Impact of the lung oncology multidisciplinary team meetings on the management of patients with cancer

Multidisciplinary meeting review in nonsmall cell lung cancer: a systematic review and meta-analysis

BACKGROUND

Lung cancer diagnosis, staging and treatment may be enhanced by multidisciplinary participation and presentation in multidisciplinary meetings (MDM). We performed a systematic review and meta-analysis to explore literature evidence of clinical impacts of MDM exposure.

METHODS

A study protocol was registered (PROSPERO identifier CRD42021258069). Randomised controlled trials and observational cohort studies including adults with nonsmall cell lung cancer and who underwent MDM review, compared to no MDM, were included. MEDLINE, CENTRAL, Embase and ClinicalTrials.gov were searched on 31 May 2021. Studies were screened and extracted by two reviewers. Outcomes included time to diagnosis and treatment, histological confirmation, receipt of treatments, clinical trial participation, survival and quality of life. Risk of bias was assessed using the ROBINS-I (Risk of Bias in Non-randomised Studies - of Interventions) tool.

RESULTS

2947 citations were identified, and 20 studies were included. MDM presentation significantly increased histological confirmation of diagnosis (OR 3.01, 95% CI 2.30-3.95; p<0.00001) and availability of clinical staging (OR 2.55, 95% CI 1.43-4.56; p=0.002). MDM presentation significantly increased likelihood of receipt of surgery (OR 2.01, 95% CI 1.29-3.12; p=0.002) and reduced the likelihood of receiving no active treatment (OR 0.32, 95% CI 0.21-0.50; p=0.01). MDM presentation was protective of both 1-year survival (OR 3.23, 95% CI 2.85-3.68; p<0.00001) and overall survival (hazard ratio 0.63, 95% CI 0.55-0.72; p<0.00001).

DISCUSSION

MDM presentation was associated with increased likelihood of histological confirmation of diagnosis, documentation of clinical staging and receipt of surgery. Overall and 1-year survival was better in those presented to an MDM, although there was some clinical heterogeneity in participants and interventions delivered. Further research is required to determine the optimal method of MDM presentation, and address barriers to presentation.

Impact of multidisciplinary team meetings on the management of patients with breast cancer in a large private healthcare facility

AIMS

Multidisciplinary meetings (MDMs) play a crucial role in decision-making in breast cancer patient care. This study aimed to firstly assess the impact of breast cancer MDMs in decision-making for breast cancer patients and secondly to determine the concordance between MDM recommendations and implementation of clinical practice.

METHODS

Patient cases to be presented at the weekly breast cancer MDMs were identified and prospectively enrolled. Management plans were predicted by the treating surgeon with the pre-MDM management plans then compared to MDM recommendations. Changes in decision-making were assessed in the following domains: further surgery, systemic therapy (endocrine, chemotherapy or targeted), radiotherapy, enrolment in a clinical trial, further investigations, and referral to other specialists or services. Patient records were subsequently reviewed at 3 months post-MDM to assess the rate of implementation of MDM recommendations and any reasons for discordance.

RESULTS

Out of 50 cases, 66% (CI 53-79%; p < .005) experienced a change in management plan as a result of MDM discussion, with a total of 66 episodes of recorded change per decision-making domain affecting the following: further surgery (7.6%), endocrine therapy (4.5%), chemotherapy (19.7%), targeted therapy (4.5%), radiotherapy (18.2%), enrolment for a clinical trial (12.1%), additional investigations (22.7%), and further referrals (10.6%). MDM recommendations were implemented in 83.7% of cases.

CONCLUSION

The breast cancer MDMs were found to substantially impact on the management plans for breast cancer patients, with 83.7% of MDM recommendations being implemented into clinical practice. This study reinforces the importance of MDMs in the management of these patients, as well as highlighting the need for further investigating and addressing the potential barriers to the implementation of MDM recommendations.

Impact of the Multidisciplinary Cancer Team on the Diagnostic and Therapeutic Care Pathway of Early Breast Cancer Patients and Perception of Team Members: The Experience of a Cancer Centre in Italy

Literature on the role of multidisciplinary team (MDT) in cancer is still controversial. We aimed to investigate MDT impact on a panel of indicators in breast cancer care in a single-center retrospective study performed in a Cancer Reference Center in Italy. We analysed the diagnostic and therapeutic care pathway (DTCP) of 266 early breast cancer patients managed by our MDT during 2019-2020. Process indicators reflecting the change of the diagnostic and therapeutic care pathways occurred after the MDT discussion were computed. Further, the performance of some quality care indicators in breast cancer care since the establishment of the MDT activity and the breast cancer MDT members' perceptions were also investigated. According to our study, the MDT approach improves breast cancer management by increasing the completion of staging and by encouraging neo-adjuvant treatment and an appropriate and faster surgery. In MDT members' perspective it also improves decision-making and training and creates a positive work environment. Globally, our study encourages MDT rollout in breast cancer care. However, to enhance the reliability and comparability of the results of studies investigating MDT effectiveness in clinical practice, shared guidelines on its operationalisation are strongly desirable.

Regional Collaboration and Trends in Clinical Management of Thyroid Cancer

OBJECTIVE

This study examines the trends in the management of thyroid cancer and clinical outcomes in the Southwestern region of The Netherlands from 2010 to 2021, where a regional collaborative network has been implemented in January 2016.

STUDY DESIGN

Retrospective cohort study.

SETTING

This study encompasses all patients diagnosed with thyroid cancer of any subtype between January 2010 and June 2021 in 10 collaborating hospitals in the Southwestern region of The Netherlands.

METHODS

The primary outcome of this study was the occurrence of postoperative complications. Secondary outcomes were trends in surgical management, centralization, and waiting times of patients with thyroid cancer.

RESULTS

This study included 1186 patients with thyroid cancer. Median follow-up was 58 [interquartile range: 24-95] months. Surgery was performed in 1027 (86.6%) patients. No differences in postoperative complications, such as long-term hypoparathyroidism, permanent recurrent nerve paresis, or reoperation due to bleeding were seen over time. The percentage of patients with low-risk papillary thyroid carcinoma referred to the academic hospital decreased from 85% (n = 120/142) in 2010 to 2013 to 70% (n = 120/171) in 2014 to 2017 and 62% (n = 100/162) in 2018 to 2021 (P < .01). The percentage of patients undergoing a hemithyroidectomy alone was 9% (n = 28/323) in 2010 to 2013 and increased to 20% (n = 63/317; P < .01) in 2018 to 2021.

CONCLUSION

The establishment of a regional oncological network coincided with a de-escalation of thyroid cancer treatment and centralization of complex patients and interventions. However, no differences in postoperative complications over time were observed. Determining the impact of regional oncological networks on quality of care is challenging in the absence of uniform quality indicators.

The Best Supportive Care in Stage III Non-Small-Cell Lung Cancer

Lung cancer is a major cause of cancer deaths worldwide. Non-small-cell lung cancer (NSCLC) represents most lung cancer cases, and approximately one-third of patients present with stage III disease at diagnosis. As multiple treatment plans can be adopted for these patients depending on tumor size and nodal staging, stage III NSCLC management is challenging. Over the past decades, multidisciplinary teams (MDTs) have been implemented in healthcare services to coordinate actions among the different health care professionals involved in cancer care. The aim of this review was to discuss real-world evidence of the impact of MDTs on stage III NSCLC management, survival, and quality of life. Here, we performed a literature review to investigate the role of nutrition and navigational nursing in NSCLC care and the influence of MDTs in the choice of treatment plans, including immunotherapy consolidation, and in the management of chemotherapy and radiotherapy-related adverse events. We also performed a mapping review to identify gaps in the implementation of cancer care MDTs in healthcare services around the world.

