Impact of a prostate multidisciplinary clinic program on patient treatment decisions and on adherence to NCCN guidelines: the William Beaumont Hospital experience. Am J Clin Oncol. 2013;36:121-125. [PMID: 22307214 DOI: 10.1097/coc.0b013e318243708f]

Variation in content discussed by specialty in consultations for clinically localized prostate cancer

INTRODUCTION

Multidisciplinary consultations improve decisional conflict and guideline-concordant treatment for men with prostate cancer (PC), but differences in the content discussed by specialty during consultations are unknown.

METHODS

We audiorecorded and transcribed 50 treatment consultations for localized PC across a multidisciplinary sample of urologists, radiation oncologists, and medical oncologists. Conversation was coded for narrative content using an open coding approach, grouping similar topics into major content areas. The number of words devoted to each content area per consult was used as a proxy for time spent. Multivariable Poisson regression calculated incidence rate ratios (IRR) for content-specific word count across specialties after adjustment for tumor risk and patient demographics.

RESULTS

Coders identified 8 narrative content areas: overview of PC; medical history; baseline risk; cancer prognosis; competing risks; treatment options; physician recommendations; and shared decision making (SDM). In multivariable models, specialties significantly differed in proportion of time spent on treatment options, SDM, competing risks, and cancer prognosis. Urologists spent 1.8-fold more time discussing cancer prognosis than medical oncologists (IRR1.80, 95%CI:1.14-2.83) and radiation oncologists (IRR1.84, 95%CI:1.10-3.07). Urologists (IRR11.38, 95%CI:6.62-19.56) and medical oncologists (IRR10.60, 95%CI:6.01-18.72) spent over 10-fold more time discussing competing risks than radiation oncologists. Medical oncologists (IRR2.60, 95%CI:1.65-4.10) and radiation oncologists (IRR1.77, 95%CI:1.06-2.95) spent 2.6- and 1.8-fold more time on SDM than urologists, respectively.

CONCLUSIONS

Specialists focus on different content in PC consultations. Our results suggest that urologists should spend more time on SDM and radiation oncologists on competing risks. Our results also highlight the importance of medical oncologists in facilitating SDM.

The role of the radiologist in the prostate cancer multidisciplinary conference

The broad range of disease aggressiveness together with imperfect screening, diagnostic, and treatment options in prostate cancer (PCa) makes medical decision-making complex. The primary goal of a multidisciplinary conference is to improve patient outcomes by combining evidence-based data and expert opinion to discuss optimal management, including for those patients with challenging presentations. The primary purpose of the genitourinary imaging specialist in the prostate cancer multidisciplinary conference is to use imaging findings to reduce uncertainty by answering clinical questions. In this review, we discuss the role and the opportunities for an imaging specialist to add value in the care of men with prostate cancer discussed at multidisciplinary conferences.

Criteria and indicators to evaluate quality of care in genitourinary tumour boards

PURPOSE

Genitourinary (GU) multidisciplinary tumour boards (GUMTBs) are key components of patient care, as they might lead to changes in treatment plan, improved survival, and increased adherence to guidelines. However, there are no guidelines on how GUMTBs should operate or how to assess their quality of performance.

METHODS

A systematic literature review was conducted to identify criteria and indicators to evaluate quality in GUMTBs. A scientific committee-comprising 12 GU cancer specialists from seven disciplines-proposed a list of criteria and developed indicators, evaluated in two rounds of Delphi method. Appropriateness and utility of indicators were scored using a 9-point Likert scale. Consensus was defined as at least two-thirds of Delphi respondents selecting a score sub-category that encompassed the median score of the group.

RESULTS

Forty-five criteria were selected to evaluate the quality of GUMTBs covering five dimensions: organisation, personnel, protocol and documentation, resources, and interaction with patients. Then, 33 indicators were developed and evaluated in the first round of Delphi, leading to a selection of 26 indicators in two dimensions: function, governance and resources, and GUMTB sessions. In the second round, consensus was reached on the appropriateness of all 26 indicators and on the utility of 24 of them. Index cards for criteria and indicators were developed to be used in clinical practice.

CONCLUSIONS

Criteria and indicators were developed to evaluate the quality of GUMTBs, aiming to serve as a guide to improve quality of care and health outcomes in patients with GU cancer.

Quality Measures for Multidisciplinary Tumor Boards and Their Role in Improving Cancer Care

While multidisciplinary tumor boards (MTBs) are widely used in managing patients with cancer, their impact on patient care and outcome is not routinely measured in different settings. The authors conducted a literature review in Medline, Google Scholar, Embase, and Web of Science using the following keywords: cancer, multidisciplinary, tumor board, quality performance indicator, lung cancer, and lymphoma. Standards from various accreditation and professional organizations were reviewed to compile relevant standards for MTB. A list of quality performance indicators that can be used to improve MTBs' performance and impact was compiled. Specific examples for non-Hodgkin lymphoma and lung cancer MTBs were presented. Guidance was provided to help MTB team members select implement the appropriate quality measures. The functions and impact of MTBs should be monitored and evaluated by a set of measures that help guide MTBs to improve their performance and provide better care to their patients.

