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Multidisciplinary cancer care 

Multidisciplinary cancer care

Chapter:
Multidisciplinary cancer care
Author(s):

David N. Church

, Rachel Kerr

, and David J. Kerr

DOI:
10.1093/med/9780199656103.003.0022
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date: 22 May 2017

Introduction to multidisciplinary cancer care

Given the complex biology of the disease and the many different medical specialties required to deliver a cancer management plan in keeping with current best practice, it is not surprising that cancer care has the real potential to become fragmented, arbitrary, and suboptimal. The ideal scenario would be one in which the patient moved seamlessly along the care pathway, receiving appropriate interventions from expert specialists as tumour type and stage demanded. This ‘journey’ would be coordinated by a case officer managing the various interfaces and streamlining communication so that the patient felt supported, informed and confident that each element was part of a cohesive whole. It might be worth pause for reflection now so that the reader might consider the situation in their own hospital, centre, or clinic and how far from or close to this ideal their own practice may be.

Certainly in the UK ten to 15 years ago there was a growing recognition, driven initially by the compartmentalization of cancer care, the length of waiting times for operations or access to radiotherapy, and the fact that the UK’s cancer outcomes fell short of the major European nations and the USA that changes in the delivery of care were much needed [1, 2]. A major policy decision taken at that time was to promote multidisciplinary working as a key element in service improvement. The definition of multidisciplinary cancer care is variable [3, 4, 5, 6], and may include multidisciplinary clinics [7, 8, 9], multidisciplinary protocols for diagnosis and treatment [10], and multidisciplinary team (MDT) meetings [11]. However, it is undoubtedly the last category that has had the greatest impact on working practices, as MDT discussion has become mandated for all new incident cases of cancer in the UK over the last two decades. The MDT is typically defined as a group of doctors and other health professionals with expertise in a specific cancer, who discuss each case before tailoring a personalized management plan. The specific composition of any MDT depends on the tumour type cared for, but most teams will involve one or several surgeons, radiologists, histopathologists, medical oncologistsand clinical radiation oncologists, palliative care physicians and clinical nurse specialists. Other health professionals, including clinical geneticists, physiotherapists, occupational therapists, psychologists, dieticians, speech therapists, and pharmacists, may also be involved.

Since their inception, MDTs have become progressively more site specialised, and although initially this was manifested predominantly as surgeons focusing their attention on particular tumour types in order to increase and refine their caseloads, over time there has been a shift to a tumour-specific focus for all team members. Clearly this raises issues for staffing and time commitments, and begs the question as to whether there is sufficient capacity to support this degree of specialization. Irrespective of their composition, however, the importance of MDTs in many healthcare systems has increased substantially over recent years. In the UK, the proportion of cancer cases managed by an MDT has increased from less than 20% to greater than 80% over the last two decades [12], and multidisciplinary care is mandated by healthcare organizations in the UK, mainland Europe, the USA, and Australia [4, 13, 14, 15]. In addition to improved coordination and delivery of care, many other benefits of MDTs working for patients and healthcare professionals have been suggested. However, the organization of MDT care requires substantial time and cost commitments, and the cost-effectiveness of MDTs is difficult to ascertain. Furthermore, high-quality evidence of benefit of MDTs working on patient outcomes is at best scanty, for reasons discussed below. Nevertheless, the UK NHS cancer plan regards MDTs as an essential part of the management of common cancers, and has recommended the extension of multidisciplinary care to rare tumours.

Organization and delivery of multidisciplinary cancer care

The purpose of the MDT is to collate sufficient clinical, pathological, and radiological data to enable the team to make a consensus recommendation for the optimum modality and sequence of treatment. In general, the patient history is presented by either the clinician who made primary contact or the clinical nurse specialist who has been appointed the ‘key worker’ for the patient; the histopathologist reports the tumour characteristics (ideally using a nationally agreed proforma designed to capture validated prognostic factors in addition to conventional TNM staging); and the radiologist delineates the primary tumour and annotates the presence/absence of distant metastases (Figure 22.1). The MDT may request further information (e.g., MRI scan of liver if there is doubt on the CT scan about presence of hepatic metastases), but if there are sufficient data, a treatment plan is formulated and a referral to initiate treatment made to the primary clinician, who could be a surgeon, radiotherapist, medical oncologist, or palliative care specialist, depending on clinical circumstance. Coordination is essential as often the patient will have to meet new clinical teams situated in different areas of the hospital or even in a completely different centre. The roles of the MDT coordinator and the clinical nurse specialists are pivotal as, for the MDT to function effectively, the results of the discussions need to be disseminated to the relevant healthcare professionals, and to the patients themselves, accurately and expeditiously.

Fig. 22.1 Organization of MDT meetings. The clinical history and other salient features are typically presented by the clinician who made primary contact with the patient, or the clinical nurse specialist (CNS). The tumour pathology is summarized by the histopathologist and the imaging findings presented by the radiologist. The MDT then discusses the case and a tailored management plan is formulated. This should be both evidence-based and consistent with national and international guidelines. By collecting many specialists together, the MDT should expedite delivery of care when compared with sequential referrals between specialists.

Fig. 22.1 Organization of MDT meetings. The clinical history and other salient features are typically presented by the clinician who made primary contact with the patient, or the clinical nurse specialist (CNS). The tumour pathology is summarized by the histopathologist and the imaging findings presented by the radiologist. The MDT then discusses the case and a tailored management plan is formulated. This should be both evidence-based and consistent with national and international guidelines. By collecting many specialists together, the MDT should expedite delivery of care when compared with sequential referrals between specialists.

As mentioned, in response to the unacceptable delays in treatment for cancer of a decade ago, the NHS in the UK has mandated that all new cancer patients should be discussed by an MDT, and that this is subject to audit as a quality surrogate in an ongoing national programme. The frequency of MDT meetings varies with caseload and tumour prevalence, though MDTs for the common solid tumours (lung, breast, colorectal, and urogenital) tend to meet weekly. The implementation of MDT working has helped to reduce waiting times to more internationally acceptable figures and has also improved the patient experience of the cancer journey.

