The multidiscipline team in a cancer center

Influence of endocrine multidisciplinary tumor board on patient management and treatment decision making

BACKGROUND

Multidisciplinary Tumor Boards (MDT) are used to obtain input regarding cancer management. This study assessed the impact of our institutional Endocrine MDT.

METHODS

MDT notes on patients with thyroid cancer treated during 2012-2018 were abstracted retrospectively from the electronic medical record. Management change (MC) was prospectively collected by the MDT coordinator. Biannual evaluations reviewed the impact of the MDT as observed by attendees.

RESULTS

MC was recommended in 47 (15%) of 286 presentations, with additional imaging being the most frequent (43%). Presentation of recurrences were more likely to result in MC (24% vs. 13% initial, p = 0.03). Overall, 98% of attendees found the conference exceeded educational expectations. About 24% reported intending to use a more evidence/guideline-based approach after attending and this trend increased over time (p = 0.002).

CONCLUSION

MDT presentations led to a higher rate of MC particularly in recurrent TC patients and increased evidenced-based practice for attendees.

The impact of tumor board on cancer care: evidence from an umbrella review

Background

Tumor Boards (TBs) are Multidisciplinary Team (MDT) meetings in which different specialists work together closely sharing clinical decisions in cancer care. The composition is variable, depending on the type of tumor discussed. As an organizational tool, MDTs are thought to optimize patient outcomes and to improve care performance. The aim of the study was to perform an umbrella review summarizing the available evidence on the impact of TBs on healthcare outcomes and processes.

Methods

Pubmed and Web of Science databases were investigated along with a search through citations. The only study design included was systematic review. Only reviews published after 1997 concerning TBs and performed in hospital settings were considered. Two researchers synthetized the studies and assessed their quality through the AMSTAR2 tool.

Results

Five systematic reviews published between 2008 and 2017 were retrieved. One review was focused on gastrointestinal cancers and included 16 studies; another one was centered on lung cancer and included 16 studies; the remaining three studies considered a wide range of tumors and included 27, 37 and 51 studies each. The main characteristics about format and members and the definition of TBs were collected. The decisions taken during TBs led to changes in diagnosis (probability to receive a more accurate assessment and staging), treatment (usually more appropriate) and survival (not unanimous improvement shown). Other outcomes less highlighted were quality of life, satisfaction and waiting times.

Conclusions

The study showed that the multidisciplinary approach is the best way to deliver the complex care needed by cancer patients; however, it is a challenge that requires organizational and cultural changes and must be led by competent health managers who can improve teamwork within their organizations. Further studies are needed to reinforce existing literature concerning health outcomes. Evidence on the impact of TBs on clinical practices is still lacking for many aspects of cancer care. Further studies should aim to evaluate the impact on survival rates, quality of life and patient satisfaction. Regular studies should be carried out and new process indicators should be defined to assess the impact and the performance of TBs more consistently.

A Multidisciplinary Team Approach to Brain and Spine Stereotactic Radiosurgery Conferences: A Unique Institutional Model

OBJECTIVE

The use of multidisciplinary teams (MDTs) comprised of all members of the patient care team is becoming increasingly popular in the field of oncology. We present a single-center experience exploring the utility and uniqueness of an MDT in the care of patients undergoing brain and spine stereotactic radiosurgery (SRS).

METHODS

The weekly SRS conference brought together neurosurgeons, radiation oncologists, neuroradiologists, physicists, dosimetrists, therapists, advanced practice providers, and trainees in these fields as well as researchers from a variety of disciplines with a goal of optimizing patient care. A survey of 20 conference attendees from 7 different facets of the MDT was conducted for feedback.

RESULTS

The survey results revealed that most respondents believed the SRS conference increased educational opportunities, provided opportunities for research and collaborations, helped streamline patient care, and was beneficial to their practice.

CONCLUSIONS

We present our institutional MDT model, a framework and workflow that can be incorporated at other large academic centers. We believe that the SRS conference has educational, academic, and patient care value.

