Impact of a multidisciplinary tumour board meeting for upper-GI malignancies on clinical decision making: a prospective cohort study

Multidisciplinary neurofibromatosis conference in the management of patients with neurofibromatosis type 1 and schwannomatosis in a single tertiary care institution

OBJECTIVE

To evaluate the role of weekly neurofibromatosis (NF) multi-disciplinary conferences (MDC) on the diagnostic and therapeutic plan for patients with NF type 1 (NF1) and schwannomatosis (SWN).

MATERIALS AND METHODS

This retrospective study reviewed patients with confirmed or suspected NF1 and SWN discussed in weekly MDC from March to July 2021. Demographic data collected included patient age, sex, pre-conference and post-conference diagnosis, radiological studies reviewed, and provider specialties in attendance. Outcomes reported included changes in imaging interpretation and treatment plans, changes in post-conference diagnosis relative to pre-conference diagnosis, and time to completion of the recommended change in treatment.

RESULTS

Data from 17 MDC "pre-conference" lists included 75 patients (38 female, 37 males, mean age (years): 38 (range: 6-80)) with NF1 (52%, 39/75) and SWN (36%, 27/75) discussed over a total of 91 case reviews. 18.7% (14/75) of all patients had NF2-related SWN, and 17.3% (13/75) of all patients had non-NF2 SWN. The MDC led to changes in imaging interpretation in 18.7% and changes in patient management in 74.7% (diagnostic testing (n = 52), surgical plan (n = 24), medical treatment (n = 9), clinical trial status (n = 4), and radiation treatment (n = 1)) of cases. Among patients for whom a change in management was recorded, 91% (62/68) completed at least one recommendation (mean time to completion (days): 41.4 (range: 0-278)).

CONCLUSION

Weekly MDC changes the diagnostic and therapeutic management of the majority of patients discussed (74.7%) and promotes a high adherence rate to recommendations (91%).

Machine learning to predict curative multidisciplinary team treatment decisions in oesophageal cancer

BACKGROUND

Rising workflow pressures within the oesophageal cancer (OC) multidisciplinary team (MDT) can lead to variability in decision-making, and health inequality. Machine learning (ML) offers a potential automated data-driven approach to address inconsistency and standardize care. The aim of this experimental pilot study was to develop ML models able to predict curative OC MDT treatment decisions and determine the relative importance of underlying decision-critical variables.

METHODS

Retrospective complete-case analysis of oesophagectomy patients ± neoadjuvant chemotherapy (NACT) or chemoradiotherapy (NACRT) between 2010 and 2020. Established ML algorithms (Multinomial Logistic regression (MLR), Random Forests (RF), Extreme Gradient Boosting (XGB)) and Decision Tree (DT) were used to train models predicting OC MDT treatment decisions: surgery (S), NACT + S or NACRT + S. Performance metrics included Area Under the Curve (AUC), Accuracy, Kappa, LogLoss, F1 and Precision -Recall AUC. Variable importance was calculated for each model.

RESULTS

We identified 399 cases with a male-to-female ratio of 3.6:1 and median age of 66.1yrs (range 32-83). MLR outperformed RF, XGB and DT across performance metrics (mean AUC of 0.793 [±0.045] vs 0.757 [±0.068], 0.740 [±0.042], and 0.709 [±0.021] respectively). Variable importance analysis identified age as a major factor in the decision to offer surgery alone or NACT + S across models (p < 0.05).

CONCLUSIONS

ML techniques can use limited feature-sets to predict curative UGI MDT treatment decisions. Explainable Artificial Intelligence methods provide insight into decision-critical variables, highlighting underlying subconscious biases in cancer care decision-making. Such models may allow prioritization of caseload, improve efficiency, and offer data-driven decision-assistance to MDTs in the future.

What is the Value of Radiology Input During a Multidisciplinary Orthopaedic Oncology Conference?

BACKGROUND

Multidisciplinary orthopaedic oncology conferences are important in developing the treatment plan for patients with suspected orthopaedic bone and soft tissue tumors, involving physicians from several services. Past studies have shown the clinical value of these conferences; however, the impact of radiology input on the management plan and time cost for radiology to staff these conferences has not been fully studied.

QUESTIONS/PURPOSES

(1) Does radiology input at multidisciplinary conference help guide clinical management and improve clinician confidence? (2) What is the time cost of radiology input for a multidisciplinary conference?

METHODS

This prospective study was conducted from October 2020 to March 2022 at a tertiary academic center with a sarcoma center. A single data questionnaire for each patient was sent to one of three treating orthopaedic oncologists with 41, 19, and 5 years of experience after radiology discussion at a weekly multidisciplinary conference. A data questionnaire was completed by the treating orthopaedic oncologist for 48% (322 of 672) of patients, which refers to the proportion of those three oncologists' patients for which survey data were captured. A musculoskeletal radiology fellow and musculoskeletal fellowship-trained radiology attending physician provided radiology input at each multidisciplinary conference. The clinical plan (leave alone, follow-up imaging, follow-up clinically, recommend different imaging test, core needle biopsy, surgical excision or biopsy or fixation, or other) and change in clinical confidence before and after radiology input were documented. A second weekly data questionnaire was sent to the radiology fellow to estimate the time cost of radiology input for the multidisciplinary conference.

RESULTS

In 29% (93 of 322) of patients, there was a change in the clinical plan after radiology input. Biopsy was canceled in 30% (24 of 80) of patients for whom biopsy was initially planned, and surgical excision was canceled in 24% (17 of 72) of patients in whom surgical excision was initially planned. In 21% (68 of 322) of patients, there were unreported imaging findings that affected clinical management; 13% (43 of 322) of patients had a missed finding, and 8% (25 of 322) of patients had imaging findings that were interpreted incorrectly. For confidence in the final treatment plan, 78% (251 of 322) of patients had an increase in clinical confidence by their treating orthopaedic oncologist after the multidisciplinary conference. Radiology fellows and attendings spent a mean of 4.2 and 1.5 hours, respectively, reviewing and presenting at a multidisciplinary conference each week. The annual combined prorated time cost for the radiology attending and fellow was estimated at USD 24,310 based on national median salary data for attendings and internal salary data for fellows.

CONCLUSION

In a study taken at one tertiary-care oncology program, input from radiology attendings and fellows in the setting of a multidisciplinary conference helped to guide the final treatment plan, reduce procedures, and improve clinician confidence in the final treatment plan, at an annual time cost of USD 24,310.

CLINICAL RELEVANCE

Multidisciplinary orthopaedic oncology conferences can lead to changes in management plans, and the time cost to the radiologists should be budgeted for by the radiology department or parent institution.

Hospital practice variation in the proportion of patients with esophagogastric cancer discussed during an expert multidisciplinary team meeting

BACKGROUND

Multidisciplinary team meetings (MDTM) and especially MDTMs in which expert centres are involved (expert MDTMs) are a key element in adequate cancer care. However, variation among hospitals in the proportion of patients presented during an expert MDTM has been described. This study aims to investigate national practice variation in the proportion of patients with oesophageal or gastric cancer being discussed during an expert MDTM.

METHODS

Patients diagnosed with oesophageal or gastric cancer in 2018-2019 were selected from the Netherlands Cancer Registry (n = 6,921). Multilevel logistic regression analyses were used to analyse the association between patient, and tumour characteristics, and the probability to be discussed in an expert MDTM. Variation was analysed according to the hospital and region of diagnosis for: all patients, patients with a potentially curable (cT1-4A cTX, any cN, cM0) or incurable tumour stage (cT4b and/or cM1).

RESULTS

In total, 79% of patients were discussed during an expert MDTM, of whom 84% (n = 3,424) and 71% (n = 2,018) with potentially curable, or incurable oesophageal or gastric cancer, respectively. The proportion of patients discussed during an expert MDTM ranged from 54% to 98%, and 17% to 100% between hospitals for potentially curable and incurable patients, respectively (all p < 0.0001). Adjusted analyses showed significant hospital (all p < 0.0001), but no regional variation regarding the patients discussed during an expert MDTM.

