The impact of a dedicated multidisciplinary team on the management of early rectal cancer

Attitudes of physicians and patients toward immediate and intraoperative chemotherapy treatment in colon cancer

INTRODUCTION

We have shown in a Phase I trial that immediate adjuvant chemotherapy (IAC) during surgical resection and immediately postoperative is safe and feasible in patients with colon cancer (CC). IAC avoids delays in adjuvant treatment and has the potential to improve survival and quality of life. We aim to determine patients and providers attitudes toward this novel multidisciplinary treatment approach.

METHODS

Two web-based surveys were administered to newly diagnosed CC patients, survivors, surgeons and oncologists. Surveys assessed treatment preferences and perceived barriers to IAC. Chi-square tests were conducted to compare differences between patients' and providers' responses.

RESULTS

Responses were collected from 35 patients and 40 providers. Patients were more willing to: (1) proceed with IAC to finish treatment earlier thus possibly improving quality of life (p = 0.001); (2) proceed with IAC despite potential side effects (p < 0.001); and (3) proceed with a dose of intraoperative chemotherapy even if on final pathology, may not have been needed (p = 0.002). Patients were more likely to indicate no barriers to collaborative care (p = 0.001) while providers were more likely to cite that it is time consuming, thus a barrier to participation (p = 0.001), has scheduling challenges (p = 0.001), and physicians are not available to participate (p = 0.003).

CONCLUSIONS

We observed a discordance between what providers and patients value in perioperative and adjuvant CC treatment. Patients are willing to accept IAC despite potential side effects and without survival benefit, highlighting the importance of understanding patient preference.

The impact of oncological package implementation on the treatment of rectal cancer in years 2013-2019 in Poland - multicenter study

<b><br>Introduction:</b> In 2015, in Poland, the oncological package (OP) was established. This law constituted a fast track of oncological diagnosis and treatment and obligatory multidisciplinary team meetings (MDT).</br> <b><br>Aim:</b> The aim of this study was to analyze the impact of OP on rectal cancer treatment.</br> <b><br>Methods:</b> The study was a multicenter, retrospective analysis of data collected from five centers. It included clinical data of patients operated on due to rectal cancer between 2013 and 2019. For most analyses, patients were categorized into three groups: 2013-2014 - before OP (A), 2015-2016 - early development of OP (B), 2017-2019 - further OP functioning (C).</br> <b><br>Results:</b> A total of 1418 patients were included. In all time intervals, the majority of operations performed were anterior resections. There was a significantly lower local tumor stage (T) observed in subsequent time intervals, while there were no significant differences for N and M. In period C, the median of resected nodes was significantly higher than in previous periods. Four of the centers showed an increasing tendency in the use of preoperative radiotherapy. The study indicated a significant increase in the use of short-course radiotherapy (SCRT) and a decrease in the number of patients who did not receive any form of preoperative therapy in subsequent periods. In the group that should receive radiotherapy (T3/4 or N+ and M0), the use of SCRT was also significantly increasing.</br> <b><br>Conclusions:</b> In the whole cohort, there was a significant increase in the use of preoperative radiotherapy and a decrease in the T stage, changing with the development of OP. Nevertheless, this relation is indirect and more data should be gathered for further conclusions.</br>.

Update on The National Accreditation Program for Rectal Cancer (NAPRC): the radiologist's role

The National Accreditation Program for Rectal Cancer (NAPRC) was established by the American College of Surgeons with the goal of standardizing care of rectal cancer patients in order to improve outcomes. NAPRC accreditation requires compliance with an established set of standards, many of which are directly related to radiology participation in multidisciplinary conference, rectal MR image acquisition, interpretation and reporting, and radiologist education. This paper outlines the pertinent standards/requirements for radiologists as part of the Rectal Cancer Multidisciplinary Team in the NAPRC guidelines, with proposed methods and tips for implementation of these standards from the perspective of the radiologist.

Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.

Outcomes of complex colorectal polyps managed by multi-disciplinary team strategies-a multi-centre observational study

PURPOSE

Team management strategies for complex colorectal polyps are recommended by professional guidelines. Multi-disciplinary meetings are used across the UK with limited information regarding their impact. The aim of this multi-centre observational study was to assess procedures and outcomes of patients managed using these approaches.

METHOD

This was a retrospective, observational study of patients managed by six UK sites. Information was collected regarding procedures and outcomes including length of stay, adverse events, readmissions and cancers.