Total times to treatment completion and clinical outcomes in odontogenic sinusitis

BACKGROUND

Multidisciplinary collaboration is essential for effective odontogenic sinusitis (ODS) management. One point of debate has been the optimal timing of primary dental treatment and endoscopic sinus surgery (ESS), but differences in time to completion of these treatment pathways have not been studied.

METHODS

A retrospective cohort study was conducted on ODS patients from 2015 to 2022. Demographic and clinical variables were recorded, and various durations of time were analyzed from rhinologic consultation through treatment completion. Resolution of sinusitis symptoms and purulence on endoscopy was also recorded.

RESULTS

Eighty-nine ODS patients were analyzed (47.2 % male, median 59 years-old). Of the 89 ODS patients, 56 had treatable dental pathology, and 33 had no treatable dental pathology. Median time to treatment completion for all patients was 103 days. Of 56 ODS patients with treatable dental pathology, 33 had primary dental treatment, and 27 (81 %) required secondary ESS. In patients who underwent primary dental treatment followed by ESS, median time from initial evaluation to treatment completion was 236.0 days. If ESS was pursued primarily followed by dental treatment, median time from initial evaluation to treatment completion was 112.0 days, which was significantly shorter than if dental treatment was pursued primarily (p = 0.002). Overall symptomatic and endoscopic resolution was 97.8 %.

CONCLUSIONS

After dental and sinus surgical treatment, ODS patients experienced 97.8 % resolution of symptoms and purulence on endoscopy. In patients with ODS due to treatable dental pathology, primary ESS followed by dental treatment resulted in a shorter overall treatment duration than primary dental treatment followed by ESS.

Real-world clinical practice and outcomes in treating stage III non-small cell lung cancer: KINDLE-Asia subset

Introduction

Stage III non-small cell lung cancer (NSCLC) is a heterogeneous disease requiring multimodal treatment approaches. KINDLE-Asia, as part of a real world global study, evaluated treatment patterns and associated survival outcomes in stage III NSCLC in Asia.

Methods

Retrospective data from 57 centers in patients with stage III NSCLC diagnosed between January 2013 and December 2017 were analyzed. Median progression free survival (mPFS) and median overall survival (mOS) estimates with two sided 95% confidence interval (CI) were determined by applying the Kaplan-Meier survival analysis.

Results

Of the total 1874 patients (median age: 63.0 years [24 to 92]) enrolled in the Asia subset, 74.8% were men, 54.7% had stage IIIA disease, 55.7% had adenocarcinoma, 34.3% had epidermal growth factor receptor mutations (EGFRm) and 50.3% had programmed death-ligand 1 (PD-L1) expression (i.e. PD-L1 ≥1%). Of the 31 treatment approaches as initial therapy, concurrent chemoradiotherapy (CRT) was the most frequent (29.3%), followed by chemotherapy (14.8%), sequential CRT (9.5%), and radiotherapy (8.5%). Targeted therapy alone was used in 81 patients of the overall population. For the Asia cohort, the mPFS and mOS were 12.8 months (95% CI, 12.2–13.7) and 42.3 months (95% CI, 38.1–46.8), respectively. Stage IIIA disease, Eastern Cooperative Oncology Group ≤1, age ≤65 years, adenocarcinoma histology and surgery/concurrent CRT as initial therapy correlated with better mOS (p &lt; 0.05).

Conclusions

The results demonstrate diverse treatment patterns and survival outcomes in the Asian region. The high prevalence of EGFRm and PD-L1 expression in stage III NSCLC in Asia suggests the need for expanding access to molecular testing for guiding treatment strategies with tyrosine kinase inhibitors and immunotherapies in this region.

Establishing a Multicenter Network for Patients With Thyroid Nodules and Cancer: Effects on Referral Patterns

OBJECTIVE

To perform a qualitative evaluation of the Thyroid Network, with a quantitative analysis of second opinion referrals for patients in the southwestern part of the Netherlands who have thyroid nodules and cancer.

METHODS

This prospective observational study registered all patients with thyroid nodules and cancer who were referred to the academic hospital from 2 years before and 4 years after the foundation of the Thyroid Network. We implemented biweekly regional multidisciplinary tumor boards using video conference and a regional patient care pathway for patients with thyroid nodules and cancer. For qualitative evaluation, interviews were conducted with a broad selection of stakeholders via maximum variation sampling. The primary outcome was the change in second opinions after the foundation of the Thyroid Network.

RESULTS

Second opinions from Thyroid Network hospitals to the academic hospital decreased from 10 (30%) to 2 (7%) two years after the start of the Thyroid Network (P = .001), while patient referrals remained stable (n = 108 to 106). Qualitative evaluation indicated that the uniform care pathway and the regional multidisciplinary tumor board were valued high.

DISCUSSION

Establishing a regional network, including multidisciplinary tumor boards and a care pathway for patients with thyroid nodules and cancer, resulted in a decrease in second opinions of in-network hospitals and high satisfaction of participating specialists.

IMPLICATIONS FOR PRACTICE

The concept of the Thyroid Network could spread to other regions as well as to other specialties in health care. Future steps would be to assess the effect of regional collaboration on quality of care and patient satisfaction.

Home-based multidisciplinary interventions on skin adverse reactions in EGFR-TKI-treated patients with lung cancer: a protocol for a randomised controlled trial

INTRODUCTION

Here, we provide a feasible, well-designed protocol of a randomised controlled trial for the assessment of the effects of a home-based multidisciplinary intervention on the severity of skin adverse drug reactions and health-related indicators in patients with non-small cell lung cancer (NSCLC) under epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) therapy.

METHODS AND ANALYSIS

The study will be a two-group, parallel randomised controlled trial conducted at patients' homes by a multidisciplinary team in Zhengzhou in Henan Province, China. Patients with NSCLC who received EGFR-TKI therapy and experienced adverse skin reactions will be randomised and receive either ordinary care or home-based multidisciplinary interventions. The intervention will be divided into an intensive stage (6 weeks) and a maintenance stage (6 weeks) with baseline and follow-up assessment. Interventions in the intensive stage will include general interventions such as health education, follow-up, behaviour guide and social support and targeted interventions such as skill training, coping with adverse drug reaction and problem-solving. The measures that will be carried out in maintenance stage are continuous interventions consisted of an intensive intervention. The multidisciplinary team will be responsible for managing skin adverse drug reactions as required at patients' homes. Data collection and analysis will be performed by researchers at baseline, the end of the sixth week of intervention and the third month after the intervention. The primary outcome is the degree of skin adverse drug reactions, while the secondary outcomes, for example, self-management ability, quality of life, outpatient visits and health economics indicators, will also be presented.

ETHICS AND DISSEMINATION

This study was reviewed and approved by the Ethics Committee of Zhengzhou University (No. ZZUIRB-2020-97). Findings will be available to patients, clinicians, nurses, pharmacists, community medical staff, funders and health policymakers through peer-reviewed publications, social media and patient support groups.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trials Registry (ChiCTR2000040643).