Potential benefits of multidisciplinary care

By pooling the expertise of healthcare professionals from various clinical specialities, MDTs aim to provide a personalized and optimum management plan for each case discussed. As a result, patients should benefit from expert diagnosis and staging, with secondary review of imaging and pathology resulting in improved diagnostic accuracy, particularly in uncommon cancers [16, 17]. The presence of different specialists should mean that consideration is given to the full range of therapeutic modalities available for each patient, rather than the preferred therapy of the primary physician or surgeon [18, 19]. This is of particular importance for complex cases, for patients with comorbidities and for cases where combined modality therapy—such as chemoradiotherapy—is indicated. For more straightforward situations, MDT teamwork may facilitate closer adherence to evidence-based guidelines [20, 21]. In addition, MDT discussion should prevent inappropriate referrals and expedite care delivery compared with the traditional model of sequential consultations with different specialists.

More generally, the structure of MDT meetings is consistent with the application of peer review, and the teamworking required may help promote initiatives for service improvement [22]. The MDT provides an ideal forum at which to identify patients who may be eligible for clinical trials, and the presence of a research nurse at the MDT may help ensure that the option of study participation is available to all eligible. Improved data collection as a result of MDTs should facilitate audit and research. In response to a survey of MDTs in the UK in 2009, characteristics of effective MDTs have been published to serve as a model for MDT improvement [23, 24]. Intended benefits for patients from having their case managed by an MDT are summarized in Box 22.1.

In addition to directly improving patient care, participating healthcare professionals may also benefit from working in a MDT. Communication between different team members is also often better where they have a formal working relationship but within the structure of regular discourse and mutual support. For challenging cases, the reassurance of corporate decision-making may be beneficial, although the legal position of such recommendations is unclear [25]. The open communication between professionals is also conducive to learning about novel treatments and clinical trials [26, 27].

Challenges for multidisciplinary care

A typical MDT meeting involves ten to 20 healthcare professionals, lasts between one and three hours, and may require substantial preparation for participants—particularly radiologists and pathologists who may have to review 20 to 30 cases beforehand. The average clinician may attend between one and three such meetings a week, and even the most cursory of calculations will demonstrate the significant time commitments that MDT working demands from members. Consequently, it is perhaps unsurprising that a common contributor to suboptimal MDT effectiveness is lack of attendance at meetings [28, 29, 30]. A study of breast cancer MDTs showed that while surgeons and clinical nurse specialists were present for the entire meeting 95% of the time, and pathologists and radiologists in 90–95% of cases, the proportion of clinical oncologists who attended the entire meeting was 70%, and medical oncologists were present throughout in only 44.1% of cases. Medical oncologists were more likely to attend the whole MDT meeting if it was held in a protected session (71% versus 54%), though only 28% of MDT meetings were in protected time. A subsequent study of breast cancer MDTs reported similar findings, and lack of attendance of core members has also been noted in colorectal and head and neck cancer MDTs [29, 30, 31]. Time pressures may also lead to challenges in ensuring each case is discussed in sufficient detail to permit the formulation of a detailed management plan. As a representative example, the Oxford colorectal cancer MDT comprises 12 to 15 consultants, four to six specialist nurses and two MDT coordinators, and discusses an average of 30 to 40 new patients each week in a 1–1.5-hour slot. The team is absolutely committed to joint working, but feels that the need to spend more time discussing more complex or difficult cases means that a ‘tick-box’ mentality is sometimes applied to straightforward cases.

The logistics of conducting an MDT meeting is in itself a substantial undertaking. Meeting rooms require information technology support to permit projection of imaging and histopathology, and in many cases to enable videoconferencing with other hospitals. The MDT coordinator plays a pivotal role in ensuring that correct meeting facilities are booked, that the necessary patient information is available, and that the result of discussions is accurately recorded and expeditiously disseminated to all those involved in the patient’s care [18, 30, 32].

As a result of the staff and support costs, MDT working requires substantial investment, and it has been shown that funding strategies often underestimate the true costs of MDT service. A recent analysis collated all salary and support costs of breast MDTs in one UK cancer centre during 2009. During this period the MDT met 53 times and formulated treatment plans for 1315 patients from 2343 discussions. The total cost for the year was £114,948, translating to a cost per management plan of £87.41—similar to the NHS estimate of £85.62 for an average MDT decision. Staff costs comprised 86% of the total [33]. Though this likely represents a worthwhile investment, such evaluation is essential if the true value of MDTs to patient care is to be calculated.

As with any team, successful MDT working is also dependent on the ability of the group to perform well together, a characteristic dependent on both team composition and size [33]. The MDT chair should foster an environment in which all members are encouraged to contribute, with mutual respect for opinions that may differ, and constructive feedback provided on previous decisions [18, 34, 35, 36, 37]. This aspect of MDT working is potentially at odds with the historical role of the clinician as largely autonomous care provider, and teams do not typically function well without guidance and training for members [20, 38]. To address this common deficiency, in the UK an MDT self-assessment programme, MDT-FIT (‘feedback for improving team-working’) is under development with the aim of improving MDT performance [39].

A further potential Achilles heel of MDT working is that central decision-making may be perfectly coordinated but delivery of the treatment plan may be fragmented. Although the ideal of patients moving smoothly along the care pathway from one specialty to another is entirely achievable, the many transitions along the route have the potential to lead to a rather disjointed and daunting experience for the patient at a time of maximum vulnerability. This risk is significantly reduced by the availability of a clinical nurse specialist or key care worker able to accompany the patient when they attend for primary and subsequent treatments in order to maintain continuity and ensure that patients do not get lost in the system. Although many clinical nurse specialists perform this function excellently, again, time pressures prevent them from providing this level of care and support as routine and in every case.