CONCLUSION

For patients with oesophageal or gastric cancer the probability of being discussed during an expert MDTM varies considerably according to the hospital of diagnosis.

The Oesophageal Cancer Multidisciplinary Team: Can Machine Learning Assist Decision-Making?

BACKGROUND

The complexity of the upper gastrointestinal (UGI) multidisciplinary team (MDT) is continually growing, leading to rising clinician workload, time pressures, and demands. This increases heterogeneity or 'noise' within decision-making for patients with oesophageal cancer (OC) and may lead to inconsistent treatment decisions. In recent decades, the application of artificial intelligence (AI) and more specifically the branch of machine learning (ML) has led to a paradigm shift in the perceived utility of statistical modelling within healthcare. Within oesophageal cancer (OC) care, ML techniques have already been applied with early success to the analyses of histological samples and radiology imaging; however, it has not yet been applied to the MDT itself where such models are likely to benefit from incorporating information-rich, diverse datasets to increase predictive model accuracy.

METHODS

This review discusses the current role the MDT plays in modern UGI cancer care as well as the utilisation of ML techniques to date using histological and radiological data to predict treatment response, prognostication, nodal disease evaluation, and even resectability within OC.

RESULTS

The review finds that an emerging body of evidence is growing in support of ML tools within multiple domains relevant to decision-making within OC including automated histological analysis and radiomics. However, to date, no specific application has been directed to the MDT itself which routinely assimilates this information.

CONCLUSIONS

The authors feel the UGI MDT offers an information-rich, diverse array of data from which ML offers the potential to standardise, automate, and produce more consistent, data-driven MDT decisions.

The role of the multidisciplinary tumor board (MDTB) in the assessment of pancreatic cancer diagnosis and resectability: A tertiary referral center experience

Background

The introduction of multidisciplinary tumor boards (MDTBs) for the diagnostic and therapeutic pathway of several oncological disease significantly ameliorated patients' outcomes. However, only few evidences are currently present on the potential impact of the MDTB on pancreatic cancer (PC) management. Aim of this study is to report how MDTB may influence PC diagnosis and treatment, with particular focus on PC resectability assessment and the correspondence between MDTB definition of resectability and intraoperative findings.

Methods

All patients with a proven or suspected diagnosis of PC discussed at the MDTB between 2018 and 2020 were included in the study. An evaluation of diagnosis, tumor response to oncological/radiation therapy and resectability before and after the MDTB was conducted. Moreover, a comparison between the MDTB resectability assessment and the intraoperative findings was performed.

Results

A total of 487 cases were included in the analysis: 228 (46.8%) for diagnosis evaluation, 75 (15.4%) for tumor response assessment after/during medical treatment, 184 (37.8%) for PC resectability assessment. As a whole, MDTB led to a change in treatment management in 89 cases (18.3%): 31/228 (13.6%) in the diagnosis group, 13/75 (17.3%) in the assessment of treatment response cohort and 45/184 (24.4%) in the PC resectability evaluation group. As a whole, 129 patients were given indication to surgery. Surgical resection was accomplished in 121 patients (93.7%), with a concordance rate of resectability between MDTB discussion and intraoperative findings of 91.5%. Concordance rate was 99% for resectable lesions and 64.3% for borderline PCs.

Conclusions

MDTB discussion consistently influences PC management, with significant variations in terms of diagnosis, tumor response assessment and resectability. In this last regard, MDTB discussion plays a key role, as demonstrated by the high concordance rate between MDTB resectability definition and intraoperative findings.

Team dynamics and clinician’s experience influence decision-making during Upper-GI multidisciplinary team meetings: A multiple case study

Background

The probability of undergoing treatment with curative intent for esophagogastric cancer has been shown to vary considerately between hospitals of diagnosis. Little is known about the factors that attribute to this variation. Since clinical decision making (CDM) partially takes place during an MDTM, the aim of this qualitative study was to assess clinician’s perspectives regarding facilitators and barriers associated with CDM during MDTM, and second, to identify factors associated with CDM during an MDTM that may potentially explain differences in hospital practice.

Methods

A multiple case study design was conducted. The thematic content analysis of this qualitative study, focused on 16 MDTM observations, 30 semi-structured interviews with clinicians and seven focus groups with clinicians to complement the collected data. Interviews were transcribed ad verbatim and coded.

Results

Factors regarding team dynamics that were raised as aspects attributing to CDM were clinician’s personal characteristics such as ambition and the intention to be innovative. Clinician’s convictions regarding a certain treatment and its outcomes and previous experiences with treatment outcomes, and team dynamics within the MDTM influenced CDM. In addition, a continuum was illustrated. At one end of the continuum, teams tended to be more conservative, following the guidelines more strictly, versus the opposite in which hospitals tended towards a more invasive approach maximizing the probability of curation.

Conclusion

This study contributes to the awareness that variation in team dynamics influences CDM during an MDTM.

Evaluation of multidisciplinary team decisions in neuroendocrine neoplasms: Impact of expert centres

OBJECTIVE

To evaluate the impact of multidisciplinary team (MDT) meetings on the management of patients with neuroendocrine neoplasms (NENs).

METHODS

All newly referred gastro-entero-pancreatic (GEP)-NEN patients discussed from 1 April to 1 October 2017 in the MDT of seven European expert centres were prospectively included. The impact on patients' management was defined as a change in diagnosis, grade, stage or treatment.

RESULTS

A total of 292 patients were included, mainly small intestinal (siNENs) (32%) and pancreatic NENs (28%), with distant metastases in 51%. Patients had received prior surgery in 43% of cases and prior medical treatment in 32%. A significant change occurred in 61% of NENs: 7% changes in diagnosis, 8% in grade and 16% in stage. The MDT recommended a new treatment for 51% of patients, mainly surgery (9%) or somatostatin analogues (20%). A significant change was most frequently observed in patients with Stage IV disease (hazard ratio [HR] 3.6, 95% confidence interval [CI]: 1.9-6.9 vs. Stage I) and G2 NENs (vs. G1, HR 2.1 95% CI: 1.2-3.8).

CONCLUSION

NEN-dedicated MDT discussion in expert centres yields significant management changes in over 60% of patients and thus represents the gold standard for the management of these patients.

Clinical variation in the organization of clinical pathways in esophagogastric cancer, a mixed method multiple case study

Background

Among esophagogastric cancer patients, the probability of having undergone treatment with curative intent has been shown to vary, depending on the hospital of diagnosis. However, little is known about the factors that contribute to this variation. In this study, we sought to understand the organization of clinical pathways and their association with variation in practice.

Methods

A mixed-method study using quantitative and qualitative data was conducted. Quantitative data were obtained from the Netherlands Cancer Registry (e.g., outpatient clinic consultations and diagnostic procedures). For qualitative data, thematic content analysis was performed using semi-structured interviews (n = 30), observations of outpatient clinic consultations (n = 26), and multidisciplinary team meetings (MDTM, n = 16) in eight hospitals, to assess clinicians’ perspectives regarding the clinical pathways.

Results

Quantitative analyses showed that patients more often underwent surgical consultation prior to the MDTM in hospitals associated with a high probability of receiving treatment with curative intent, but more often consulted with a geriatrician in hospitals associated with a low probability of such treatment. The organization of clinical pathways was analyzed quantitatively at three levels: regional, local, and patient levels. At a regional level, hospitals differed in terms of the number of patients discussed during the MDTM. At the local level, the revision of radiological images and restaging after neoadjuvant treatment varied. At the patient level, some hospitals routinely conduct fitness tests, whereas others estimated the patient’s physical fitness during an outpatient clinic consultation. Few clinicians performed a standard geriatric consultation in older patients to assess their mental fitness and frailty.

Conclusion

Surgical consultation prior to MDTM was more often conducted in hospitals associated with a high probability of receiving treatment with curative intent, whereas a geriatrician was consulted more often in hospitals associated with a low probability of receiving such treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07845-2.