Novel hormone therapy and coordination of care in high-risk biochemically recurrent prostate cancer

Biochemical recurrence (BCR) occurs in 20-50% of patients with prostate cancer (PCa) undergoing primary definitive treatment. Patients with high-risk BCR have an increased risk of metastatic progression and subsequent PCa-specific mortality, and thus could benefit from treatment intensification. Given the increasing complexity of diagnostic and therapeutic modalities, multidisciplinary care (MDC) can play a crucial role in the individualized management of this patient population. This review explores the role for MDC when evaluating the clinical evidence for the evolving definition of high-risk BCR and the emerging therapeutic strategies, especially with novel hormone therapies (NHTs), for patients with either high-risk BCR or oligometastatic PCa. Clinical studies have used different characteristics to define high-risk BCR and there is no consensus regarding the definition of high-risk BCR nor for management strategies. Next-generation imaging and multigene panels offer potential enhanced patient identification and precision-based decision-making, respectively. Treatment intensification with NHTs, either alone or combined with radiotherapy or metastasis-directed therapy, has been promising in clinical trials in patients with high-risk BCR or oligometastases. As novel risk-stratification and treatment options as well as evidence-based literature evolve, it is important to involve a multidisciplinary team to identify patients with high-risk features at an earlier stage, and make informed decisions on the treatments that could optimize their care and long-term outcomes. Nevertheless, MDC data are scarce in the BCR or oligometastatic setting. Efforts to integrate MDC into the standard management of this patient population are needed, and will likely improve outcomes across this heterogeneous PCa patient population.

Addressing Challenges and Controversies in the Management of Prostate Cancer with Multidisciplinary Teams

The diagnostic and treatment landscapes of prostate cancer are rapidly evolving. This has led to several challenges and controversies regarding optimal management of the disease that outpace guidelines and clinical data. Multidisciplinary teams (MDTs) can be used to engage the array of specialists that collaborate to treat complex malignancies such as prostate cancer. While the rationale for the use of MDTs in prostate cancer is well known, ways to optimally use MDTs to address the challenges and controversies associated with prostate cancer management are less well understood. One area of MDT care that remains undefined is how MDTs can most effectively provide guidance on clinical decision-making in situations in which information from novel diagnostic testing (genetic testing, molecular imaging) is substantially different from the established clinical risk factors. In this review, we provide a clinical perspective on ways that MDTs can be used to address this and other challenges and controversies across the prostate cancer disease continuum, from diagnosis to end-of-life considerations. Beyond clinical scenarios, we also review ways in which MDTs can mitigate disparities of care in prostate cancer. Overall, MDTs play a central role in helping to address the daily vexing issues faced by clinicians related to diagnosis, risk stratification, and treatment. Given the accelerating advances in precision medicine and targeted therapy, and the new questions and controversies these will bring, the value of MDTs for prostate cancer management will only increase in the future.

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

Objectives

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

Methods

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

Results

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

Discussion and conclusion

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

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

Multidisciplinary Team Meeting Proposal and Final Therapeutic Choice in Early Breast Cancer: Is There an Agreement?

Background

A multidisciplinary team meeting (MDM) approach in breast cancer (BC) management is a standard of care. One of the roles of MDMs is to identify the best diagnostic and therapeutic strategies for patients (pts) with new diagnosis of early BC. The purpose of this study was to define whether there was an agreement between the planned program (i.e., MDMs-based decision) and that actually applied. In addition, the study explored factors associated with discordance.

Methods

We conducted a retrospective study of a consecutive series of 291 patients with new diagnosis of early BC, discussed at MDMs at the University Hospital of Udine (Italy), from January 2017 to June 2018. The association between clinico-biological factors and discordance between what was decided during the MDMs and what was consequently applied by the oncologist was explored through uni- and multivariate logistic regression analyses.

Results

The median age was 62 years (range 27-88 years). Among invasive early BC patients, the most frequent phenotype was luminal A (38%), followed by luminal B (33%), HER2-positive (12%), and triple-negative (5%). In situ carcinoma (DCIS) represented 12% of cases. The median time from MDM discussion to first oncologic examination was 2 weeks. The rate of discordance between MDM-based decision and final choice, during a face-to-face consultation with the oncologist, was 15.8% (46/291). The most frequent reason for changing the MDM-based program was clinical decision (87%). Follow-up was preferred to the chemotherapy (CT) proposed within the MDMs in 15% of cases, and to the endocrine therapy (ET) in 39% of cases (among these, 44.5% had a diagnosis of DCIS). Therapeutic change from sequential CT-ET to ET alone was chosen in 16/46 pts (35%): among these patients, seven had a luminal B disease and six had an HER2-positive disease. On univariate analysis, factors associated with discordance were values of Ki-67 14%-30% (OR 3.91; 95% CI 1.19-12.9), age >70 years (OR 2.44, 95% CI 1.28-4.63), housewife/retired status (OR 2.35, 95% CI 1.14-4.85), polypharmacy (OR 1.95; 95% CI 1.02-3.72), postmenopausal status (OR 4.15; 95% CI 1.58-10.9), and high Charlson Comorbidity Index (OR 1.31; 95% CI 1.09-1.57). The association with marital status, educational level, alcohol and smoke habits, presence of a caregiver, parity, grading, histotype and phenotype, and stage was not statistically significant. On multivariate analysis, only Ki-67 value maintained its statistical significance.

Conclusion

The results of our study could be useful for enhancing the role of MDMs in the clinical decision-making process in early BC.

Diagnostic assessment program for prostate cancer: Lessons learned after 2 years and degree of compliance to Canadian guidelines

BACKGROUND

In 2018, our Institute launched the Diagnostic Assessment Program (DAP) for prostate cancer. It enabled quick access to a urologist for patients presented to family physician with elevated PSA and allowed fast multidisciplinary patient care. We aim to document our data over 2 years in comparison to data before implementation of DAP and its impact on the degree of adherence to Canadian guidelines.