RESULTS

Two thousand one hundred ninety-two complex polyps in 2109 patients were analysed with increasing referrals annually. Most presented symptomatically and the mean polyp size was 32.1 mm. Primary interventions included endoscopic therapy (75.6%), conservative management (8.3%), colonic resection (8.1%), trans-anal surgery (6.8%) or combined procedures (1.1%). The number of primary colonic resections decreased over the study period without a reciprocal increase in secondary procedures or recurrence. Secondary procedures were required in 7.8%. The median length of stay for endoscopic procedures was 0 days with 77.5% completed as day cases. Median length of stay was 5 days for colonic resections. Overall adverse event and 30-day readmission rates were 9.0% and 3.3% respectively. Malignancy was identified in 8.8%. Benign polyp recurrence occurred in 13.1% with a median follow up of 30.4 months. Screening detected lesions were more likely to undergo bowel resection. Colonic resection was associated with longer stays, higher adverse events and more cancers on final histology.

CONCLUSION

Multi-disciplinary team management of complex polyps is safe and effective. Standardisation of organisation and quality monitoring is needed to continue positive effects on outcomes and services.

Endorectal Ultrasound Shear-Wave Elastography of Complex Rectal Adenoma and Early Rectal Cancer

Purpose: To investigate the diagnostic performance of endorectal ultrasound (ERUS), shear-wave elastography (SWE), and magnetic resonance imaging (MRI) in patients with a complex rectal adenoma or an early rectal cancer, i.e., T1 or T2 adenocarcinoma in a clinical setting, and to evaluate the association between SWE and stromal fraction (SF) and apparent diffusion coefficient (ADC) and SF. Method: This prospective study included patients undergoing ERUS and SWE for a rectal tumor subsequently confirmed by histopathology to be an adenoma or a T1 or T2 adenocarcinoma. The accuracy of the imaging methods was assessed by comparing the T category as determined by ERUS and MRI with histopathology, which served as the gold standard. SF was assessed on surgical specimens. Results: A total of 86 patients were included. Of these, 62 patients had adenomas and 24 patients had carcinomas, of which 11 were T1 tumors and 13 were T2 tumors. ERUS and MRI yielded sensitivity, specificity, and accuracy of 0.79 and 0.73, 0.95 and 0.90, and 0.86 and 0.78, respectively, for discrimination between benign and malignant lesions. The area under the receiver operating characteristics curve for SWE was 0.88, and with a cut-off value of 40 kPa the sensitivity, specificity, and accuracy were 0.79, 0.89, and 0.86, respectively. There was a positive correlation between SF and SWE with a p-value of <0.001 and a negative correlation between SF and ADC with a p-value of 0.011. Conclusion: Both ERUS and MRI classified T categories with a high accuracy; however, ERUS classified more adenomas correctly than MRI. In this small population, SWE could differentiate an adenoma from early carcinoma. SF was correlated with both SWE and ADC, as increasing SF tended to yield higher SWE and lower ADC values.

MDT stage migration in MRI of significant rectal polyps and early rectal cancers

PURPOSE

To audit the diagnostic accuracy of MRI for staging early and polyp rectal cancers with the purpose of identifying scope for service improvement.

METHODS

This is an IRB approved retrospective study of patients who underwent staging MRI for rectal growths followed by upfront TME type surgery or local excision without neoadjuvant therapy between 2018 and 2021. MR-T-stage was compared with surgical histopathology. The degree of stage migration in the multidisciplinary team meetings (MDT) was assessed and training needs were identified.

RESULTS

53 patients (32 males) with a mean (SD) age of 56.7 (13.6) years with 54 rectal lesions and underwent trans-anal excision (n = 18) or upfront surgery (n = 35) were included. Pathology showed < / = pT1 stage in n = 18 and > / = pT2 stage in n = 36. Radio-pathological concordance rate was 38.9% and 74.1%, respectively, for primary reports and MDT reads, respectively, and during MDT, the rates improved by 44.5% and 30.5% for < / = pT1 and > / = pT2 stages ,respectively. The overall T-stage migration rate at MDT was 44.6% (25/54) and the migration rate was higher (61.1%) for < / = pT1 stage lesions. The best sensitivity, specificity, PPV, NPV and accuracy of MRI for T-staging was 83.3%, 91.6%, 83.3%, 91.6% and 88.8%, respectively.