Understanding clinical decision-making in mesothelioma care: a mixed methods study

INTRODUCTION

Malignant pleural mesothelioma is a rare, incurable cancer arising from previous asbestos exposure; patients have a poor prognosis, with a median survival rate of 8-14 months. Variation in mesothelioma clinical decision-making remains common with a lack of multidisciplinary knowledge sharing, leading to inconsistencies in treatment decisions. The study aimed to explore which factors impacted on clinicians' decision-making in mesothelioma care, with a view to optimising the mesothelioma care pathway.

METHODS

This mixed methods study consisted of documentary analysis of local and national guidelines, policies or documents pertaining to mesothelioma care pathways, secondary analysis of mesothelioma patient data, and interviews with clinicians attending lung cancer and/or mesothelioma-specific multidisciplinary team meetings. The study took place at three National Health Service trusts in England. Documentations relating to patients' treatment pathways were collated and reviewed qualitatively. Records of patients with mesothelioma were extracted from hospital patient records and data collected on diagnosis date, treatment, mortality rates, survival postdiagnosis, age and clinical care team. Data were statistically analysed. Interviews with clinicians explored influences on clinical decision-making, including challenges or barriers involved. Data were thematically analysed. The Strengthening the Reporting of Observational Studies in Epidemiology reporting checklist was used.

RESULTS

There were differences in the structure and delivery of mesothelioma treatment and care between trusts. Four main themes were identified: 'collaboration and communication', 'evidence base and knowledge', 'role of the clinician' and 'role of the patient'. Two cross-cutting themes relating to the role of the mesothelioma nurse specialist and the impact of COVID-19 were identified.

DISCUSSION

There is a need to review the structure of mesothelioma multidisciplinary team meetings to ensure patients are reviewed by clinicians with appropriate knowledge, expertise and understanding of how, why and when decisions should be made. There is a need for expert clinicians in mesothelioma care to promote an up-to-date evidence and knowledge base within the wider multidisciplinary team.

Implementation rate and effects of multidisciplinary team meetings on decision making about radiotherapy: an observational study at a single Japanese institution

BACKGROUND

Cancer treatment requires a multidisciplinary approach. Therefore, multidisciplinary team meetings (MDTMs) have been widely used to determine the direction of treatment. However, no standard provisions exist for conducting MDTMs, and recommendations discussed in MDTMs are sometimes not implemented. ​This study analyzed the indications for radiotherapy discussed and recommended at MDTMs, identified the rate of radiotherapy recommendations for patients that were not implemented, and clarified the reasons at a single academic center in Japan.

METHODS

This was a cross-sectional study that analyzed the minutes and electronic medical records of cases discussed at MDTMs held between April 2012-March 2017 at Yamagata University Hospital. We categorized how radiotherapy was initially presented at MDTMs, determined the rate of radiotherapy recommendations made through MDTMs, analyzed whether treatment recommendations were subsequently implemented, and examined the causes of non-implementation. We performed a statistical analysis to assess some clinical factors (sex, age, number of multidisciplinary team meetings, and classification of planned treatment) associated with the non-implementation of radiotherapy recommendations from MDTMs.

RESULTS

A total of 1813 cases were discussed at MDTMs, of which 71% (1293 cases) were presented with treatment plans, including radiotherapy. Further, 66% (1205 cases) were recommended for radiotherapy through the MDTMs. Recommendations from MDTMs were not implemented in 7% (142 cases). The most typical reason for non-implementation was the clinician's opinion (30%), followed by patient preferences (27%) and disease progression (20%). Change in cancer stage and improvement in symptoms were 12% and 4%, respectively. These ratios were similar each year. We could not find the factors associated with the non-implementation of radiotherapy recommendations from MDTMs.

CONCLUSIONS

MDTMs had a significant effect on the recommendation of radiotherapy for each patient with a tumor. The primary reason for the non-implementation of decisions made at MDTMs was the opinion of clinicians and the patient's preference. These results were similar to previous studies. We need to establish a monitoring system where patients themselves can decide the treatments based on their choices while using the recommendations from MDTMs.

The Effects of Multidisciplinary Team Meetings on Clinical Practice for Colorectal, Lung, Prostate and Breast Cancer: A Systematic Review

Simple Summary

Multidisciplinary team meetings have increasingly been implemented in cancer care worldwide to ensure timely, accurate and evidence-based diagnosis, and treatment plans. Nowadays, multidisciplinary team meetings are generally considered indispensable. However, they are considered time-consuming and expensive, while the effects of multidisciplinary team meetings are not yet fully understood. The aim of this systematic review is to update and summarize the literature and create an overview of the existing knowledge. Cancer types such as colorectal, lung, prostate and breast cancer with rapidly increasing incidence rates will inevitably impact the workload of clinicians. Understanding the effects of the widely implemented multidisciplinary team meetings in oncology care is fundamental in order to optimize care pathways and allocate resources in the rapidly diversifying landscape of cancer therapies.

Abstract

Objective: The aim of our systematic review is to identify the effects of multidisciplinary team meetings (MDTM) for lung, breast, colorectal and prostate cancer. Methods: Our systematic review, performed following PRISMA guidelines, included studies examining the impact of MDTMs on treatment decisions, patient and process outcomes. Electronic databases PUBMED, EMBASE, Cochrane Library and Web of Science were searched for articles published between 2000 and 2020. Risk of bias and level of evidence were assessed using the ROBINS-I tool and GRADE scale. Results: 41 of 13,246 articles were selected, evaluating colorectal (21), lung (10), prostate (6) and breast (4) cancer. Results showed that management plans were changed in 1.6–58% of cases after MDTMs. Studies reported a significant impact of MDTMs on surgery type, and a reduction of overall performed surgery after MDTM. Results also suggest that CT and MRI imaging significantly increased after MDTM implementation. Survival rate increased significantly with MDTM discussions according to twelve studies, yet three studies did not show significant differences. Conclusions: Despite heterogeneous data, MDTMs showed a significant impact on management plans, process outcomes and patient outcomes. To further explore the impact of MDTMs on the quality of healthcare, high-quality research is needed.

Cardiovascular Oncology: The Need for a Multidisciplinary Approach

Improved cancer survivorship has led to an increase in cardiovascular (CV) complications in the oncologic population, mainly associated with therapeutic regimens. Hence, cardio-oncology has grown toward unifying the cancer care process in which the best prevention, early detection, treatment, and CV surveillance are offered to patients. This multidisciplinary approach allows us to optimize and agree upon clinical decisions to enhance clinical outcomes. Atrial fibrillation is one of the hot topics in the field because it is still challenging in cancer patients. The optimal antithrombotic therapy remains unclear. Nevertheless, evidence supports that specific recommendations are needed due to a hemorrhagic/thrombotic disbalance present within this subgroup of patients and a low rate of anticoagulation treatments compared with the general population. Further, cardiotoxicity management is currently transforming. Increasingly, early detection of subclinical alterations is raising awareness. When medical therapy is initiated early, fewer patients progress to ventricular dysfunction and the rate of patients completing cancer therapy gradually increases. New approaches are demonstrating better outcomes and these strategies will expectedly be established in clinical practice. Cardio-oncology enables us to find the best balance between cancer treatment and CV health protection. Nowadays, more and more physicians are being instructed in this discipline, which gradually exhibits a greater presence in conferences and scientific journals. However, given the need for physicians thoroughly trained in cardio-oncology, this subspecialty must be promoted further.

