The Multidisciplinary Approach to GI Cancer Results in Change of Diagnosis and Management of Patients. Multidisciplinary Care Impacts Diagnosis and Management of Patients

Models and Outcomes of Multidisciplinary Clinics in Colorectal Cancer

Multidisciplinary clinics (MDCs) represent a potential platform through which high-quality, patient-centered care grounded in interdisciplinary expertise may be delivered for patients with colorectal cancer (CRC). This is increasingly important with the rapidly emerging diagnostic and treatment modalities as well as differential sequences of therapies available. MDCs have been reported to improve various outcomes across numerous non-colorectal cancers; however, data specific to the use of MDCs in CRC are more limited. In this report, we provide a narrative review of the different models of CRC MDCs in the literature and their associations with cancer care outcomes. We found significant heterogeneity in MDC operational logistics as well as reported outcomes across different practice settings. Further research is needed to better understand how MDCs may be optimally structured to meet the unique needs of patients with CRC and how they may affect CRC outcomes.

Unreimbursed Costs of Multidisciplinary Conferences to a Radiology Department: A Prospective Analysis at an Academic Medical Center

PURPOSE

Multidisciplinary conferences (MDCs) are important for clinical care but are unreimbursed and can be time-consuming for radiologists to prepare for and present. The purpose of this single-center, prospective, survey-based study is to measure the per-conference time and total time radiologists devote to MDCs at a single academic medical center. Secondary objectives are to determine the source of radiologist preparation time, and calculate the per conference and overall radiology departmental costs of MDC participation.

METHODS

A prospective survey was performed to capture all radiology preparation and presentation time for MDCs in a 3-month period, which was then annualized. Total cost was calculated on the basis of Association of Administrators in Academic Radiology survey data for nonchair academic radiologist compensation plus a 30% fringe-benefit rate.

RESULTS

The survey response rate was 86.9%. A total of 3,358 hours were devoted annually to MDCs, which represents time equivalent to 1.9 full-time equivalents or $1,155,152 in unreimbursed radiology departmental costs. Per-MDC total preparation and presentation time was 2.7 hours, at an annual cost of $46,440 for each weekly MDC. Radiologists used a combination of personal time (49.7%), academic time (42%), and/or clinical time (35.4%) to prepare for MDCs. Radiologists devoted a mean of 47.9 hours (1.2 weeks) of time per annum to MDCs.

CONCLUSIONS

Radiologist time devoted to MDCs at the survey institution was substantial, and preparation time was drawn disproportionately from personal and academic time, which may have negative implications for burnout, recruitment and retention, and academic productivity unless it is effectively mitigated.

Contemporary Surgical Management of Colorectal Liver Metastases

Colorectal cancer is the third most common cancer in the United States and the second most common cause of cancer-related death. Approximately 20-30% of patients will develop hepatic metastasis in the form of synchronous or metachronous disease. The treatment of colorectal liver metastasis (CRLM) has evolved into a multidisciplinary approach, with chemotherapy and a variety of locoregional treatments, such as ablation and portal vein embolization, playing a crucial role. However, resection remains a core tenet of management, serving as the gold standard for a curative-intent therapy. As such, the input of a dedicated hepatobiliary surgeon is paramount for appropriate patient selection and choice of surgical approach, as significant advances in the field have made management decisions extremely nuanced and complex. We herein aim to review the contemporary surgical management of colorectal liver metastasis with respect to both perioperative and operative considerations.

Health Care Contact Days Experienced by Decedents With Advanced GI Cancer

PURPOSE

Frequent visits to health care facilities can be time intensive and all-consuming for people with cancer. We measured health care contact days (days with healthcare contact outside the home) among decedents with advanced GI cancer and examined sources of contact days, their associations with demographic and clinical factors, and their temporal patterns over the course of illness.

METHODS

We conducted a retrospective cohort study using a tumor registry and electronic medical record data for decedents with stage IV GI cancer between 2011 and 2019 in a large health care network in MN. We determined contact days from diagnosis to death using chart review. Using multivariable beta regression adjusted for sociodemographic and clinical characteristics offset by survival, we calculated adjusted estimates of contact days and determined patient-level factors associated with percentage of contact days.

RESULTS

We identified 809 patients eligible for analysis (median [IQR] age at diagnosis, 65 [56-73] years). The median (IQR) overall survival was 175 (56-459) days. Patients spent a median (IQR) of 25.8% (17.4%-39.1%) of these as contact days. Of these days, 83.6% were spent on outpatient visits. In the multivariable analysis, older age, Black race, and never receiving systemic cancer-directed treatment were associated with a higher percentage of contact days. The percentage of contact days was highest in the first month after diagnosis (39.6%) and before death (32.2%), with a more moderate middle phase (U-shaped curve).

