Result of the implementation of multidisciplinary teams in rectal cancer

The impact of multidisciplinary cancer conferences on overall survival: a meta-analysis

BACKGROUND

Multidisciplinary cancer conferences consist of regular meetings between diverse specialists working together to share clinical decision making in cancer care. The aim of this study was to systematically review and meta-analyze the effect of multidisciplinary cancer conference intervention on the overall survival of patients with cancer.

METHODS

A systematic literature search was conducted on Ovid MEDLINE, EMBASE, and the Cochrane Controlled Register of Trials for studies published up to July 2023. Studies reporting on the impact of multidisciplinary cancer conferences on patient overall survival were included. A standard random-effects model with the inverse variance-weighted approach was used to estimate the pooled hazard ratio of mortality (multidisciplinary cancer conference vs non-multidisciplinary cancer conference) across studies, and the heterogeneity was assessed by I2. Publication bias was examined using funnel plots and the Egger test.

RESULTS

A total of 134 287 patients with cancer from 59 studies were included in our analysis, with 48 467 managed by multidisciplinary cancer conferences and 85 820 in the control arm. Across all cancer types, patients managed by multidisciplinary cancer conferences had an increased overall survival compared with control patients (hazard ratio = 0.67, 95% confidence interval = 0.62 to 0.71, I2 = 84%). Median survival time was 30.2 months in the multidisciplinary cancer conference group and 19.0 months in the control group. In subgroup analysis, a positive effect of the multidisciplinary cancer conference intervention on overall survival was found in breast, colorectal, esophageal, hematologic, hepatocellular, lung, pancreatic, and head and neck cancer.

CONCLUSIONS

Overall, our meta-analysis found a significant positive effect of multidisciplinary cancer conferences compared with controls. Further studies are needed to establish nuanced guidelines when optimizing multidisciplinary cancer conference integration for treating diverse patient populations.

Impact of positron-emission tomography on the surgical treatment of locoregionally recurrent colorectal cancer

BACKGROUND

The effect of positron emission tomography (PET) on the surgical treatment of locoregionally recurrent colorectal cancer (LRRCRC) remains unclear and warrants further investigation.

MATERIAL AND METHODS

A total of 193 patients with LRRCRC were identified from a prospectively maintained institutional database, of whom 134 LRRCRCs were deemed resectable and underwent resection with curative intent, whereas the remaining 59 LRRCRCs were unresectable. Patients with resectable LRRCRC were further classified according to whether recurrence was detected solely by PET (n = 35, PET-only group) or by a combination of computed tomography (CT)/magnetic resonance imaging (MRI) and PET (n = 99, CT/MRI/PET group). Clinicopathologic features, operative morbidity/mortality, and overall survival were compared between the patient groups based on long-term follow-up for at least 5 years.

RESULTS

Patients in the PET-only group tended to have less extensive organ resection (p = 0.0074), less blood loss (p < 0.0001), and shorter operation time and hospitalization (p < 0.0001), but surgical complication and readmission rates were not significantly different (p > 0.05) compared with the CT/MRI/PET group. Although the PET-only group had significantly higher R0 resection rate (80 % vs. 54.55 %, p = 0.0079), they also had a higher risk (17.14 % vs. 2.02 %, p = 0.0011) of sham operation. The estimated 5-year and 10-year survival rates significantly decreased in order (p < 0.0001) from PET-only (85.71 % and 57.98 %) and CT/MRI/PET (41.41 % and 15.93 %) to unresectable group of patients (16.95 % and 1.88 %). Subset analysis of the CT/MRI/PET group indicated that PET improved surgical decision-making because 24 (24.2 %) LRRCRCs that manifested on CT/MRI as equivocal lesions were later confirmed by PET as resectable recurrences, while 18 (19.4 %) LRRCRCs that manifested on CT/MRI as resectable lesions were later diagnosed by PET as more disseminated unresectable recurrences and precluded futile surgery.

CONCLUSION

PET alone can identify a subset (20.9 %) of LRRCRCs with less tumor burden for timely surgery; PET in combination with CT/MRI can better define the resectability of LRRCRCs. The positive impacts of PET can translate into better surgical outcomes, with enhanced safety and patient survival.

Importance of interdisciplinarity in modern oncology: results of a national intergroup survey of the Young Oncologists United (YOU)

PURPOSE

Modern, personalized treatment concepts in oncology require an interdisciplinary and multiprofessional collaboration. In addition to its relevance in patient care, interdisciplinary collaboration is also becoming increasingly important in clinical research as well as medical education and resident training in oncology.

METHODS

Between November 2021 and March 2022, an online survey was conducted among German early career research groups, represented by Young Oncologists United (YOU). The aim was to identify the status and need for interdisciplinarity at clinic, educational, and research levels.

RESULTS

A total of 294 participants completed the questionnaire in full. 90.7% of the respondents fully or predominantly agreed with the statement that interdisciplinary work plays a major role in their daily clinical work. 78.9% wished for more interdisciplinary collaboration. Of the 49.7% of participants who have never participated in an interdisciplinary research project, 80.1% said they would like to participate in such a study project in the future. Lack of time resources, too much organizational effort, and possible political conflicts between institutions were identified as factors that make practical implementation difficult. 74.1% declared their willingness to become active in an oncology early career research group.

CONCLUSION

Interdisciplinary collaboration has become increasingly important in oncology. Networks that span different disciplines could help to promote interdisciplinary research projects among young scientists and improve exchange in professional practice and education with the implication of improved patient care.

