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Effects of a multidisciplinary team on colorectal cancer treatment
Formosan Journal of Surgery (2015) 48, 145e150
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.e-fjs.com
MINI-REVIEW
Effects of a multidisciplinary team on colorectal cancer treatment Yuan-Tzu Lan a,b, Jen-Kou Lin a,b, Jeng-Kai Jiang a,b,* a Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan b School of Medicine, National Yang-Ming University, Taipei, Taiwan
Received 2 March 2015; received in revised form 4 May 2015; accepted 3 July 2015
Available online 2 November 2015
KEYWORDS colorectal cancer; multidisciplinary team; quality of cancer care; survival
Abstract Multidisciplinary teams (MDTs) are now widely accepted as a standard of quality control and a model for various approaches to cancer care in many countries. Evidence has shown that MDTs can improve clinical decision-making as well as the outcomes and experiences of patients with various cancers. Adopting MDTs for treating patients with colorectal cancer has considerably influenced current medical practice. Most of the decisions made by MDTs are implemented, and preoperative evaluation can be achieved more completely with more accurate preoperative staging. Patients who receive care under the guidance of MDTs have higher rates of access to multimodal therapies than do patients who do not. In addition, pathology reports are more likely to be of higher quality. In an MDT setting, adjuvant chemotherapies are prescribed in a more suitable manner and overall survival is improved. An MDT can determine whether patients with rectal cancer should first be treated surgically or receive neoadjuvant therapy. MDTs considerably influence decisions regarding the choice of staging modality and neoadjuvant treatment. However, results regarding the reduced rate of positive circumferential resection margins and more favorable overall survival are controversial. In conclusion, most of the influence of MDTs on current treatment for colorectal cancer is positive; therefore, establishing MDTs should be encouraged to enhance the quality of colorectal cancer care. Copyright ª 2015, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Number 201 Section 2, Shih-Pai Road, Beitou District, Taipei 11217, Taiwan. E-mail address: [email protected] (J.-K. Jiang). http://dx.doi.org/10.1016/j.fjs.2015.07.003 1682-606X/Copyright ª 2015, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
146
1. Introduction The multidisciplinary team (MDT) approach has been adopted in various fields of medicine and patient care. Because treatment options for cancer care have increased rapidly in recent decades, establishing an MDT is crucial to fulfilling the requirement of multimodal treatments in current practice in cancer treatment. Establishing MDTs for treating various cancers is encouraged in some countries and is considered a standard of quality control in cancer care. The influence of MDTs has been evaluated by several researchers, but some controversial results have been obtained. Therefore, clarifying the role of MDTs in cancer treatment is essential. Here, we present a literature review that focuses on the influence of MDTs in colorectal cancer treatment.
2. Definition of MDTs An MDT is defined as “a group of people of different healthcare disciplines, which meets together at a given time (whether physically in one place, or by video or teleconferencing) to discuss a given patient and who are each able to contribute independently to the diagnostic and treatment decisions about the patient”.1 Through regular meetings and discussions within MDTs, healthcare professionals can improve communication, cooperation, and decision-making regarding cancer treatment. In general, the composition of an MDT for cancer care includes specialists from medical oncology, surgical oncology, radiation oncology, pathology, diagnostic and interventional radiology, palliative care, nursing professionals, nutritionists, and social workers.2 The composition of an MDT may vary depending on the cancer type.
3. MDTs in cancer care Since 1996, the Department of Health of the UK has issued a series of population-based publications on the improved outcomes of patients with breast cancer, colorectal cancer, lung cancer, gynecological cancer, and upper gastrointestinal cancer.2 National standards and guidance for cancer care were established in these publications, and the establishment of MDTs has been a consistent recommendation in these reports and other publications since 1996.3e5 MDTs are now widely accepted as a model of various approaches to cancer care in many other countries, such as the USA,6e8 Canada,9 Australia,10,11 and some countries in Europe12,13 and Asia.14 The effect of MDTs on more favorable patient selection and improved patient survival has been demonstrated in patients with esophageal,15,16 gastric,16 pancreatic,17 lung,13,18 breast,7 and gynecological cancers.14,19,20 The cancer-specific outcome is considered more favorable when patients are managed under MDT care. Evidence has shown that MDTs can improve clinical decision-making as well as the outcomes and experiences of patients with various cancers.6,15,21 However, validating the specific effects of MDTs on patient outcomes is challenging because most studies on MDTs are observational or retrospective, and multiple concurrent advances occur
Y.-T. Lan et al. regarding cancer treatment and care.2,22 Therefore, initiating a randomized trial validating the effects of MDTs is impossible.