CONCLUSION

Decedents with advanced GI cancer spend 1 in 4 days alive with health care contact, despite a median survival of under 6 months. This is even higher immediately postdiagnosis and near death. These findings highlight the need to understand sources of variation, benchmark appropriate care, and deliver more efficient care for this vulnerable population with limited time.

Pulmonary metastasectomy is associated with survival after lung-only recurrence in pancreatic cancer

BACKGROUND

After surgical resection of pancreatic ductal adenocarcinoma, 14% of patients have lung-only recurrence. We hypothesize that in patients with isolated lung metastases from pancreatic ductal adenocarcinoma, pulmonary metastasectomy offers a survival benefit with minimal additional morbidity after resection.

METHODS

This was a single-institution, retrospective study of patients who underwent definitive resection of pancreatic ductal adenocarcinoma and later developed isolated lung metastases between 2009 and 2021. Patients were included if they carried a diagnosis of pancreatic ductal adenocarcinoma, underwent pancreatic resection with curative intent, and subsequently developed lung metastases. Patients were excluded if they developed multiple sites of recurrence.

RESULTS

We identified 39 patients with pancreatic ductal adenocarcinoma and isolated lung metastases, 14 of whom underwent pulmonary metastasectomy. During the study period, 31 (79%) patients died. Across all patients, there was an overall survival of 45.9 months, a disease-free interval of 22.8 months, and survival after recurrence of 22.5 months. Survival after recurrence was significantly longer in patients who underwent pulmonary metastasectomy than those who did not (30.8 months vs 18.6 months, P < .01). There was no difference in overall survival between groups. However, patients who underwent pulmonary metastasectomy were significantly more likely to be alive 3 years after their diagnosis (100.0% vs 64%, P = .02) and 2 years after recurrence (79% vs 32%, P < .01) than those in who did not undergo pulmonary metastasectomy. No mortalities occurred related to pulmonary metastasectomy, and procedure-related morbidity was 7%.

CONCLUSION

Patients who underwent pulmonary metastasectomy for isolated pulmonary pancreatic ductal adenocarcinoma metastases had significantly longer survival after recurrence and clinically meaningful survival benefit with minimal additional morbidity after pulmonary resection.

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).

Pancreatic incidentalomas: Investigation and management

The incidence of pancreatic incidentalomas (PIs) detected in otherwise asymptomatic patients is growing with the increasing quality and use of advanced imaging techniques. PI can present as isolated main pancreatic duct dilation or as a solid or cystic lesion. Although historically thought to be relatively rare, PIs are rather common, particularly cystic lesions of the pancreas, which can be detected in up to 49% of the general population. With the poor prognosis of pancreatic cancer, PIs are an opportunity for prevention and early diagnosis, but when managed poorly, they can also lead to overtreatment and unnecessary morbidity. The management of PI should begin with a dedicated pancreas protocol computed tomography (CT) scan or magnetic resonance imaging (MRI) to accurately characterize duct size, lesion characteristics and establish an accurate baseline for subsequent follow up. Diagnosis and subsequent management depends on the extent of main duct dilation and solid versus cystic appearance. Solid lesions are highly concerning for malignancy. Cystic lesions can be further categorized as intraductal papillary mucinous neoplasms of the pancreas (IPMNs) or mucinous cystic neoplasms (MCNs), both of which harbour malignant potential, or as serous cystic neoplasms (SCNs) that are benign. In this paper, we summarize the major challenges related to PI and present pragmatic suggestions for management.

The Volume-Outcome Effect Calls for Centralization of Care in Esophageal Adenocarcinoma: Results From a Large National Cancer Registry

INTRODUCTION

Using the National Cancer Database, we assessed the relationship between facility overall esophageal adenocarcinoma (EAC) case volume and survival.

METHODS

We categorized facilities into volume quintiles based on annual EAC patient volume and performed a multivariable Cox proportional hazards regression between facility patient volume and survival.

RESULTS

In a cohort of 116,675 patients, facilities with higher vs lower (≥25 vs 1-4 cases) annual EAC patient volume demonstrated improved survival (adjusted hazard ratio: 0.80. 95% confidence interval: 0.70-0.91).

DISCUSSION

This robust volume-outcome effect calls for centralization of care for EAC patients at high annual case volume facilities.

Contribution of FDG-PET/CT to the management of esophageal cancer patients at multidisciplinary tumor board conferences

Background

A multidisciplinary team approach to the management of esophageal cancer patients leads to better clinical decisions.