Evidence of benefit from the MDT approach

There are relatively few studies evaluating the effect of MDT working in any form, and those focusing on its effect on cancer outcomes are even less common. The logistics of organizing a randomized controlled trial comparing MDT working with non-MDT working would be challenging to say the least, and as MDT working is both common, and in many cases mandated, internationally such a study is highly unlikely to be performed. Consequently, most data are retrospective, with many before-and-after studies that run substantial risk of confounding due to improvements in care outwith the MDT during the study period. A systematic review of MDT effectiveness published in 2010 [6]‌ identified two systematic reviews [40, 41], one abstract, and 18 original studies [42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58] analysing the effects of MDT working on cancer survival. Of these, 12 studies (one prospective [57]) and six retrospective cohort studies [42, 43, 44, 46, 54, 58], five before-and-after series [47, 50, 51, 52, 56] reported statistically significant associations between multidisciplinary care and patient survival. However, significant methodological limitations, including heterogeneity of the definition of multidisciplinary care and a lack of comparison with control groups were common. Thus, it was possible that some of the benefit of MDT working was in fact due to confounding factors including biases in patient selection and improved survival secondary to improved treatments during the study period [6, 40]. Consequently, although the collective weight of evidence to date suggests that multidisciplinary care improves cancer survival, this cannot be authoritatively asserted at present. More controversial still is the evaluation of whether the costs of MDT working justify clinical benefits. Studies evaluating the effects of MDT working on treatment and outcomes for common cancers are discussed below and summarized in Table 22.1.

Table 22.1 Summary of studies evaluating the effects of MDT working

Tumour type

Intervention evaluated

Comparison group used

Study design

Sample size

Effect of MDT care on patient management

Effect of MDT care on survival

Notes

Reference

Breast cancer

Effect of introduction of MDT care in health board areas (intervention area)

Adjacent health board areas without introduction of MDT care (non-intervention area)

Temporally matched comparison before and after introduction of MDTs

N = 14, 358

Not reported

18% reduction in breast cancer mortality (HR 0.82, 0.74–0.91) and 11% reduction in all cause mortality (0.89, 0.82–0.97) in intervention area compared to compared to non-intervention area

Highest quality evidence of benefit of MDT care on cancer survival. Screen-detected cancers excluded to avoid bias. Survival improvement persisted after adjustment for confounders

[60]

Receipt of multimodality treatment/high surgical caseload (>30 cases/year)

Patients not treated with multimodality therapy/low surgical caseload

Population-based retrospective cohort study (1979–1988)

N = 12,861

Patients treated by surgeons with high caseload more likely to receive adjuvant chemotherapy and hormone therapy

Receipt of multimodality therapy associated with improved survival

High surgical caseload likely to be associated with MDT working

[43]

Receipt of multimodality treatment/high surgical caseload (>30 cases/year)

Patients not treated with multimodality therapy/low surgical caseload

Population-based retrospective cohort study (1989–1994)

N = 11,329

Patients treated by surgeons with high caseload more likely to receive chemotherapy

Management by surgeon with high caseload associated with five-year survival of 68% versus 60% for cases managed by surgeons with lowest caseload

High surgical caseload likely to be associated with MDT working

[46]

Impact of Calman–Hine recommendations, including MDTs

Cases managed by surgeons with less adoption of MDT working

Population-based, retrospective cohort study

N = 12,961

Increased adherence of teams to manual of cancer service standards associated with greater use of postoperative radiotherapy following breast-conserving surgery (OR = 1.22, P = 0.05)

Trend towards improved survival with increasing surgical site specialization (HR = 0.93, 95% P = 0.1)

Study noted variable implementation of Calman–Hine recommendations

[53]

Introduction of one-stop multidisciplinary clinic

Cases managed prior to introduction of multidisciplinary clinic

Single centre, before-after study

N1 = 162 N2 = 177

Significant decrease in time to initiation of treatment with MDT clinic (29.6 days versus 42.2 days; P = 0.0008). Improved patient satisfaction

Not reported

Authors note pivotal role of nursing coordinator in multidisciplinary care delivery

[7]‌

Effect of MDT review on diagnosis/management plan

Nil

Single centre, retrospective review of during six-month period

N = 75

MDT revised treatment plans in 32 cases (43%)

Not reported

[11]

Effect of MDT review on diagnosis/management plan

Nil

Single centre, retrospective review during one-year period

N = 149

Change in interpretation of imaging in 67 cases (45%) and to interpretation of pathology in 43 patients (29%). Alteration of management plans in 77 cases (52%)

Not reported

[59]

Lung cancer

MDT case discussion

Lung cancer cases not discussed in MDT during same period

Retrospective study of all patients with lung cancer diagnosed between 2005 and 2008

988

MDT case discussion associated with increased use of chemotherapy (46% versus 29%; P < 0.01), radiotherapy (66% versus 33%; P < 0.01) and palliative care (66% versus 53%; P < 0.01

No change in survival

Greater number of patients >80 years age in non-MDT group (25% versus 13%)

[61]

Introduction of MDT meetings for non-small cell lung cancer

Cases before introduction of MDT meetings

Single centre, before-after study comparing two one-year periods (N1: 1997, N2: 2001)

N1 = 117

N2 = 126

Implementation of MDT working associated with increased use of chemotherapy (23% versus 7%; P < 0.001)

MDT care associated with improved survival: 6.6 versus 3.2 months (P<0.001)

MDT meetings contained respiratory physicians, medical and clinical oncologists, palliative care physician, radiologist and lung CNS

[50]

Implementation of MDT meetings and appointment of specialist thoracic surgeon

Cases managed before adoption of MDT working and specialist surgeon

Before-after series

N1 = 65

N2 = 175

Significant increase in overall resection rate (23.4% versus 12.2%; P < .001) and operations in the elderly (18% versus 4%; P = 0.02)