The Next Step Toward Patient-Centeredness in Multidisciplinary Cancer Team Meetings: An Interview Study with Professionals

Background

Patient-centeredness is essential in complex oncological multidisciplinary team decision-making. Improvement seems to be needed, while there is a lack of knowledge about health care providers’ needs for improvement.

Objective

To explore multidisciplinary team members’ perspectives on the need to improve patient-centeredness in complex decision-making, and subsequently the strategies to enhance it.

Methods

This was a qualitative descriptive interview study. The participants were twenty-four professionals who attended multidisciplinary cancer team meetings weekly. The setting was five multidisciplinary teams (gastrointestinal, gynecological, urological, head and neck, and hematological cancer) in a Dutch academic hospital. Data were collected by semi-structured interviews and were analyzed with a combination of inductive and deductive content analysis.

Results

The participants voiced the need for additional information (patient-centered information, patients’s needs and preferences, individualized medical information) during the multidisciplinary team meeting, to be more patient-centered in the decision-making conversation with the patient following the meeting, and for more information following the meeting to support patient-centeredness. The strategies, which mostly originated from the needs, were categorized as organization, decision-making, and communication. The most prominent strategies were those aimed at collecting and using patient-centered information, and to facilitate the decision-making conversation with the patient following the multidisciplinary team meeting.

Conclusion

Our findings highlighted the need to improve patient-centeredness in oncological multidisciplinary teams and provided a comprehensive overview of strategies for improvement, supported by multidisciplinary team members. These strategies emphasize involvement of patients throughout the continuous process of decision-making for patients with cancer. These strategies may be implemented in other oncological multidisciplinary teams, taking in mind the local needs. Future research may help to prioritize the strategies and to determine and evaluate the effect on endpoints, like patient or professional satisfaction, shared decision-making, and on the decision that was made.

Nontuberculous mycobacterial pulmonary disease: an integrated approach beyond antibiotics

Nontuberculous mycobacterial (NTM) pulmonary disease (PD) is an emerging condition with heterogeneous manifestations from both the microbiological and the clinical point of view. Diagnostic and therapeutic guidelines are available but there are still unmet patients' and physicians' needs, including therapy-related adverse events, symptom control, management of comorbidities, risk of re-exposure to the pathogen and unfavourable outcomes.

In the present review, we provide currently available evidence for an integrated approach to NTM-PD beyond antibiotic therapy. This includes 1) avoiding exposure to environments where mycobacteria are present and careful evaluation of lifestyle and habits; 2) implementing a personalised pulmonary rehabilitation plan and airway clearance techniques to improve symptoms, exercise capacity, health-related quality of life (QoL) and functional capacity in daily living activities; 3) a nutritional evaluation and intervention to improve health-related QoL and to control gastrointestinal side-effects during antimicrobial therapy, particularly in those with low body mass index and history of weight loss; and 4) managing comorbidities that affect disease outcomes, including structural lung diseases, immune status evaluation and psychological support when appropriate.

An integrated approach, including risk factor prevention, management of comorbidities, nutritional evaluation and intervention and pulmonary rehabilitation, should be considered in the optimal management of nontuberculous mycobacterial pulmonary diseasehttps://bit.ly/2YEqvQg

Translation of oncology multidisciplinary team meeting (MDM) recommendations into clinical practice

Background

Multidisciplinary team meeting (MDM) processes differ according to clinical setting and tumour site. This can impact on decision making. This study aimed to evaluate the translation of MDM recommendations into clinical practice across solid tumour MDMs at an academic centre.

Methods

A retrospective audit of oncology records was performed for nine oncology MDMs held at Liverpool Hospital, NSW, Australia from 1/2/17–31/7/17. Information was collected on patient factors (age, gender, country of birth, language, postcode, performance status, comorbidities), tumour factors (diagnosis, stage) and MDM factors (number of MDMs, MDM recommendation). Management was audited up to a year post MDM to record management and identify reasons if discordant with MDM recommendations. Univariate and multivariable regression analyses were performed to assess for factors associated with concordant management.

Results

Eight hundred thirty-five patients were discussed, median age was 65 years and 51.4% were males. 70.8% of patients were presented at first diagnosis, 77% discussed once and treatment recommended in 73.2%. Of 771 patients assessable for concordance, management was fully concordant in 79.4%, partially concordant in 12.8% and discordant in 7.8%. Concordance varied from 84.5% for lung MDM to 97.6% for breast MDMs. On multivariable analysis, breast and upper GI MDMs and discussion at multiple MDMs were significantly associated with concordant management. The most common reason for discordant management was patient/guardian decision (28.3%).

Conclusion

There was variability in translation of MDM recommendations into clinical practice by tumour site. Routine measurement of implementation of MDM recommendations should be considered as a quality indicator of MDM practice.

The Impact of Multidisciplinary Team Meetings on Patient Management in Oncologic Thoracic Surgery: A Single-Center Experience

BACKGROUND

the aim of this paper is to quantify multidisciplinary team meeting (MDT) impact on the decisional clinical pathway of thoracic cancer patients, assessing the modification rate of the initial out-patient evaluation.

METHODS

the impact of MDT was classified as follows: confirmation: same conclusions as out-patient hypothesis; modification: change of out-patient hypothesis; implementation: definition of a clear clinical track/conclusion for patients that did not receive any clinical hypothesis; further exams required: the findings that emerged in the MDT meeting require further exams.

RESULTS

one thousand consecutive patients evaluated at MDT meetings were enrolled. Clinical settings of patients were: early stage lung cancer (17.4%); locally advanced lung cancer (27.4%); stage IV lung cancer (9.8%); mesothelioma (1%); metastases to the lung from other primary tumors (4%); histologically proven or suspected recurrence from previous lung cancer (15%); solitary pulmonary nodule (19.2%); mediastinal tumors (3.4%); other settings (2.8%).

CONCLUSIONS

MDT meetings impact patient management in oncologic thoracic surgery by modifying the out-patient clinical hypothesis in 10.6% of cases; the clinical settings with the highest decisional modification rates are "solitary pulmonary nodule" and "proven or suspected recurrence" with modification rates of 14.6% and 13.3%, respectively.

Applicability of the PACIFIC trial results in patients not eligible for the PACIFIC trial: Canadian rapid consensus statement and recommendations

BACKGROUND

The PACIFIC study established durvalumab as a standard of care for consolidation therapy in patients treated with radical intent chemoradiation for stage III inoperable non-small cell lung cancer. In clinical practice, many patients are not eligible for trials, yet radical intent chemoradiation may still be used.

METHODS

A virtual anonymous tumour board Delphi-model was used in order to generate consensus on the use of durvalumab in six clinical situations where chemoradiation is used in clinical practice and recommended in guidelines, yet not PACIFIC eligible. Two anonymous iterations were sent and recommendations were circulated for approval and comment. Results are presented using a modified PICOT format (patients, intervention, control, outcomes, and ongoing trials).

RESULTS

In three of the scenarios, consensus was reached and recommendations were for the use of consolidation durvalumab, but being respectful of potentially increased toxicity/reduced benefit in comparison to PACIFIC results (treatment of stage IIB inoperable, recurrent mediastinal disease, and residual gross disease post attempted surgical removal). There was a recommendation against using durvalumab in resected stage III disease with R1 or R0 margins, even if chemoradiation were considered. There was not consensus on the use of consolidation durvalumab in the setting of oligometastatic disease or in the setting of large cell neuroendocrine carcinoma or combined small cell carcinoma.