4. MDTs in colorectal cancer treatment The diagnosis and treatment of colorectal cancer have rapidly developed in the past decade, and like other cancers, managing colorectal cancer through a single treatment is difficult. After the 1995 CalmaneHine report was presented in the UK, the implementation of an MDT approach for colorectal cancer has been widely accepted.4,23 Although some limitations regarding MDTs are emphasized in the literature,24e26 such as debates on decisionmaking within MDTs, the costs of MDTs (extra hours and workload for members attending MDT meetings, unnecessary discussion in routine cases), and the limitation of discussion regarding elective cancer patients, MDTs have been incorporated into government policies and guidelines. In the USA, the American College of Surgeons Commission on Cancer has included MDTs as a key program requirement for colorectal cancer care. A project for optimizing rectal cancer treatment has been initiated by the Optimizing Surgical Treatment of Rectal Cancer (OSTRiCh) group, a consortium of 18 healthcare institutions whose purpose is to transform the delivery of rectal cancer care in the USA.27 Establishing MDTs and training MDT members to treat patients with rectal cancer are encouraged by the OSTRiCh group. The German Cancer Society has provided certification for oncological care institutions since 2003 and the numbers of pretreatment and postoperative case presentations at MDT conferences are evaluation indicators for colorectal cancer care.28 According to the 2013 benchmarking report, the rate of pretreatment case presentations on primary-care patients with rectal carcinoma or colon carcinoma at UICC Stage IV increased to 91.8% in 2012, and the rate of postoperative case presentations has remained at an extremely high level of > 95% since 2010.28 In Taiwan, a certification program on the quality of cancer care in hospitals was initiated by the National Health Research Institutes in 2008.29 Establishing MDTs for cancer care is required for certification.30 The results of certification are available on a website for public access and influence national health insurance payments by the government. At Taipei Veterans General Hospital, Taipei, Taiwan an MDT for colorectal cancer was established in October 2007. The core members are surgeons, medical oncologists, radiation oncologists, pathologists, diagnostic and interventional radiologists, nurse specialists, and coordinators. Regular weekly group meetings are held for treatment planning. Initially, the group included colorectal and hepatobiliary surgeons as team members, and because of an increase in treatment demands for pulmonary metastatic lesions, thoracic surgeons have been included since October 2011.
4.1. Decision-making Decisions regarding the choice of treatment may be changed after MDT meetings, but not every decision can be
Colorectal cancer treatment implemented despite an MDT discussion. According to a systematic review, MDTs changed cancer management by individual physicians in 2e52% of cases, whereas decisions could not be implemented in 1e16% of cases.31 Wood et al32 examined the implementation of an MDT approach in the decision-making process and reasons for disagreement in colorectal cancer treatment. The authors demonstrated that most colorectal MDT decisions were implemented and only w10% of the decisions were not implemented in a total of 201 consecutive treatment decisions. Furthermore, they confirmed a colorectal MDT as an effective forum. In cases of disagreement, the final treatment was always more conservative than the initial treatment planned and provided by MDTs. The reasons for changes were mostly associated with patients’ comorbidity, which was not considered during meetings; moreover, treatment with a palliative intent is another major reason for not following MDT recommendations. Ryan and Faragher25 prospectively assessed 197 consecutive cases presented to a colorectal MDT and compared the plans made using routine care pathways and those made at MDT meetings. The authors demonstrated that discussing routine cases of colon cancer rarely changed management (3.4%). Conversely, management changed in 50% of complex cases after MDT discussion. Topics that commonly generated useful discussion were the preoperative management of rectal cancer, management of metastatic or recurrent disease, management of malignant polyps, and patients for whom no written management pathway was present to guide treatment. Only 4% of all cases deviated from the proposed treatment because of complex patient factors, poor prognostic features, patient age, and medical comorbidity.25 These findings highlight the need of information on the general health status of patients and their preference for treatment, which should be available at MDT meetings. Typically, MDT decisions are made by physician members according to biomedical information and patient choice is seldom considered in the decision-making process.31 Nurses should attend MDT meetings because they can offer the views of patients and the psychosocial aspects of care to the meetings. When nurses are actively involved, the performance of an MDT is apparently higher.3
4.2. Preoperative workup Evidence has shown that implementing an MDT approach for managing colorectal cancer can result in more complete preoperative evaluations as well as higher rates of access to multimodal therapies.33,34 When the preoperative tests prescribed by the National Comprehensive Cancer Network guidelines were considered, the proportion of patients with colon cancer who underwent complete preoperative tests was significantly higher under MDT care (91.7% vs. 27.5%, p < 0.001), and this trend was also observed in patients with rectal cancer (84.0% vs. 15.3%, p < 0.001). Differences were observed in the rates of chest computed tomography (CT) scan (95.0% vs. 37.1%, p < 0.001), carcinoembryonic antigen testing (100% vs. 63.8%, p < 0.001), and transrectal ultrasound for rectal cancer (88.0% vs. 37.7%, p < 0.001).34 Another study demonstrated that significantly more