METHODS

From April 2016 to April 2020, 880 patients who were evaluated for prostate cancer at Thunder Bay Regional Health Sciences Centre (TBRHSC) were included in this study. Patients' characteristics, clinical data, waiting times and line of treatment before and after implementation of DAP were calculated and statistically analysed.

RESULTS

The median waiting time to urology consultation was significantly reduced from 68 (IQR 27-168) days to 34 (23-44) days (p < 0.001). The time from patient's referral to prostate biopsy decreased substantially from 34 (20-66) days to 18(11- 25) days after DAP (p < 0.001). After DAP, the percentage of Gleason 6 detected prostate cancers were significantly increased (19.7% to 30%) (p = 0.02). After DAP, rate for intermediate-risk patients elected for external beam radiotherapy (from 53.5% to 57.9%, p = 0.53) and radical prostatectomy (from 34.5% to 39.4%, p = 0.47) increased. More compliance to Canadian guidelines was observed in intermediate risk patients (88% vs 97.3%, p =.008).

CONCLUSIONS

Implementation of DAP has led to a notable reduction of waiting time to urology consult and prostate biopsy. There is significant increase in Gleason 6 detected prostate cancer. Increased compliance to Canadian guidelines was detected in intermediate risk patients.

Dynamic multidisciplinary team discussions can improve the prognosis of metastatic castration-resistant prostate cancer patients

BACKGROUND

Multidisciplinary team (MDT) management is a popular treatment paradigm in managing cancer patients, which provides fully-discussed, interdisciplinary treatment recommendations for patients. However, there has been a lack of data on its actual impact on the overall survival (OS) of metastatic castration-resistant prostate cancer (mCRPC) patients. mCRPC is the end stage of prostate cancer, facing a treatment dilemma of overwhelming options; therefore, we hypothesize dynamic MDT discussions can be helpful in comprehensively managing these patients.

METHODS

We retrospectively collected 422 mCRPC patients' clinical information from 2013 to 2020 from our institute. Patients can voluntarily choose whether to enroll in the dynamic MDT group, which includes discussions at CRPC diagnosis and subsequent disease progression. All patients were followed up regularly, and OS from CRPC diagnosis to death was set as the endpoint of this study.

RESULTS

Participating in MDT discussions is a favorable independent indicator of longer overall survival (median OS: MDT (+): 39.7 months; MDT (-): 27.0 months, hazard ratio: 0.549, p = .001). Moreover, this survival benefit of MDT remained in subgroups with first-line therapy [median OS: MDT (+): not reached; MDT (-): 27.0 months, p = .001) and with multi-line therapy until the end of follow-up (median OS: MDT (+): 36.7 months; MDT (-): 25.6 months, p = .044).

CONCLUSION

Therefore, regular MDT discussions are valuable in the management of mCRPC patients. Clinicians are encouraged to tailor MDT discussions dynamically to provide mCRPC patients with a better and more individualized treatment plan and more prolonged survival. Take-home messages ● The MDT model is defined as dynamic MDT discussions at the time of mCRPC diagnosis and each time they progressed later on throughout the disease management. ● Prostate cancer MDT usually includes specialists in urologic oncology, pathology, chemotherapy, radiotherapy, ultrasound, imaging and nuclear medicine. ● MDT model can benefit mCRPC patients in terms of overall survival.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

[Quality criteria in urology : How to obtain comparable results?]

The standardization of procedural flow and medical documentation increasingly allows further possibilities. The best-known example of process standardization is the centralized treatment of complex clinical pictures, while patient-reported outcome measurements (PROMs) enable standardized documentation. Using the example of prostate cancer, existing literature on the topic of quality optimization in medicine is discussed. The following key points are addressed: (1) Increasing use of standardized PROMs for outcome documentation. (2) The transfer of complex clinical pictures to dedicated specialized centers has been shown to increase the quality of patient care as long as standardized PROMs are used. (3) Healthcare policymakers benefit from the use of PROMs and increasingly pursue a "value-based healthcare" approach.

Value-Based Healthcare in Urology: A Collaborative Review

CONTEXT

In response to growing concerns over rising costs and major variation in quality, improving value for patients has been proposed as a fundamentally new strategy for how healthcare should be delivered, measured, and remunerated.

OBJECTIVE

To systematically review the literature regarding the implementation and impact of value-based healthcare in urology.

EVIDENCE ACQUISITION

A systematic review was performed to identify studies that described the implementation of one or more elements of value-based healthcare in urologic settings and in which the associated change in healthcare value had been measured. Twenty-two publications were selected for inclusion.

EVIDENCE SYNTHESIS

Reorganization of urologic care around medical conditions was associated with increased use of guidelines-compliant care for men with prostate cancer, and improved outcomes for patients with lower urinary tract symptoms. Measuring outcomes for every patient was associated with improved prostate cancer outcomes, while the measurement of costs using time-driven activity-based costing was associated with reduced resource utilization in a pediatric multidisciplinary clinic. Centralization of urologic cancer care in the UK, Denmark, and Canada was associated with overall improved outcomes, although systems integration in the USA yielded mixed results among urologic cancer patients. No studies have yet examined bundled payments for episodes of care, expanding the geographic reach for centers of excellence, or building enabling information technology platforms.