CONCLUSION

Radio-pathological correlation for MRI T-stage is excellent for MDT reads by experienced radiologists. MDT reads lead to significant down-staging of T-stage in polyp and early rectal cancer thereby improving radio-path correlation.

Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

Multidisciplinary decision-making strategies may reduce the need for secondary surgery in complex colonic polyps - A systematic review and pooled analysis

AIM

The recognition of complex colonic polyps is increasing. Management varies considerably and the impact of this on clinical outcomes is unclear. The aim of this systematic review was to assess the impact of group decision-making strategies and defined selection criteria on the treatment outcomes of complex colonic polyps.

METHOD

A systematic literature review identified studies reporting complex polyp treatment outcomes and describing their decision-making strategies. Databases searched included PubMed, Web of Science, CINAHL and Scopus. Articles were identified by two blinded reviewers using defined inclusion criteria. The review protocol was registered on PROSPERO and performed in line with PRISMA guidelines.

RESULTS

There were 303 identified articles describing treatment outcomes of complex colonic polyps. Only nine of these fully described the decision-making strategy and met the inclusion criteria. Adverse events ranged from 1.3% to 10% across the studies. Unsuspected malignancy and secondary surgery rates ranged from 2.4% to 15.4% and 3.3% to 43.9%, respectively. Grouping of articles into a hierarchy of decision-making strategies demonstrated a sequential reduction in secondary surgery rates with improving strategies. There were no differences in comparisons of adverse event or unsuspected malignancy rates.

CONCLUSIONS

There is limited description of decision-making strategies and variability in reporting of studies describing complex polyp treatment outcomes. The use of multidisciplinary decision-making and defined selection criteria may reduce the need for secondary surgical intervention in complex colonic polyps, but further evidence is required to draw definite conclusions.

Telehealth Adaptation for Multidisciplinary Colorectal Cancer Clinic During the COVID-19 Pandemic

Background The study objectives were to transition in-person colorectal cancer multidisciplinary clinic (MDC) to a telehealth MDC (tele-MDC) format and to assess early outcomes.  Methods A colorectal tele-MDC was devised, in which patients used remote-access technology while supervised by a clinician. The team consisted of surgeons, medical oncologists, radiation oncologists, radiologists, and pathologists. Outcomes were assessed with patient and provider surveys, using a 5-point Likert scale (higher = more favorable). Results A total of 18 patients participated in the tele-MDC. Surveyed patients (n=18) and physicians (n=19) were satisfied with the quality of care (mean Likert = 4.93, 4.53, respectively), and low standard deviations (range 0-1.03) across all questions reflected homogeneity in satisfaction with the metrics surveyed. Conclusions This pilot study demonstrates that a functional colorectal cancer tele-MDC is a feasible alternative to in-person MDC during the coronavirus disease 2019 (COVID-19) pandemic, with the potential for a high degree of patient and physician satisfaction.

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.

Development of a multidisciplinary colorectal and pelvic health program: Program implementation and clinical impact

INTRODUCTION

Pediatric patients with complex colorectal and genitourinary conditions often require coordinated multidisciplinary care; however, this coordinated care can be hard to structure and deliver. The purpose of this paper is to review the development and implementation of a multidisciplinary colorectal and pelvic health program, one year after the program's initiation.

METHODS

This is an observational retrospective 1-year study (10/1/2017 to 9/30/2018). In fiscal year (FY) 2018, a multidisciplinary colorectal and pelvic health program was initiated. The program development incorporated bimonthly team meetings, educational conferences, and initiation of three clinics: a complex colorectal and genitourinary reconstruction clinic, a bowel management clinic, and a colonic motility clinic. Conditions treated included complex anorectal and cloacal malformations, Hirschsprung disease, and idiopathic constipation. The fiscal year was selected to provide comparative administrative data after program implementation.

RESULTS

During the study period, 121 patients underwent comprehensive collaborative evaluation of which 58 (47%) were new to the institution compared to 12 (19%) new patients in the previous year (p < 0.001). In FY 2018, there were 130 procedures performed and 512 collaborative visits with an average of 47 visits per month. This was a 3.4-fold increase in visits compared to FY2017 (171 visits). Of the new patients, 60% (35/58), traveled a median of 181 miles, representing 33 statewide counties, and 4 states compared to a median of 93 miles in the previous fiscal year (p = 0.004).

CONCLUSION

The development of a colorectal and pelvic health program is feasible and requires a collaborative approach, necessitating multiple service lines within an institution. Program creation and implementation can result in rapid institutional clinical growth by filling a local and regional need through coordinated multidisciplinary care.