147 patients underwent CT TNM staging when under the care of an MDT (81.3% vs. 41.1%, p < 0.001).35 In a populationbased study in The Netherlands, magnetic resonance imaging (MRI) was used more often (p Z 0.001) and TNM staging was more complete (p < 0.001) under the care of an MDT.36 In addition to the completeness of preoperative workup, staging accuracy also improves after an MDT approach has been established. Radiological TNM staging according to CT scans was compared with the final pathological stage between the periods before and after the establishment of an MDT approach; CT TNM staging was more accurate in the MDT group than in the pre-MDT group (64.0% vs. 45.9%, p Z 0.044).35
4.3. Access to multimodal therapy for rectal cancer The multimodal characteristics of different treatment approaches have rendered the treatment of rectal cancer complex in current daily practice. Therefore, in many respects, MDTs are crucial for treating patients with rectal cancer. According to an international survey, regular MDT meetings significantly influence decisions on the choice of staging modality, neoadjuvant treatment, and several other critical factors in the preoperative planning of rectal cancer treatment.33 The main components of rectal cancer treatment include: (1) total mesorectal excision; (2) assessment of the quality of surgery by pathologists; (3) identification of patients at a high risk of local recurrence through imaging techniques; (4) use of effective neoadjuvant and adjuvant therapies, including radiotherapy and chemotherapy; and (5) an MDT approach that identifies, coordinates, delivers, and monitors the ideal treatment on an individual basis.27 An MDT approach enables distinguishing between patients who should first be treated surgically and those who should be offered neoadjuvant therapy.37 Thus, patients with advanced disease (cT3 or Nþ), those with distal tumors, and those who receive preoperative chemoradiotherapy are more often discussed by MDTs.36 According to an international survey involving 123 colorectal cancer centers in North America, Europe, and Asia, departments with regular MDT meetings were more likely to use MRI to determine local staging and were more likely to encourage patients with threatened circumferential resection margins to undergo neoadjuvant treatment.33 In a survey by Levine et al,34 the proportion of patients who underwent neoadjuvant therapy was significantly higher for patients under MDT care (76% vs. 20%, p < 0.001). This survey also included a subgroup analysis of patients with Stages II and III disease, and the results showed that patients under MDT care were more likely to undergo neoadjuvant therapy (Stage II: 87.5% vs. 31.3%, p Z 0.03; Stage III: 87.5% vs. 23.8%, p Z 0.003). However, controversial results exist regarding MDT care. According to a survey conducted in The Netherlands, the proportion of patients with T2-3/M0 rectal cancer who received preoperative radiotherapy was not different between MDT and control groups [odds ratio (OR) Z 0.98, 95% confidence interval (CI) Z 0.96e1.14].23 Moreover, no difference was observed in using preoperative chemoradiation for patients
148 with T4/M0 rectal cancer (OR Z 1.27, CI Z 0.81e2.01); however, the actual numbers used to calculate the proportion were not mentioned.23 In a survey in the UK, an MDT score was calculated based on each unit’s adherence to the criteria of the ideal colorectal cancer team. An increase of 25% in the MDT score was initially associated with a 58% increased odds of using preoperative radiotherapy for rectal cancer, but after the collinearity of the MDT score and time was considered, the effect of a 25% increase in the MDT score on the use of preoperative radiotherapy was not evident (OR Z 0.99, 95% CI Z 0.75e13.2).4 In addition to neoadjuvant treatment, conducting MDT meetings for treating rectal cancer has resulted in a reduced positive circumferential resection margin rate, a lower rate of local recurrence, more effective evidencebased care, and more favorable overall survival.38 In Burton et al’s38 study, a higher positive rate (26%) of the circumferential resection margin was observed in 62 patients who underwent surgery alone without MRI-based MDT discussion than in those who underwent surgery with MRI-based MDT discussion (1%). Furthermore, the positive circumferential resection margin rate decreased to 7% overall at 1 year of follow-up after compulsory MDT discussion in 96% of patients with rectal cancer.38 However, a population-based study showed that the overall positive rate of the circumferential resection margin did not significantly differ between patients with and without MDT discussion (10% vs. 14%, p Z 0.392).36 For early rectal cancer, determining suitability for local excision is a multifactorial decision that must consider pathological factors, local and regional stages, and patient comorbidities and desires. A retrospective study investigated the influence of introducing an MDT for early rectal cancer and found improvement in preoperative staging, a reduction in margin positivity, and an increase in the use of local excision.39 However, the statistical significance in that study is questionable because the number of patients was excessively low.