Effect of digital-enabled multidisciplinary therapy conferences on efficiency and quality of the decision making in prostate cancer care

Objectives

To investigate the impact on efficiency and quality of preprostatectomy multidisciplinary therapy conferences (MDT) at Karolinska University Hospital related to the use of a digital solution compared with standard of care. Further, to explore whether gains in MDT efficiency and quality impact oncological or functional patient outcomes.

Methods

We conducted a prospective, observational study of preoperative prostate cancer MDT at Karolinska between February 2017 and March 2021, including 1329 patients. We compared efficiency and quality of the standard MDT and the MDT using the digital solution IntelliSpace Precision Medicine Multidisciplinary Team Orchestrator (ISPM) based on the previously used MDT-MODe approach. Clinical and patient-reported functional outcomes were derived from the medical records and the Swedish National Prostate Cancer Register.

Results

While ISPM was used during the MDT meeting, the time spent per patient was reduced by 24% (p<0.001) and most of the MDT-MODe items were scored significantly higher. There was a reduction in pelvic lymph-node dissection procedures in the ISPM cohort (p=0.001) and an increased proportion of unilateral nerve-sparing procedures (p=0.005), while all other outcome-related measures were not significantly different between the two patient groups.

Discussion and conclusion

To increase the value of the MDT, all data relevant for treatment decision need to be purposefully presented and compiled, which also enables secondary use of the data.

The use of a digital solution during preoperative MDTs for prostate cancer decision making at Karolinska University Hospital improved the efficiency and quality of this multidisciplinary team meeting without impacting patient outcomes.

From “Cure” to “Care”: The Role of the MultiDisciplinary Team on Colorectal Cancer Patients’ Satisfaction and Oncological Outcomes

Background

Methods

Results

Conclusion

Role of Dedicated Subspecialized Radiologists in Multidisciplinary Team Discussions on Lower Gastrointestinal Tract Cancers

Objective

To determine the impact of dedicated subspecialized radiologists in multidisciplinary team (MDT) discussions on the management of lower gastrointestinal (GI) tract malignancies.

Materials and Methods

We retrospectively analyzed the data of 244 patients (mean age ± standard deviation, 61.7 ± 11.9 years) referred to MDT discussions 249 times (i.e., 249 cases, as five patients were discussed twice for different issues) for lower GI tract malignancy including colorectal cancer, small bowel cancer, GI stromal tumor, and GI neuroendocrine tumor between April 2018 and June 2021 in a prospective database. Before the MDT discussions, dedicated GI radiologists reviewed all imaging studies again besides routine clinical reading. The referring clinician’s initial diagnosis, initial treatment plan, change in radiologic interpretation compared with the initial radiology report, and the MDT’s consensus recommendations for treatment were collected and compared. Factors associated with changes in treatment plans and the implementation of MDT decisions were analyzed.

Results

Of the 249 cases, radiologic interpretation was changed in 73 cases (29.3%) after a review by dedicated GI radiologists, with 78.1% (57/73) resulting in changes in the treatment plan. The treatment plan was changed in 92 cases (36.9%), and the rate of change in the treatment plan was significantly higher in cases with changes in radiologic interpretation than in those without (78.1% [57/73] vs. 19.9% [35/176], p < 0.001). Follow-up records of patients showed that 91.2% (227/249) of MDT recommendations for treatment were implemented. Multiple logistic regression analysis revealed that the nonsurgical approach (vs. surgical approach) decided through MDT discussion was a significant factor for patients being managed differently than the MDT recommendations (Odds ratio, 4.48; p = 0.017).

Conclusion

MDT discussion involving additional review of radiology examinations by dedicated GI radiologists resulted in a change in the treatment plan in 36.9% of cases. Changes in treatment plans were significantly associated with changes in radiologic interpretation.

Implementing multidisciplinary tumor boards in oncology: a narrative review

The healthcare industry compares unfavorably with other ultra-safe industries such as aviation and nuclear power plants, which address complexity by reducing the vulnerability of a single person and promoting teams and strong systems. A multidisciplinary tumor board (MTB) is an evidence-based organizational approach to implementing a more effective concept in oncology practice. Studies addressing the correlation between MTBs and cancer outcomes show promising results, and other potential benefits are also addressed. The objectives of this article are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs effectiveness and address challenges to the implementation and maintenance of MTBs. In this commentary-type narrative review, the authors present their opinions and, whenever possible, substantiate recommendations by citing supportive literature.

The Effects of Multidisciplinary Team Meetings on Clinical Practice for Colorectal, Lung, Prostate and Breast Cancer: A Systematic Review

Simple Summary

Multidisciplinary team meetings have increasingly been implemented in cancer care worldwide to ensure timely, accurate and evidence-based diagnosis, and treatment plans. Nowadays, multidisciplinary team meetings are generally considered indispensable. However, they are considered time-consuming and expensive, while the effects of multidisciplinary team meetings are not yet fully understood. The aim of this systematic review is to update and summarize the literature and create an overview of the existing knowledge. Cancer types such as colorectal, lung, prostate and breast cancer with rapidly increasing incidence rates will inevitably impact the workload of clinicians. Understanding the effects of the widely implemented multidisciplinary team meetings in oncology care is fundamental in order to optimize care pathways and allocate resources in the rapidly diversifying landscape of cancer therapies.