Purpose

The contribution of CT, endoscopic and laparoscopic ultrasound to clinical staging and treatment selection by multidisciplinary tumor boards (MTB) in patients with esophageal cancer is well documented. However, there is a paucity of data addressing the role that FDG-PET/CT (PET/CT) plays to inform the clinical decision-making process at MTB conferences. The aim of this study was to assess the impact and contribution of PET/CT to clinical management decisions and to the plan of care for esophageal cancer patients at the MTB conferences held at our institution.

Materials and methods

This IRB approved study included all the cases discussed in the esophageal MTB meetings over a year period. The information contributed by PET/CT to MTB decision making was grouped into four categories. Category I, no additional information provided for clinical management; category II, equivocal and misguiding information; category III, complementary information to other imaging modalities, and category IV, information that directly changed clinical management. The overall impact on management was assessed retrospectively from prospectively discussed clinical histories, imaging, histopathology, and the official minutes of the MTB conferences.

Results

79 patients (61 males and 18 females; median age, 61 years, range, 33–86) with esophageal cancer (53 adenocarcinomas and 26 squamous cell carcinomas) were included. The contribution of PET/CT-derived information was as follows: category I in 50 patients (63%); category II in 3 patients (4%); category III in 8 patients (10%), and category IV information in 18 patients (23%). Forty-five patients (57%) had systemic disease, and in 5 (11%) of these, metastatic disease was only detected by PET/CT. In addition, PET/CT detected previously unknown recurrence in 4 (9%) of 43 patients. In summary, PET/CT provided clinically useful information to guide management in 26 of 79 esophageal cancer patients (33%) discussed at the MTB.

Conclusion

The study showed that PET/CT provided additional information and changed clinical management in 1 out of 3 (33%) esophageal cancer cases discussed at MTB conferences. These results support the inclusion whenever available, of FDG-PET/CT imaging information to augment and improve the patient management decision process in MTB conferences.

Role of a multidisciplinary team in administering radiotherapy for esophageal cancer

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Development and characteristics of a multidisciplinary colorectal cancer clinic

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Changes in health-related quality of life in oesophagogastric cancer patients participating in palliative and curative therapies

Background: Various treatments are used to prolong survival and improve quality of life (QOL). The purpose of this study was to assess the change in QOL scores in patients with Oesophagogastric (OG) cancer undergoing curative intent and palliative therapy.

Methods: This was a mix-designed cohort study with a consecutive sampling of patients with OG cancer who underwent curative or palliative treatment regimens. The QOL, as a determinant of efficacy and impact of cancer care, was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires. QOL data were collected from the eligible subjects at three points of time. The repeated measurement test was used to compare the significance of change in scores.

Results: Overall, 149 patients (54.4% male, 61.1% curative intent, 52.3% esophageal, 37.6 % gastric, 10.1% OG junction cancer; with mean age 62 year) with OG cancer were eligible for inclusion in the study. Compared to the palliative group, the curative group was more likely to have an esophageal tumor site, Squamous Cell Carcinoma, and stage 2 (versus stomach, Adenocarcinoma, and stage 4 in the palliative group). In comparing the patients' functional, global health status, and cancer symptom, considering time, group of treatment, and their mutual effect the result indicated significant difference between the intervention groups.

Conclusion: Most patients with Oesophagogastric cancer are diagnosed with an incurable form of the disease. Hence in absence of curative treatment, palliative therapy is the most effective therapy to maintain patient independency and relieve pain and symptom in order to improve their QOL. The present study has shown that palliative similar to curative intervention can improve the QOL in cancer patient especially in short term.

Less is More: The Impact of Multidisciplinary Thyroid Conference on the Treatment of Well-Differentiated Thyroid Carcinoma

BACKGROUND

In 2006, a multidisciplinary thyroid conference (MDTC) was implemented to better plan management of thyroid cancer patients at our institution. This study assessed the clinical impact of a MDTC on radioactive iodine (RAI) treatment patterns.

METHODS

A prospective database (2003-2014) collected patient and tumor characteristics, RAI doses, and tumor recurrences. Patients treated with total thyroidectomy for differentiated thyroid carcinoma ≥1 cm were stratified based on American Thyroid Association (ATA) risk classification. RAI regimens were compared before initiation of MDTC (2003-2005, n = 88), after establishment of MDTC (2007-2009, n = 95), and after the release of 2009 ATA guidelines (2011-2014, n = 181). RAI doses were defined as low (≤75 mCi), intermediate (76-150 mCi), and high (>150 mCi).

RESULTS

There was a significant decrease in the number of patients who received high-dose RAI after implementation of MDTC compared to before initiation of MDTC in the intermediate and high-risk patient groups (p = 0.04 and p < 0.01) without an associated increase in tumor recurrence (11 vs. 7%, p = 0.74). On multivariable analysis, presentation of a patient at MDTC was a negative predictor for receiving high-dose RAI (p = 0.002). As might be expected, there was also a significant decrease in use of RAI after the 2009 ATA guidelines were issued compared to after implementation of MDTC (p < 0.01).