CONCLUSIONS

Few studies have critically assessed the actual or simulated implementation of value-based healthcare in urology, but the available literature suggests promising early results. In order to effectively redesign care, there is a need for further research to both evaluate the potential results of proposed value-based healthcare interventions and measure their effects where already implemented.

PATIENT SUMMARY

While few studies have evaluated the implementation of value-based healthcare in urology, the available literature suggests promising early results.

Patterns of Multidisciplinary Care of Head and Neck Squamous Cell Carcinoma in Medicare Patients

Importance

Multidisciplinary care (MDC) yields proven benefits for patients with cancer, although it may be underused in the complex management of head and neck squamous cell carcinoma (HNSCC).

Objective

To characterize the patterns of MDC in the treatment of HNSCC among elderly patients in the US.

Design, Setting, and Participants

This nationwide, population-based, retrospective cohort study used Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from January 1, 1991, to December 31, 2011, to identify patients 66 years or older diagnosed with head and neck cancer and determine the dates of diagnosis, oncology consultations, treatment initiation, and speech therapy evaluation in addition to MDC completion. Multidisciplinary care was defined in a stage-dependent manner: localized disease necessitated consultations with radiation and surgical oncologists, and advanced-stage disease also included a medical oncology consultation, all before definitive treatment. Data were analyzed between December 2016 and September 2020.

Main Outcomes and Measures

Rates of MDC across all subsites of head and neck cancer as measured by the presence of an evaluation for each oncologist on the MDC team and its effect on treatment initiation.

Results

This cohort study assessed 28 293 patients with HNSCC (mean [SD] age, 75.1 [6.6] years; 67% male; 87% White) from the SEER-Medicare linked database. The HNSCC subsites included larynx (40%), oral cavity (30%), oropharynx (21%), hypopharynx (7%), and nasopharynx (2%). Overall, the practice of MDC significantly increased over time, from 24% in 1991 to 52% in 2011 (P < .001). For patients with localized (stage 0-II) tumors, 60% received care in the multidisciplinary setting, whereas 28% of those with advanced-stage disease did. A total of 18 181 patients (64%) were treated with initial definitive nonsurgical therapy across all stages. Regardless of stage and subsite, few patients (2%) underwent evaluation by a speech-language pathologist before definitive therapy. Multidisciplinary care prolonged the time to initiation of definitive treatment by 11 days for localized disease and 10 days for advanced disease.

Conclusions and Relevance

This cohort study found that most elderly patients with localized HNSCC received MDC, whereas few patients with advanced-stage disease received such care, although a significant proportion received adjuvant therapy. Multidisciplinary care may prolong time to initiation of definitive treatment with an uncertain impact. Consultation with a speech-language pathologist before definitive therapy was rare.

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.

Development and characteristics of a multidisciplinary colorectal cancer clinic

BACKGROUND

Multidisciplinary cancer clinics deliver streamlined care and facilitate collaboration between specialties. We described patient volume and specialty service utilization, including surgery, of a multidisciplinary colorectal cancer clinic established at a tertiary care academic institution.

METHODS

We conducted a retrospective observational cohort study of adult patients with colorectal adenocarcinoma from 2012 to 2017. We performed a descriptive analysis of patient volume, percentage of rectal cancer patients, and the number of patients who saw and received surgery, chemotherapy, and radiation each year.

RESULTS

Over 5 years, 1711 patients were served at the multidisciplinary clinic. Patient volume increased 37%, from n = 228 (annualized) to n = 312. The percentage of rectal cancer patients increased from 29% in 2013 to 42% in 2017. The highest rate of utilization was for surgery; 792 (46%) patients had surgery at the multidisciplinary clinic institution, and 510 (30%) received chemotherapy there. Out of 635 rectal cancer patients, 114 (18%) received radiation there.

CONCLUSIONS

Over the five-year experience of a colorectal cancer-focused multidisciplinary clinic, overall patient volume increased by 37%. Over the study period, 63% of patients seen at the multidisciplinary clinic ultimately received at least one treatment modality at the clinic institution. Overall, the clinic's establishment resulted in the increased referral of complex patients.

National Comprehensive Cancer Network guidelines compliance of a sarcoma service: A retrospective review

BACKGROUND

Clinical workup and treatment guidelines have been published by the National Comprehensive Cancer Network (NCCN) to ensure patients are treated uniformly and appropriately. This study sought to retrospectively review patients with a new diagnosis of sarcoma who were treated in a National Cancer Institute (NCI) designated center and determine compliance rates with guidelines for sarcoma.

AIM

To evaluate our compliance of NCCN sarcoma guidelines at a major NCI designated center and to report instances of deviation that could be used for future studies to improve patient care.

METHODS

Data was collected retrospectively as an internal review and quality assessment of 35 newly diagnosed and treated patients. Demographic data were recorded and information concerning whether patients had appropriate imaging, biopsy and management. Variables of interest were expressed as raw numbers and percentages.

RESULTS

Primary site imaging was obtained in 100% of cases. Chest and full-body imaging were obtained in 97% and 100% of indicated cases, respectively. Tissue was obtained preoperatively in 97% of cases. Imaging was reviewed at multidisciplinary Treatment Planning Conference (TPC) in 97% of cases. Pathology was reviewed in 94% of cases in TPC. Both tumor, node, metastasis staging and plan of care were reviewed in 100% of cases in TPC. Treatment guidelines were followed in 94% of cases reviewed.