Treatment decision-making during outpatient clinic visit of patients with esophagogastric cancer. The perspectives of clinicians and patients, a mixed method, multiple case study

BACKGROUND

The probability of undergoing treatment with curative intent according to the hospital of diagnosis varies for esophagogastric cancer in the Netherlands. Little is known about the factors contributing to this variation. This study aimed to improve the understanding of the differences between the multidisciplinary team meeting treatment proposal and the treatment that was actually carried out and to qualitatively investigate the differences in treatment decision-making after the multidisciplinary team meeting treatment proposal between hospitals.

METHODS

To gain an in-depth understanding of treatment decision-making, quantitative data (i.e., multidisciplinary team meeting proposal and treatment that was carried out) were collected from the Netherlands Cancer Registry. Changes in the multidisciplinary team meeting proposal and applied treatment comprised changes in the type of treatment option (i.e., curative or palliative, or no change) and were calculated according to the multivariable multilevel probability of undergoing treatment with curative intent (low, middle, and high). Qualitative data were collected from eight hospitals, including observations of 26 outpatient clinic consultations, 30 in-depth interviews with clinicians, seven focus groups with clinicians, and three focus groups with patients. Clinicians and patients' perspectives were assessed using thematic content analysis.

RESULTS

The multidisciplinary team meeting proposal and applied treatment were concordant in 97% of the cases. Clinicians' implementation of treatment decision-making in clinical practice varied, which was mentioned by the clinicians to be due to the clinician's personality and values. Differences between clinicians consisted of discussing all treatment options versus only the best fitting treatment option and the extent of discussing the benefits and harms. Most patients aimed to undergo curative treatment regardless of the consequences, since they believed this could prolong their life.

CONCLUSION

Since changes in the multidisciplinary team meeting-proposed treatment and actual treatment were rarely observed, this study emphasizes the importance of an adequately formulated multidisciplinary team meeting proposal.

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.

The Impact of Multidisciplinary Conferences on Treatment Plans for Patients With Inflammatory Bowel Disease in a Tertiary Canadian Centre

Background

Multidisciplinary conference presentation may provide recommendations for diagnosis, monitoring and treatment for patients with inflammatory bowel disease.

Methods

A prospective observational study was completed evaluating if case presentation resulted in a direct change in management for patients presented over a 2-year period in a tertiary Canadian centre. Change in management was defined as hospital admission, surgery or surgical referral, start/change in biologic therapy or other medication or initiation of parenteral nutrition. Secondary outcomes included the involvement of specialists and other referrals. Data were analyzed using frequencies and means with standard deviations.

Results

In 63 multidisciplinary conferences, 181 patients were presented, of whom 136 patients met the inclusion criteria of inflammatory bowel disease (Crohn’s n = 45, ulcerative colitis n = 88, undifferentiated n = 3). The majority were outpatient cases 110 (81%). Indications included 71 (52%) patients presented for IBD management with diagnosis > 1 year, 37 (27%) with an acute IBD flare in a chronic patient (>1 year since diagnosis) and 24 (18%) with new diagnosis of IBD. Change in management was recommended in 35 (26%) patients. The most common change was referral to surgery in 17 (13%), surgery in 12 (9%) or change in biologic therapy 11 (8%). Compliance with the recommendations was 85%. There was frequent specialist involvement in case discussions (gastroenterologist 100%, surgeon 60%, radiologist 68% and pathologist 32%).

Conclusions

Presentation of complex inflammatory bowel disease cases at multidisciplinary conference leads to a direct change in treatment in one quarter of cases, with surgical referral as the most frequent outcome.

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.

Multidisciplinary team meetings: are all patients presented and does it impact quality of care and survival - a registry-based study

Background

Multidisciplinary team meetings (MDTMs) are part of the standard cancer care process in many European countries. In France, they are a mandatory condition in the authorization system for cancer care administration, with the goal to ensure that all new patients diagnosed with cancer are presented in MDTMs.

Aim

Identify the factors associated with non-presentation or unknown presentation in MDTMs, and study the impact of presentation in MDTMs on quality of care and survival in patients diagnosed with colorectal cancer (CRC).

Methods

3999 CRC patients diagnosed between 2005 and 2014 in the area covered by the “Calvados Registry of Digestive Tumours” were included. Multivariate multinomial logistic regression was used to assess the factors associated with presentation in MDTMs. Univariate analyses were performed to study the impact of MDTMs on quality of care. Multivariate Cox model and the Log-Rank test were used to assess the impact of MDTMs on survival.

Results

Non-presentation or unknown presentation in MDTMs were associated with higher age at diagnosis, dying within 3 months after diagnosis, unknown metastatic status, non-metastatic cancer and colon cancer. Non-presentation was associated with a diagnosis after 2010. Unknown presentation was associated with a diagnosis before 2007 and a longer travel time to the reference care centres. Presentation in MDTMs was associated with more chemotherapy administration for patients with metastatic cancer and more adjuvant chemotherapy for patients with stage III colon cancer. After excluding poor prognosis patients, lower survival was significantly associated with higher age at diagnosis, unknown metastatic status or metastatic cancer, presence of comorbidities, rectal cancer and non-presentation in MDTMs (HR = 1.5 [1.1–2.0], p < 0.001).

Conclusions

Elderly and poor prognosis patients were less presented in MDTMs. Geriatric assessments before presentation in MDTMs were shown to improve care plan establishment. The 100% objective is not coherent if MDTMs are only to discuss diagnosis and curative cares. They could also be a place to discuss therapeutic limitations. MDTMs were associated with better treatment and longer survival. We must ensure that there is no inequity in presentation in MDTMs that could lead to a loss of chance for patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07022-x.

Clinically decisive (dis)agreement in multidisciplinary team assessment of esophageal squamous cell carcinoma; a prospective, national, multicenter study

BACKGROUND

Decisions regarding tumor staging, operability, resectability, and treatment strategy in patients with esophageal cancer are made at multidisciplinary team (MDT) conferences. We aimed to assess interobserver agreement from four national MDT conferences and whether this would have a clinical impact.

METHODS

A total of 20 patients with esophageal cancer were included across all four upper gastrointestinal (GI) cancer centers. Fully anonymized patient data were distributed among the MDT conferences which decided on TNM category, resectability, operability, curability, and treatment strategy blinded to each other's decisions. The interobserver agreement was expressed as both the raw observer agreement and with Krippendorff's α values. Finally, a case-by-case evaluation was performed to determine if disagreement would have had a clinical impact.

RESULTS

A total of 80 MDT evaluations were available for analysis. A moderate to near-perfect observer agreement of 79.2%, 55.8%, and 82.5% for TNM category was observed, respectively. Substantial agreement for resectability and moderate agreement for curability were found. However, an only fair agreement was observed for the operability category. The treatment strategies had a slight agreement which corresponded to disagreement having a clinical impact in 12 patients.

CONCLUSIONS

Esophageal cancer MDT conferences had an acceptable interobserver agreement on resectability and TM categories; however, the operability assessment had a high level of disagreement. Consequently, the agreement on treatment strategy was reduced with a potential clinical impact. In future MDT conferences, emphasis should be on prioritizing the relevant information being readily available (operability, T & M categories) to minimize the risk of disagreement in the assessments and treatment strategies, and thus, delayed or suboptimal treatment.

Impact on Quality of Documentation and Workload of the Introduction of a National Information Standard for Tumor Board Reporting

PURPOSE

Tumor boards, clinical practice guidelines, and cancer registries are intertwined cancer care quality instruments. Standardized structured reporting has been proposed as a solution to improve clinical documentation, while facilitating data reuse for secondary purposes. This study describes the implementation and evaluation of a national standard for tumor board reporting for breast cancer on the basis of the clinical practice guideline and the potential for reusing clinical data for the Netherlands Cancer Registry (NCR).

METHODS

Previously, a national information standard for breast cancer was derived from the corresponding Dutch clinical practice guideline. Using data items from the information standard, we developed three different tumor board forms: preoperative, postoperative, and postneoadjuvant-postoperative. The forms were implemented in Amphia Hospital’s electronic health record. Quality of clinical documentation and workload before and after implementation were compared.