CONCLUSION

Treatment of 'real-world' lung cancer often involves chemoradiation in settings outside of stage III and eligible for the PACIFIC study. This paper offers recommendations in these scenarios based on a consensus approach.

Benefits and Limitations of a Multidisciplinary Approach in Cancer Patient Management

Over the years, a growing body of literature has confirmed as beneficial the implementation of a multidisciplinary approach in the so-often-intricate scenario of cancer patients' management. Together with the consolidation of tumor-board experience in clinical practice, certain aspects have emerged as controversial and a source of current debate. In this systematic literature review, we focused our attention on the impact of multidisciplinary tumor boards, assessing benefits and limitations as a result of the dissemination of such approaches. On the bright side, adherence to clinical guidelines, treatment outcomes, and overall improvement in decision-making processes have been recognized as advantages. On the other side, our analysis highlights a few limitations that should be taken into account to optimize cancer patients' management. Of note, some issues, such as costs, legal responsibility, geographic barriers, and treatment delays, have yet to be resolved. In order partly to address this matter, software platforms and novel methods of computational analysis may provide the needed support. Therefore, the aim of our analysis was to describe the multidisciplinary approach in cancer care in terms of adherence to clinical guidelines, treatment outcomes, and overall improvement in decision-making processes through a systematic review of the literature.

Locally advanced non-small cell lung cancer: the place of specialist thoracic surgery in the multidisciplinary team

One reason that lung cancer is the leading cause of cancer mortality worldwide, is that surgical intervention is highly dependent on earlier tumor stage and good patient condition. As large proportion of cases are already metastatic at presentation and many are locally advanced, curative surgery is only possible in a minority of fit patients. Increasing the number of patients achieving complete resection is one of the avenues to increase overall survival using our existing technology. In the past, complex cases may have been sporadically discussed between various specialists in order to achieve better outcomes. More recently, the idea of discussing those cases on a routine basis, rather than an accident of geography or referral pattern, gave rise to the multidisciplinary team. Lung cancer management is now increasingly complex, especially with novel modalities such as targeted therapies, immune checkpoint inhibitors and stereotactic body radiotherapy delivery. Likewise, in thoracic surgery, minimally invasive techniques, early recovery after surgery protocols and complex techniques for resecting locally advanced tumours or preserving lung parenchyma must all be deployed appropriately to continue our incremental gains in survival and quality of life. To highlight the role of specialist thoracic surgeon in the multidisciplinary care of locally advanced non-small cell lung cancer, we conducted a search of English language publications for its multidisciplinary-based surgical management. We limited our search to the last decade, then hand-searched relevant references. In addition, we used our large prospective database as a team-oriented specialized thoracic surgical service to benchmark and demonstrate the benefits of specialist surgeons in the modern multidisciplinary team. In conclusion, patients with locally advanced non-small cell lung cancer should have any surgical option withheld without a specialist thoracic surgical opinion as part of the multidisciplinary team discussion.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Lung cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Lung cancer is the leading cause of cancer mortality and has a wide variation in treatment and outcomes in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must only be carried out in lung cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

A review on the impact of lung cancer multidisciplinary care on patient outcomes

International guidelines recommend a multidisciplinary approach to the management of lung cancer due to the complexity of both patients and their disease and the multiple treatment options available. This care can be provided through patient discussion at multidisciplinary meetings where relevant medical and allied health staff formulate a consensus management plan taking all factors into consideration. This model can be extended further to include multidisciplinary clinics where the patient is present for assessment and discussion. However, conducting regular multidisciplinary meetings or clinics has significant time, resource and financial costs and therefore, it is important to assess the impact of multidisciplinary care. We aimed to review published evidence, from 2000 to 2019, to evaluate the impact of multidisciplinary care on lung cancer outcomes. There were 29 studies found, 11 evaluating multidisciplinary clinics, 14 studying multidisciplinary meetings and four where the model of care was not defined. There was only one randomised trial and three prospective studies, the remainder being retrospective studies. Despite limitations in trial design and confounding factors, overall, multidisciplinary care in lung cancer was associated with improvements in patient outcomes, in particular improved survival for all stages of lung cancer. Lung cancer patients managed in a multidisciplinary setting were more likely to receive active treatment and had improved utilisation of all treatment modalities: surgery, radiotherapy and chemotherapy. In addition, the treatment recommendations were more likely to be consistent with lung cancer management guidelines. These improved outcomes support the recommendations for a multidisciplinary approach to lung cancer care.

Implementation of lung cancer multidisciplinary teams: a review of evidence-practice gaps

Multidisciplinary care (MDC) is considered best practice in lung cancer care. Health care services have made significant investments in MDC through the establishment of multidisciplinary team (MDT) meetings. This investment is likely to be sustained in future. It is imperative that MDT meetings are efficient, effective, and sufficiently nimble to introduce new innovations to enable best practice. In this article, we consider the ‘evidence-practice gaps’ in the implementation of lung cancer MDC. These gaps were derived from the recurrent limitations outlined in existing studies and reviews. We address the contributions that implementation science and quality improvement can make to bridge these gaps by increasing translation and improving the uptake of innovations by teams.

Optimizing lung cancer MDT data for maximum clinical impact-a scoping literature review

Multidisciplinary care in is widely recommended as best practice for lung cancer in many countries and jurisdictions. A number of studies suggest multidisciplinary care benefits patient outcomes, with analyses based on a range of data sources including national, state and local registries as well as multidisciplinary team meeting (MDT)-based data collections, often focused on different questions depending on data sources. MDT data collection and linkage are not standardized and not routine although data collection and feedback are specifically recommended by at least one statutory body. We performed a scoping review of current evidence for lung cancer MDT data collection and analysis, to identify discrete strategies through illustrative examples and to make recommendations for future approaches. Thirteen studies were identified that presented lung cancer MDT-related clinical outcomes, three included MDTs from multiple tumour streams while 10 studies focussed on lung cancer MDT meetings. Eleven studies measured the effect of MDT discussion on clinical outcomes of which eight were positive. Data sources included MDT records (3 studies), medical or hospital records (3 studies), institutional registries (5 studies) and state or national administrative datasets (6 studies), with some overlap. Examples of studies based on different data sources (local MDT, institutional registry, national registry) exemplified the different types of clinical research questions appropriate for each data source. While MDT data collection is not well-defined, the importance of clinical audit and data feedback and the potential for real-time analysis to improve outcomes deserve further investigation. Optimized datasets and linkage strategies are likely to maximize benefits for patients.

Household disposable income and long-term survival after pulmonary resections for lung cancer

Introduction

Socioeconomic disparities have been linked to survival differences in patients with lung cancer. Swedish healthcare is tax-funded and provides equal access to care, therefore, survival following lung cancer surgery should be unrelated to household income. The aim of this study was to investigate the association between household disposable income and survival following surgery for lung cancer in Sweden.

Methods

We conducted a nationwide population-based cohort study including all patients who underwent pulmonary resections for lung cancer in Sweden 2008–2017. Individual-level record linkages between national quality and health-data registers were performed to acquire information regarding socioeconomic status and medical history. Cox regression by quintiles of household disposable income was used to estimate the adjusted risk for all-cause mortality.

