AND METHODS: Patients from the histopathology database aged less than 75 years and with a diagnosis of localized prostate cancer between 1993 and 1995 were included in a notes audit. A second group consisted of patients recommended for curative treatment for localized prostate cancer by the local MDT in 2004. Data on comorbidity, prostatic malignancy and survival up to 10 years was collected. The prognostic accuracy of the CS was assessed for those patients offered radical treatment between 1993 and 1995. RESULTS: Of 1043 patients initially assessed, 37 patients with localized prostate cancer were identified. Using Cox regression, we found the CS to be a statistically significant predictor of survival, following radical treatment for localized prostate cancer (P=0.005). Current practice in 2004 (56 patients) shows a mean (range) Charlson probability of 10-year survival for radical prostatectomy of 0.823 (0.592-0.923) and for radical radiotherapy of 0.653 (0.07-0.936). CONCLUSIONS: Our results support the findings of recent research. We also found the CS easy to calculate and therefore feasible to use in our MDT setting. We propose the introduction of the Charlson score by prostate cancer MDTs to assess age and comorbidity.     

The impact of multidisciplinary therapy in node-positive rectal cancer

Multidisciplinary therapy (MDT) of node-positive rectal cancer is considered optimal. We performed a retrospective cohort study of node positive rectal cancer patients diagnosed between January 1, 1994 and December 31, 2003 in Region 5 of the California Cancer Registry to determine the impact of MDT on disease specific survival (DSS). During the study period, 398 patients with stage III rectal cancer were identified. Only 251 patients (63.1%) received radiation (XRT). Patients receiving XRT had significantly improved survival when compared with those who did not (5 year DSS 55% with XRT vs. 36% without XRT, median follow-up 43 months, P < 0.001). There was no statistically significant difference in Tstage (P = 0.41), the number of N1 patients (P = 0.45), or the number of positive nodes harvested (mean 11.5 w/o XRT vs. 12.8 w/XRT, P = 0.37) between patients receiving XRT and those who did not. Patients receiving XRT were far more likely to receive systemic chemotherapy (83% vs. 27%, P < 0.0001). Multidisciplinary therapy of node-positive rectal cancer is associated with improved DSS. However, substantial numbers of node positive rectal cancer patients are not receiving MDT. Greater efforts are needed to implement consistent multidisciplinary algorithms into rectal cancer management.     

多学科专家组诊疗模式的组织和规范实施

随着分子生物学、基因学知识的快速增长,以及新的化疗和靶向治疗的进展,恶性肿瘤的治疗愈加复杂。针对恶性肿瘤的多学科专家组（MDT）诊疗模式在很多欧洲国家和美国已被广泛接受,MDT诊疗模式促进了组内成员的合作、沟通和正确决策。在中国,MDT模式正在被关注,并在少数医疗中心已建立该模式。但在多数医疗中心,建立MDT仍存在一些障碍。而且,已经建立的MDT运行仍有问题。     

结直肠癌肝转移多学科综合治疗协作组模式的规范化实施

肝转移是结直肠癌病人诊治中常见的情况,很大程度上决定了病人的预后。结直肠癌肝转移的治疗需要综合外科、化疗科、放疗科、影像科、病理科、介入科等多学科的意见。针对该方面的多学科综合治疗协作组（MDT）模式已经在临床上得到了广泛的开展,然而其运作流程尚无统一的共识和规范。明确参与人员资质、合理选择讨论对象、规范MDT流程制度、保持MDT的先进性对于结直肠癌MDT更好的开展意义重大。MDT的规范化实施将为结直肠癌肝转移病人的诊治提供有力保障。