CONCLUSION

This study evaluated the workup and treatment provided by a single NCI designated sarcoma service to a series of patients with pathologies defined with the NCCN sarcoma treatment guidelines. Although adherence to NCCN was reported to be very high future prospective studies are required to investigate whether NCCN guidelines impact patient outcomes.

How Effective Is the Multidisciplinary Team Approach in Bariatric Surgery?

BACKGROUND

Multidisciplinary team (MDT) meetings are widely recommended in the management of bariatric surgery patients; however, there is limited evidence for their effectiveness. The aims of this study were to evaluate the decision-making process of a single-day bariatric MDT clinic and secondly to evaluate whether these MDT decisions were implemented.

METHODS

This was a retrospective observational study analysing MDT treatment decisions from February 2012 to June 2013 using an MDT proforma. The decision-making process of the MDT meeting was investigated by assessing the alterations in management plan between the surgeon and the rest of the MDT. Adherence to MDT decisions was also assessed.

RESULTS

Decisions regarding 200 consecutive patients were analyzed. There was MDT agreement for 55%, and patients were listed for surgery on the day of the MDT. There was MDT disagreement regarding 45%, with conflicting opinions expressed by surgeons in 33/200 (17%), anaesthetists in 60/200 (30%) and dieticians in 65/200 (33%). The MDT plan was instigated in 78% and the most common reason for failure was patients failing to attend for further assessment. By the end of the study, 85% of patients underwent bariatric surgery, 11.5% declined further input, 2.5% chose further weight loss and 1% were removed from waiting list.

CONCLUSION

Use of a single-day MDT clinic format resulted in a change in plan for a significant number of patients. This can be interpreted as improved quality of care for these patients, and we conclude the MDT approach is valuable.

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.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Multidisciplinary teams for the proper management of patients with genitourinary tumors: When topics set scientific societies’ agenda

Introduction:

The multidisciplinary management of oncologic patients is identified as the bottom line element of quality in tumor care.

Methods:

In 2015, 7 Italian scientific societies representing the specialists involved in the diagnosis and treatment of genitourinary tumors joined efforts in the Italian uro-oncologic multidisciplinary teams (MDTs) project. The aims were to promote the reorganization of genitourinary cancer care, switching to a multidisciplinary approach, reach a consensus on the core elements for the setup of MDTs in genitourinary oncology, and support health policy makers and managers in remodeling of the assistance and care of uro-oncologic patients on a national level.

Results:

The first activity was the setup of 5 working groups, given the task of exploring selected topics: general principles, organization of MDTs, minimal requirements, economic evaluation, and relations with authorities. The groups participated in the writing of a document that was approved by the scientific societies and published on their web sites. Moreover, a few items summarizing the extensive document were approved in the first MDT Consensus Conference held in Milan in December 2015.

Conclusions:

The experience of this initial phase led to the opening of the team to other professionals and societies, in line with a correct management of patients with genitourinary tumors, which need a multidisciplinary as well as a multiprofessional approach with emerging techniques and procedures, and with a new project work package on genitourinary paths of care and indicators.

Results of a nationwide survey on multidisciplinary teams on thyroid cancer in Spain

AIM

There is an important lack of knowledge as to the functioning of multidisciplinary teams on thyroid cancer in current clinical practice. We aimed to retrieve data on the composition, structure, and procedures developed by the multidisciplinary units of thyroid cancer in Spain.

METHODS

A nationwide survey consisting of questions about composition, structure, and functioning of multidisciplinary teams was designed. It was available online from November 15, 2017 to February 15, 2018.

RESULTS

Seventy-two multidisciplinary units responded to our survey. Of these, 15 (20.8%) focused only in thyroid cancer, while 57 (79.2%) included other endocrine disorders or non-endocrine tumors. The median (interquartile range) of members of the teams was 11 (9-14). The most frequent medical specialties in the units were endocrinology (100%), surgery (94.4%), pathology (80.6%), radiology (75.0%), nuclear medicine (73.6%), and medical oncology (55.6%). The annual number of patients reviewed by the teams was 40 (20-74). 56.9% of the multidisciplinary teams have elaborated clinical protocols for local use. Apart from clinical case discussions in the meetings, 45.8% of the units included educational activities and 36.1% research subjects. Quality indicators were developed by 22% of the teams.

CONCLUSIONS

These results suggest that there are some hopeful signs that international recommendations of having multidisciplinary approach to patients with thyroid cancer are being followed in Spain. This gives us the opportunity to proceed with further studies to analyze the real impact of this high standard of care on patient outcomes.

Multi-disciplinary and shared decision-making approach in the management of organ-confined prostate cancer

Decision-making in the management of organ-confined prostate cancer is complex as it is based on multi-factorial considerations. It is complicated by a multitude of issues, which are related to the patient, treatment, disease, availability of equipment(s), expertise, and physicians. Combination of all these factors play a major role in the decision-making process and provide for an interactive decision-making preferably in the multi-disciplinary team (MDT) meeting. MDT decisions are comprehensive and are often based on all factors including patients' biological status, disease and its aggressiveness, and physician and centres' expertise. However, one important and often under rated factor is patient-related factors. There is considerable evidence that patients and physicians have different goals for treatment and physicians' understanding of their own patients' preferences is not accurate. Several patient-related key factors have been identified such as age, religious beliefs, sexual health, educational background, and cognitive impairment. We have focused on these areas and highlight some key factors that need to be taken considered whilst counselling a patient and understanding his choice of treatment, which might not always be match with the clinicians' recommendation.