The efficiency of electronic list-based multidisciplinary team meetings in management of gastrointestinal malignancy: a single-center experience in Southern China

Background

The multidisciplinary team (MDT) discussion has earned increasing popularity for the delivery of cancer care. However, MDT meeting (MDTM) is time and resource intensive, and some efforts to optimize discussion processes are required. This study aims to investigate the efficiency of electronic list-based MDTM in treatment of gastrointestinal (GI) malignancy.

Methods

Between January 2015 and December 2016, patients with GI cancers were retrospectively reviewed. Patients permitting an MDTM with our novel technique (eMDT group) were compared with those undergoing a traditional discussion (cMDT group). The efficiency of MDT working, including time cost per meeting or case and overall number of reviewed cases, was checked, with accuracy of clinical staging and other outcomes explored meanwhile.

Results

Three thousand six hundred seventy-four patients were included, with 2156 (58.7%) and 1518 (41.3%) cases for eMDT and cMDT groups, respectively. Comparisons in age (P = 0.529), gender (P = 0.844), cancer type (P = 0.218), treatment plan (P = 0.737), and pathological stage (P = 0.098) were not significant between groups. However, the average time cost in both each meeting (149.4 vs. 205.1 min; P < 0.001) and each case (3.1 vs. 6.2 min; P < 0.001) was markedly reduced. Besides, this novel technique was associated with improved accuracy of clinical staging (P = 0.070) and reduced hospital stay (P < 0.001) compared with the traditional approach, with similar incidence of complications observed (P = 0.243).

Conclusions

The MDT working based on an intelligent checklist could save considerable time while not affecting treatment of GI malignancies. The improved efficiency also earns an increased capacity of hospital admission and in-patient care.

The Value of Multidisciplinary Team Meetings for Patients with Gastrointestinal Malignancies: A Systematic Review

INTRODUCTION

The incidence of gastrointestinal (GI) cancer is rising and most patients with GI malignancies are discussed by a multidisciplinary team (MDT). We performed a systematic review to assess whether MDTs for patients with GI malignancies can correctly change diagnosis, tumor stage and subsequent treatment plan, and whether the treatment plan was implemented.

METHODS

We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We conducted a search of the PubMed, MEDLINE and EMBASE electronic databases, and included studies relating to adults with a GI malignancy discussed by an MDT prior to the start of treatment which described a change of initial diagnosis, stage or treatment plan. Two researchers independently evaluated all retrieved titles and abstracts from the abovementioned databases.

RESULTS

Overall, 16 studies were included; the study quality was rated as fair. Four studies reported that MDTs changed the diagnoses formulated by individual physicians in 18.4-26.9% of evaluated cases; two studies reported that MDTs formulated an accurate diagnosis in 89 and 93.5% of evaluated cases, respectively; nine studies described that the treatment plan was altered in 23.0-41.7% of evaluated cases; and four studies found that MDT decisions were implemented in 90-100% of evaluated cases. The reasons for altering a treatment plan included the patient's wishes, and comorbidities.

CONCLUSIONS

MDT meetings for patients with a GI malignancy are responsible for changes in diagnoses and management in a significant number of patients. Treatment plans formulated by MDTs are implemented in 90-100% of discussed patients. All patients with a GI malignancy should be discussed by an MDT.

Improving outcomes in urological cancers: The impact of “multidisciplinary team meetings”

INTRODUCTION

In order to improve the outcomes of urological cancers, guidelines published by the National Institute of Clinical Excellence encourage the management of cancer patients by specific Multi-Disciplinary Teams (MDTs) with discussion of cancer patients at MDT Meetings. The aim of this prospective study was to examine the changes in management resulting from review at MDT Meetings in our unit.

METHODS

Over a six month period 124 cancer cases were discussed at 10 meetings. Prior to the meetings consultants completed a form stating their proposed management and whether they thought this would be changed after discussion. At the meeting histological, radiological and clinical data were reviewed and a collective decision about the optimal treatment was made. Any changes were recorded.