LEVEL OF EVIDENCE

IV.

Multimodal Endoscopic Assessment Guides Treatment Decisions for Rectal Early Neoplastic Tumors

BACKGROUND

There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment.

OBJECTIVE

We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions.

DESIGN

This was a retrospective study.

SETTING

The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer.

PATIENTS

A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported.

RESULTS

After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up.

LIMITATIONS

This was a retrospective study from a tertiary referral unit.

CONCLUSIONS

Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACIÓN ENDOSCÓPICA MULTIMODAL COMO GUÍA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLÁSICOS PRECOCES: La tendencia actual es la preservación del órgano en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluación endoscópica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografía colonoscópica seleccionada) para tumores rectales neoplásicos tempranos y así notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizó en una unidad de referencia terciaria para endoscopia intervencionista y cáncer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplásicos precoces de recto mediante una evaluación endoscópica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cáncer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal y la biopsia previa para predecir el cáncer invasivo y se notificaron los resultados para el tratamiento.Después de la evaluación endoscópica multimodal, las lesiones se clasificaron como: cáncer invasive (al menos invasión submucosa profunda n = 65); cáncer invasive (invasión submucosa superficial o alto riesgo de cáncer encubierto n = 119) y finalmente aquellos de bajo riesgo de cáncer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal para el diagnóstico de cáncer invasivo, la invasión submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificación combinada de todas las lesiones con cáncer invasivo o de alto riesgo de cáncer encubierto tuvo un VPN del 96% para el cáncer invasivo en la histopatología final. La sensibilidad fué de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugía radical, 33 por microcirugía endoscópica transanal. Ningún paciente sin cáncer invasivo fue sometido a cirugía radical. Inicialmente, 222 pacientes fueron sometidos a resección endoscópica. De los 203 sin invasión submucosa profunda, el 95% evitó la cirugía y no tuvieron recurrencia en el último seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluación endoscópica multimodal estandarizada guía las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de órganos para todos los pacientes sin cáncer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.

Treatment of the SPECC lesion

The treatment of the Significant Polyp and Early Colorectal Cancer lesion has evolved from strategies formally based around didactic pathological diagnoses ('cancer or no cancer?') and the limited availability of certain techniques ('what can we do?') into a more advanced situation of understanding diagnostic uncertainty ('the what if scenario'), factoring patient preference & approach to risk and the availability of a wide range of techniques in both the rectum and the colon. It is now the former rather than the latter which are driving decision making and treatment strategies ('what should we do'). Decisions are now made around possible planes of 'safe' excision and options for completion treatment and these issues are discussed in full. The range of techniques available extends to cover advanced endoscopic endoluminal therapies as well as the recently expanded range of surgical options for endoluminal treatment particularly in rectal lesions. This review looks at these and considers two new paradigms the therapeutic strategies available and those which are evolving.

Impact of a Multidisciplinary Team Approach for Managing Advanced and Recurrent Colorectal Cancer

BACKGROUND

The wide variety of treatment strategies makes clinical decision-making difficult in advanced and recurrent colorectal cancer cases. Many hospitals have started multidisciplinary team (MDT) meetings comprising a team of dedicated specialists for discussing cases. MDTs for selected cases that are difficult to diagnose and treat are alternatives to regular MDTs. This study's aim was to determine the impact of a MDT for colorectal cancer on clinical decision-making.

METHODS

Cases were discussed when clinical specialists had difficulty making decisions alone. All processes done by the MDT were then recorded in prospectively designed medical case forms.

RESULTS

From Jan 2011 to Dec 2014, 1383 cases were discussed. A total of 549 (39.8%) case forms were completed for patients with newly diagnosed colorectal cancer, whereas 833 (60.2%) were completed for those with recurrent diseases. The MDT altered the proposed treatment of the referring physician in 179 (13%) cases. In 85 of the 179 (47.5%) altered cases, the radiologist's review of clinical information affected the diagnosis and decision. Furthermore, 152 of the 1383 MDT decisions were not implemented. Treatment intent, therapeutic plan, and alteration of decision were important reasons for not following the MDT's recommendation.

CONCLUSION

Case discussions in MDT meetings resulted in altered clinical decisions in >10% cases. Implementation rates after MDT discussions might be affected by the treatment decision-making process. Imperfect decisions made by individual physicians can be decreased by the multidisciplinary decision-making process.