Helping patients make informed decisions. Two-year evaluation of the Gustave Roussy prostate cancer multidisciplinary clinic

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The initial treatment decision for newly diagnosed non-metastatic prostate cancer is complex.

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Specialist multidisciplinary consultations focus on shared decision-making.

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The Gustave Roussy PCMC rendered high patient satisfaction and promoted active participation.

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Information offered at the Gustave Roussy PCMC strongly influenced final treatment decisions.

Objectives

The initial treatment decision for newly diagnosed non-metastatic prostate cancer is complex. Multiple valid approaches exist, without a clear and absolute consensus for every clinical scenario, and therefore specialist opinions may vary. Multidisciplinary consultations focusing on shared decision-making aim to provide an apposite tool for the initial treatment decision. We have evaluated the first two years of activity of the Gustave Roussy Prostate Cancer Multidisciplinary Clinic (PCMC), dedicated to the initial decision-making for non-metastatic prostate cancer.

Methods

PCMC consists of two consecutive specialist consultations with a urological surgeon and a radiation oncologist, followed by a dedicated Tumor Board discussion. A study questionnaire was addressed to all PCMC patients via postal mail. Medical notes and questionnaire responses of 195 eligible patients were analyzed.

Results

The questionnaire response rate was 69% (134 patients). Complete satisfaction rate was high (114 of 118 responders, 97%). Patients were offered new treatment options in 55% of cases, and felt better informed in 98% (122 of 125 responders). The double consultation was considered useful (124 of 129 responders, 96%). Reported feeling of active participation was significantly elevated (117 of 131 responders, 89%), while 46% of patients (57 of 125) modified their decision on the management of their prostate cancer following their PCMC consultation.

Conclusions

The experience of a multidisciplinary consultation in the initial management of non-metastatic prostate cancer renders high patient satisfaction, improves their appreciation of feeling better informed, promotes active participation and shared decision-making and strongly influences their final decision.

Systematic Review of Decision Aids for the Management of Men With Localized Prostate Cancer

A broader range of decisional tools should be investigated. This paper will update the decisional outcome data and assess the features of decisional tool. Literature search strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Articles that cited Lin et al and Violette et al were searched. Features of decisional tools were analyzed using the International Patient Decision Aid Standards Instrument criteria. The scores of the 31 decisional tools ranged from 6 to 15, which did not correlate proportionally with the positive decisional outcomes. Personal importance appeared to be a significant component. Multidisciplinary clinics are superior in improving decisional outcomes as they promote more at shared decision making.

An audit of referral and treatment patterns of high-risk prostate cancer patients in Alberta

INTRODUCTION

We aimed to determine the impact of clinical practice guidelines (CPG) on rates of radiation oncologist (RO) referral, androgen-deprivation therapy (ADT), radiation therapy (RT), and radical prostatectomy (RP) in patients with high-risk prostate cancer (HR-PCa).

METHODS

All men >18 years, diagnosed with PCa in 2005 and 2012 were identified from the Alberta Cancer Registry. Patient age, aggregated clinical risk group (ACRG) score, Gleason score (GS), pre-treatment prostate-specific antigen (PSA), RO referral, and treatment received were extracted from electronic medical records. Logistic regression modelling was used to examine associations between RO referral rates and relevant factors.

RESULTS

HR-PCa was diagnosed in 261 of 1792 patients in 2005 and 435 of 2148 in 2012. Median age and ACRG scores were similar in both years (p>0.05). The rate of patients with PSA >20 were 67% and 57% in 2005 and 2012, respectively (p=0.004). GS ≤6 was found in 13% vs. 5% of patients, GS 7 in 27% vs. 24%, and GS ≥8 in 59% vs. 71% in 2005 and 2012, respectively (p<0.001). In 2005, RO referral rate was 68% compared to 56% in 2012 (p=0.001), use of RT + ADT was 53% compared to 32% (p<0.001), and RP rate was 9% vs. 17% (p=0.002). On regression analysis, older age, 2012 year of diagnosis and higher PSA were associated with decreased RO referral rates (odds ratios [OR] 0.49, 95% confidence interval [CI] 0.39-0.61; OR 0.51, 95% CI 0.34-0.76; and OR 0.64, 95% CI 0.39-0.61), respectively [p<0.001]).

CONCLUSIONS

Since CPG creation in 2005, RO referral rates and ADT + RT use declined and RP rates increased, which demonstrates a need to improve adherence to CPG in the HR-PCa population.

Patterns of multidisciplinary care in the management of non-metastatic invasive breast cancer in the United States Medicare patient

PURPOSE

Multidisciplinary care (MDC) in managing breast cancer is resource-intensive and growing in prevalence anecdotally, although care patterns are poorly characterized. We sought to determine MDC patterns and effects on care in the United States Medicare patient.

METHODS

Patients diagnosed with non-metastatic invasive breast cancer from 1992-2009 were reviewed using the Survival, Epidemiology, and End Results (SEER)-Medicare linked dataset. MDC was defined as a post-diagnosis, preoperative visit with a surgical, medical, and radiation oncologist. Same-day MDC (MDCSD) was the MDC subset having all three visits on one date.