CONCLUSION

In conjunction with implementation of a thyroid malignancy multidisciplinary conference, we observed significantly decreased postoperative dosing of RAI without increased tumor recurrence. The 2009 ATA guidelines were associated with a further decrease in RAI administration. Treatment for patients with thyroid carcinoma is optimized by a multidisciplinary approach.

Multidisciplinary Approach to the Management of Esophageal Malignancies

INTRODUCTION

A multidisciplinary approach in the management of complex malignancies is becoming more common, and likewise, adopting such an approach to the care of patients with locally advanced esophageal is recommended in order to optimize clinical outcomes.

METHODS

In this review, we discuss both the surgical and medical oncology perspectives in the management of patients with locally advanced esophageal cancer. We review the data supporting the current standard-of-care approach, namely trimodality therapy with neoadjuvant chemo-radiotherapy followed by surgery. Other aspects of managing these patients including the control of dysphagia and pain as well as nutritional support are discussed. Finally, we review data that support the importance of incorporating a multidisciplinary streamlined approach in the management of these patients.

RESULTS

Rather than having patients see each provider separately, a multidisciplinary approach to esophageal cancer allows for the seamless flow of communication and proactive management of the patient's symptoms. These benefits include increasing the likelihood of evidence-based decision making, shorter time to treatment, and increased patient quality of life, all of which can result in improved patient outcomes.

CONCLUSION

The use of a multidisciplinary team can lead to a more accurate staging paradigm and thereby, better management decisions that translate to improved clinical outcomes. Therefore, optimizing the multidisciplinary approach for the care of patients with locally advanced esophageal cancer is essential for successful and individualized patient care.

Improving outcomes in veterans with oropharyngeal squamous cell carcinoma through implementation of a multidisciplinary clinic

BACKGROUND

Treatment of head and neck cancer is complex, and a multidisciplinary clinic may improve the coordination of care. The value of a head and neck multidisciplinary clinic has not yet been established in oropharyngeal squamous cell carcinoma (SCC).

METHODS

A retrospective review was conducted of Veterans Affairs patients with oropharyngeal SCC undergoing concurrent chemoradiation before and after implementation of the head and neck multidisciplinary clinic.

RESULTS

Fifty-two patients before and 54 patients after multidisciplinary clinic were included in this study. Age, tobacco use, and p16+ status were similar between groups. With multidisciplinary clinic, time to treatment decreased, and utilization of supportive services, including speech pathology, dentistry, and nutrition increased. The 5-year disease-specific survival rate increased from 63% to 81% (p = .043) after implementation of the multidisciplinary clinic. Multivariate analysis showed that disease stage (p = .016), p16 status (p = .006), and multidisciplinary clinic participation (p = .042) were predictors of disease-specific survival.

CONCLUSION

Implementation of a multidisciplinary clinic improved care coordination and disease-specific survival in patients with oropharyngeal SCC. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1106-1112, 2017.

The Value of Multidisciplinary Team Meetings for Patients with Gastrointestinal Malignancies: A Systematic Review

INTRODUCTION

The incidence of gastrointestinal (GI) cancer is rising and most patients with GI malignancies are discussed by a multidisciplinary team (MDT). We performed a systematic review to assess whether MDTs for patients with GI malignancies can correctly change diagnosis, tumor stage and subsequent treatment plan, and whether the treatment plan was implemented.

METHODS

We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We conducted a search of the PubMed, MEDLINE and EMBASE electronic databases, and included studies relating to adults with a GI malignancy discussed by an MDT prior to the start of treatment which described a change of initial diagnosis, stage or treatment plan. Two researchers independently evaluated all retrieved titles and abstracts from the abovementioned databases.

RESULTS

Overall, 16 studies were included; the study quality was rated as fair. Four studies reported that MDTs changed the diagnoses formulated by individual physicians in 18.4-26.9% of evaluated cases; two studies reported that MDTs formulated an accurate diagnosis in 89 and 93.5% of evaluated cases, respectively; nine studies described that the treatment plan was altered in 23.0-41.7% of evaluated cases; and four studies found that MDT decisions were implemented in 90-100% of evaluated cases. The reasons for altering a treatment plan included the patient's wishes, and comorbidities.

CONCLUSIONS

MDT meetings for patients with a GI malignancy are responsible for changes in diagnoses and management in a significant number of patients. Treatment plans formulated by MDTs are implemented in 90-100% of discussed patients. All patients with a GI malignancy should be discussed by an MDT.