Impact of multidisciplinary tumor boards on patients with rectal cancer

Οncological outcomes in patients with primary rectal cancer have markedly improved over the last few years, mainly due to the widespread application of the total mesorectal excision technique. This improvement should also be largely attributed to multiple specialties, other than colorectal surgery, such as radiology, oncology and pathology. Therefore, a multimodal approach is key to efficient and appropriate rectal cancer management. Multidisciplinary tumor (MDT) boards have become an important asset for the management and treatment of patients with rectal cancer, and a number of studies published to date suggest the beneficial effect of the multidisciplinary approach on the management of such patients. The available evidence demonstrates a modification of the treatment plan, attributed to the MDT implementation, in a non-negligible proportion of these patients. However, more studies are required in order to assess the exact impact of MDT boards on disease-free and overall survival of patients with primary rectal cancer.

The role of multidisciplinary meetings for benign pancreatobiliary diseases: a tertiary centre experience

Multidisciplinary meetings are central to the management of chronic and complex diseases and they have become widely established across the modern healthcare. Patients with pancreatobiliary diseases can often present with complex clinical dilemmas, which fall out with the scope of current guidelines. Therefore, these patients require a personalised management approach discussed in a multidisciplinary meeting.

Do Multidisciplinary Team (MDT) processes influence survival in patients with colorectal cancer? A population-based experience

Background

MDT (multidisciplinary team) meetings are considered an essential component of care for patients with cancer. However there is remarkably little direct evidence that such meetings improve outcomes. We assessed whether or not MDT (multidisciplinary team) processes influenced survival in a cohort of patients with colorectal cancer.

Methods

Observational study of a population-based cohort of 586 consecutive patients with colorectal cancer diagnosed in Tayside (Scotland) during 2006 and 2007.

Results

Recommendations from MDT meetings were implemented in 411/586 (70.1 %) of patients, the MDT+ group. The remaining175/586 (29.9 %) were either never discussed at an MDT, or recommendations were not implemented, MDT- group. The 5-year cause-specific survival (CSS) rates were 63.1 % (MDT+) and 48.2 % (MDT-), p < 0.0001. In analysis confined to patients who survived >6 weeks after diagnosis, the rates were 63.2 % (MDT+) and 57.7 % (MDT-), p = 0.064. The adjusted hazard rate (HR) for death from colorectal cancer was 0.73 (0.53 to 1.00, p = 0.047) in the MDT+ group compared to the MDT- group, in patients surviving >6 weeks the adjusted HR was 1.00 (0.70 to 1.42, p = 0.987). Any benefit from the MDT process was largely confined to patients with advanced disease: adjusted HR _(early) 1.32 (0.69 to 2.49, p = 0.401); adjusted HR_(advanced) 0.65 (0.45 to 0.96, p = 0.031).

Conclusions

Adequate MDT processes are associated with improved survival for patients with colorectal cancer. However, some of this effect may be more apparent than real – simply reflecting selection bias. The MDT process predominantly benefits the 40 % of patients who present with advanced disease and conveys little demonstrable advantage to patients with early tumours. These results call into question the current belief that all new patients with colorectal cancer should be discussed at an MDT meeting.

Recent advances in multidisciplinary approach for rectal cancer

Surgery is a major treatment option for rectal cancer, and total mesorectal excision has been demonstrated to be advantageous in terms of oncological outcome and thus has been the standard surgical approach. Radiotherapy before or after radical surgery is the optimal treatment to control local recurrence of advanced rectal cancer. To date, in many countries, the combination of neoadjuvant concurrent chemotherapy and radiotherapy is considered the standard therapy. A more recent interest in neoadjuvant therapy has been the use of oxaliplatin or targeted agents for neoadjuvant chemoradiotherapy. However, despite many trials of oxaliplatin and targeted agents, 5-FU-based concurrent chemoradiotherapy has remained the only standard treatment option. Postoperative adjuvant chemotherapy with neoadjuvant chemoradiotherapy or induction chemotherapy with neoadjuvant chemoradiotherapy may further improve patient survival, as some clinical studies recently indicated. In Japan, neoadjuvant therapy is not the standard treatment method, because surgery with lateral lymph node dissection is usually performed and this type of surgery may reduce recurrence rate as does radiation therapy. The phase III study to evaluate the oncological effect of the Japanese standard operation (mesorectal excision, ME) with lateral lymph node dissection in comparison with ME alone for clinical stage II and III lower rectal cancer is currently ongoing.