Multidisciplinary team meetings in cancerology: setting priorities for improvement

Resulting medical decision from a multidisciplinary team (MDT) meeting has to be accurate regarding to various patient criteria and relevant specialists participation. The target is to optimize treatment or management options for patients taking into account patients' benefit. The aim of our study was to examine quality criteria of MDT meeting processes, implementation of the MDT decision, and the follow-up of national or regional clinical guidelines. The results lead us to discuss about care management in cancer. Ten various medical specialities of MDT meetings were studied. Relevant multidisciplinarity varied between MDT meetings specialities and was effective between 55 and 100%. Implementation of the decisions that arise from MDT meetings was 86.3%. The most frequent grounds of non-application were patient refusal and new or previous unknown clinical data. The percentage of MDT meetings decisions following national or regional recommendations was 74%. The main reason of not following was the complexity of clinical patient circumstances. Participation in MDT meetings is more and more time-consuming related to enforce the completeness referred to the Plan Cancer (National recommendations). Leading to completeness raises questions about medical time employment and meaning of the MDT meeting for standard clinical cases. The priority seems to enforce multidisciplinarity rather than reach completeness.     

Risk creation,loss of chance,and legal liability

One can now only speculate as to the future of the law regarding risk creation and loss of chance. Freed from the moorings of the traditional rules in medical malpractice cases, courts are adopting a variety of approaches to this problem in a manner that approaches the idiosyncratic--the law is whatever it happens to be on any given day, in any given jurisdiction. Regrettably, until such time as uniform guiding principles are established, it appears that the laws governing the interaction between risk, causation, and liability will remain in a state of flux.     

Meeting patient expectations in the cancer consultation

Background: Low scores on satisfaction measures may be anticipated when patients' expectations of the doctor are unmet during the cancer consultation. We correlated discrepancies between patient expectations of their ideal doctor and their perceptions of their actual doctor with scores on a validated satisfaction scale to determine whether patients whose expectations were unmet were less satisfied.Patients and methods: The expectations questionnaire used a forced choice method designed to elicit patient preferences for either emotional or informational support from the physician. One hundred and five new patients with heterogeneous cancers, of five medical oncologists at a major teaching hospital were sampled. The patients were mostly female (55%) middle aged (mean age 54.3) and newly diagnosed with cancer (56% within two months prior to consultation).Results: Patients did not demonstrate a clear preference for an emotionally or informationally supportive approach. Seventy percent of patients did not want emotionally negative physicians but most (88.4%) would tolerate negative information. The mean number of exact matches between patients expectations of the ideal and their perceptions of their actual doctor was 3.7 (from a total of six). 5.9% of patients received exactly the doctor they wanted. No significant differences in satisfaction were found between patients whose expectations were met and those whose expectations were not met.Conclusions: Patient satisfaction with the consultation was independent of patient expectation for informational or emotional support.     

Group decisions in oncology: doctors' perceptions of the legal responsibilities arising from multidisciplinary meetings

There is growing consensus that multidisciplinary meetings (MDMs) are the optimal means of arriving at a comprehensive treatment plan for cancer patients. However, if a patient was grieved by a decision made by an MDM and wished to recover damages, the courts would find all involved consultants responsible for decisions related to their area of expertise. The aim of this study was to assess (i) whether doctors participating in oncology MDMs are aware that they are individually accountable for the MDM decisions and (ii) whether MDMs are conducted in a way that reflects this individual responsibility. A 35-question survey was developed and peer reviewed. Doctors attending MDMs in four Australian tertiary-care hospitals were invited to respond. One hundred and thirty-six responses (91% response rate) were received from 18 MDMs across 4 hospitals. Only 48% of doctors believe they are individually liable for decisions made by the MDM. This awareness was greater for an MDM where the patient attends, than in those that were 'discussion only' (58 vs 37%; P = 0.036). Seventy-three per cent stated they would like further education about their legal responsibilities in MDMs. Thirty-three per cent of doctors feel that the MDM discussion environment is suboptimal and radiation oncologists are significantly more likely to hold this view. Even though 85% of doctors have disagreed with the final MDM decision in an important way at some time, 71% did not formally dissent on those occasions. Doctors should be made aware of the legal implications of their participation in MDMs. A greater awareness of these responsibilities and improved team dynamics should optimize patient outcomes while limiting exposure of participants to legal liability.     