Abstract

Objective: The aim of our systematic review is to identify the effects of multidisciplinary team meetings (MDTM) for lung, breast, colorectal and prostate cancer. Methods: Our systematic review, performed following PRISMA guidelines, included studies examining the impact of MDTMs on treatment decisions, patient and process outcomes. Electronic databases PUBMED, EMBASE, Cochrane Library and Web of Science were searched for articles published between 2000 and 2020. Risk of bias and level of evidence were assessed using the ROBINS-I tool and GRADE scale. Results: 41 of 13,246 articles were selected, evaluating colorectal (21), lung (10), prostate (6) and breast (4) cancer. Results showed that management plans were changed in 1.6–58% of cases after MDTMs. Studies reported a significant impact of MDTMs on surgery type, and a reduction of overall performed surgery after MDTM. Results also suggest that CT and MRI imaging significantly increased after MDTM implementation. Survival rate increased significantly with MDTM discussions according to twelve studies, yet three studies did not show significant differences. Conclusions: Despite heterogeneous data, MDTMs showed a significant impact on management plans, process outcomes and patient outcomes. To further explore the impact of MDTMs on the quality of healthcare, high-quality research is needed.

Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study

AIM

It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice.

METHOD

A multidisciplinary panel was convened and a modified two-phase Delphi method was used to select a set of quality indicators. Phase 1 included a literature review with written feedback from the panel. Phase 2 included an in-person workshop with anonymous voting. The selection criteria for the indicators were strength of evidence, ease of capture and usability. Indicators for which ≥90% of the panel members voted 'to keep' were selected as the final set of indicators.

RESULTS

During phase 1, 68 potential indicators were generated from the literature and an additional four indicators were recommended by the panel. During phase 2, these 72 indicators were discussed; 48 indicators met the 90% inclusion threshold and included eight pathology, five radiology, 11 surgical, six radiation oncology and 18 MCC indicators.

CONCLUSION

A modified Delphi method was used to select 48 multidisciplinary quality indicators to specifically measure the uptake of key processes necessary for high quality care of patients with rectal cancer. These quality indicators will be used in future work to identify and address gaps in care in the uptake of these clinical processes.

A systematic review of colorectal multidisciplinary team meetings: an international comparison

Background

Colorectal multidisciplinary teams (CR MDTs) were introduced to enhance the cancer care pathway and allow for early investigation and treatment of cancer. However, there are no ‘gold standards’ set for this process. The aim of this study was to review the literature systematically and provide a qualitative analysis on the principles, organization, structure and output of CR MDTs internationally.

Methods

Literature on the role of CR MDTs published between January 1999 and March 2020 in the UK, USA and continental Europe was evaluated. Historical background, structure, core members, education, frequency, patient-selection criteria, quality assurance, clinical output and outcomes were extracted from data from the UK, USA and continental Europe.

Results

Forty-eight studies were identified that specifically met the inclusion criteria. The majority of hospitals held CR MDTs at least fortnightly in the UK and Europe by 2002 and 2005 respectively. In the USA, monthly MDTs became a mandatory element of cancer programmes by 2013. In the UK, USA and in several European countries, the lead of the MDT meeting is a surgeon and core members include the oncologist, specialist nurse, histopathologist, radiologist and gastroenterologist. There were differences observed in patient-selection criteria, in the use of information technology, MDT databases and quality assurance internationally.

Conclusion

CR MDTs are essential in improving the patient care pathway and should express clear recommendations for each patient. However, a form of quality assurance should be implemented across all MDTs.

Improved Overall Survival of Colorectal Cancer under Multidisciplinary Team: A Meta-Analysis

Purpose

The purpose of the current meta-analysis was to evaluate whether multidisciplinary team improved overall survival of colorectal cancer.

Methods

PubMed, EMBASE, and Cochrane Library database were searched from inception to October 25, 2020. The hazard ratio (HR) and 95% confidence (CI) of overall survival (OS) were calculated.

Results

A total of 11 studies with 30814 patients were included in this meta-analysis. After pooling the HRs, the MDT group was associated with better OS compared with the non-MDT group (HR = 0.81, 95% CI 0.69-0.94, p = 0.005). In subgroup analysis of stage IV colorectal cancer, the MDT group was associated with better OS as well (HR = 0.73, 95% CI 0.59-0.90, p = 0.004). However, in terms of postoperative mortality, no significant difference was found between MDT and non-MDT groups (OR = 0.84, 95% CI 0.44-1.61, p = 0.60).

Conclusion

MDT could improve OS of colorectal cancer patients.

Impact of optional multidisciplinary tumor board meeting on the mortality of patients with gastrointestinal cancer: A retrospective observational study

Background

Multidisciplinary tumor board meetings (MDTs) have shown a positive effect on patient care and play a role in the planning of care. However, there is limited evidence of the association between MDTs and patient mortality and in‐hospital morbidity for mixed cases of gastrointestinal (GI) cancer.

Aim

To evaluate the influence of optional MDTs on care of patients with cancer to determine potential associations between MDTs and patient mortality and morbidity.

Methods and results

This was a retrospective observational study at the referral center of King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia. Among all adult patients diagnosed with GI cancer from January 2017 to June 2019, 130 patients were included. We categorized patients into two groups: 66 in the control group (non‐MDT) and 64 in the MDT group. The main outcome measure was overall mortality, measured by survival analysis. The follow‐up was 100% complete. Four patients in the MDT group and 13 in the non‐MDT group died (P = .04). The median follow‐up duration was 294 days (interquartile range [IQR], 140‐434) in the non‐MDT group compared with 176 days (IQR, 103‐466) in the MDT group (P = .20). There were no differences in intensive care unit or hospital length‐of‐stay or admission rates. The overall mortality at 2 years was 13% (95% confidence interval [CI], 0.06‐0.66) in the MDT group and 38% (95% CI, 0.10‐0.39) in the non‐MDT group (P = .08). The MDT group showed a 72% (adjusted hazard ratio [HR], 0.28; 95% CI, 0.08‐0.90; P = .03) decrease in mortality over time compared with the non‐MDT group.

