The need for a multidisciplinary approach in the treatment of advanced colorectal cancer: a critical review from a medical oncologist and surgeon

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

Purpose

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

Methods

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

Results

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

Conclusion

MDT could improve OS of colorectal cancer patients.

The impact of multidisciplinary team management on outcome of hepatic resection in liver-limited colorectal metastases

Hepatic resection is the gold standard treatment for patients affected by liver-limited colorectal metastases. Reports addressing the impact of multidisciplinary team (MDT) evaluation on survival are controversial. The aim of this study was to evaluate the benefit of MDT management in these patients in our Institution experience. The objective of the analysis was to compare survivals of patients managed within our MDT (MDT cohort) to those of patients referred to surgery from other hospitals without MDT discussion (non-MDT cohort). Of the 523 patients, 229 were included in the MDT cohort and 294 in the non-MDT cohort. No difference between the two groups was found in terms of median overall survival (52.5 vs 53.6 months; HR 1.13; 95% CI, 0.88-1.45; p = 0.344). In the MDT cohort there was a higher number of metastases (4.5 vs 2.7; p < 0.0001). The median duration of chemotherapy was lower in MDT patients (8 vs 10 cycles; p < 0.001). Post-operative morbidity was lower in the MDT cohort (6.2 vs 21.5%; p < 0.001). One hundred and ninety-seven patients in each group were matched by propensity score and no significant difference was observed between the two groups in terms of OS and DFS. Our study does not demonstrate a survival benefit from MDT management, but it allows surgery to patients with a more advanced disease. MDT assessment reduces the median duration of chemotherapy and post-operative morbidities.

Evaluating population-based breast cancer surgical practice in real time with a web-based synoptic operative reporting system

BACKGROUND

A Web-based synoptic operative reporting system (WebSMR) incorporates implicit guidelines and real-time feedback of a surgeon's practice compared with provincial data. This study compares rates of total mastectomy (TM) between the overall provincial and WebSMR patients and examines decision-making factors in WebSMR patients.

METHODS

Patients treated for invasive breast cancer (2007 to 2011) were identified from WebSMR and the Alberta Cancer Registry. Reports include surgery type and reasons for TM.

RESULTS

Among 5,787 patients in WebSMR (2007 to 2011), TM rate decreased from 48% to 42% (P < .001). In 2011, the provincial cancer registry recorded a 56% TM rate compared to 42% in WebSMR patients. Patient preference accounted for 36% in the latter group.

CONCLUSIONS

In WebSMR patients, TM rates were lower than the overall provincial rate and decreased significantly during the study period. Reasons are unclear, but guidelines and real-time feedback likely plays a role.

Multidisciplinary Versus One-on-One Setting: A Qualitative Study of Clinicians' Perceptions of Their Relationship With Patients With Prostate Cancer

PURPOSE

Previous studies indicate that a multidisciplinary approach could be suitable for dealing with the complex issues faced by physicians in the management of prostate cancer; however, few studies have investigated clinicians' perceptions of multidisciplinary care. Our aim was to evaluate clinicians' perceptions of the patient-clinician relationship in a multidisciplinary context, and to compare this with physicians' perceptions of providing care independently.

METHODS

A qualitative observational study was performed in 2009. Three radiation oncologists, three urologists, three medical oncologists and one psychologist from the multidisciplinary clinic (MDC) team at the Prostate Program of Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy, were interviewed to assess their perceptions of their relationship with the patient.

RESULTS

Clinicians reported that the MDC has advantages regarding providing patients with more accurate information and acquiring information from patients, but a clear preference for a multidisciplinary setting did not emerge. Clinicians reported that in one-on-one examinations (1) they feel more comfortable listening to the patient and more able to manage communication, and that (2) the process of building trust is easier.

CONCLUSION

Clinicians appear to recognize the value of the MDC in terms of effective communication with patients but feel that other aspects of relationship building are hindered in a multidisciplinary setting. Organizational and teamwork issues need to be addressed to optimize the implementation of a multidisciplinary approach.

Effect of multidisciplinary team treatment on outcomes of patients with gastrointestinal malignancy

AIM: To evaluate the effect of multidisciplinary team (MDT) treatment modality on outcomes of patients with gastrointestinal malignancy in China.

METHODS: Data about patients with gastric and colorectal cancer treated in our center during the past 10 years were collected and divided into two parts. Part 1 consisted of the data collected from 516 consecutive complicated cases discussed at MDT meetings in Peking University School of Oncology (PKUSO) from December 2005 to July 2009. Part 2 consisted of the data collected from 263 consecutive cases of resectable locally advanced rectal cancer from January 2001 to January 2005. These 263 patients were divided into neoadjuvant therapy (NT) group and control group. Patients in NT group received MDT treatment, namely neoadjuvant therapy + surgery + postoperative adjuvant therapy. Patients in control group underwent direct surgery + postoperative adjuvant therapy. The outcomes in two groups were compared.

RESULTS: The treatment strategy was altered after discussed at MDT meeting in 76.81% of gastric cancer patients and in 58.33% of colorectal cancer patients before operation. The sphincter-preservation and local control of tumor were better in NT group than in control group. The 5-year overall survival rate was also higher in NT group than in control group (77.23% vs 69.75%, P = 0.049).

CONCLUSION: MDT treatment modality can significantly improve the outcomes of patients with gastrointestinal malignancy in China.

Opening the black box of cancer surgery quality: WebSMR and the Alberta experience

A web-based synoptic operative report, the WebSMR (Surgical Medical Record), was developed to define and improve the quality of cancer surgery. Surgeons accurately record the essential steps of an operation including important decision-making in an analyzable format. Outcomes can be reviewed with provincial aggregates for quality improvement and maintenance of certification. Future synoptic pathology and follow-up templates will open the "black box" of surgical processes to define quality indicators for the improvement of cancer outcomes.