Results

We included 5500 patients and the age-adjusted and sex-adjusted incidence rate of death per 100 person-years was 15 and 9.4 in the lowest and highest income quintile, respectively (mean follow-up time 3.2 years). Deprived patients were older, had more comorbidities and were less likely to have preoperative positron emission tomography or minimally invasive surgery, compared with patients with higher income. The adjusted HR for death was 0.77 (95% CI: 0.62 to 0.96) for the highest income quintile compared with the lowest.

Conclusions

We found an association between household disposable income and survival in patients who underwent surgery for lung cancer in Sweden, despite tax-funded universal health coverage. The association remained after adjustment for differences in baseline characteristics.

Multidisciplinary Lung Cancer Tumor Board Connecting Eight General Hospitals in Japan via a High-Security Communication Line

PURPOSE

The complexity of lung cancer treatment is rapidly increasing, necessitating the use of multidisciplinary approaches for improving outcomes. Although it is common for institutions to have their own tumor boards, tumor boards connecting several general hospitals, and therefore allowing for more diverse opinions, are not prevalent.

MATERIALS AND METHODS

A tumor board connecting eight hospitals was formed to discuss patients for whom formulating a treatment strategy was difficult. Physicians and hospital staff accessed a high-security communication line via LiveOn ( Japan Media Systems Corporation, Tokyo, Japan), which is completely isolated from the Internet and password protected, that enables each hospital to share the electronic medical records and images of relevant patients at other hospitals on desktop computers in real time. The lung cancer tumor board began in April 2017 and has since been held every Tuesday evening for 1 hour. Preparatory records containing the age, sex, histology, TNM classification, background, and discussion points for each patient are created before each tumor board meeting. After the tumor board discussion, all conclusions and related articles used in the board are added to the minutes, which are finalized as Microsoft Word files, consolidated, and archived. These files can be retrieved later using key words.

RESULTS

From April 2017 to June 2018, 202 patients were discussed. Although TNM classification was not changed for any patient, diverse opinions led to a change in the proposed strategy for 49 of 202 patients.

CONCLUSION

The multidisciplinary tumor board was useful in obtaining various opinions from the perspectives of different experts. This should be evaluated in a prospective study.

Early experience with Watson for Oncology: a clinical decision-support system for prostate cancer treatment recommendations

PURPOSE

Urological oncologists have difficulty providing optimal personalized care due to rapid alterations in scientific research results, medical advancements, and treatment guidelines. IBM's Watson for Oncology (WFO) is an artificial intelligence clinical decision-support system that assists oncologists with evidence-based treatment recommendations. In the present study, we examined the level of concordance between the treatment recommendations for prostate cancer according to WFO and the actual treatments that the patients received in the department of urology.

METHODS

We enrolled 201 patients who received prostate cancer treatment between January 2018 and June 2018. WFO provided treatment recommendations using clinical data in three categories: recommended, for consideration, and not recommended. These were compared with the actual treatments received by patients. Prostate cancer treatments were considered concordant if the received treatments were included in the "recommended" or "for consideration" categories by WFO.

RESULTS

The patients' mean age was 71.2 years. There were 60 (29.9%) and 114 (56.7%) patients with an Eastern Cooperative Oncology Group (ECOG) performance score ≥ 1 and non-organ confined disease (stage III/IV), respectively. The overall prostate cancer treatment concordance rate was 73.6% ("recommended": 53.2%; "for consideration": 20.4%). An ECOG performance score ≥ 1 and older age (≥ 75 years) were significantly associated with discordance (p = 0.001 and p = 0.026, respectively) on multivariate analysis.

CONCLUSION

In the present study, the treatment recommendations by WFO and the actual received treatments in the department of urology showed a relatively high concordance rate in prostate cancer patients.

Clinical impact of data feedback at lung cancer multidisciplinary team meetings: A mixed methods study

AIM

Multidisciplinary team (MDT) meetings can facilitate optimal lung cancer care, yet details of structured data collection and feedback remain sparse. This study aimed to investigate data collection and the impact of feedback to lung cancer MDTs.

METHODS

A mixed-methods study using pre and post-test surveys, semistructured interviews, and observation to evaluate data collection and response to modeled data feedback in three Australian lung cancer MDTs at different locations and development stage (site A: outer metropolitan, established; site B, outer metropolitan, new; and site C, inner metropolitan, established).

RESULTS

MDT attendees (range 13-25) discussed 5-8 cases per meeting. All sites collected data prospectively (80% prepopulated) into local oncology medical information systems. The pretest survey had 17 respondents in total (88% clinicians). At sites A and C, 100% of respondents noted regular data audits, occasional at site B. Regular audit data included number of cases, stage, final diagnosis, and time to diagnosis and treatment. The post-test survey had 25 respondents in total, all clinicians. The majority (88-96%) of respondents found modeled data easy to interpret, relevant to clinical practice and the MDT, and welcomed future regular data presentations (as rated on a 5-point Likert scale mean weighted average 4.5 where > 4 demonstrates agreement). Semistructured interviews identified five major themes for MDTs: current practice, attitudes, enablers, barriers, and benefits for the MDT.

CONCLUSIONS

MDT teams exhibited positive responses to modeled data feedback. Key characteristics of MDT data were identified and may assist with future team research and development.

Assessing Concordance With Watson for Oncology, a Cognitive Computing Decision Support System for Colon Cancer Treatment in Korea

PURPOSE

IBM Watson for Oncology (WFO) is a clinical decision-support computing system that provides oncologists with evidence-based treatment recommendations for a variety of cancer diagnoses. The evidence-based supported treatment recommendations are presented in three categories: Recommended, representing the Memorial Sloan Kettering Cancer Center (MSKCC) preferred approach; For Consideration, evidence-based alternative treatments; and Not Recommended, alternative therapies that may be unacceptable. We examined the absolute concordance of treatment options with that of the recommendations of a multidisciplinary team of oncologists from Gachon University, Gil Medical Centre, Incheon, South Korea.

METHODS

We enrolled 656 patients with stage II, III, and IV colon cancer between 2009 and 2016. Cases were processed using WFO and, using retrospective clinical data, outputs were compared with the actual treatment the patient received. Absolute concordance was defined as an alignment of recommendation in the Recommended MSKCC preferred-approach category. Treatment recommendations that were represented in the For Consideration category were not the focus of this study.

RESULTS

The absolute concordance between the WFO-derived MSKCC preferred approach and Gil Medical Centre treatment recommendations was 48.9%. The percentage of cases found to be acceptable was 65.8% (432 of 656) and the stage-specific concordance rate was 32.5% for patients with stage II disease who had risk factors and 58.8% for patients with stage III disease. Patients 70 years of age and older had a concordance rate of only 20.2%, whereas younger patients had a concordance rate of 63.8% ( P = .0001).

CONCLUSION

The main reasons attributed to the low concordance rate were age, reimbursement plan, omitting chemotherapy after liver resection, and not recommending biologic agents (ie, cetuximab and bevacizumab).

Impact of GI Tumor Board on Patient Management and Adherence to Guidelines

Purpose

As the burden of cancer on the population and the health care system continues to increase with more complicated treatment options, the need for multidisciplinary teams to be as efficient as possible becomes more vital. Our study aimed to evaluate the consistency of GI Tumor Board (GI TB) recommendations with international guidelines, the adherence of physicians involved in patient care to TB recommendations, and the impact on the management of patients.