Conclusions

MDTs were associated with decreased mortality over time. Thus, MDTs have a positive influence on patient care by improving survival and should be incorporated into care.

Do Multidisciplinary Tumor Board Discussions Correlate With Increase in 5-Year Survival? A Meta-Analysis Study

Introduction

Due to the complex nature of cancer cases, it is imperative that the involved healthcare providers coordinate the patients care plan in union to reach the best possible outcome in the smoothest and fastest manner. This is what multidisciplinary tumor board (MTB) meetings strive to achieve. Conducting regular MTB meetings requires significant investment of time and finances. It is thus vital to assess the empirical benefits of such practice.

Methods

A meta-analysis was conducted to evaluate the literature regarding the impact of MTB meetings on patient 5-year survival. Relevant studies were identified by searching Ovid MEDLINE and Embase databases from January 1995 to July 2019. Studies were included if they assessed 5-year survival in cases discussed in MTB meetings and used a comparison group and/or a pretest and posttest design.

Results

Five articles met the study's inclusion criteria. Quality of studies was affected by selection bias and the use of historic cohorts. The results showed significantly improved 5-year survival in the MTB group compared with the non-MTB groups (odds ratio for 5-year death rate of 0.59, CI 0.45-0.78, p < 0.001).

Conclusion

This meta-analysis showed that cancer MTB meetings have a significant impact on patients' 5-year survival. This could be because of several reasons, such as less time to treatment initiation, better adherence to guidelines, higher numbers of investigational imaging, lesser surgical complications, and recurrence rates. Future prospective studies are needed to further delineate reasons for improvement of outcome to enhance the benefits of this approach.

Match between therapeutic proposal in multidisciplinary tumor board and actual treatment in head and neck cancer

OBJECTIVES

There are few published studies evaluating the quality and outcome of multidisciplinary tumor board (MDTB) decisions. The aim of the present study was to evaluate adherence to MDTB recommendations in head and neck cancer and to document reasons in case of discordance.

MATERIAL AND METHODS

We included all patients with newly diagnosed head and neck cancer presented in our MDTB meetings between January 1st and December 31st, 2018, whatever the tumor site, histology type and TNM classification. MDTB recommendations were compared to actual treatment. Discordance was defined as treatment partially or entirely different from the treatment decision recorded in the MDTB minutes.

RESULTS

Board decisions were made for 344 new patients. Complete treatment concordance rate was 91.6% (315/344 patients), with deviation in 29 patients. Reasons for deviation were complications of treatment in 10 cases, patient refusal in 8, and physician's decision in 4 cases. Five patients died before therapy initiation. Mean interval from board discussion to treatment was 21 days, and depended on type of treatment (range, 1 to 74 days).

CONCLUSION

This study shows the importance of evaluating concordance between the protocol proposed in the MDTB and the treatment actually received, to identify factors for deviation and remedy them when possible.

Analysis and impact of a multidisciplinary lymphoma virtual tumor board

The aim is to prospectively evaluate the impact of a multidisciplinary lymphoma virtual tumor board. The utility of multi-site interactive lymphoma-specific tumor boards has not been reported. The Mayo Clinic Lymphoma Tumor Board is a component of the International Mayo Clinic Care Network (MCCN). The format includes the clinical case presentation, presentation of radiology and hematopathology findings by the appropriate subspecialist, proposed treatment options, review of the literature pertinent to the case, pharmacy contributions, and discussion followed by recommendations. Three hundred and nine consecutive highly selected real-time cases with a diagnosis of lymphoma were presented at the Mayo Clinic Lymphoma Tumor Board from January 2014 to June 2018 and decisions were prospectively tracked to assess its impact on the treatment decisions. A total of 309 cases were prospectively evaluated. One hundred and forty (45.3%) cases had some changes made or recommended. The total changes suggested were 179, as some cases had more than one recommendation. There were 93 (30%) clinical management recommendations, 45 (14.6%) additional testing recommendations, 29 (9.4%) pathology changes, and 6 (1.9%) radiology changes. In an electronic evaluation process, 93% of the responders reported an improvement in knowledge and competence, and 100% recommended no change in format of the board. A multidisciplinary lymphoma tumor board approach was found to have a meaningful impact on lymphoma patients while enhancing interdisciplinary interactions and education for multiple levels of the clinical care team.

The multidisciplinary management of rectal cancer

Rectal cancer treatment has evolved during the past 40 years with the use of a standardized surgical technique for tumour resection: total mesorectal excision. A dramatic reduction in local recurrence rates and improved survival outcomes have been achieved as consequences of a better understanding of the surgical oncology of rectal cancer, and the advent of adjuvant and neoadjuvant treatments to compliment surgery have paved the way for a multidisciplinary approach to disease management. Further improvements in imaging techniques and the ability to identify prognostic factors such as tumour regression, extramural venous invasion and threatened margins have introduced the concept of decision-making based on preoperative staging information. Modern treatment strategies are underpinned by accurate high-resolution imaging guiding both neoadjuvant therapy and precision surgery, followed by meticulous pathological scrutiny identifying the important prognostic factors for adjuvant chemotherapy. Included in these strategies are organ-sparing approaches and watch-and-wait strategies in selected patients. These pathways rely on the close working of interlinked disciplines within a multidisciplinary team. Such multidisciplinary forums are becoming standard in the treatment of rectal cancer across the UK, Europe and, more recently, the USA. This Review examines the essential components of modern-day management of rectal cancer through a multidisciplinary team approach, providing information that is essential for any practising colorectal surgeon to guide the best patient care.