No change in five-year survival (31% versus 32%)

[49]

Central multidisciplinary two-stop clinic for patients with suspected lung cancer

Cases randomized to standard workup

Randomized, controlled pilot study

N = 88

Time to initiation of treatment significantly less in MDT group (three weeks versus seven weeks; P < 0.0025)

No difference in survival at two years

Authors noted that definitive trial would require substantial commitment for patients and clinicians

[45]

Gastrointestinal cancer

Impact of Calman–Hine recommendations, including MDTs for colorectal cancer

Cases managed by colorectal surgeons with less adoption of MDT working

Population-based, retrospective cohort study

N = 12, 358

Increased use of preoperative radiotherapy for rectal cancer with increase in team specialization (HR = 1.43, P < 0.04)

3% decrease in relative risk of death per 25% increase in team score (HR = 0.97, 95% CI 0.94–0.99)

Team score reflected implementation of Calman-Hine recommendations, including MDT care

[54]

Impact of introduction of colorectal cancer MDT

Patients treated prior to implementation of MDT care

Before-after study (N1: 1997–2002, N2: 2002 to 2005)

N1 = 176

N2 = 134

Increased use of adjuvant chemotherapy after introduction of MDT care (31% versus 13%; P < 0.01)

Increased three-year overall survival for patients with stage III disease following MDT implementation (66% versus 58%; P–0.023)

[56]

Impact of introduction of dedicated MDT with liver surgeon for metastatic colorectal cancer

Patients referred directly to specialist hepatobiliary unit

Prospective cohort study

N = 331

Frequency of preoperative chemotherapy not reported

Five-year survival greater for patients referred via specialist MDT (49.9% versus 43.3%; P = 0.0001)

[57]

Impact of MDT on outcome for patients with oesophageal cancer

Patients treated prior to implementation of MDT care

Before-after study (N1: 1991–1997, N2: 1998 to 2003)

N1 = 77

N2 = 67

Greater use of radical radiotherapy (P = 0.001) and palliative chemotherapy and radiotherapy (P<0.001) following adoption of MDT working

Five-year survival in group managed by MDT 52% versus 10% for historical controls (P<0.001)

MDT comprised specialist surgeons, oncologist, radiologists, pathologist, gastroenterologists, CNS

[52]

Impact of tertiary centre MDT review for pancreatic cancer

Nil

Prospective study of 203 cases in one-year period

Revision to radiological staging in 38 cases (18.7%), to pathological interpretation in 7 cases (3.4%). Alteration of management plan in 48 patients (23.6%)

Not reported

[62]

Urological cancer

Introduction of concurrent multidisciplinary clinic for low risk prostate cancer

Sequential specialist consultations

Retrospective multicentre study during one-year period

N = 701

Higher proportion of patients in MDT cohort managed with active surveillance (43% versus 22%; P<0.001)

Not reported

High rate of patient satisfaction from MDT clinic

[66]

Effect of MDT meetings on patient management for urological cancers

Nil

Prospective single-centre study during six-month period

N = 124

Major change to diagnosis/staging* in 2 cases (1.6%), minor change in 5 cases (4.0%)

Not reported

Prior to MDT referring clinicians documented proposed management plans and comparison was made with MDT recommendation

[67]

Central MDT discussion of selected urologic cancers

Local MDT discussion

Retrospective review of 87 cases during one-year period

N = 87

Change in management from local MDT plan recommended in 0/67 prostate, 4/19 (21.0%) bladder, and 1/1 renal cancer cases

Not reported

Referral to central MDT based on pre-defined criteria

[67]

Gynaecologic cancer

Management of ovarian cancer at multidisciplinary clinic

Patients not managed at joint clinic during same period

Population-based retrospective cohort (one-year period)

N = 533

Patients twice as likely to receive platinum-based chemotherapy (P < 0.001)

Five-year survival 35.3% versus 19.2% (P < 0.001)

130 patients of 479 assessable during study period seen at joint clinic. Improved survival unlikely to be due solely to chemotherapy use

[42]

Management of ovarian cancer by multidisciplinary team at cancer centre

Patients treated at peripheral units

Retrospective cohort study

N = 287

Higher proportion of patients managed by MDT in cancer centre treated with postoperative platinum-based chemotherapy (98% versus 86%; P = 0.008)

Survival in cases managed in peripheral units significantly less than in those managed by MDT (HR 1.79; P = 0.02)

Service evaluation prior to introduction of management guidelines for ovarian cancer

[58]

Tumour board discussion of gynaecologic cancers

Nil

Retrospective review during 3-year period (391 new cases, 68 recurrences)

N = 459

Major revision to diagnosis/staging* in 23 cases (5.0%), minor change in 9 cases (2.0%)

Not reported

Authors concluded tumour board review affects patient care

[71]

MDT discussion of gynaecologic cancers

Nil

Retrospective review during one-year period

N = 509

Major revision to diagnosis/staging* in 30 patients (5.9%) and minor discrepancies in 16 cases (3.1%) Commonest alterations were recommendations for chemotherapy and surgery

Not reported

Authors concluded tumour board review affects patient care

[69]

Tumour board discussion of gynaecologic cancers

Nil

Prospective analysis over one-year period

N=153

Major revision to diagnosis/staging resulting in change in management in 8.5% and minor change in 26.1%

Not reported

[80]

Discussion of cases of uterine sarcoma at MDT meeting

Cases not discussed at MDT

Population-based retrospective cohort study

N = 87

Less use of adjuvant chemotherapy in patients discussed by MDT

No impact of MDT discussion on survival apparent

[30]

Head and neck squamous cell carcinoma (HNSCC)

Multidisciplinary clinic with surgeons and oncologists

Cases prior to adoption of MDT working

Retrospective audit—before-after (1: 1996–1997, 2: 1999–2000)