Hopes and expectations of swedish cancer patients: Contradictions surrounding patient satisfaction with care

This paper presents a study of hopes and expectations concerning the professional health-care sector, as expressed by a group of Swedish cancer patients. The data are derived from a cross-sectional interview study of patients diagnosed with a malignant disease at one general hospital in Stockholm in 1987. A seeming discrepancy exists between the problematic situations and experiences described in narrative form by the participants, and the high rate of positive responses to direct questions concerned with satisfaction with care in this study. A combination of data types and an analytic process derived from medical anthropology has been utilized in order to understand the culturally related hopes and expectations which are behind statements of satisfaction with care. Hopes and expectations reflect the perceived breadth and limits of the professional health-care sector. Patients appear to organize their experiences in manners which ‘work’. General dissatisfaction with care may not be an effective technique for promoting well-being when diagnosed with a potentially life-threatening disease. The patients in this study actively avoid dissatisfaction in a number of ways, which include assuming responsibility themselves, accepting the unarticulated as a form of discourse and adapting frameworks for that which is ‘normal’ from the professional sector.     

进展期食管胃结合部癌多学科协作诊疗1 例

食管胃结合部（esophageal gastric junction ,EGJ）癌的生物学特性不同于胃癌和食管癌,其初始治疗的选择尤为重要。本文介绍了1 例进展期食管胃结合部癌病例,试图通过多学科协作的方式指导治疗,对放化疗的治疗模式进行总结,以期给患者带来更好的预后,并对胃上部癌治疗模式提出新的策略,以助于制定规范的临床路径及治疗指南。     

转移性去势抵抗性前列腺癌多学科临床讨论

  目的  探讨转移性去势抵抗性前列腺癌（metastatic castration resistant prostate cancer,mCRPC）多学科协作体系（multidisciplinary treatment,MDT）的诊治流程。  方法  分析2017年12月上海交通大学医学院附属新华医院收治的1例mCRPC患者的MDT诊疗过程。患者经MDT讨论后采用阿比特龙联合唑来膦酸治疗,辅以左股骨下段转移病灶局部放疗,并密切监测前列腺特异性抗原（prostate specific antigen,PSA）变化及治疗不良反应。  结果  治疗后患者PSA逐渐下降,4个月后随访总前列腺特异性抗原（total prostate specific antigen,tPSA）已下降至1.29 ng/mL,且无明显相关不良反应。  结论  个体化治疗是mCRPC未来的发展趋势,平衡疗效和不良反应是临床医生应重点考虑的问题。采取MDT有利于制定规范化、个体化的治疗方案,针对mCRPC患者探索更有效的治疗方法可让更多患者获益。      

直肠癌伴同时性多发性肺转移患者的多学科临床决策探讨

结直肠癌患者中肺是继肝脏之后最常见的远处转移器官之一,但由于肺转移发病率较低且生物学侵袭性相对温和,因而与结直肠癌肝转移相比,结直肠癌肺转移无论是关注程度、综合治疗理念还是相关的临床和基础研究都相对匮乏。本文现介绍1例直肠癌伴同时性多发性肺转移患者在浙江大学医学院附属第二医院大肠癌诊治中心的多学科综合治疗(multidisciplinary team,MDT)经过,以探讨该类患者的临床病理特征、预后影响因素、合理的综合治疗决策以及现有的诊治争议与共识,以期促进临床诊疗的规范化和个体化,使患者更多获益。      

The use of videophones for patient and family participation in hospice interdisciplinary team meetings: a promising approach

PARKER OLIVER P., DEMIRIS G., WITTENBERG‐LYLES E. & POROCK D. (2010) European Journal of Cancer Care 19 , 729–735
The use of videophones for patient and family participation in hospice interdisciplinary team meetings: a promising approach Inclusion of patients and caregivers in decisions related to the delivery of care is inherent in the hospice philosophy. Telemedicine technologies offer a potential solution to the challenges presented by the geographic distance between team meetings and the home environment. While inclusion requires additional coordination by the hospice team, it also offers an important opportunity to improve communication between the team and the patient and family. A modified conceptual model based on two previous frameworks is outlined to support patient and family involvement in hospice team meetings. Further research is suggested to determine the structural feasibility of patient and family involvement via videophone as well as the structural and procedural changes resulting from this inclusion. Finally, clinical outcomes and family evaluation of the inclusion experience need to be thoroughly researched before final conclusions may be reached.     

The correlation between patient characteristics and expectations of benefit from Phase I clinical trials

BACKGROUND: Patients in Phase I clinical trials sometimes report high expectations regarding the benefit of treatment. The authors examined a range of patient characteristics to determine which factors were associated with greater expectations of benefit from Phase I trials. METHODS: Participants were adult patients with cancer who had been offered participation in Phase I studies and had decided to participate. Patients completed interviewer-administered surveys before initiation of treatment. Physicians assessed Eastern Cooperative Oncology Group performance status for each patient. Statistical analyses (Pearson product moment correlation and t tests) used multiple imputation to account for missing data. RESULTS: Overall, 593 patients who were offered participation in Phase I trials were contacted, and 328 patients agreed to participate in a study of decision making by cancer patients. Of these, 260 patients (79%) enrolled in a Phase I trial. Patients' expectations regarding the chance that their disease would be controlled with experimental therapy were unrelated to age, gender, living situation, education level, or functional status. Expectations were correlated positively with beliefs about the benefit of standard therapy and the maximum benefit patients may experience from experimental therapy. Greater expectations of benefit were associated with better health-related quality of life, stronger religious faith, optimism, relative health stock, monetary risk seeking, and poorer numeracy. CONCLUSIONS: Expectations expressed as beliefs in personal outcomes may be related more to quality of life and personality variables than to patients' knowledge or functional status. Whether such expectations are accurate reflections of knowledge has important implications for evaluating the informed consent process.     