RESULTS

Two of 124 cases had their clinical management changed as a result of the meeting. These were identified (amongst 10 others) as potential 'change cases' prior to the meeting. Four changes were made to histological reports and 1 to radiology; none of these affected clinical management.

CONCLUSION

Discussion of cancer cases at MDMs made no difference to the clinical management in over 98% of cases. Consultants correctly identified cases requiring discussion, indicating that a selective rather than blanket approach would be appropriate. This has the potential to reduce the considerable costs involved without affecting patient care.

In vitro chemosensitivity testing and its clinical application in human gliomas

Several in vitro chemosensitivity assays have been developed for predicting clinical response to chemotherapeutic and biologic agents, alone and in combinations. The most widely accepted assay is the colony forming assay (CFA) which assesses the clonogenic capability of stem cells. Other methods include growth inhibition assays by evaluating cell number; thymidine incorporation; or amino acid uptake. More recently an automatic colorimetric technique utilizing crystal violet dye or a tetrazolium (MTT) vital dye has been developed for more rapid assessment of cytotoxic or growth inhibitory activity in vitro. Several reports have compared the results of in vitro tests with patients' clinical response. Two major problems affect the predictive value of in vitro chemosensitivity tests. The foremost is cellular heterogeneity which exists within a single tumor as well as between tumors. Artificial selective pressure inherent to tissue culture system is the other problem. In general, in vitro tests predict clinical resistance more consistently than clinical sensitivity. However, chemosensitivity assays remain useful in screening new agents and preclinical modeling of clinical trials.

Multidisciplinary pretreatment cancer planning

One can estimate that 60% or more of cancer patients stand to benefit from the multidisciplinary treatment of cancer. Different treatments given in sequence mean real benefit in terms of absolute cure or length of disease-free life for many. While the details of treatment techniques can usually be worked out for each patient in expert fashion, the process of planning to fit the three main modalities together into a single plan presents complex problems. To obtain optimum results someone must assemble and coordinate the opinions of the oncologists who are consulted in each case; and someone must do it before treatment begins. Benefit is significantly reduced if the planning process is delayed until recurrence occurs. Those who act as primary physicians in caring for cancer patients have a newly defined major role to play: they must select the oncology team, coordinate the various opinions, and continue to supervise the course of the cancer throughout in order that the patients receive the best care. When a physician prepares for, and accepts, this role of leader-coordinator, and outlines in broad general terms a properly integrated plan from the first, details of therapy fall easily into place.

Helping the parents of children with malignancy

The parents of children with cancer experience a uniquely stressful situation that poses a profound threat to the equilibrium of the entire family. As health professionals, we recognize, with the parents, that this is a crisis and an ordeal, but that it can be resolved; we mobilize them to broaden their understanding of their situation and find constructive solutions to the problems that develop. For our patients with good prognoses, we hope to ensure a future for the whole family that is as healthy emotionally as it is physically; for those who become fatally ill, we hope to help their families support them and emerge from this experience with new adaptive abilities. Our group program is open to parents of patients who have various diagnoses, with a format that is unstructured and focuses on problems of daily living as well as the possibility of death. We have found that this is an effective approach for the delivery of mental health services to our growing population, early in the course of treatment, and for the identification of families that need ongoing counseling. Our experience with the large number of parents who have participated demonstrates that the program provides the support that the parents need and that it plays a vital role in resolving the problems that confront them as they struggle with this very difficult experience.

Radiation in bone sarcomas: a re-evaluation in the era of intensive systemic chemotherapy

We have reviewed the literature and described experience in treating Ewing's sarcoma and osteosarcoma before and during the era of intensive systemic chemotherapy. Local control of Ewing's sarcoma may relate to increasing doses of radiation, especially when intensive chemotherapy is administered also. Problems of radiation enhancement by chemotherapy have caused us to reconsider time-dose and volume parameters in treating these patients. The role of radiation in osteogenic sarcoma is limited to patients with inoperable lesions and metastases.