Methods

A prospective cohort study was conducted from January to June 2016 at our institution, which is a major tertiary hospital that provides comprehensive cancer care. All cases presented at the GI TB during this period were included. Data regarding adherence to National Comprehensive Cancer Network guidelines, adherence to TB recommendations, and changes made to the management of patients were collected weekly from the GI TB in a data collection form.

Results

Of the 104 patients included, 57 (55%) were males and the median age was 58 (16 to 85) years. Colorectal cancer was the most common diagnosis, in 65 patients (63%). Nearly one-half of cases (45%) were stage IV cancers. Starting new treatment was recommended for 72 patients (69%). Further investigations were requested for 15 patients (14%). For imaging, 24 recommendations (23%) were made. Adherence to National Comprehensive Cancer Network guidelines was observed in 97% of total recommendations. New findings were found in pathology (11%), radiology (13%), and staging (4%). Management plans were changed in 37 cases (36%). Over a 3-month period after presentation to the GI TB, most of the recommendations (87%) were performed.

Conclusion

A multidisciplinary tumor board enhances the adherence to guidelines and has an impact on patient management in approximately one-third of patients. Among physicians, adherence to recommendations of the TB was high.

Multidisciplinary management improves survival at 1 year after surgical treatment for non-small-cell lung cancer: a propensity score-matched study

OBJECTIVES

The management of patients affected by lung cancer requires the expertise of specialists from different disciplines. Although the advantages of multidisciplinary team discussions seem obvious, there are limited studies evaluating the influence of this approach on postoperative outcomes in non-small-cell lung cancer (NSCLC). The aim of this study is to examine the impact of a multidisciplinary approach on survival of patients undergoing surgery for NSCLC.

METHODS

A retrospective analysis was performed on consecutive patients who underwent surgery for NSCLC between January 2008 and December 2015. Data were compared between patients treated before the implementation of a multidisciplinary tumour board (MTB), between 2008 and 2012, and those who received treatment after the implementation of the MTB, between 2012 and 2015. Patients were matched one to one according to the discussion of the MTB and on the basis of a propensity score built using several patient characteristics. A propensity score-matched analysis was performed to compare patient outcomes.

RESULTS

A total of 246 patients were treated prior to the initiation of the MTB and 231 patients after the initiation of the MTB. Based on the propensity score, 2 well-matched groups of 170 patients were identified. Patients who were discussed at the MTB were noted to have better outcomes when compared with those who were not discussed at the MTB on different terms including complete staging evaluation, early tumour, node and metastasis (TNM) stages and 1-year survival rate.

CONCLUSIONS

Implementation of a multidisciplinary thoracic malignancy conference increased the 1-year survival rate of patients who underwent a surgical resection for NSCLC.

Educational level and management and outcomes in non-small cell lung cancer. A nationwide population-based study

OBJECTIVES

We examined associations between educational level and clinical presentation, patterns of management and mortality in patients with non-small cell lung cancer (NSCLC) in Sweden, a country with a National Health Care System.

MATERIALS AND METHODS

We identified 39,671 patients with a NSCLC diagnosis 2002-2016 in Lung Cancer Data Base Sweden (LCBaSe), a population-based research database. In analyses adjusted for comorbidity and other prognostic factors, odds Ratios (OR) and hazard Ratios (HR) were estimated to examine associations between patients' educational level and aspects of management and mortality.

RESULTS

Stage at diagnosis and waiting times did not differ between educational groups. In multivariable analysis, the likelihood to undergo PET/CT and assessment in a multidisciplinary team setting were higher in patients with high compared to low education (aOR 1.14; CI 1.05-1.23 and aOR 1.22; CI 1.14-1.32, respectively). In patients with early stage IA-IIB disease, the likelihood to undergo stereotactic radiotherapy was elevated in patients with high education (aOR 1.40; CI 1.03-1.91). Both all-cause (aHR 0.86; CI 0.77-0.92) and cause-specific mortality (aHR 0.83; CI 0.74-0.92) was lower in patients with high compared to low education in early stage disease (IA-IIB). In higher stage NSCLC no differences were observed. Patterns were similar in separate assessments stratified by sex and histopathology.

CONCLUSIONS

While stage at diagnosis and waiting times did not differ between educational groups, we found socioeconomic differences in diagnostic intensity, multidisciplinary team assessment, stereotactic radiotherapy and mortality in patients with NSCLC. These findings may in part reflect social gradients in implementation and use of novel diagnostic and treatment modalities. Our findings underscore the need for improved adherence to national guidelines.

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.

Pan-Asian adapted Clinical Practice Guidelines for the management of patients with metastatic non-small-cell lung cancer: a CSCO-ESMO initiative endorsed by JSMO, KSMO, MOS, SSO and TOS

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of metastatic non-small-cell lung cancer (NSCLC) was published in 2016. At the ESMO Asia Meeting in November 2017 it was decided by both ESMO and the Chinese Society of Clinical Oncology (CSCO) to convene a special guidelines meeting immediately after the Chinese Thoracic Oncology Group Annual Meeting 2018, in Guangzhou, China. The aim was to adapt the ESMO 2016 guidelines to take into account the ethnic differences associated with the treatment of metastatic NSCLC cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with metastatic NSCLC representing the oncological societies of China (CSCO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices and the drug availability and reimbursement situations in the six participating Asian countries. During the review process, the updated ESMO 2018 Clinical Practice Guidelines for metastatic NSCLC were released and were also considered, during the final stages of the development of the Pan-Asian adapted Clinical Practice Guidelines.

Patient and Facility Demographics Related Outcomes in Early-Stage Non-Small Cell Lung Cancer Treated with Radiofrequency Ablation: A National Cancer Database Analysis

PURPOSE

To determine facility and patient demographics associated with survival in early-stage non-small cell lung cancer (NSCLC) treated with radiofrequency (RF) ablation.

MATERIALS AND METHODS

The National Cancer Database was queried for cases of stage 1a NSCLC treated with RF ablation without chemotherapy or radiotherapy from 2004 to 2014. High-volume centers (HVCs) were defined as the top 95^th percentile of facilities by number of procedures performed. Overall survival (OS) was estimated with the Kaplan-Meier method, and comparisons between survival curves were performed with the log-rank test. Propensity score-matched cohort analysis was performed. P values less than .05 were considered statistically significant.

RESULTS

In the final cohort, 967 cases were included. Estimated median survival and follow-up were 33.1 and 62.5 months, respectively. Of 305 facilities, 15 were determined to be HVCs, treating 13 or more patients from 2004 to 2014. A total of 335 cases (34.6%) were treated at HVCs. On multivariate Cox regression analysis, treatment at an HVC was independently associated with improved OS (hazard ratio [HR] = 0.766; P = .006). After propensity score adjustment, 1-, 3-, and 5-year OS was 89.8%, 51.2%, and 27.7%, respectively, for patients treated at HVCs, compared to 85.2%, 41.5%, and 19.6%, respectively, for patients treated at non-HVCs (P = .015). Increasing age (HR = 1.012; P = .013) and higher T-classification (HR = 1.392; P < .001) were independently associated with worse OS.

CONCLUSION

Patients with early-stage NSCLC treated with RF ablation at HVCs experienced a significant increase in OS, suggesting regionalization of lung cancer management as a means of improving outcomes.

