Analysis of clinical decision-making in multi-disciplinary cancer teams

Predictors of multivisceral resection in patients with locally advanced colorectal cancer

BACKGROUND

Practice guidelines recommend en bloc multivisceral resection (MVR) for all involved organs in patients with locally advanced adherent colorectal cancer (LAACRC) to reduce local recurrence and improve survival. We found that MVR was performed in one-third of eligible American patients in the Surveillance, Epidemiology and End Results cancer registry but that study could not identify factors amenable to quality improvement. This study was conducted to examine rates, and predictors of MVR among Canadian patients with LAACRC.

METHODS

Rates of MVR were examined by observational study. Eligible patients were aged 20-74 years who had surgery for nonmetastatic LAACRC from July 1997 to December 2000. Patient, tumor, surgeon, and hospital characteristics were extracted from medical records. Summary statistics were compared by type of surgery (MVR, partial MVR, standard resection). To identify factors associated with MVR we analyzed operative notes and transcripts from interviews with general surgeons using standard qualitative methods.

RESULTS

Factors associated with MVR included fewer years in practice, preoperative treatment planning, involvement of surgical consultants, and access to diagnostic imaging and systems to enable preoperative multidisciplinary planning. Judgments regarding the nature of peritumoral adhesions, resectability, and personal technical skill may mediate decision-making. Many surgeons would prefer to refer patients than undertake complicated, lengthy cases.

CONCLUSION

Further research is required to validate these findings in larger studies and among patients undergoing surgery for conditions other than LAACRC, and evaluate strategies to improve rates of MVR through enhanced individual awareness and system capacity.

Multiple factors influence compliance with colorectal cancer staging recommendations: an exploratory study

BACKGROUND

For patients with colorectal cancer (CRC) retrieval by surgeons, and assessment by pathologists of at least 12 lymph nodes (LNs) predicts the need for adjuvant treatment and improved survival. Different interventions (educational presentation, engaging clinical opinion leaders, performance data sent to hospital executives) to improve compliance with this practice had variable results. This exploratory study examined factors hypothesized to have influenced the outcome of those interventions.

METHODS

Semi-structured interviews were conducted with 26 surgeons and pathologists at eleven hospitals. Clinicians were identified by intervention organizers, public licensing body database, and referral from interviewees. An interview guide incorporating open-ended questions was pilot-tested on one surgeon and pathologist. A single investigator conducted all interviews by phone. Transcripts were analyzed independently by two investigators using a grounded approach,ho then compared findings to resolve differences.

RESULTS

Improvements in LN staging practice may have occurred largely due to educational presentations that created awareness, and self-initiated changes undertaken by pathologists. Executives that received performance data may not have shared this with staff, and opinion leaders engaged to promote compliance may not have fulfilled their roles. Barriers to change that are potentially amenable to quality improvement included perceptions about the practice (perceived lack of evidence for the need to examine at least 12 LNs) and associated responsibilities (blaming other profession), technical issues (need for pathology assistants, better clearing solutions and laboratory facilities), and a lack of organizational support for multidisciplinary interaction (little communication between surgeons and pathologists) or quality improvement (no change leaders or capacity for monitoring).

CONCLUSION

Use of an exploratory approach provided an in-depth view of the way that numerous factors amenable to quality improvement influenced the adoption of new CRC LN staging recommendations. Continued interventions targeting physicians and executives, in the absence of a receptive organizational infrastructure, may be fruitless. Individualized rather than regional or punitive performance data, coupled with increased organizational capacity for change may stimulate greater surgical and organizational response to quality improvement. Descriptive or experimental studies are needed to test these hypotheses.

Pulmonary metastasectomy: a common practice based on weak evidence

The resection of secondary metastases from the lungs is a wide-spread surgical practice. Patients are referred from coloproctology teams to thoracic surgeons specifically for this surgery. What is the expected benefit? I have explored the rationale and searched the literature in order to present these patients with a well-informed opinion for their consideration. I find only weak evidence based on uncontrolled retrospective series which have been interpreted as showing a survival benefit. This has been extrapolated to policy and practice that do not stand up to scrutiny. The practice has never been subjected to randomised trial and I will argue that the present evidence is insufficient to justify the uncontrolled use of an intervention with inescapable short-term morbidity, permanent loss of function, and major cost implications. I propose ways in which the evidence may be improved, including a trial in the areas of most uncertainty.

Quality of life during potentially curative treatment for locally advanced oesophageal cancer

Background

Combination chemoradiotherapy with or without surgery are internationally applied alternative strategies for potential cure of oesophageal cancer. This study compared health-related quality of life (HRQL) between patients selected for chemoradiation and those who had combination treatment including oesophagectomy.

Methods

Patients with stage II or III oesophageal cancer completed HRQL assessments at baseline, at the worst expected HRQL time point and at expected recovery. HRQL was compared between groups using linear regression, adjusting for age, sex, performance status, tumour stage and type, and baseline HRQL.

Results

Some 132 patients began treatment, of whom 51 had chemoradiotherapy and 81 combination treatment including surgery. Patients selected for chemoradiotherapy were older, more likely to have squamous cell cancer and reported poorer HRQL than those selected for surgery. At the worst expected time point after treatment, both groups reported multiple symptoms and poor function, but surgery was associated with a greater reduction in HRQL from baseline than chemoradiotherapy. Recovery of HRQL was achieved within 6 months after chemoradiotherapy, but complete recovery had not occurred 6 months after surgery and there was persistent significant deterioration in some aspects.

Conclusion

The negative treatment-related impact of chemoradiation on short-term HRQL is less than that experienced with combination treatment including surgery. Patients preferring early recovery should consider definitive chemoradiation.