Improvement of Care in Patients With Colorectal Cancer: Influence of the Introduction of Standardized Structured Reporting for Pathology

PURPOSE

The use of standardized structured reporting (SSR) can improve communication between cancer specialists, which might improve clinical care; however, there are no reliable data on whether the introduction of SSR is associated with improvements in clinical outcome.

PATIENTS AND METHODS

We performed a retrospective cohort study in the Netherlands, including all patients with colorectal cancer (CRC) from 2009 to 2014. As a reference, cohorts of 2007 and 2008 were included. Data from the Netherlands Cancer Registry were used and combined with data from the Dutch Pathology Registry (PALGA) and the Dutch ColoRectal Audit. We tested the preformulated hypothesis that use of SSR improves the care of patients with CRC by improving the completeness of the pathology reports, the quality of the pathology evaluation, and patient outcomes with respect to treatment and survival.

RESULTS

We included 72,859 patients with CRC (23.8% reference, 32.9% SSR, and 43.3% narrative reports). Use of SSR increased over time, which resulted in more complete pathology reports (95.8% v 89.8%; P < .001). Risk assessment in stage II colon cancer was more adequate and resulted in an increased delivery of adjuvant therapy in patients with SSR (19.6% v 15.1%; P = .001). Risk of death for patients in the SSR group was significantly lowered (corrected hazard ratio, 0.94; 95% CI 0.90 to 0.97).

CONCLUSION

We demonstrate that use of SSR improved patient care in those with CRC by providing more complete reports of higher quality, which had significant effects on the delivery of adjuvant therapy and patient outcomes.

Identification of barriers and facilitators in nationwide implementation of standardized structured reporting in pathology: a mixed method study

Standardized structured reporting (SSR) enables high-quality pathology reporting, but implementing SSR is slow. The objective of this study is to identify both barriers and facilitators that pathologists encounter in SSR, in order to develop tailored implementation tools to increase SSR usage. We used a mixed method design: a focus group interview helped to identify barriers and facilitators in SSR. The findings were classified into the following domains: innovation, individual professional, social setting, organization, and economic and political context. We used a web-based survey among Dutch pathologists to quantify the findings. Ten pathologists participated in the focus group interview, and 97 pathologists completed the survey. The results of both showed that pathologists perceive barriers related to SSR itself. Particularly its incompatibility caused lack of nuance (73%, n = 97) in the standardized structured pathology report. Regarding the individual professional, knowledge about available SSR-templates was lacking (28%, n = 97), and only 44% (n = 94) of the respondents agreed that using SSR facilitates the most accurate diagnosis. Related to social setting, support from the multidisciplinary team members was lacking (45%, n = 94). At organization level, SSR leads to extra work (52%, n = 94) because of its incompatibility with other information systems (38%, n = 93). Main facilitators of SSR were incorporation of speech recognition (54%, n = 94) and improvement in communication during multidisciplinary team meetings (69%, n = 94). Both barriers and facilitators existed in various domains. These factors can be used to develop implementation tools to encourage SSR usage.

Effectiveness of the Multidisciplinary Team Model in Treating Colorectal Cancer

The multidisciplinary team (MDT) model involves multiple medical professionals providing integrated medical care. Colorectal cancer (CRC) has the highest prevalence of cancer in Taiwan. This study examines and evaluates the survival rates of CRC patients treated under the MDT model. In this retrospective and prospective study, 651 CRC patients were recruited. They were divided into 2 groups: the MDT group and the traditional care (TC) group. The MDT group comprised 326 patients who received care from a MDT. The TC group comprised 325 patients who received care from a TC. The outcome variables were survival rates, follow-up appointment compliance, and 14-day readmission rates. Adopting the MDT model for CRC care increased patient follow-up appointment compliance rates at the first week, first month, and third month (p = .032, p = .007, p = .001, respectively). The model also effectively reduced patients' 14-day readmission rates. The results indicated that the survival rates of the MDT care were superior to those of TC. The adoption of the MDT model to treat CRC effectively enhanced clinical treatment adherence, increased survival rates, and reduced the 14-day readmission rate.

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database

IMPORTANCE

Management of pancreatic cancer is complex, requiring coordination of multiple providers. National Comprehensive Cancer Network guidelines, developed for standardization and quality improvement, recommend a multimodal approach.

OBJECTIVE

This study analyzed national rates of compliance with National Comprehensive Cancer Network recommendations, assessed factors affecting compliance, and evaluated whether compliance with evidence-based guidelines improved overall survival.

DESIGN

This is a retrospective review of adults diagnosed with pancreatic cancer entered into the National Cancer Database. Patients included had stage I and II pancreatic cancer, and complete data in the database. Patients were classified as compliant if they underwent both surgery and a second treatment modality (chemotherapy, radiation, or chemoradiation). Clinico-pathologic variables were analyzed using univariate and multivariate models to predict overall survival.

SETTING

Hospital-based national study population.

PARTICIPANTS

Patients with stage I or II pancreatic cancer.

MAIN OUTCOMES AND MEASURES

Compliance with National Comprehensive Cancer Network recommendations, factors affecting compliance, and overall survival based on compliance.

RESULTS

A total of 52,450 patients were included; 19,272 patients (37%) were compliant. Patients were found to be most compliant in the 50-59-year-old range (49% complaint), with decreased compliance at the extremes of age. Male patients were more compliant than female patients (39 vs 34%, p < 0.0001). Caucasians were more compliant (39%) than African Americans (32%) or other races (32%, p < 0.0001). Patients treated at academic/research centers were more compliant than patients treated at other facilities (39% compliant, p < 0.0001). Patients with stage II disease were more compliant compared with stage I disease (43 vs 18%, p < 0.0001). Compliance was shown to improve overall survival (p < 0.0001).