RESULTS

Both draft and final tumor board reports were collected from 27 and 31 patients in baseline and effect measurements, respectively. Completeness of final reports increased from 39.5% to 45.4% (P = .04). The workload for tumor board preparation and discussion did not change significantly. Standardized tumor board reports included 50% (61/122) of the data items carried in the NCR. An automated process was developed to upload information captured in tumor board reports to the NCR database.

CONCLUSION

This study shows implementation of a national standard for tumor board reports improves quality of clinical documentation, without increasing clinical workload. Simultaneously, our work enables data reuse for secondary purposes like cancer registration.

Treatment Patterns and Outcomes in Patients with Esophageal Cancer: An Analysis of a Multidisciplinary Tumor Board Database

BACKGROUND

Multidisciplinary management strategies are standard in esophageal cancer. Based on a multidisciplinary tumor board (MTB) database in a high-volume center, we aimed to evaluate real-world treatment patterns and patient outcomes in patients with esophageal cancer. In addition, we determined the impact of MTB discussions on patient prognosis.

METHODS

Patients diagnosed with esophageal cancer between 2010 and 2019 were retrospectively reviewed. The pattern of treatment modalities and overall survival (OS) of patients with limited, locally advanced, and advanced/metastatic disease were reported.

RESULTS

Data from 1132 patients, including 247 patients with limited esophageal cancer, 606 patients with locally advanced esophageal cancer, and 279 patients with advanced/metastatic esophageal cancer were included. Upfront surgery was the most common (56.3%) treatment modality for patients with limited esophageal cancer, while treatment for locally advanced esophageal cancer included upfront surgery (19.1%), neoadjuvant chemoradiotherapy (44.9%), and definitive chemoradiotherapy (36.0%); however, 27.9% of patients undergoing neoadjuvant chemoradiotherapy did not receive planned esophagectomy. Definitive chemoradiotherapy was mainly used for patients with locally advanced and advanced/metastatic disease, but had an incompletion rate of 22.0% and 33.7%, respectively. Regarding survival, the 5-year OS rates were 56.4%, 26.3%, and 5.1% in patients with limited, locally advanced, and advanced/metastatic disease, respectively. Additionally, patients whose clinical management was discussed in the MTB had a significantly better 5-year OS rate than the other patients (27.3% vs. 20.5%, p < 0.001).

CONCLUSIONS

We report the real-world data of treatment patterns and patient outcomes in patients with esophageal cancer with respect to multidisciplinary management, and demonstrate the positive impact of MTB discussions on patient prognosis.

Implementation of a regional video multidisciplinary team meeting is associated with an improved prognosis for patients with oesophageal cancer A mixed methods approach

BACKGROUND

Studies have shown that multidisciplinary team meetings (MDTM) improve diagnostic work-up and treatment-decisions. This study aims to evaluate the influence of implementing a regional-video-Upper-GI-MDTM (uMDTM) for oesophageal cancer (OC) on the number of patients discussed, treatment-decisions, perspectives of involved clinicians and overall survival (OS) in the Eindhoven Upper-GI Network consisting of 1 resection hospital and 5 referring hospitals.

METHODS

Between 2012 and 2018, patients diagnosed with OC within this region, were selected from the Netherlands Cancer Registry(n = 1119). From 2014, an uMDTM was gradually implemented and a mixed-method quantitative and qualitative design was used to analyse changes. Quantitative outcomes were described before and after implementation of the uMDTM. Clinicians were interviewed to assess their perspectives regarding the uMDTM.

RESULTS

After participation in the uMDTM more patients were discussed in an MDTM (80%-89%,p < 0.0001) and involvement of a resection centre during the uMDTM increased (43%-82%,p < 0.0001). The proportion of patients diagnosed with potentially curable OC (cT1-4a-x, any cN, cM0) remained stable (59%-61%, p = 0.452). Endoscopic or surgical resections were performed more often (28%-34%,p = 0.034) and the use of best supportive care decreased (21%-15%,p = 0.018). In the qualitative part an improved knowledge, collaboration and discussion was perceived due to implementation of the uMDTM. Three-year OS for all OC patients increased after the implementation of the uMDTM (24%-30%,p = 0.025).

CONCLUSIONS

Implementation of a regional Upper-GI MDTM was associated with an increase in patients discussed with a resection centre, more curative resections and a better OS. It remains to be elucidated which factors in the clinical pathway explain this observed improved survival.

Impact of a Virtual Multidisciplinary Sarcoma Case Conference on Treatment Plan and Survival in a Large Integrated Healthcare System

PURPOSE

Quantifying the impact of a multidisciplinary cancer case conference on patient outcome and care quality remains challenging.

PATIENTS AND METHODS

We prospectively investigated the impact of our virtual multidisciplinary sarcoma case conference (VMSCC) on treatment plan in patients presented to the VMSCC from July to October 2020 (prospective cohort) and retrospectively in patients with metastatic or locally advanced high-grade soft-tissue sarcoma (STS) reviewed in the VMSCC in 2016 and 2017 (high-grade STS cohort). We also investigated the factors related to the nonadherence to the VMSCC-recommended plan in both cohorts.

RESULTS

In both cohorts, approximately 28% of the patients were referred to the VMSCC for review without a treatment plan. In significantly more cases, referring physicians outside of the sarcoma group did not have a plan formulated before the VMSCC review compared with the referring physicians within the sarcoma group. In 28.2% (prospective cohort) and 19.5% (high-grade STS cohort) of the patients, VMSCC recommended a different plan. The adherence to the VMSCC-recommended plan was 87.9% and 83.1%, respectively. The causes of the nonadherence were primarily due to disease progression or patient's decision against recommended therapy. The median overall survival for the high-grade STS cohort was 26 months.

CONCLUSION

VMSCC affected the treatment plan in approximately 50% of the patients in both cohorts. The median overall survival of the patients with high-grade STS reviewed by the VMSCC in our cohort is comparable with the literature.

Impact of multidisciplinary approach and radiologic review on surgical outcome and overall survival of patients with pancreatic cancer: a retrospective cohort study

AIM

To evaluate the impact of multidisciplinary team case discussion including computed tomography (CT) radiologic review on surgical outcome and overall survival (OS) of patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

Patients with PDAC evaluated in 2008-2011 and 2013-2016 (before and after multidisciplinary team introduction), aged <85 years and staged I-III, were included. Surgical failures and 2-year OS were compared in these periods. Available CT scans of preintervention period (2008-2011) cases were reviewed by two radiologists in consensus, assigning a resectability judgment to evaluate in how many cases a different recommendation would be achieved.

RESULTS

A total of 316 patients (49.3% female, age 71±10 years) were included: 132 in 2008-2011 and 184 in 2013-2016. The proportion of patients who underwent upfront surgery was similar in the two periods (51% vs 47% in 2008-2011 vs 2013-2016). Neoadjuvant referral increased from 7% to 21% and surgical resection was excluded for 42% patients in 2008-2011 vs 33% in 2013-2016 (p = 0.002). Adjusting by age, sex, and stage, surgical failures slightly decreased in 2013-2016 (odds ratio 0.89, 95% confidence interval 0.53-1.51); the decrease was stronger when therapeutic choice complied with CT indications (odds ratio 0.76, 95% confidence interval 0.36-1.63); in both cases, the decrease could be due to chance. After correction for age, sex, and stage, the hazard ratio of 2013-2016 for OS was 0.83 (95% confidence interval 0.64-1.09). In 33/114 (29%) patients, CT retrospective review produced a change in resectability judgment.

CONCLUSION

Although differences could be due to chance or generic improvement, the consistency between process and outcome indicators suggests that multidisciplinary team approach with radiologic review may improve outcomes.

Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors

Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.

Changes in hospital variation in the probability of receiving treatment with curative intent for esophageal and gastric cancer

BACKGROUND

Previous studies describe a large variation in the proportion of patients undergoing treatment with curative intent for esophageal (EC) and gastric cancer (GC). Since centralization of surgical care was initiated and more awareness regarding hospital practice variation was potentially present, we hypothesized that hospital practice variation for potentially curable EC and GC patients changed over time.