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

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

Quality assurance of surgery in gastric and rectal cancer

Multimodality and quality controlled treatment result in improved treatment outcome in patients with solid tumours. Quality assurance focuses on identifying and reducing variations in treatment strategy. Treatment outcome is subsequently improved through the introduction of programs that reduce treatment variations to an acceptable level and implement standardised treatment. In chemotherapy and radiotherapy, such programmes have been introduced successfully. In surgery however, there has been little attention for quality assurance so far. Surgery is the mainstay in the treatment of patients with gastric and rectal cancer. In gastric cancer, the extent of surgery is continuously being debated. In Japan, extended lymph node dissection is favoured whereas in the West this type of surgery is not routinely performed with two large European trials concluding that there is no survival benefit from regional lymph node clearance. Post-operative chemoradiation is part of the standard treatment in the United States, although its role in combination with adequate surgery has not been established yet. These global differences in treatment policy clearly relate to the extent and quality of surgical treatment. As for gastric cancer, surgical treatment of rectal cancer patients determines patient's prognosis to a large extent. With the introduction of total mesorectal excision, local control and survival have improved substantially. Most rectal cancer patients receive adjuvant treatment, either pre- or post-operatively. The efficacy of many adjuvant treatment regimens has been investigated in combination with conventional suboptimal surgery. Traditional indications of adjuvant treatment might have to be re-examined, considering the substantial changes in surgical practise. Quality assurance programs enable the introduction of standardised and quality controlled surgery. Promising adjuvant regimens should be investigated in combination with optimal surgery.

The importance of quality assurance in surgical oncology

AIMS

The aims were to review the existing methods of quality assurance in surgical oncology and to determine a relationship between surgery-related factors and the variety in outcomes in the treatment of solid cancers.

METHODS

The literature was reviewed by searching Medline and Cancerlit databases.

RESULTS

Wide variations were found in virtually all tumour types. Clear evidence was found that an improvement in the quality of the surgical procedure could have major implications for the prognosis and quality of life of cancer patients.

CONCLUSIONS

These findings emphasize the need for strict quality control procedures in surgical oncology and might imply a considerable change in cancer treatment strategies, because the routine use of adjuvant therapies could be questioned.

A clinical nomogram for predicting long-term survival in advanced colorectal cancer

From our prospectively accrued database of patients with gastrointestinal cancer, 1057 patients with advanced colorectal cancer were identified with the aim of determining predictive factors for survival of greater than 2 years and to use this information to develop a predictive nomogram. Patient's baseline characteristics, type and number of chemotherapy regimens received, and response to chemotherapy were assessed by univariate and multivariate logistic regression comparing those who survived greater than or less than 2 years. A total of 161 (15.2%) patients survived more than 2 years, so-called long survivors (LS). In multivariate analysis, positive predictive factors for LS were: good performance status (PS), normal serum carcinoembryonic antigen (CEA), rectal primary, Dukes' stage A-B, well or moderate differentiation, two or less disease sites, response to chemotherapy and treatment used protracted venous infusion (PVI) 5-fluorouracil (5-FU) in first-line chemotherapy, and the increasing number of chemotherapy treatments received. From these PS, CEA, number of sites and response to first-line chemotherapy were used to develop a nomogram capable of predicting the probability of survival beyond 2 years for an individual patient. This large study confirmed the relevance of known prognostic factors in metastatic colorectal cancer and demonstrated the importance of response to chemotherapy as an independent factor to predict LS. By combining these, we developed a nomogram which provides information which is likely to prove useful in the management of patients with advanced colorectal cancer.

Colorectal cancer follow-up: perspectives for future studies

This paper reviews some of the issues involved in the planning and execution of studies to assess the effect of different follow-up strategies for colorectal cancer patients. Mathematical models and many previous studies have failed to indicate strong support for the hypothesis that extensive follow-up leads to an increase in survival rates. In order to assess the best follow-up strategies, at present, within the different Dukes' stages, extremely large trials are required and none of the previous studies have satisfied this criterion, though recently planned studies will, if recruitment targets are met. The large number of patients required, the length of time the study must run, existing accepted follow-up practices in different countries, and the difficulty of managing patients on different follow-up strategies within the same centre all pose problems for the design of a randomized trial. These are not insurmountable, but do contribute to a possible downfall of a large multicentre randomized trial of follow-up strategies. Although such a trial will require considerable international cooperation it will have enormous benefits and implications if it is managed and completed successfully.

Combined modality therapy of rectal cancers

Rectal cancer accounts for about 10% of new cancer cases each year. It strikes men and women at nearly the same rate, generally in the range of 50-80 years of age, with rising incidence with age. Despite simple screening procedures rectal cancer is often advanced when discovered. Current trends in the management of cancer have focused on organ preservation and improved quality of life without compromising the overall survival. During the last decade substantial progress has been made in treatment modalities: new and improved radiation techniques (conformal radiotherapy, altered fractionation, brachytherapy), chemotherapy (protracted infusion, use of radiosensitizers) and development of surgical procedures-enabling safer postoperative irradiation. In patients with advanced/unresectable disease aggressive combined chemoradiation can be added prior to surgery to downstage the tumour and increase the proportion treated with anal-rectal-sparing procedures. Preoperative chemoradiation therapy regimens are as safe and tolerable as the standard postoperative treatment. In this presentation indications for preoperative radiochemotherapy will be discussed in detail, together with treatment-related side effects, prognostic parameters, tumour response and outcome. Different irradiation settings and chemotherapy schedules are described. In patients with primary resectable disease (mainly Dukes C) several prospective randomised trials have shown less local recurrence with postoperative combined modality therapy.