CONCLUSION

Adherence to National Comprehensive Cancer Network guidelines for pancreatic cancer patients improves survival. Compliance nationwide is low, especially for older patients and minorities and those treated outside academic centers. More studies will need to be performed to identify factors that hinder compliance.

The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature

BACKGROUND

Conducting regular multidisciplinary team (MDT) meetings requires significant investment of time and finances. It is thus important to assess the empirical benefits of such practice. A systematic review was conducted to evaluate the literature regarding the impact of MDT meetings on patient assessment, management and outcomes in oncology settings.

METHODS

Relevant studies were identified by searching OVID MEDLINE, PsycINFO, and EMBASE databases from 1995 to April 2015, using the keywords: multidisciplinary team meeting* OR multidisciplinary discussion* OR multidisciplinary conference* OR case review meeting* OR multidisciplinary care forum* OR multidisciplinary tumour board* OR case conference* OR case discussion* AND oncology OR cancer. Studies were included if they assessed measurable outcomes, and used a comparison group and/or a pre- and post-test design.

RESULTS

Twenty-seven articles met inclusion criteria. There was limited evidence for improved survival outcomes of patients discussed at MDT meetings. Between 4% and 45% of patients discussed at MDT meetings experienced changes in diagnostic reports following the meeting. Patients discussed at MDT meetings were more likely to receive more accurate and complete pre-operative staging, and neo-adjuvant/adjuvant treatment. Quality of studies was affected by selection bias and the use of historical cohorts impacted study quality.

CONCLUSIONS

MDT meetings impact upon patient assessment and management practices. However, there was little evidence indicating that MDT meetings resulted in improvements in clinical outcomes. Future research should assess the impact of MDT meetings on patient satisfaction and quality of life, as well as, rates of cross-referral between disciplines.

Do Multidisciplinary Team (MDT) processes influence survival in patients with colorectal cancer? A population-based experience

Background

MDT (multidisciplinary team) meetings are considered an essential component of care for patients with cancer. However there is remarkably little direct evidence that such meetings improve outcomes. We assessed whether or not MDT (multidisciplinary team) processes influenced survival in a cohort of patients with colorectal cancer.

Methods

Observational study of a population-based cohort of 586 consecutive patients with colorectal cancer diagnosed in Tayside (Scotland) during 2006 and 2007.

Results

Recommendations from MDT meetings were implemented in 411/586 (70.1 %) of patients, the MDT+ group. The remaining175/586 (29.9 %) were either never discussed at an MDT, or recommendations were not implemented, MDT- group. The 5-year cause-specific survival (CSS) rates were 63.1 % (MDT+) and 48.2 % (MDT-), p < 0.0001. In analysis confined to patients who survived >6 weeks after diagnosis, the rates were 63.2 % (MDT+) and 57.7 % (MDT-), p = 0.064. The adjusted hazard rate (HR) for death from colorectal cancer was 0.73 (0.53 to 1.00, p = 0.047) in the MDT+ group compared to the MDT- group, in patients surviving >6 weeks the adjusted HR was 1.00 (0.70 to 1.42, p = 0.987). Any benefit from the MDT process was largely confined to patients with advanced disease: adjusted HR _(early) 1.32 (0.69 to 2.49, p = 0.401); adjusted HR_(advanced) 0.65 (0.45 to 0.96, p = 0.031).

Conclusions

Adequate MDT processes are associated with improved survival for patients with colorectal cancer. However, some of this effect may be more apparent than real – simply reflecting selection bias. The MDT process predominantly benefits the 40 % of patients who present with advanced disease and conveys little demonstrable advantage to patients with early tumours. These results call into question the current belief that all new patients with colorectal cancer should be discussed at an MDT meeting.

Reviewing cancer care team effectiveness

PURPOSE

The management of cancer varies across its type, stage, and natural history. This necessitates involvement of a variety of individuals and groups across a number of provider types. Evidence from other fields suggests that a team-based approach helps organize and optimize tasks that involve individuals and groups, but team effectiveness has not been fully evaluated in oncology-related care.

METHODS

We undertook a systematic review of literature published between 2009 and 2014 to identify studies of all teams with clear membership, a comparator group, and patient-level metrics of cancer care. When those teams included two or more people with specialty training relevant to the care of patients with cancer, we called them multidisciplinary care teams (MDTs). After reviews and exclusions, 16 studies were thoroughly evaluated: two addressing screening and diagnosis, 11 addressing treatment, two addressing palliative care, and one addressing end-of-life care. The studies included a variety of end points (eg, adherence to quality indicators, patient satisfaction with care, mortality).

RESULTS

Teams for screening and its follow-up improved screening use and reduced time to follow-up colonoscopy after an abnormal screen. Discussion of cases within MDTs improved the planning of therapy, adherence to recommended preoperative assessment, pain control, and adherence to medications. We did not see convincing evidence that MDTs affect patient survival or cost of care, or studies of how or which MDT processes and structures were associated with success.

CONCLUSION

Further research should focus on the association between team processes and structures, efficiency in delivery of care, and mortality.

Utilizing the multidisciplinary team for planning and monitoring care and quality improvement

Multidisciplinary team management of patients with rectal cancer requires a dedicated group of surgeons, medical and radiation oncologists, pathologists, radiologists, and mid-level providers who meet to discuss every patient with rectal cancer. The data from that meeting is collected prospectively, recommendations made for case, follow-up obtained, and quality issues monitored. Improved case is the result.