Does presentation at multidisciplinary team meetings improve lung cancer survival? Findings from a consecutive cohort study

BACKGROUND

Multidisciplinary team (MDT) presentation in lung cancer has the potential to improve longterm outcomes, although this varies between studies. This study aims to evaluate outcomes including survival, according to MDT presentation and to explore the utility of data obtained from local clinical sources.

PATIENTS AND METHODS

Prospective cases of lung cancer recorded in our institution's cancer registry were analyzed according to MDT presentation for patient and tumour characteristics, adjusted survival and referral to palliative care.

RESULTS

1197 cases were included, 295 (24.6%) with MDT presentation and 902 (75.4%) without. 60% of patients were male with median (IQR) age at diagnosis of 70 years (62-78). Histopathology distribution (non-small cell lung cancer and small-cell lung cancer) was similar between the two groups. Compared with the non-MDT group, the MDT group had (1) ECOG score recorded more often (71.9% vs. 47.6%), (2) higher proportion of ECOG 0 cases (31.2% vs. 11.9%) and ECOG 1 cases (28.8% vs. 20.3%), (3) higher proportion of early stage disease (stage I - 23.1% vs. 9.7% stage II - 10.2% vs. 4.8%, stage IIIA - 14.6% vs 6.3%) and (4) lower proportion of metastatic disease (stage IV - 39.3% vs. 56.1%). Referral to palliative care was incompletely recorded in both groups (MDT: n = 116/295, 39.3%; non-MDT: n = 430, 47.7%) but did not differ significantly for stage IV cases. Survival analyzed by stage was greater in the MDT group at 1, 2 and 5 years for all stages except stage IIIB at 1 year post-diagnosis. Adjusted survival analysis for the entire cohort showed improved survival at 5 years for the MDT group (HR 0.7 (0.58-0.85), p < 0.001).

CONCLUSION

MDT presentation is associated with improved adjusted survival for lung cancer in this single institutional cohort in an analysis of local clinical cancer registry data.

Opinions of lung cancer clinicians on shared decision making in early-stage non-small-cell lung cancer

OBJECTIVES

To investigate the opinions of lung cancer clinicians concerning shared decision making (SDM) in early-stage non-small-cell lung cancer patients.

METHODS

A survey was conducted among Dutch cardiothoracic surgeons and lung surgeons, pulmonologists and radiation oncologists. The opinions of clinicians on the involvement of patients in treatment decision making was assessed using a 1-5 Likert-type scale. Through open questions, we queried barriers to and drivers of SDM in clinical practice. Clinicians were asked to review 7 hypothetical cases and indicate which treatment strategy they would choose using a 1-7 Likert-type scale.

RESULTS

Twenty-six percent of surgeons, 20% of pulmonologists and 12% of radiation oncologists indicated that they always engage in SDM (16% missing; P-value = 0.10). Most respondents stated that, ideally, doctors and patients should decide together (surgeons 52%, pulmonologists 67% and radiation oncologists 35%; P-value = 0.005). Thirty percent of surgeons, 27% of pulmonologists and 44% of radiation oncologists indicated that doctors are not properly trained to implement SDM in clinical practice (P-value = 0.37). SDM may not always be feasible due to low patient education level and minimal knowledge about lung cancer. Wide variations in the clinicians' lung cancer treatment preferences were observed in the responses to the hypothetical cases.

CONCLUSIONS

In current clinical decision making in lung cancer treatment, a majority of clinicians agree that it is important to involve lung cancer patients in treatment decision making but that time constraints and the inability of some patients to make a weighted decision are important barriers. The observed variation in lung cancer treatment preferences among clinicians suggests that for most patients both surgery and radiotherapy are suitable options, and it underlines the sensitive nature of treatment choices in early-stage non-small-cell lung cancer.

Impact of a Non-small Cell Lung Cancer Educational Program for Interdisciplinary Teams

BACKGROUND

Successful implementation of non-small cell lung cancer (NSCLC) evidence-based guideline recommendations requires effective educational programs that target all clinicians from interdisciplinary teams. This study describes and evaluates the Engaging an Interdisciplinary Team for NSCLC (GAIN 3.0) experiential learning-based educational curriculum.

METHODS

GAIN 3.0 was designed to enhance interdisciplinary collaboration for effective NSCLC diagnosis, assessment, and treatment. The program used a flipped classroom model that included an e-learning component prior to a live 6-hour interactive program. The interactive program included hands-on simulations, small group workshops, gamification, and case discussions. Participants included academic and community members of multidisciplinary lung cancer teams. Assessments included an online baseline survey, a pretest and posttest, a program evaluation, a long-term survey (LTS), and on-site faculty evaluation of participants.

RESULTS

Of 416 attendees to 13 live GAIN 3.0 programs (nine in the United States and four in Europe), 304 (73%) completed the pretest and 187 (45%) completed the posttest. Out of a perfect score of 12 points, program participants had a mean test score of 6.3 ± 2.1 on the pretest (52%) and 7.8 ± 2.1 on the posttest (65%) (P = .03). There was an overall knowledge increase of 13% from pretest to posttest. Most LTS respondents (65%) rated the GAIN 3.0 live programs as "high impact." On the LTS, the areas with the greatest gains in participants who had very high confidence were communication across disciplines, use of a team-based approach, and personalized treatment.

CONCLUSIONS

GAIN 3.0 was a highly successful interdisciplinary activity that improved participants' knowledge, competence, and likely the clinical care provided to patients with NSCLC.

Management of colorectal cancer with synchronous liver metastases: impact of multidisciplinary case conference review

BACKGROUND

While no evidence exists to support mandatory multidisciplinary case conference (MCC) review for patients with synchronous colorectal cancer and liver metastases, this unique population may benefit greatly from multidisciplinary discussion.

METHODS

We retrospectively identified patients who underwent liver resection with curative intent for colorectal liver metastases (CRLM) at a tertiary center between January 2008 and June 2015. The characteristics of patients discussed at a weekly regional MCC were examined, and the effect of MCC review on treatment approach was assessed.

RESULTS

Sixty-six patients underwent elective surgery for synchronous colorectal cancer and liver metastases during the study period. Twenty-nine patients (44%) were presented at a MCC. Presentation was associated with greater likelihood of undergoing simultaneous or liver-first resection (P≤0.0001), with no difference in the extent of liver resection or location of primary tumor between the groups. A greater proportion of patients received chemotherapy and/or radiation following MCC discussion, without statistical significance.

CONCLUSIONS

The treatment approach for patients with synchronous colorectal cancer and liver metastases may be significantly altered based on MCC review. Multidisciplinary discussion is advocated in order to facilitate equal access to individualized care.

Multidisciplinary Care

Optimal multidisciplinary care of the lung cancer patient at all stages should encompass integration of the key relevant medical specialties, including not only medical, surgical, and radiation oncology, but also pulmonology, interventional and diagnostic radiology, pathology, palliative care, and supportive services such as physical therapy, case management, smoking cessation, and nutrition. Multidisciplinary management starts at staging and tissue diagnosis with pathologic and molecular phenotyping, extends through selection of a treatment modality or modalities, management of treatment and cancer-related symptoms, and to survivorship and end-of-life care. Well-integrated multidisciplinary care may reduce treatment delays, improve cancer-specific outcomes, and enhance quality of life. We address key topics and areas of ongoing investigation in multidisciplinary decision making at each stage of the lung cancer treatment course for early-stage, locally advanced, and metastatic lung cancer patients.