METHODS

Patients with potentially curable EC (n = 10,115) or GC (n = 3988) diagnosed between 2012-2017 were selected from the Netherlands Cancer Registry. Multilevel multivariable logistic regression was used to analyze the differences in the probability of treatment with curative intent between hospitals of diagnosis over time, comparing 2012-2014 with 2015-2017. Relative survival (RS) between hospitals with different probabilities of treatment with curative intent were compared.

RESULTS

The range of proportions of patients undergoing treatment with curative intent per hospital of diagnosis for EC was 45-95 % in 2012-2014 and 54-89 % in 2015-2017, and for GC 52-100 % and 45-100 %. The adjusted variation declined for EC with Odds Ratios ranging from 0.50 to 1.72 between centers in the first period to 0.70-1.44 in the second period (p < 0.001) and did not change for GC (Odds Ratios ranging from 0.78 to 1.23 to 0.82-1.23, (p = 1.00)). A higher probability of treatment with curative intent was associated with a better survival for both malignancies.

CONCLUSION

Although substantial variation between hospitals of diagnosis in the probability in receiving treatment with curative intent still exists for both malignancies, it has decreased for EC. A low probability of receiving curative treatment remained associated with worse survival.

The impact of the multidisciplinary tumor board (MDTB) on the management of pancreatic diseases in a tertiary referral center

BACKGROUND

The implementation of multidisciplinary tumor board (MDTB) meetings significantly ameliorated the management of oncological diseases. However, few evidences are currently present on their impact on pancreatic cancer (PC) management. The aim of this study was to evaluate the impact of the MDTB on PC diagnosis, resectability and tumor response to oncological treatment compared with indications before discussion.

PATIENTS AND METHODS

All patients with a suspected or proven diagnosis of PC presented at the MDTB from 2017 to 2019 were included in the study. Changes of diagnosis, resectability and tumor response to oncological/radiation treatment between pre- and post-MDTB discussion were analyzed.

RESULTS

A total of 438 cases were included in the study: 249 (56.8%) were presented as new diagnoses, 148 (33.8%) for resectability assessment and 41 (9.4%) for tumor response evaluation to oncological treatment. MDTB discussion led to a change in diagnosis in 54/249 cases (21.7%), with a consequent treatment strategy variation in 36 cases (14.5%). Change in resectability was documented in 44/148 cases (29.7%), with the highest discrepancy for borderline lesions. The treatment strategy was thus modified in 27 patients (18.2%). The MDTB brought a modification in the tumor response assessment in 6/41 cases (14.6%), with a consequent protocol modification in four (9.8%) cases.

CONCLUSIONS

MDTB discussion significantly impacts on PC management, especially in high-volume centers, with consistent variations in terms of diagnosis, resectability and tumor response assessment compared with indications before discussion.

Role of a multidisciplinary team in administering radiotherapy for esophageal cancer

BACKGROUND

Radiotherapy (RT) is the major part of the treatment strategy set by a multidisciplinary team (MDT) for patients diagnosed with esophageal cancer (EC). The effect of an MDT collaboration on patients with EC who underwent RT is unclear.

METHODS

We retrospectively collected all patients diagnosed with EC in the radiation oncology department at our institution from January 2015 to May 2017. The patients were divided into groups based on if they had their cases presented or not presented at the MDT meeting (with MDT and non-MDT, respectively). Propensity score matching (PSM) was applied at a ratio of 1:1 and the nearest neighbor matching method to compare the two groups.

RESULTS

A total of 212 consecutive patients were analyzed, including 157 with MDT and 55 non-MDT. In the unmatched population, the patients with MDT were more likely to received chemotherapy than the non-MDT patients (84.7% vs. 69.1%; × 2 = 6.373; P = 0.012).MDT-patients had significantly improved overall survival compared with non-MDT patients (p = 0.025). In the multivariate analysis, MDT was an independent prognostic factor for OS in patients with EC who underwent RT (P = 0.019, HR 0.59, 95% CI 0.38-0.92). After PSM for baseline characteristics, the benefit of MDT for OS became more obvious. Additionally, we also found that MDT was an independent predictor of receiving chemotherapy by using logistic regression analysis.

CONCLUSION

In patients who underwent radiotherapy for esophageal cancer, MDT was an independent factor for overall survival, which probably due to the selection of multimodality treatment when compared to non-MDT setting.

Quality Improvement for Surgical Resection of Pancreatic Head Adenocarcinoma : Hospital and Surgeon Predictors of Higher Than Expected R1 Resection Using the National Cancer Database

BACKGROUND

The mainstay of treatment for pancreatic cancer is surgical resection; however, positive surgical margins remain commonplace. We identified hospitals with higher than predicted rates of positive margins and isolated factors that caused this discordance.

METHODS

This is a retrospective review of patients with head of the pancreas adenocarcinoma in the National Cancer Database between 2004 and 2015. A nomogram was used to calculate the observed to expected positive margin rates (O/E) for facilities. If the O/E differed significantly (P < .05), it was considered an outlier.

RESULTS

Among a total of 19 968 patients, 24.3% had positive margins. Among hospitals with lower than expected positive margin rates, 73.6% were academic or research programs, 17% were comprehensive community cancer programs, and none were community cancer programs (P = .0002). Within the group with higher than expected positive margin rates, 47% were comprehensive community cancer programs and 38.6% were academic or research programs (P = .0002). The mean hospital volume was higher in the low positive margin group (110.4 vs 48.8, P < .0001).

CONCLUSIONS

Facility type and hospital volume can predict improvement in the O/E ratio for margin positivity in pancreatic adenocarcinoma resection. Surgeons should consider referral to academic or research facilities with higher case volumes for improved surgical resection.

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.

Quantifying the utility of a multidisciplinary neuro-oncology tumor board

OBJECTIVE

There has been limited research on the efficacy of multidisciplinary tumor boards (MDTBs) in improving the treatment of patients with tumors affecting the nervous system. The objective of the present study was to quantify the utility of MDTBs in providing alternative diagnostic interpretations and treatment plans for this patient population.

METHODS

The authors performed a prospective study of patients in 4 hospitals whose cases were discussed at MDTBs between July and November 2019. Patient demographic data, diagnoses, treatment plans, and eligibility for clinical trials were recorded, among other variables.

RESULTS

A total of 176 cases met eligibility criteria for study inclusion. The majority (53%) of patients were male, and the mean patient age was 52 years. The most frequent diagnosis was glioblastoma (32.4%). Among the evaluable cases, MDTBs led to 38 (21.6%) changes in image interpretation and 103 (58.2%) changes in patient management. Additionally, patients whose cases were discussed at MDTBs had significantly shorter referral times than patients whose cases were not discussed (p = 0.024).

CONCLUSIONS

MDTB discussions led to significant numbers of diagnostic and treatment plan changes as well as shortened referral times, highlighting the potential clinical impact of multidisciplinary care for patients with nervous system tumors.

A Multidisciplinary Toxicity Team for Cancer Immunotherapy-Related Adverse Events

BACKGROUND

Immune checkpoint inhibitors (ICIs) may cause immune-related adverse events (irAEs). Methods to obtain real-time multidisciplinary input for irAEs that require subspecialist care are unknown. This study aimed to determine whether a virtual multidisciplinary immune-related toxicity (IR-tox) team of oncology and medicine subspecialists would be feasible to implement, be used by oncology providers, and identify patients for whom multidisciplinary input is sought.

PATIENTS AND METHODS

Patients treated with ICIs and referred to the IR-tox team in August 2017 through March 2018 were identified. Feasibility was defined as receipt of electronic referrals and provision of recommendations within 24 hours of referral. Use was defined as the proportion of referring providers who used the team's recommendations, which was determined through a postpilot survey. Demographics and tumor, treatment, and referral data were collected. Patient features and irAE associations were analyzed.