N1 = 566

N2 = 727

Not reported

MDT management associated with trend to improved two-year survival in first audit (P = 0.1) and significant improvement in second audit (P = 0.02)

Greater use of MDT working following publication of Calman-Hine report

[47]

Miscellaneous tumour types

Adoption of weekly MDT meetings as part of creating of dedicated cancer centre

Patients managed before MDT implementation, SEER data

Before-after series

N1 = 5, 487

N2 = 10, 548

Decrease in proportion of cases managed with surgery alone (36.9% to 31.0%; P<0.0001). Increase in proportion of patients treated with systemic therapy (24.6% to 42.1%; P<0.0001)

Increase in five-year actuarial survival for all tumour types (52% to 58%; P<0.0001]. Significantly improved survival for cancers of breast, lung, prostate, stomach, pancreas, oral cavity

Authors conclude multiple advantages to multidisciplinary team approach

[51]

Notes: * resulted in change in patient management.

Breast cancer

MDT management of breast cancer is now standard in the UK and much of the developed world. However, despite early studies reporting that breast MDT cancer care was associated with frequent alteration of patient management plans [11, 59], shorter time to treatment, and greater patient satisfaction [7]‌, a systematic review in 2006 found no evidence that MDTs were associated with improved survival for patients with breast cancer [40]. The authors concluded that while MDT care should in theory be associated with improvement in survival, there was a lack of high-quality evidence to support this.

An important recent report by Kesson and colleagues from Scotland has gone some way to correcting this apparently anomalous situation [60]. In 1995 MDT care was introduced in the Greater Glasgow health board area as part of an initiative to improve the quality of care, but not in areas managed by other health boards in the west of Scotland. Following this introduction, care in the intervention area applied common principles of MDT care—regular meetings, application of evidence-based guidelines and audit—while care in the non-intervention area remained organized along traditional lines, with surgeons unilaterally responsible for making decisions on surgery and adjuvant therapy. Following publication of national guidance on cancer care in 1999, the non-intervention areas also adopted MDT care, and the discrepancy ceased to exist. By comparing outcomes between areas before the introduction of MDT care (analysed time period January 1990 to September 1995) and during the intervention period (time period October 1995 to December 2000), the authors were able to address many of the limitations of previous studies, by defining the composition of an MDT at the outset, observing the effect of care where no other model was available, and including a contemporaneous comparison population to adjust for temporal improvements in survival. Before the introduction of MDTs, breast cancer mortality was 11% higher in the intervention area than in the non-intervention area (hazard ratio adjusted for year of incidence, age at diagnosis, and deprivation = 1.11; 95% confidence interval 1.00 to 1.20). After multidisciplinary care was introduced, breast cancer mortality was 18% lower in the intervention area than in the non-intervention area (0.82, 0.74–0.91). All cause mortality did not differ significantly between populations in the earlier period, but was 11% lower in the intervention area than in the non-intervention area in the later period (HR 0.89, CI 0.82–0.97). Interrupted time series analyses showed a significant improvement in breast cancer survival in the intervention area in 1996, compared with the expected survival in the same year had the pre-intervention trend continued (P = 0.004). This improvement was maintained after the intervention was introduced. It would appear therefore, that multidisciplinary care was associated with improved survival and reduced variation in survival among hospitals. These results provide the most convincing evidence of benefit for patients with any tumour type from MDT care to date.

Lung cancer

The diagnostic workup for suspected lung cancers often requires multiple investigations, including imaging studies such as 18FDG-PET, bronchoscopy, endobronchial ultrasound (EBUS), mediastinoscopy, and thoracoscopy, many of which are performed by different specialists. In addition, management is frequently multimodal and both the type and scheduling of treatment vary substantially depending on tumour histology and stage. Intuitively, MDTs would be expected to have substantial impact in this tumour type.

In an early effort to assess the effectiveness of MDT working in lung cancer, a pilot study to assess the feasibility and efficacy of referral to a central multidisciplinary diagnostic clinic for diagnostic workup compared with conventional investigation was conducted by investigators at the Royal Marsden Hospital in London. Reported in 2003, this showed that MDT review was associated with shorter time to initiation of treatment though on follow-up no difference in survival between groups was detected. Although the investigators confirmed the feasibility of the pilot, they noted that expanding the study to a size powered to detect survival change would require substantial commitment from patients and physicians [45]. Another study evaluated treatment and survival of patients with non-small-cell lung cancer (NSCLC) before and after the implementation of MDT care in a single centre in Scotland [50]. The pre- and post-cohorts were well matched for baseline variables. Adoption of MDT care was associated with significant increases in the proportion of patients treated with chemotherapy (23% versus 7%; P < 0.001) and in overall survival (6.6 months versus 3.2 months; P < 0.001). However, the before-and-after nature of this study might mean that improvements in systemic therapy and supportive care during the study period may have contributed to the results.

Both of these studies were included in a systematic review of the effect of MDT working on lung cancer outcomes published in 2008. Sixteen studies met the authors’ inclusion criteria, including several in which the primary focus was not MDT care per se. Statistical pooling was not possible due to a clinical heterogeneity; however, only two publications, including the study by Forrest, reported improved survival [41]. Both were potentially confounded by the before-and-after design and the authors concluded that although MDT review may be associated with improved survival in lung cancer, the published evidence did not provide conclusive support for this at present. In an attempt to address these deficiencies by minimizing confounding due to temporal changes in management, Boxer and co-workers compared outcomes for 988 patients diagnosed with NSCLC between 2005 and 2008 in Southwestern Australia according to whether or not their cases were discussed in an MDT. Cases discussed at MDT had better documentation of disease stage and performance status, and these patients were also more likely to receive chemotherapy, radiotherapy, and palliative care referrals that patients whose cases were not discussed (P < 0.001 all comparisons). Despite this, no effect of MDT discussion on patient survival was evident [61].