Optimisation of preoperative assessment in patients diagnosed with rectal cancer

AIMS

Treatment decision making for patients with rectal cancer is complex and optimal preoperative assessment is important to ensure patients receive appropriate and high-quality care. Therefore, our objective was to develop an evidence-based, multidisciplinary guideline to assist physicians treating rectal cancer to ensure that preoperative assessment is optimal.

MATERIALS AND METHODS

A multidisciplinary expert panel of physicians who treat rectal cancer was selected as members of the Cancer Care Ontario Preoperative Assessment for Rectal Cancer Guideline Development Group (GDG). This group initially met to identify important clinical questions with respect to optimisation of preoperative assessment in patients diagnosed with rectal cancer. A systematic review, specific to each of these clinical questions, was then conducted using MEDLINE, EMBASE and the Cochrane Library databases. The GDG met at regular intervals to review the evidence and to develop guidelines to address each of the clinical questions.

RESULTS

The GDG identified seven important clinical questions with respect to the optimisation of preoperative assessment in patients diagnosed with rectal cancer. The clinical questions pertained to: (i) investigations required to assess distant metastasis (one question); (ii) imaging for local staging of rectal cancer (five questions); (iii) multidisciplinary cancer conference (MCC) (one question); (iv) restaging-magnetic resonance imaging (one question). The systematic reviews related to these clinical questions yielded 31 articles that were abstracted and reviewed by the GDG. Based on the systematic reviews, a guideline was developed containing seven recommendations that were either adapted from existing guidelines, based on review of the evidence or by consensus when evidence was limited.

CONCLUSIONS

A set of seven recommendations have been developed in order to optimise pretreatment assessment in patients with rectal cancer by promoting evidence-based practice. These guidelines are based on the best available evidence and have been peer reviewed by two independent multidisciplinary expert panels for relevance and validity.

Effect of holistic health education prescription in colorectal cancer patients undergoing surgery

AIM: To assess the effect of holistic health education prescription in colorectal cancer patients undergoing surgery.

METHODS: One hundred and sixty patients with colorectal cancer treated from January 2011 to May 2014 at our hospital were randomly divided into either an observation group (80 cases) or a control group (80 cases). Holistic health education prescription was applied in the observation group, and routine oral health education was applied in the control group. Colorectal cancer awareness, clinical knowledge and function recovery, complications, and patient's satisfaction to medical care were compared for the two groups.

RESULTS: The rates of awareness of basic knowledge on colorectal cancer, complications, treatment, drugs, diet nursing, sports training and bowel habit were significantly higher in the observation group than in the control group (93.75% vs 70.00%, 87.50% vs 52.50%, 90.00% vs 56.25%, 87.50% vs 55.00%, 91.25% vs 56.25%, 91.25% vs 53.75%, P < 0.05). The times to ambulation and first anal exhaust were significantly shorter in the observation group than in the control group (11.58 h ± 2.00 h vs 18.07 h ± 3.76 h, 32.15 h ± 7.83 h vs 64.73 h ± 10.52 h, P < 0.05). The rate of complications was significantly lower in the observation group (10.00% vs 45.00%, P < 0.05), and the rate of patient's satisfaction to medical care was significantly higher in the observation group (97.50% vs 68.75%, P < 0.05).

CONCLUSION: The application of holistic health education prescription in patients with colorectal cancer can improve the awareness of colorectal cancer knowledge, promote recovery, reduce complications, and increase patient's satisfaction.

An Internet-Based Collaborative Cancer Conference for Rectal Cancer Influenced Surgeon Treatment Recommendations

INTRODUCTION

In many jurisdictions geographic and resource constraints are barriers to multidisciplinary cancer conference review of all patients undergoing cancer surgery. We piloted an internet-based collaborative cancer conference (I-CCC) for rectal cancer to overcome these barriers in the LHIN4 region of Ontario (population 1.4 million).

METHODS

Surgeons practicing at one of 10 LHIN4 hospitals were invited to participate in I-CCC reviews. A secure internet audio and visual link facilitated review of cross-sectional images and case details. Before review, referring surgeons detailed initial treatment plans. Main treatment options included preoperative radiation, straight to surgery, and plan uncertain. Changes were noted following I-CCC review from initial to final treatment plan. Major changes included: redirect patient to preoperative radiation from straight to surgery or plan uncertain; and redirect patient to straight to surgery from preoperative radiation or plan uncertain. Minor changes included: change type of neoadjuvant therapy; request additional tests (e.g., pelvic MRI); or formal MCC review.

RESULTS

From November 2010 to May 2012, 20 surgeons (7 academic and 13 community) submitted 57 rectal cancer cases for I-CCC review. After I-CCC review, 30 of 57 (53 %) cases had treatment plan changes: 17 major and 13 minor. No patient or tumour factors predicted for treatment plan change.

CONCLUSIONS

An I-CCC for rectal cancer in a large geographic region was feasible and influenced surgeon treatment recommendations in 53 % of cases. Because no factor predicted for treatment plan change, it is likely prudent that all rectal cancer patients undergo some form of collaborative review.

National and international guidelines for rectal cancer

AIM

Rectal cancer is a common malignancy. Differences in daily practice may influence the morbidity and mortality, and many national and international organizations have created guidelines for staging and treatment of rectal cancer. Even though consensus is reached within individual guidelines, this might not be the case between guidelines. No formal evaluation of the contrasting guidance has been reported.

METHOD

A systematic search for national and international guidelines on rectal cancer was performed. Eleven guidelines were identified for further analysis.