RESULTS

The IR-tox team was found to be feasible and used: 117 referrals from 102 patients were received in 8 months, all providers received recommendations within 24 hours, 100% of surveyed providers used the recommendations, and 74% changed patient management based on IR-tox team recommendations. Referrals were for suspected irAEs (n=106; 91%) and suitability to treat with ICIs (n=11; 10%). In referred patients, median age was 64 years, 54% were men, 13% had prior autoimmunity, and 46% received ICI combinations versus monotherapy (54%). The most commonly referred toxicities were pneumonitis (23%), arthritis (16%), and dermatitis (15%); 15% of patients had multisystem toxicities. Multiple referrals were more common in those treated with combination ICIs (odds ratio [OR], 6.0; P=.035) or with multisystem toxicities (OR, 8.1; P=.005). The IR-tox team provided a new multidisciplinary forum to assist providers in diagnosing and managing complex irAEs. This model identifies educational and service needs, and patients with irAEs for whom multidisciplinary care is most sought.

CONCLUSIONS

A virtual multidisciplinary toxicity team for irAEs was a feasible and used service, and facilitated toxicity identification and management.

Value of multidisciplinary collaboration in acute and chronic pancreatitis

Multidisciplinary collaboration (MDC) has been widely adopted in healthcare to optimize patient care. MDC brings several specialized healthcare providers to the table using several methods, including multidisciplinary meetings (MDMs), multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels, to reach the goal of achieving the best diagnosis and treatment plan for complex diseases. Diagnosis and management of acute/chronic pancreatitis is complex which necessitates the development and utilization of MDC. The key members of pancreatitis MDM include gastroenterologists, radiologists, pathologists, hepatobiliary surgeons, chairperson, and a coordinator. After selection of admitted or referred patients, the availability of required information is reviewed, and then each case is discussed. The final diagnosis and treatment plan is confirmed by consensus, especially for complex cases that require endoscopic intervention or pancreatectomy and patients with the possibility of pancreatic adenocarcinoma. It has been shown that MDMs have improved the clinical outcome of patients with acute/chronic pancreatitis. In addition to MDM, the feasibility of multidisciplinary clinics, teleconferences, and online multidisciplinary expert panels for the management of pancreatic disorders has been investigated. Understanding structure, potential advantages, and limitations of MDC will help clinicians and healthcare systems in developing an optimized MDC to improve the management of acute/chronic pancreatitis. This narrative review summarized prior recommendations and explored the impact of MDC on clinical outcomes of patients with pancreatitis. Our recommendations offer a generalizable method that can be utilized by healthcare systems.

Impact of multidisciplinary tumor board discussion on palliation of patients with esophageal or gastro-esophageal junction cancer: a population-based study

Background: The Dutch guidelines for esophageal and gastro-esophageal junction (GEJ) cancer recommend discussion of patients by a multidisciplinary tumor board (MDT). Despite this recommendation, one previous study in the Netherlands suggested that therapeutic guidance was missing for palliative care of patients with esophageal cancer. The aim of the current study was therefore to assess the impact of an MDT discussion on initial palliative treatment and outcome of patients with esophageal or GEJ cancer.Material and methods: The population-based Netherlands Cancer Registry was used to identify patients treated for esophageal or GEJ cancer with palliative intent between 2010 and 2017 in 7 hospitals. We compared patients discussed by the MDT with patients not discussed by the MDT in a multivariate analysis. Primary outcome was type of initial palliative treatment. Secondary outcome was overall survival.Results: A total of 389/948 (41%) patients with esophageal or GEJ cancer were discussed by the MDT before initial palliative treatment. MDT discussion compared to non-MDT discussion was associated with more patients treated with palliative intent external beam radiotherapy (38% vs. 21%, OR 2.7 [95% CI 1.8-3.9]) and systemic therapy (30% vs. 23%, OR 1.6 [95% CI 1.0-2.5]), and fewer patients treated with stent placement (4% vs. 12%, OR 0.3 [95% CI 0.1-0.6]) and best supportive care alone (12% vs. 33%, OR 0.2 [95% CI 0.1-0.3]). MDT discussion was also associated with improved survival (169 days vs. 107 days, HR 1.3 [95% CI 1.1-1.6]).Conclusion: Our study shows that MDT discussion of patients with esophageal or GEJ cancer resulted in more patients treated with initial palliative radiotherapy and chemotherapy compared with patients not discussed by the MDT. Moreover, MDT discussion may have a positive effect on survival, highlighting the importance of MDT meetings at all stages of treatment.

The results of pancreatic operations after the implementation of multidisciplinary team conference (MDT): A quality improvement study

BACKGROUND

Centralization has improved the outcome of complex operations including cancer surgery. Moreover, the implementation of multidisciplinary team conferences (MDT) has ameliorated the decision making, but the impact on patient outcome is controversial. The aim of the study was to investigate the outcome of pancreatic surgery in the setting of centralization and upfront multidisciplinary decision making.

METHOD

The decisions of MDT from 2010 to 2016 and the outcome of operations were compared with operations from 2003 to 2009 before centralization of pancreatic surgery and implementation of MDT. Data were drawn from the department's database and from hospital's electronic patient files.

RESULTS

From 2010 to 2016, 7.015 patients were evaluated at the MDT. In 72.6% of patients a treatment plan followed the first evaluation, the referral diagnosis was changed in 12.4% of cases. Of 3.362 solid neoplasms, 1.680 (50.0%) were evaluated as resectable and 1.080 (32.1%) patients were operated. The annual resection rate of operated patients was78.3%-88.5% (median 80.0%) compared to 21.4% to 80.% (median 68.6%, p = 0.0001) from 2003 to 2009 with 279 operated patients. The post-operative 30 - and 90-days mortality from 2003 to 2009 and 2010 to 2016 was 3.4% vs. 1.8% (NS) and 5.0% vs 3.6% (NS). In the same periods explorative laparotomies and palliative resections decreased from 18.3% to 3.6% (p = 0.0001) and 18.6%-10.2% (p = 0.0002). The median survival of radically resected pancreatic adenocarcinoma (PAC) from 2003 to 2009 and from 2010 to 2016 was 20.2 and 21.9 months, respectively (p = 0.687).

CONCLUSION

The MDT increased patient flow, improved quality of decision-making and offered more patients surgical treatment without increasing morbidity or mortality. But an impact on the long-term survival of patients with PAC was not found.

The 2016-2019 ImmunoTOX assessment board report of collaborative management of immune-related adverse events, an observational clinical study

PURPOSE

We investigated the activities of an ImmunoTOX board, an academic, multidisciplinary group of oncologists and organ specialists that adopts a real-life, case-by-case approach in the management of patients with immune-related adverse events (irAEs).

EXPERIMENTAL DESIGN

The ImmunoTOX assessment board was set up in 2016 at Gustave Roussy in France. It meets every 2 weeks to discuss the case-by-case management of patients presenting with irAEs. Here, we describe the ImmunoTOX board's activities between 2016 and 2019.

RESULTS

Over study period, 398 requests (concerning 356 patients) were submitted to the ImmunoTOX board. Most of the requests concerned the putative causal link between immunotherapy and the irAE (n = 148, 37%), followed by possible retreatment after temporary withdrawal because of an adverse event (n = 109, 27%), the clinical management of complex situations (n = 100, 25%) and the initiation of immunotherapy in patients with pre-existing comorbidities (n = 41, 10%). The ImmunoTOX board discerned 273 irAEs. The five organ systems most frequently involved by irAEs were lung (n = 58, 21%), gastrointestinal tract (n = 36, 13%), liver or biliary tract (n = 33, 12%), musculoskeletal system (n = 27, 10%), and nervous system (n = 23, 8%). The time to occurrence was shorter for severe irAEs (grade III and VI) than for mild irAEs (grades I and II), with medians of 47 and 91 days, respectively (p = 0.0216).

CONCLUSION

The main medical needs in the management of irAEs involved the lung organ. Severe irAEs were expected to occur earlier than mild irAEs. This real-life study can help to better estimate medical needs and therefore help to assess the management of irAEs.