Consequently, although MDT working clearly impacts on patient management in lung cancer, current data do not conclusively prove its benefit in improving patient outcome.

Gastrointestinal cancer

Several studies have examined the effect of MDT working on gastrointestinal malignancies. In an early study, Stephens and colleagues compared outcomes for 67 consecutive patients with oesophageal cancer treated after the adoption of MDT working in 1997 with 77 consecutive historical controls managed by individual surgeons previously [52]. Five-year survival was dramatically higher in the group managed by MDT (52% versus 10%, P<0.0001). Patients managed by MDT were significantly more likely to receive palliative chemotherapy and radiotherapy, though the proportion of patients treated with preoperative chemotherapy was not documented. Though it is likely that the improvement in outcome resulted from multiple factors, many of these are likely to have been secondary to the adoption of MDT working. The effect of MDT care on management of pancreatic cancer was examined in 203 patients treated at a tertiary centre multidisciplinary clinic between 2006 and 2007. MDT review of imaging led to a change in disease stage in 38 cases (18.7%), and in pathological interpretation in seven cases (3.4%). The treatment recommendation of the MDT differed from that previously planned for the patient in 48 cases [62]. Survival outcomes were not reported in this study.

In common with the examples cited above in breast and lung cancer, a multidisciplinary approach to colorectal cancer management can result in alteration in management [63]. A study performed by Burton and co-workers demonstrated that MDT discussion of staging MRI for rectal cancer cases reduced positive circumferential resection margins through improved preoperative treatment [64], and MDT management was associated with increased use of neoadjuvant therapy in a US study [63]. A large study examining the effect of the Calman–Hine recommendations on colorectal cancer care in Yorkshire in the UK ranked colorectal cancer teams according to how closely they adhered to the ideal MDT published in the UK manual of cancer standards, with increasing team score indicating closer adherence. The investigators found no significant link between increase in team score and the frequency of chemotherapy overall, or of preoperative radiotherapy for rectal cancers. However, for every 25% increase in team score a statistically significant 3% reduction in risk of death for all colorectal cancer patients was observed (HR = 0.97, 95% CI = 0.94–0.99) [54]. Although the large size of this study (12,358 patients) and its population-based nature strengthen these conclusions when compared to single-centre studies, the possibility that the improvements in survival may have resulted from factors other than MDT working remains. The multimodality management of liver metastases from colorectal cancer is a notable success of contemporary cancer medicine, and multidisciplinary care has been an integral component in this. However, specialist radiology and surgical review are required to identify cases suitable for curative resection and absence of these may result in patients being denied radical treatment inappropriately. Therefore, in most large centres discussion of such patients at a specialist hepatobiliary MDT is recommended. A recent study retrospectively identified patients with colorectal liver metastases treated with palliative chemotherapy by oncologists without specialist hepatobiliary MDT review. Imaging prior to chemotherapy was reviewed by liver surgeons blinded to patient management [65]. Of 52 patients with liver-only disease, 33 (63%) were considered potentially resectable by the expert panel. Although this decision was based on purely radiological grounds, it is unlikely that all of these patients would have been unfit for surgery.

Urological cancer

Prostate cancer is a heterogeneous malignancy, the optimum management of which varies from active surveillance to radical prostatectomy or radical radiotherapy. Treatment recommendations for patients may vary according to care providers’ biases, and a noteworthy recent study provides an interesting insight into the effects of multidisciplinary working on this. In this large retrospective study of men with low-risk prostate cancer, review at a concurrent multidisciplinary clinic (including a urologist, radiotherapist, and medical oncologist) was associated with a higher proportion of men selected for active surveillance and lower rates of treatment with radical prostatectomy or radiation than in patients seen by practitioners sequentially [66]. This difference was not due to temporal change in practice as all patients were treated in 2009, and the authors conclude that these results may have significant clinical implications. In contrast to these data, Acher and colleagues examined the frequency with which MDT review changed management plans for urology patients in a single centre over a six-month period. Prior to each meeting, referring surgeons completed a form for patients stating their proposed management plan, and this was then compared with the team decision made at the meeting. There was concordance between the two in over 98% of cases, and the authors concluded that it may be possible to reserve MDT discussion for challenging cases without compromising patient care [67]. Similarly, in a report analysing the importance of central MDT review (based on defined criteria) for urological malignancies, management was not changed in any cases of prostate cancer, while for bladder malignancies 4 out of 19 cases (21.0%) had a change in management [68].

Gynaecologic cancer

Several studies report that MDT review of gynaecological malignancies frequently results in change in diagnosis and staging [69, 70, 71]. Cohen and co-workers investigated the frequency with which pathological and radiological findings were altered by discussion at a specialist gynaecology MDT in New Zealand [69]. Discrepancies were classified as major if they resulted in a change in patient management, and minor if they did not. From 509 cases discussed during the one-year period analysed, 46 deviations were found (9%), with 30 major (5.9%) and 16 minor (3.1%) discrepancies. The most frequent changes to patient management were recommendations for chemotherapy and surgery. Similar findings were noted in an early study of the effects of multidisciplinary working for all cases of ovarian cancer diagnosed in Scotland in 1997, in which MDT management was associated with increased use of platinum-based chemotherapy. Notably in this study, MDT care was also associated with improved survival, with an effect beyond that explicable by the greater use of platinum-based treatment in this group [42].

Head and neck squamous cell carcinoma

Birchall audited cases of head and neck cancer in the southwest of England before and after the publication of the Calman–Hine report, which promoted MDT working (periods examined 1996/1997 and 1999/2000). Although two-year overall survival was unchanged between the two periods, in both audits MDT management was significantly associated with improved survival [47]. The proportion of patients treated with surgery, radiotherapy, and chemotherapy did not alter between the first and second audits; however, whether use of these treatment modalities was more common in cases managed by MDT is not reported.