RESULTS

There was no consensus concerning the definition of rectal cancer. Ten of the 11 guidelines use the TNM staging system and there was general agreement regarding the recommendation of MRI and CT in rectal cancer. There was consensus concerning a multidisciplinary approach, preoperative chemoradiotherapy (CRT) and total mesorectal excision (TME). There was no consensus concerning local treatment of T1 tumours and adjuvant therapy, and not all guidelines included metastatic disease and recurrence. There was no consensus on the protocol for follow up. The guidelines had different approaches to evidence. All referred to evidence but not all considered the level of evidence.

CONCLUSION

The intention of the study was to provide an overview of international guidelines for rectal cancer based on the underlying evidence, but despite hard evidence it was very difficult to reach general conclusions. Despite much knowledge, there is no international consensus on guidelines for the staging and treatment of rectal cancer.

Multidisciplinary cancer conferences for gastrointestinal malignancies result in measureable treatment changes: a prospective study of 149 consecutive patients

BACKGROUND

In most jurisdictions, a minority of patients are discussed at multidisciplinary cancer conference (MCC) despite recommendations for such reviews. We assessed the impact of MCC review of gastrointestinal (GI) cancers at a stand-alone cancer center.

METHODS

Patient data were prospectively collected on consecutive cases presented at a GI MCC during a 6-month period. Original treatment plans were collected confidentially before presentation and compared to post-MCC treatment plans. We defined changes in management plans as major (change in treatment modality) or minor (testing prior to original plan).

RESULTS

A total of 149 cases were evaluated: 115 upper GI (gastric/small bowel-10 %, liver-32 %, pancreaticobiliary-36 %), and 34 lower GI (23 %). Reasons for presentation were: questions regarding progression/metastases (44 %), management (26 %), diagnosis (21 %), pathology (15 %), and resectability (7 %). Physicians were certain of their original plans being the final recommendations in 84 % (n = 125). Change in management was recommended in 36 %; 72 % were major and 28 % were minor. Patients underwent all recommended treatments at our institution in 77 % of cases, a portion in 5 %, and no recommended treatments in 18 %. On multivariate analysis, physician degree of certainty for original management plan was not predictive of a change in management plan (p = 0.61).

CONCLUSIONS

Although certainty of prediscussion treatment plan is high, changes in treatment recommendations occurred in more than one-third of patients after GI MCC. This prospective study demonstrates the value of MCC in GI cancer sites, even at a stand-alone cancer center.

Not all patients need to be discussed in a colorectal cancer MDT meeting

AIM

It is recommended that patients with cancer should be managed in the context of a multidisciplinary team (MDT). Alternatively, proponents of the standard model of care propose that the well-informed treating doctor is able to make the appropriate plan for each patient, making the need for a MDT meeting redundant. We compared the management plans made within a colorectal cancer MDT with routine care.

METHOD

Consecutive cases presenting to the colorectal MDT were prospectively assessed. Before the meeting management plans were made, based on routine care pathways. These were compared with plans made at the MDT meeting and discrepancies recorded. The number of patients who generated beneficial discussion was recorded.

RESULTS

There were 261 discussions regarding the care of 197 patients. In the 203 cases where the pathways were relevant, patient management was consistent with the pathway in 94% of the cases discussed. Discussion of routine cases of colon cancer rarely changed management (3.4%). Conversely, management changed after MDT discussion in 50% of complex cases (the preoperative management of rectal cancer, recurrence, metastatic disease and malignant polyps). The postoperative discussion of pathology findings rarely generated beneficial discussion.

CONCLUSION

Discussion of routine cases of colon cancer in our MDT rarely changed management, but it did change the decisions regarding complex cases or in patients with unusual pathology. We propose a two-tiered approach to the MDT where all patients are listed for a MDT meeting but only patients with complex pathology are discussed in detail.

Colorectal cancer

More than 1·2 million patients are diagnosed with colorectal cancer every year, and more than 600,000 die from the disease. Incidence strongly varies globally and is closely linked to elements of a so-called western lifestyle. Incidence is higher in men than women and strongly increases with age; median age at diagnosis is about 70 years in developed countries. Despite strong hereditary components, most cases of colorectal cancer are sporadic and develop slowly over several years through the adenoma-carcinoma sequence. The cornerstones of therapy are surgery, neoadjuvant radiotherapy (for patients with rectal cancer), and adjuvant chemotherapy (for patients with stage III/IV and high-risk stage II colon cancer). 5-year relative survival ranges from greater than 90% in patients with stage I disease to slightly greater than 10% in patients with stage IV disease. Screening has been shown to reduce colorectal cancer incidence and mortality, but organised screening programmes are still to be implemented in most countries.

Magnetic resonance imaging in rectal cancer: A surgeon’s perspective

Magnetic resonance imaging (MRI) in rectal cancer was first investigated in 1999 and has become almost mandatory in planning rectal cancer treatment. MRI has a high accuracy in predicting circumferential resection margin involvement and is used to plan neoadjuvant therapy. The accuracy of MRI in assessing mesorectal lymph nodes remains moderate, as there are no reliable criteria to assess nodal involvement. MRI seems to be good in assessing peritoneal involvement in upper rectal cancer; this however has been assessed in only a few studies and needs further research. For low rectal cancers, mesorectum is thin at the level of levator ani especially in relation to prostate; so predicting circumferential resection margin involvement is not easy. However high spatial resolution coronal imaging shows levator muscles, sphincter complex and intersphincteric plane accurately. This is used to stage low rectal tumors and plan plane of surgery (standard surgery, intersphincteric resection, Extralevator abdominoperineal resection). While most centres perform MRI post chemoradiotherapy, its role in accurate staging post neoadjuvant therapy remains debatable. THe role of Diffusion weighted MRI post neoadjuvant therapy is being evaluated in research settings.

Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?