Influences on multidisciplinary team decision-making

The objective is to explore how clinical decisions are made in a cancer multidisciplinary team meeting (MDM). The study design is qualitative based on participant observation, in depth interviews, and questionnaires. The research setting was weekly cancer MDM which provides a forum for clinical debate for practitioners in the field of women's health, working within one Cancer Network in England. The participants were 53 practitioners attending a weekly MDM over a 4-month period. Analysis of nonparticipant observation data and practitioner interview narratives identified key influences on the work of the MDM, and in particular decision-making. The research identified three major influences on the conduct of the MDM. First, MDM discussions are dominated by those with surgical, medical, or diagnostic expertise with limited contributions from those with a nursing, palliative, or psychosocial background. Second, decision-making is shaped by an overriding need to comply with policy initiatives concerning the organization of diagnosis and treatment. The third influence is whether the patient is known or unknown to some degree by members of the MDM. Where there is preexisting knowledge of the patient, the discussion and decision is inclusive of a wider range of disciplines. Team working in these circumstances is an acknowledged source of satisfaction and motivation. Where the patient is not known, discussion concerns only the physical details necessary to make a diagnosis and contributions from the wider team (including those with knowledge of psychosocial care) are rare. Practitioners' sphere of expertise, Department of Health policy, and familiarity of the team with the patient are key factors in shaping decision-making in MDMs.

Offering a prognosis in lung cancer: when is a team of experts an expert team?

The outlook for patients with lung cancer is poor, so an accurate estimation of prognosis will underpin treatment decisions and allow patients to make personal plans for the future. However, evidence suggests that there is a variation between doctors in their predictions of outcomes and also they tend to be over-optimistic. Two main questions are addressed in this study: whether multidisciplinary team discussion changes prognostic accuracy of individual clinicians; and whether team discussion improves the accuracy of the team's aggregated prediction. A real-time study of 50 newly diagnosed patients discussed by a regional lung cancer team was undertaken. A case pro-forma informed the completion of a pre-discussion questionnaire by each team member, seeking prognostic predictions at specific time points. This was repeated after team discussion. Medical notes were reviewed at 6 months to establish actual survival status. Group discussion did not significantly change the accuracy of survival predictions for any one clinician, but the team as a whole performed better after case discussion. Predictions which the clinicians were more confident about were found to be no more accurate than those where they were less confident. There is a wide variation in the range and accuracy of prognostic predictions made by individual clinicians, with no consistent improvement after team discussion. As such predictions are integral to decision making, further research on decision-making processes of clinical teams is required.

The role of collegial interaction in continuing professional development

INTRODUCTION

Many physicians seek information from colleagues over other sources, highlighting the important role of interaction in continuing professional development (CPD). To guide the development of CPD opportunities, this study explored the nature of cancer-related questions faced by general surgeons, and how interaction with colleagues addressed those questions.

METHODS

This study involved thematic analysis of field notes collected through observation and transcripts of telephone interviews with 20 surgeons, two pathologists, one medical oncologist, and one radiation oncologist affiliated with six community hospitals participating in multidisciplinary cancer conferences by videoconference in one region of Ontario, Canada.

RESULTS

Six multidisciplinary cancer conferences (MCCs) were observed between April and September 2006, and 11 interviews were conducted between December 2006 and January 2007. Sharing of clinical experience made possible collective decision making for complex cancer cases. Physicians thought that collegial interaction improved awareness of current evidence, patient satisfaction with treatment plans, appropriate care delivery, and continuity. By comparing proposed treatment with that of the group and gaining exposure to decision making for more cases than they would see in their own practices, physicians developed clinical expertise that could be applied to future cases. Little collegial interaction occurred outside these organized sessions.

DISCUSSION

These findings highlight the role of formally coordinated collegial interaction as an important means of CPD for general surgeons. Investment may be required for infrastructure to support such efforts and for release of health professional time for participation. Further research is required to examine direct and indirect outcomes of collegial interaction.

Multidisciplinary teams in cancer care: are they effective in the UK?

Cancer care can be complex, and given the wide range and numbers of health-care professionals involved, an enormous potential for poor coordination and miscommunication exists. Multidisciplinary teams (MDTs) should improve coordination, communication, and decision making between health-care team members and patients, and hopefully produce more positive outcomes. This review describes the many practical barriers to the successful implementation of MDT working, and shows that despite an increase in the delivery of cancer services via this method, research showing the effectiveness of MDT working is scarce.

Emerging aspects of oesophageal and gastro-oesophageal junction cancer histopathology - an update for the surgical oncologist

Adenocarcinoma of the oesophagus and gastro-oesophageal junction are rapidly increasing in incidence and have a well described sequence of carcinogenesis: the Barrett's metaplasia-dysplasia-adenocarcinoma sequence. During recent years there have been changes in the knowledge surrounding disease progression, cancer management and histopathology specimen reporting. Tumours around the gastro-oesophageal junction (GOJ) pose several specific challenges. Numerous difficulties arise when the existing TNM staging systems for gastric and oesophageal cancers are applied to GOJ tumours. The issues facing the current TNM staging and GOJ tumour classification systems are reviewed in this article. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as circumferential resection margin status and lymph node metastases, have implications for specimen reporting. With the rising use of multimodal treatments for oesophageal cancer it is important that the response of the tumour to this therapy is carefully documented pathologically. In addition, several controversial and novel areas such as endoscopic mucosal resection, lymph node micrometastases and the sentinel node concept are being studied. We aim to review these aspects, with special relevance to oesophageal and gastro-oesophageal cancer specimen reporting, to update the surgical oncologist with an interest in upper gastrointestinal cancer.