Other evidence for effectiveness of MDT care

Although as discussed above, MDTs should improve communication and enhance coordination of treatment, few studies have addressed this. One audit of head and neck cancer found that although referral pathways appeared satisfactory, delays occurred due to waits for investigations, beds, and specialist treatments, particularly radiotherapy [29]. A further concern was that MDTs were frequently understaffed. Another questionnaire-based survey published in 2003 found that 62% of lead clinicians of colorectal MDTs stated that there were difficulties in running the MDT, with 32% lacking a dedicated MDT coordinator. The authors emphasized the essential role of MDT coordinators, and stressed the importance of mapping the patient care pathway to identify bottlenecks where delays occurred [30]. A study of breast cancer teams found that clinical performance was improved by the number of breast care nurses, and positively correlated with the workload of the MDT. This study also demonstrated that teams with a number of leaders were associated with greater effectiveness, while a single, clear leader negatively predicted innovation and effectiveness in audit and research. Interestingly, levels of psychiatric morbidity were lower for MDT members than those reported for other health teams and the NHS workforce in general [35], a finding mirrored by another report which found less psychiatric morbidity overall in MDT members than previously published rates for UK clinicians. However, this average is perhaps an oversimplification as the researchers found substantial variation within teams and high rates of emotional exhaustion in MDT leaders [72]. Although commonly postulated as an advantage of MDT working, evidence for an impact of MDT working on clinical trial recruitment is limited, though published data are consistent with increased frequency of clinical trial participation in patients identified as eligible by MDTs [26, 73, 74].

The future of multidisciplinary cancer care

Cancer is largely a disease of ageing, and the increasing proportion of the elderly who suffer malignant disease poses a particular challenge of MDT working. Although meetings are generally excellent at recording disease stage and pathological factors, documentation of other patient factors such as performance status and comorbidities is frequently variable and occasionally absent. A study of patients with upper gastrointestinal cancers discussed at MDTs found that in 15.1% of cases the MDT recommendation was not implemented. In 43.9% of these cases the discordance was due to comorbidity and in 34.2% to patient choice. The authors concluded that more information on comorbid disease was required for MDTs to make informed recommendations on patient care [75]. Other studies have reported that MDT treatment plans for patients were not actioned in 10–24% cases of colorectal cancer, and 4.4% of lung cancer cases [76] due mainly to a combination of comorbidities and patient refusal [21, 77]. Although validated scales such as the Charlson comorbidity index provide prognostic information for patients with cancer [78] they are not commonly used outside clinical trials. Incorporation of such indices into MDT discussion would substantially strengthen recommendations for the elderly, and is increasingly straightforward using the computer-based applications available. At the very least, a minimum dataset comprising performance status and concurrent illnesses should be available for each patient discussed.

Given the general acceptance that MDT meetings are integral to current best practice in oncology, attention is likely to focus on the refinement, standardization, and streamlining of MDT function. The application of modern information technology (IT) methodology promises significant improvements in all areas. The current MDT model of discussion of each case by core MDT members followed by formulation of an optimum management plan is typically accompanied by limited, if any, documentation of the factors decisions are based upon and little context between one patient and the next. To the external observer, particularly those from backgrounds in engineering and decision science, MDT meetings are in large part art and in small part science. Though the development of evidence-based checklists to structure MDT meetings [39] is a step in the right direction, it is possible to develop integrative software tools to record, display, and report the decision-making process and its outcome in a structured way. Such a system, MATE (Multidisciplinary meeting Assistant and Treatment sElector), developed at the Royal Free Hospital in London was designed to capture patient data including pathology and imaging results, identify patients eligible for clinical trials, and suggest evidence-based treatment recommendations. The developers performed a prospective evaluation through 2008 and 2009 during which MDT patient data was entered onto MATE, though the MDT were unaware of the treatment recommendations generated by the software. On analysis, the recommendations made by MATE displayed better concordance with clinical practice guidelines than MDT recommendations (97% versus 93.2%); in addition, the software identified 61% more patients eligible for clinical trials than the MDT [79].

It is likely that in the next few years MATE, and similar software, will be sufficiently adaptable to contain multifactorial analysis based on genomic data in addition to traditional prognostic factors in order to take advantage of the revolution in genomics which underpins personalized cancer medicine. The logical endpoint of this development will be a suite of software for the management of cancer patients, not only combining current patient data, but also able to display it within the context of a database of previous patients with annotated outcomes, and links to national cancer treatment guidelines and expert disease management systems. This will propel the MDT into an era in which clinical outcomes become the gold standard used to compare the quality of teams and hospitals and, when made publicly available, allow citizens better to choose the centres to which they would prefer referral.

Conclusions

There is clear evidence that MDT working results in change in patient management, and, though limited, outcome data are consistent with a benefit for patients with cancer from MDT care. As discussed previously, the widespread adoption of MDT working internationally means that such a randomized controlled trial of MDT care is unlikely to take place, although prospective audits should help to confirm that the benefits of MDT working are being realized in practice.

Multidisciplinary care probably improves patient outcomes by influencing various aspects of care. These factors include adherence to guidelines and nurse education, increased surgical volume and experience, and improved interdisciplinary working. Although multidisciplinary care is considered standard practice in many countries, access to such care still varies. However, these results support the universal provision of cancer care by specialist, multidisciplinary teams. The importance of good communication cannot be overstated, and is likely to become more rather than less important as cancer is resolved into a greater number of biomarker-determined disease subtypes. While it is likely that MDTs will remain site-based for the foreseeable future, there will be increasing specializations around targeted molecular pathways as the application of high-throughput sequencing technologies to clinical samples becomes routine. Further work should address other cancer types, tease out which are the most important contributory elements of team-delivered cancer care, and address the issue of cost-effectiveness.