RESULTS

Among 88,865 patients, MDC was utilized in 2.9 %, with 14.1 % of these having MDCSD. MDC use did not vary by stage, but MDC patients were more likely to be younger, black, receive lumpectomy, have fewer nodes examined, and receive radiotherapy. MDCSD patients were more likely than non-MDC patients to be black, receive mastectomy, and receive radiotherapy. MDC and MDCSD use increased over time and varied by geographic region, with rural patients less likely to receive MDC (OR 0.54 [95 % CI 0.45-0.65]) and MDCSD (OR 0.32 [95 % CI 0.19-0.54]). Radiotherapy after breast conserving surgery, used in 86.2 % of non-MDC patients, was administered to 90.2 % of MDC (p < 0.001) and 92.6 % of MDC(SD) (p = 0.096) patients. Post-mastectomy radiotherapy was administered in 52.0 % of non-MDC patients, 63.8 % of MDC (p = 0.050), and 89.1 % of MDC(SD) (p = 0.011) patients after propensity score adjustment.

CONCLUSION

While increasing, few Medicare patients undergo MDC and MDCSD is rare. MDC may improve quality and MDCSD should be considered for patient convenience. While not yet widespread, efforts should integrate MDC and MDCSD across the U.S.

Assessment of the Rate of Adherence to International Guidelines for Androgen Deprivation Therapy with External-beam Radiation Therapy: A Population-based Study

BACKGROUND

The National Comprehensive Cancer Network and the European Association of Urology guidelines recommend using radiation therapy (RT) with androgen deprivation therapy (ADT) to treat high-risk and locally advanced prostate cancer patients.

OBJECTIVE

To evaluate the degree of adherence to these guidelines.

DESIGN, SETTING, AND PARTICIPANTS

Between 2003 and 2009, in the Surveillance Epidemiology and End Results (SEER)-Medicare database, 14 180 patients were diagnosed with high-risk (T1-T2 with World Health Organization histologic grade 3) or locally advanced (T3-T4 with any histologic grade) prostatic adenocarcinoma.

INTERVENTION

Administration of RT-ADT versus RT alone.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We assessed the rate of adherence to guidelines with respect to use of RT-ADT in the overall population and after stratification according to stage-grade groupings (T1-T2 G3 vs T3-T4 any grade), age (66-69, 70-74, 75-79, ≥80 yr), Charlson Comorbidity Index (CCI) (0, 1, ≥2), and preexisting baseline cardiovascular (CV) disease. We depicted the rate of RT-ADT administration graphically over the study period. Multivariable logistic regression analyses were performed to assess the predictors of RT-ADT use.

RESULTS AND LIMITATIONS

RT-ADT rates and guideline adherence were 58-75%, with the highest rate (75%) in 2003 and the lowest (58%) in 2009. When stratified according to stage-grade groupings, age, CCI, and preexisting baseline CV disease, similar results were obtained. In multivariable analyses, year of diagnosis (p<0.001), patient age (p<0.001), stage-grade groupings (p<0.001), CCI (p=0.036), race (p<0.001), marital status (p<0.001), population density (p<0.001), and US regions (p<0.001) were independent predictors of RT-ADT use. The limitations of our study include age >65 yr and exclusive Medicare coverage.

CONCLUSIONS

The rate of guideline adherence regarding the use of RT-ADT is suboptimal and decreases with time instead of increasing.

PATIENT SUMMARY

This population-based study provides evidence of low adherence to international urologic guidelines regarding the combination of radiation therapy (RT) with androgen deprivation therapy (ADT) for high-risk and locally advanced prostate cancer (PCa) patients. Despite the increasing number of randomized controlled trials over time that showed a survival benefit for patients with high-risk and locally advanced PCa treated with RT-ADT compared with RT alone, the rate of adherence to guidelines decreased with time.

Australian patterns of prostate cancer care: Are they evolving?

Background

Approaches to prostate cancer (PCa) care have changed in recent years out of concern for overdiagnosis and overtreatment. Despite these changes, many patients continue to undergo some form of curative treatment and with a growing perception among multidisciplinary clinicians that more aggressive treatments are being favored. This study examines patterns of PCa care in Australia, focusing on current rates of screening and aggressive interventions that consist of high-dose-rate (HDR) brachytherapy and pelvic lymph node dissection (PLND).

Methods

Health services data were used to assess Australian men undergoing PCa screening and treatment from 2001 to 2014. Age-specific rates of prostate-specific antigen (PSA) screening were calculated. Ratios of radical prostatectomy (RP) with PLND to RP without PLND, and HDR brachytherapy to low-dose-rate (LDR) brachytherapy were determined by state jurisdictions.

Results

From 2008, the rate of PSA screening trended downward significantly with year for all age ranges (P < 0.02) except men aged ≥ 85 (P = 0.56). PLND rates for 2008–2014 were lower than rates for 2001–2007 across all states and territories. From 2008 to 2014, PLND was performed ≥ 2.7 times more frequently in New South Wales and the Australian Capital Territory than in other jurisdictions. Since 2007, brachytherapy practice across Australia has evolved towards a relatively low use of HDR brachytherapy (ratio of HDR to LDR brachytherapy < 0.5 for all jurisdictions except the Australian Capital Territory).

Conclusion

Rates of PLND and HDR brachytherapy for PCa have declined in Australia, providing evidence for the effect of stage migration due to widespread PSA screening. Currently, PSA screening rates remain high among older men, which may expose them to unnecessary investigations and treatment-related morbidity.