Practice patterns of multidisciplinary team meetings in Korean cancer care and patient satisfaction with this approach

BACKGROUND/AIMS

The multidisciplinary team (MDT) approach is a cornerstone of clinical oncology. This study investigated the current state of MDT care, including patient satisfaction, in Korea.

METHODS

We obtained the annual number of cancer patients who have received MDT care since 2014 from the registry of the Health Insurance Review and Assessment Service (HIRA). In addition, patients who received MDT care from August 2014 to May 2017 at four university hospitals were further characterized, and patient satisfaction was measured prospectively using a patient-reported questionnaire.

RESULTS

The total number of patients who received MDT care increased from 2014 to 2016 (2,113 to 9,998 patients, respectively) in the HIRA Cohort. The type of cancer that most often required MDT was breast cancer (23.8%), followed by colorectal cancer (19.1%). In the Representative Cohort (n = 1,032), MDT was requested by the surgeon more than half the time (55.7%). The main focus of MDT was decision making for further treatment planning (99.0%). The number of doctors participating in the MDT was usually five (70.0%). After initiating an MDT approach, the treatment plan changed for 17.4% of patients. Among these patients, 359 completed a prospective satisfaction survey regarding their MDT care. The overall satisfaction with the MDT approach was very high, with an average score of 9.6 out of 10 points.

CONCLUSION

The application of MDT care is a rapidly growing trend in clinical oncology, and shows high patient satisfaction. Further research is needed to determine which types of cancer patients could benefit most from MDT, and to enable MDT care to operate more efficiently so that it may expand successfully throughout Korea.

How to Manage Diversity and Enhance Team Performance: Evidence from Online Doctor Teams in China

(1) Background: Traditional one-to-one online consultations with doctors often fail to provide timely and accurate treatment plans; consequently, creating cross-hospital and cross-regional teams has become a new pattern for doctors aiming to offer Internet medical services. Because the online doctor team is a new virtual organizational model, it remains to be explained and investigated. (2) Methods: Combining the information processing view and the social categorization view, this study takes the perspective of team diversity and empirically investigates the effect of team diversity on team performance. We consider four kinds of team diversity, including status capital diversity, decision capital diversity, online reputation diversity, and professional knowledge diversity, and we investigate how team composition from the diversity perspective affects online doctor team performance and how leader reputation moderates the effect of team diversity on team performance. We use secondary data from a leading online medical consultation platform in China (Good Doctor), and our research data include 1568 teams with a total of 5481 doctors. (3) Results: The results show that status capital diversity and decision capital diversity negatively affect team performance; diversity in terms of online reputation and professional knowledge positively affect team performance; and leader reputation moderates the impact of status capital diversity and online reputation on team performance. (4) Conclusions: Our study offers management suggestions on how to form a high-performance doctor team and provides advice for the future development of online doctor teams.

Tumor Board Conferences for Multidisciplinary Skin Cancer Management: A Survey of US Cancer Centers

Background: Tumor board conferences (TBCs) are used by oncologic specialists to review patient cases, exchange knowledge, and discuss options for cancer management. These multidisciplinary meetings are often a cornerstone of treatment at leading cancer centers and are required for accreditation by certain groups, such as the American College of Surgeons' Commission on Cancer. Little is known regarding skin cancer TBCs. The objective of this study was to characterize the structure, function, and impact of existing skin cancer TBCs in the United States. Methods: A cross-sectional online survey was administered to physician leaders of skin cancer TBCs at NCI-designated Comprehensive and Clinical Cancer Centers. Results: Of the 59 centers successfully contacted, 14 (24%) reported not having a conference where skin cancer cases were discussed, and 45 (76%) identified 53 physician leaders. A total of 38 physicians (72%) completed the survey. Half of the meeting leaders were medical and/or surgical oncologists, and dermatologists led one-third of meetings. TBCs had a moderate to significant impact on patient care according to 97% of respondents. All respondents indicated that the meetings enhanced communication among physicians and provided an opportunity for involved specialists and professionals to discuss cases. The most frequently cited barrier to organizing TBCs was determining a common available date and time for attendees (62%). The most common suggestion for improvement was to increase attendance, specialists, and/or motivation. Conclusions: Results showed overall consistency in meeting structure but variability in function, which may be a reflection of institutional resources and investment in the conference. Future directions include defining metrics to evaluate changes in diagnosis or management plan after tumor board discussion, attendance, clinical trial enrollment, and cost analysis. Results of this survey may aid other institutions striving to develop and refine skin cancer TBCs.

The Role of the Small Bowel in Unintentional Weight Loss after Treatment of Upper Gastrointestinal Cancers

Upper gastrointestinal (GI) cancers are responsible for significant mortality and morbidity worldwide. To date, most of the studies focused on the treatments’ efficacy and post-treatment survival rate. As treatments improve, more patients survive long term, and thus the accompanying complications including unintentional weight loss are becoming more important. Unintentional weight loss is defined as >5% of body weight loss within 6–12 months. Malignancies, particularly GI cancers, are diagnosed in approximately 25% of patients who present with unintentional weight loss. Whereas some recent studies discuss pathophysiological mechanisms and new promising therapies of cancer cachexia, there is a lack of studies regarding the underlying mechanism of unintentional weight loss in patients who are tumor free and where cancer cachexia has been excluded. The small bowel is a central hub in metabolic regulation, energy homeostasis, and body weight control throughout the microbiota-gut-brain axis. In this narrative review article, the authors discussed the impacts of upper GI cancers’ treatment modalities on the small bowel which may lead to unintentional weight loss and some new promising therapeutic agents to treat unintentional weight loss in long term survivors after upper GI operations with curative intent.

Multidisciplinary Approach to HCC Management: How Can This Be Done?

Multidisciplinary tumor boards have evolved to address the increasing complexity of cancer care management. Given that hepatocellular carcinoma (HCC) often arises in the setting of underlying cirrhosis, expert input from hepatologists alongside hepatobiliary and transplant surgeons, radiation oncologists, interventional and body radiologists, and medical oncologists has become increasingly important in order to offer patients appropriate cancer treatments. The MDLTB structure has evolved since the early 2000s to bring these specialists together at regularly scheduled meetings to develop a therapeutic treatment plan for HCC management. MDLTBs have reduced the time to treatment and improved patient satisfaction. Standardized documentation with common data elements has been recommended to ensure adequate communication from MDLTB to referring healthcare providers. Retrospective studies consistently highlight the frequency of changes in treatment plans after MDLTB review to better adhere to guideline recommended care. Despite several decades of MDLTBs implementation, few studies describe clinical outcomes associated with MDLTBs such as patient survival and cost benefits. More research is needed in this area to further justify the heavy use of resources that are needed to maintain MDLTBs. Development and use of a centralized database to store such information may assist with future studies of clinical outcomes and inform quality improvement projects.

How multidisciplinary are multidisciplinary team meetings in cancer care? An observational study in oncology departments in Flanders, Belgium

Background

In current cancer care, multidisciplinary team meetings (MDTMs) aim at uniting care professionals from different disciplines to decide upon the best possible treatment plan for the patients based on the available scientific evidence. In Belgium, the multidisciplinary approach is mandatory and formally regulated since 2003. Current research indicates that MDTMs are not always truly multidisciplinary, ie, with a mix of medical as well as paramedical disciplines, and that the medical profession (physicians and medical specialists) tends to dominate the interaction in MDTMs. To ensure that MDTMs can benefit from their diverse membership to achieve their full potential, significant attention should be devoted to the multidisciplinary character of these meetings. The aim of this study is to explore and describe the multidisciplinary character in MDTMs and how it is actually shaped in practice in different Flemish medical oncology departments.

Methods

For this study, we carried out an observational comparative case study. We studied 59 multidisciplinary team meetings at inpatient medical oncology departments in five different Belgian hospitals (academic as well as general) and explored multidisciplinarity and how it is actually shaped in practice.