Further reading

Birchall M, Bailey D, King P, South West Cancer Intelligence Service Head and Neck Tumour Panel. Effect of process standards on survival of patients with head and neck cancer in the south and west of England. British Journal of Cancer 2004; 91(8): 1477–1481.Find this resource:

Blazeby JM, Wilson L, Metcalfe C, Nicklin J, English R et al. Analysis of clinical decision-making in multi-disciplinary cancer teams. Annals of Oncology 2006; 17(3): 457–460.Find this resource:

Boxer MM, Vinod SK, Shafiq J, Duggan KJ. Do multidisciplinary team meetings make a difference in the management of lung cancer? Cancer 2011; 117(22): 5112–5120.Find this resource:

Catt S, Fallowfield L, Jenkins V, Langridge C, Cox A. The informational roles and psychological health of members of 10 oncology multidisciplinary teams in the UK. British Journal of Cancer 2005; 93(10): 1092–1097.Find this resource:

Coory M, Gkolia P, Yang IA, Bowman RV, Fong KM. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer 2008; 60(1): 14–21.Find this resource:

Fennell ML, Das IP, Clauser S, Petrelli N, Salner A. The organization of multidisciplinary care teams: modeling internal and external influences on cancer care quality. Journal of the National Cancer Institute Monographs 2010; 2010(40): 72–80.Find this resource:

Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncology 2006; 7(11): 935–943.Find this resource:

Forrest LM, McMillan DC, McArdle CS, Dunlop DJ. An evaluation of the impact of a multidisciplinary team, in a single centre, on treatment and survival in patients with inoperable non-small-cell lung cancer. British Journal of Cancer 2005; 93(9): 977–978.Find this resource:

Gabel M, Hilton NE, Nathanson SD. Multidisciplinary breast cancer clinics. Do they work? Cancer 1997; 79(12): 2380–2384.Find this resource:

Gillis CR, Hole DJ. Survival outcome of care by specialist surgeons in breast cancer: a study of 3786 patients in the west of Scotland. British Medical Journal 1996; 312(7024): 145–148.Find this resource:

Haward R, Amir Z, Borrill C, Dawson J, Scully J et al. Breast cancer teams: the impact of constitution, new cancer workload, and methods of operation on their effectiveness. British Journal of Cancer 2003; 89(1): 15–22.Find this resource:

Hong NJL, Wright FC, Gagliardi AR, Paszat LF. Examining the potential relationship between multidisciplinary cancer care and patient survival: an international literature review. Journal of Surgical Oncology 2010; 102(2): 125–134.Find this resource:

Houssami N, Sainsbury R. Breast cancer: multidisciplinary care and clinical outcomes. European Journal of Cancer 2006; 42(15): 2480–2491.Find this resource:

Jones RP, Vauthey J-N, Adam R, Rees M, Berry D et al. Effect of specialist decision-making on treatment strategies for colorectal liver metastases. British Journal of Surgery 2012; 99(9): 1263–1269.Find this resource:

Junor EJ, Hole DJ, Gillis CR. Management of ovarian cancer: referral to a multidisciplinary team matters. British Journal of Cancer 1994; 70(2): 363–370.Find this resource:

Kesson EM, Allardice GM, George WD, Burns HJG, Morrison DS. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. British Medical Journal 2012; 344:e2718.Find this resource:

Lamb BW, Sevdalis N, Vincent C, Green JSA. Development and evaluation of a checklist to support decision making in cancer multidisciplinary team meetings: MDT-QuIC. Annals of Surgical Oncology 2012; 19(6): 1759–1765.Find this resource:

Lordan JT, Karanjia ND, Quiney N, Fawcett WJ, Worthington TR. A 10-year study of outcome following hepatic resection for colorectal liver metastases: the effect of evaluation in a multidisciplinary team setting. European Journal of Surgical Oncology 2009; 35(3): 302–306.Find this resource:

Morris E, Haward RA, Gilthorpe MS, Craigs C, Forman D. The impact of the Calman–Hine report on the processes and outcomes of care for Yorkshire's colorectal cancer patients. British Journal of Cancer 2006; 95(8): 979–985.Find this resource:

Morris E, Haward RA, Gilthorpe MS, Craigs C, Forman D. The impact of the Calman–Hine report on the processes and outcomes of care for Yorkshire's breast cancer patients. Annals of Oncology 2008; 19(2): 284–291.Find this resource:

Murray PV, O’Brien MER, Sayer R, Cooke N, Knowles G et al. The pathway study: results of a pilot feasibility study in patients suspected of having lung carcinoma investigated in a conventional chest clinic setting compared to a centralised two-stop pathway. Lung Cancer 2003; 42(3): 283–290.Find this resource:

Patkar V, Acosta D, Davidson T, Jones A, Fox J et al. Using computerised decision support to improve compliance of cancer multidisciplinary meetings with evidence-based guidance. British Medical Journal Open 2012; 2(3).Find this resource:

Ruhstaller T, Roe H, Thürlimann B, Nicoll JJ. The multidisciplinary meeting: an indispensable aid to communication between different specialities. European Journal of Cancer 2006; 42(15): 2459–2462.Find this resource:

Sainsbury R, Haward B, Rider L, Johnston C, Round C. Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet 1995; 345(8960): 1265–1270.Find this resource:

Simcock R, Heaford A. Costs of multidisciplinary teams in cancer are small in relation to benefits. British Medical Journal 2012; 344: e3700.Find this resource:

Tattersall MHN. Multidisciplinary team meetings: where is the value? Lancet Oncology 2006; 7(11): 886–888.Find this resource:

Twelves CJ, Thomson CS, Young J, Gould A. Entry into clinical trials in breast cancer: the importance of specialist teams. Scottish Breast Cancer Focus Group and Scottish Cancer Therapy Network. European Journal of Cancer 1998; 34(7): 1004–1007.Find this resource:

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