Prostate Cancer Unit Initiative in Europe: A position paper by the European School of Oncology

The Prostate Cancer Programme of the European School of Oncology developed the concept of specialised interdisciplinary and multiprofessional prostate cancer care to be formalized in Prostate Cancer Units (PCU). After the publication in 2011 of the collaborative article "The Requirements of a Specialist Prostate Cancer Unit: A Discussion Paper from the European School of Oncology", in 2012 the PCU Initiative in Europe was launched. A multiprofessional Task Force of internationally recognized opinion leaders, among whom representatives of scientific societies, and patient advocates gathered to set standards for quality comprehensive prostate cancer care and designate care pathways in PCUs. The result was a consensus on 40 mandatory and recommended standards and items, covering several macro-areas, from general requirements to personnel to organization and case management. This position paper describes the relevant, feasible and applicable core criteria for defining PCUs in most European countries delivered by PCU Initiative in Europe Task Force.

Barriers to physician adherence to evidence-based monitoring guidelines in chronic myelogenous leukemia

PURPOSE

Although monitoring of cytogenetic/molecular responses to therapy in chronic myelogenous leukemia (CML) facilitates superior outcomes, less than one half of CML patients are monitored using published evidence-based guidelines. Barriers to physician adherence with guidelines are unknown.

METHODS

An anonymous survey was mailed to 515 hematologist-oncologists in New Jersey and Indiana exploring attitudes toward monitoring guidelines.

RESULTS

Ninety-six physicians (19%) responded-89% in community practice, 83% with more than 10 years of experience, and 92% caring for CML patients. Eighty-four percent self-reported using CML monitoring guidelines, 14% were familiar with but did not adopt guidelines and 2% were unfamiliar. Eighty-four percent performed molecular monitoring quarterly as recommended; 6% did not perform molecular monitoring at all during the first year. Guidelines were considered evidence based by 98%, but only 54% strongly considered them easy to find; only 51% strongly felt they addressed all aspects of disease management. Patient resource barriers were a significant deterrent toward implementation with 30% citing high costs. Physician resources, including lack of time to search guidelines, limited use in one fifth. Despite 90% believing an online database helpful, between one third and one half did not feel that additional training, professional society endorsements, or availability of expert consultations would encourage use.

CONCLUSIONS

Significant barriers to adherence with evidence-based CML guidelines exist. Resource barriers, lack of familiarity and lack of agreement restrict adoption, but efforts to facilitate use are not desired. Multifaceted educational strategies, including automated computerized reminders at point of care, are needed to improve quality outcomes in CML.

Is it worth reorganising cancer services on the basis of multidisciplinary teams (MDTs)? A systematic review of the objectives and organisation of MDTs and their impact on patient outcomes

Multidisciplinary teams (MDTs) are considered the gold standard of cancer care in many healthcare systems, but a clear definition of their format, scope of practice and operational criteria is still lacking. The aims of this review were to assess the impact of MDTs on patient outcomes in cancer care and identify their objectives, organisation and ability to engage patients in their care. We conducted a systematic review of the literature in the Medline database. Fifty-one peer-reviewed papers were selected from November 2005 to June 2012. MDTs resulted in better clinical and process outcomes for cancer patients, with evidence of improved survival among colorectal, head and neck, breast, oesophageal and lung cancer patients in the study period. Also, it was observed that MDTs have been associated with changes in clinical diagnostic and treatment decision-making with respect to urological, pancreatic, gastro-oesophageal, breast, melanoma, bladder, colorectal, prostate, head and neck and gynaecological cancer. Evidence is consistent in showing positive consequences for patients' management in multiple dimensions, which should encourage the development of structured multidisciplinary care, minimum standards and exchange of best practices.

Standardizing treatment: a crisis in cancer care

The Institute of Medicine has emphasized the roles of multidisciplinary treatment planning, evidence-based clinical practice guidelines, and regionalization of healthcare in optimizing the quality of cancer care. We discuss these critical elements as they pertain to head and neck cancer care.

Impact of a single-day multidisciplinary clinic on the management of patients with liver tumours

PURPOSE

Multidisciplinary cancer clinics may improve patient care. We examined how a single-day multidisciplinary liver clinic (mdlc) affected care recommendations for patients compared with the recommendations provided before presentation to the mdlc.

METHODS

We analyzed the demographic and clinicopathologic data of 343 patients assessed in the Johns Hopkins Liver Tumor Center from 2009 to 2012, comparing imaging and pathology interpretation, diagnosis, and management plan between the outside provider (osp) and the mdlc.

RESULTS

Most patients were white (n = 259, 76%); median age was 60 years; and 146 were women (43%). Outside providers referred 182 patients (53%); the rest were self-referred. Patients travelled median of 83.4 miles (interquartile range: 42.7-247 miles). Most had already undergone imaging (n = 338, 99%) and biopsy (n = 194, 57%) at the osp, and a formal management plan had been formulated for about half (n = 168, 49%). Alterations in the interpretation of imaging occurred for 49 patients (18%) and of biopsy for 14 patients (10%). Referral to the mdlc resulted in a change of diagnosis in 26 patients (8%), of management plan in 70 patients (42%), and of tumour resectability in 7 patients (5%). Roughly half the patients (n = 174, 51%) returned for a follow-up, and 154 of the returnees (89%) received treatment, primarily intraarterial therapy (n = 88, 57%), systemic chemotherapy (n = 60, 39%), or liver resection (n = 32, 21%). Enrollment in a clinical trial was proposed to 34 patients (10%), and 21 of the 34 (62%) were accrued.

CONCLUSIONS

Patient assessment by our multidisciplinary liver clinic had a significant impact on management, resulting in alterations to imaging and pathology interpretation, diagnosis, and management plan. The mdlc is an effective and convenient means of delivering expert opinion about the diagnosis and management of liver tumours.