多学科协作诊疗多颅神经受累的浆母细胞型骨髓瘤1 例

浆母细胞型骨髓瘤是骨髓瘤中较少见的病理类型,需要与其他镜下表现类似的疾病相鉴别。中枢神经系统受累是骨髓瘤较为罕见的并发症,由于受累部位的特殊性,其治疗选择尤为重要。本研究介绍1 例多颅神经受累的浆母细胞型骨髓瘤病例,其诊断较为困难,通过多学科协作的方式最终明确诊断,为后续选择合适的治疗方案奠定了基础。     

Glioblastoma: changing expectations?

Glioblastoma (GB) represents the most aggressive glioma in the adult population. Despite recent research efforts, the prognosis of patients with GB has remained dismal. Lately, the knowledge of genetic information about gliomagenesis has increased; we even have a classification of the genetic expression of the tumour. The main problem is that at the moment we do not have any therapeutical resources to help us better treat these tumours, as we can do, with others tumours like breast, lung and colorectal cancer. We have also improved on diagnostic imaging, especially with the new MRI sequences; we can now better define the characteristics of the tumour area and the surrounding brain structures, allowing us to adjust resections. Thanks to the most advanced surgery techniques, such as neuronavigation, intraoperative control of the nervous function and the tumour volume, the neurosurgeon is able to complete tumour exeresis with less morbidity. These imaging techniques allow the radiation oncologist to better contour the irradiation target volume, the structures and the organs at risk, to diminish the irradiation of apparently healthy tissue. Nowadays, knowledge of brain stem cells provides new expectations for future treatments. Novel targeted agents such as bevacizumab, imatinib, erlotinib, temsirolimus, immunotherapy, cilengitide, talampanel, etc. are helping classical chemotherapeutic agents, like temozolomide, to achieve an increase in overall survival. The main objective is to improve median overall survival, which is currently between 9 and 12 months, with a good quality of life, measured by the ability to carry out daily life activities.     

Orbital rhabdomyosarcoma: Multidisciplinary treatment experience

Orbital rhabdomyosarcoma (RMS) accounts for 10% of childhood RMS and has a relatively good prognosis of up to 85% 5‐year survival. Improved survival has led to increased interest in late effects of treatment. The objective of this study was to review the results of treating orbital RMS with multidisciplinary treatment at Women's and Children's Hospital and Royal Adelaide Hospital with emphasis on late effects of treatment. A retrospective review was carried out of all patients with orbital RMS treated with multidisciplinary treatment including radiation therapy and chemotherapy in the two institutions between 1982 and 2002. A total of five patients (age range 5.5‐12 years) satisfied the eligibility requirements. Late effects were significant and included facial bone hypoplasia, cataract formation and growth hormone deficiency. Overall survival was 80% (4/5) with mean follow up of 8 years (range 3‐13 years). Given the high cure rates achieved, future treatments must aim to maintain the good results but to reduce the high incidence of late effects of treatment. Standardised rating of late toxicity, long‐term follow‐up clinics, and implementation of modern radiation techniques (3‐D conformal radiotherapy, intensity modulated radiotherapy, proton therapy) for patients with orbital RMS are important to improving outcome.     

局部晚期分化型甲状腺癌多学科临床讨论

  目的  探讨局部晚期分化型甲状腺癌（locally advanced differentiated thyroid cancer）多学科协作体系（multidisciplinary treat?ment,MDT）的诊治流程。  方法  分析2018年4月重庆大学附属肿瘤医院收治的1例局部晚期分化型甲状腺癌患者的MDT诊疗过程。经过MDT讨论后采用全喉切除+颈部淋巴结清扫+胸大肌皮瓣修复手术治疗,后续131I内照射治疗,辅以分子靶向治疗,并监测甲状腺球蛋白（thyroglobulin,Tg）的变化及不良反应。  结果  患者进行手术治疗恢复良好,随访Tg缓慢下降。  结论  个体化精准治疗是局部晚期分化型甲状腺癌未来的发展趋势,平衡疗效和不良反应是临床医生应重点考虑的问题。采取MDT有利于制定规范化、个体化的治疗方案,针对局部晚期分化型甲状腺癌患者探索更有效的治疗方法可让更多患者获益。