Results

The study is unique in identifying and analyzing three distinct types of MDTMs. The analysis of the three types revealed an inconsistent and, at times, contradictory picture of multidisciplinary team meetings. The findings also align with previous studies arguing that MDTMs in oncology are typically driven by doctors, with limited input of nurses and other nonmedical staff in which decisions are argued on biomedical information and far less consideration of psychosocial aspects.

Conclusion

The concept of a MDTM should not merely be a group of care professionals who work essentially independently and occasionally liaise with one another. Yet, this study has shown a worryingly low awareness of the true character of multidisciplinarity, particularly among medical disciplines.

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors

Background

Traditionally, research has examined systems- and cognitive-based sources of diagnostic error as individual entities. However, half of all errors have origins in both domains.

Methods

We conducted a focused ethnography of inpatient physicians at two academic institutions to understand how systems-based problems contribute to cognitive errors in diagnosis. Medicine teams were observed on rounds and during post-round work after which interviews were conducted. Field notes related to the diagnostic process and the work system were recorded, and findings were organized into themes. Using deductive content analysis, themes were categorized based on a published taxonomy to link systems-based contributions and cognitive errors such as faulty data gathering, information processing, data verification and errors associated with multiple domains.

Results

Observations, focus groups and interviews of 10 teams were conducted between January 2016 and April 2017. The following themes were identified: (1) challenges with interdisciplinary communication and communication within the electronic medical record (EMR) contributed to faulty data gathering; (2) organizational structures such as the operation of consulting services in silos promoted faulty information processing; (3) care handoffs led to faulty data verification and (4) interruptions, time constraints and a cluttered physical environment negatively influenced multiple cognitive domains.

Conclusions

Systems-based factors often facilitate and promote cognitive problems in diagnosis. Linking systems-based contributions to downstream cognitive impacts and intervening on both in tandem may help prevent diagnostic errors.

Is There a Difference in Staging and Treatment of Head and Neck Squamous Cell Tumors Between Tertiary Care and Community-Based Institutions?

Objective

To characterize the differences in the staging and treatment of patients with head and neck squamous cell carcinoma between a tertiary care center and community‐based practices.

Methods

This study is a retrospective chart review of 943 adult patients with head and neck squamous cell cancer presenting to a tertiary care center between 2008 and 2014 as part of the University of Michigan Head and Neck Cancer Specialized Program of Research Excellence (UM HN‐SPORE) database. Demographic information, diagnostic testing, staging information, and treatment recommendations were recorded.

Results

Of 943 patients reviewed, 159 had documentation of tumor stage that was assigned by the community‐based practice. Of these, 53% had a tumor staging change made at the tertiary care center, with 43% of patients upstaged and 10% of patients downstaged. Fifty‐one percent received different treatment than had previously been offered at the community‐based practice, although only 31% of these patients had a change in tumor staging.

Conclusion

Over half of patients with head and neck squamous cell carcinoma who are evaluated at a tertiary care center after the initial evaluation at a community‐based practice have their tumors staged differently, with the majority upstaged. A significant number of these patients also received different treatment than was initially offered at the referring practice. Future studies are required to determine whether these differences have an effect on tumor recurrence and patient survival rates.

Level of Evidence

2c (Outcomes Research).

Esophageal Stenting in Clinical Practice: an Overview

OPINION STATEMENT

PURPOSE OF REVIEW: Esophageal stents are used in clinical practice for endoscopic treatment of a wide variety of esophageal diseases and conditions. This review provides key principles and a literature update on the utility and limitations of esophageal stenting in clinical practice.

RECENT FINDINGS

Indications for esophageal stenting can be subdivided into two groups. The first group consists of patients with malignant or benign dysphagia, in which an esophageal stent restores luminal patency. In the past years, temporary stent placement has increasingly been used in the therapeutic management of refractory benign esophageal strictures. When endoscopic repeated bougie dilation and other endoscopic treatment modalities have failed, an esophageal stent could be considered. Based on the literature, a fully covered self-expandable metal stent may be the preferred choice for the treatment of both malignant and benign dysphagia. The second group consists of patients with leakage from the esophageal lumen into the surrounding tissue. Esophageal leakage can be subdivided into three forms, benign esophageal perforations (iatrogenic and spontaneous), anastomotic leakage after reconstructive esophageal surgery, and fistula. In a carefully selected group of patients, a covered esophageal stent may be used for sealing off the leakage, thereby preventing further contamination of the tissue surrounding the defect. The past few years, several validated prediction tools have been developed that may assist clinicians in the selection of patients eligible for esophageal stent placement. Based on retrospective studies and expert opinion, a partially or fully covered self-expandable metal stent may have a role in treatment of esophageal leakage. Research do date supports the utilization of esophageal stents for the treatment of malignant or benign dysphagia and esophageal leakage.

How Do Forensic Clinicians Decide? A Delphi Approach to Identify Domains Commonly Used in Forensic Juvenile Treatment Planning

Adolescents in forensic care display wide varieties of complex psychiatric, psychological, and contextual problems. Based on large amounts of information, clinicians need to consider, integrate, and prioritize these offender characteristics to construct individual treatment trajectories. So far, scientific knowledge on how these treatment decisions take place is scarce. Current study uses a qualitative design for detecting implicit knowledge of clinicians on which offender characteristics they consider while making treatment decisions. Using the Delphi method, 34 experienced clinicians working in forensic care facilities in the Netherlands were asked about the most important domains of offender characteristics that influence their treatment planning. Eight domains were identified as being crucial in treatment planning: Mental health problems, Personal characteristics, Family, Offense, Motivation, Treatment, School/Work/Housing, and Peers/Spare time. Based on current results, focus on a broad spectrum of individual and contextual characteristics is recommended. Moreover, protective factors and comorbid problems on multiple domains should be considered.

Efficacy of the multidisciplinary tumor board conference in gynecologic oncology: A prospective study

Evidence has shown that multidisciplinary tumor board conferences (MTBCs) improve patient management for various cancer types. However, few retrospective studies have investigated MTBC efficacy for patients with gynecologic cancers. Here, we prospectively aimed to evaluate how MTBCs influence patient management in gynecologic oncology. This prospective study included 85 consecutive cases that were presented at gynecologic oncology MTBCs in our tertiary university hospital between January 2015 and April 2016. The primary endpoint was treatment plan change rate, which included both major and minor changes. Major changes were defined as exchange, addition, or subtraction of treatment modality. Minor changes included all other, such as intramodality changes or treatment time changes. The secondary endpoints were the change rates of diagnosis, diagnostic work-up, and radiological and pathological findings.The treatment plan change rate, irrespective of changes in diagnostic work-up, was 27.1%, which included 10.6% major and 16.5% minor changes. Among the treatment plan changes, changes in the treatment plan change rate alone were noted in 16.5% of cases, and changes in diagnosis and radiological findings occurred in 7.1% and 3.5% of cases, respectively. Diagnosis and radiological findings, irrespective of changes in diagnostic work-up, were also changed in 9.4% and 10.6% of cases, respectively. However, there were no changes in pathological findings. Moreover, there was a change of diagnostic method for further work-up in 23.5% of cases. The implementation rate of MTBC-determined treatment changes was 91.8%. Gynecologic oncology MTBCs resulted in considerable changes in treatment plans. Diagnosis, diagnostic work-up, and radiological findings were influenced by MTBCs. The data emphasize the importance of adopting a multidisciplinary team approach for gynecologic cancer management.

Oesophageal cancer

Oesophageal cancer is a clinically challenging disease that requires a multidisciplinary approach. Extensive treatment might be associated with a considerable decline in health-related quality of life and yet still a poor prognosis. In recent decades, prognosis has gradually improved in many countries. Endoscopic procedures have increasingly been used in the treatment of premalignant and early oesophageal tumours. Neoadjuvant therapy with chemotherapy or chemoradiotherapy has supplemented surgery as standard treatment of locally advanced oesophageal cancer. Surgery has become more standardised and centralised. Several therapeutic alternatives are available for palliative treatment. This Seminar aims to provide insights into the current clinical management, ongoing controversies, and future needs in oesophageal cancer.