4.4. Quality of pathology reports MDTs significantly affected the quality of pathology reports (relative risk Z 4.85, 95% CI Z 1.34e17.46, p Z 0.01) in one study,33 where good quality required measuring the circumferential resection margin in millimeters. In addition, the number of lymph nodes examined in an MDT group was significantly higher than that in a pre-MDT group (8.5 vs. 13.7, p < 0.001).35 Microsatellite instability analysis was more likely to be performed if patients were under the care of an MDT (29.6% vs. 10.6%, p < 0.001).34 These results suggest that MDT meetings and discussions encourage pathologists to improve their reports to fulfill guidelines and provide more information for diagnosis and decision-making regarding treatment planning.
4.5. Adjuvant chemotherapy MDTs can provide suitable recommendations for adjuvant chemotherapy for patients with colorectal cancer. MacDermid et al40 demonstrated that significantly more patients were prescribed adjuvant chemotherapy after the
Y.-T. Lan et al. implementation of an MDT approach, even after substaging analysis (31.3% vs. 13.0%, p < 0.001; Dukes’ B, p Z 0.002; Dukes’ C, p Z 0.004). A survey conducted in The Netherlands showed a similar result. Patients with Stage III colon cancer, who were diagnosed in hospitals with MDT meetings and discussions, received adjuvant chemotherapy more frequently than control group patients did (OR Z 1.33, 95% CI Z 1.15e1.55, p < 0.05).23 Ye et al35 revealed that significantly fewer patients with Stages I and IIA disease were prescribed adjuvant chemotherapy after the implementation of an MDT approach (64% vs. 0%, p < 0.001; 82% vs. 12%, p < 0.001). No significant differences were observed in the prescription of adjuvant chemotherapy to patients with Stages IIB and III colon cancer between pre-MDT and MDT groups (Stage IIB: p Z 0.183; Stage IIIA: p Z 0.577; Stage IIIB: p Z 0.728; and Stage IIIC: p Z 0.616).35
4.6. Chemotherapy for metastatic disease For patients with metastatic disease, MDTs significantly influenced the use of new chemotherapy regimens if liver metastases were present (relative risk Z 6.41, CI Z 1.34e30.64, p Z 0.02).33 However, no difference was observed in the number of patients who were prescribed palliative chemotherapy before and after the implementation of an MDT approach (p Z 0.750 and p Z 0.431, respectively).35,40
4.7. Patient survival Most studies have confirmed a positive effect of MDTs on patient survival. However, because these studies on MDTs were observational or retrospective, the effects of multiple concurrent changes in cancer treatment and care should always be considered when the study results are interpreted, particularly regarding the influence of MDTs on patient outcome. A population-based retrospective survey by Morris et al4 showed that a 25% increase in the MDT score was associated with a 3% reduction in the risk of death for all patients with colorectal cancer [hazard ratio (HR) Z 0.97, 95% CI Z 0.94e0.99, p Z 0.01]. This reduction was significant in patients with colon cancer (HR Z 0.96, 95% CI Z 0.93e0.99, p < 0.01), but not in patients with rectal cancer (HR Z 0.99, 95% CI Z 0.95e1.04, p Z 0.81).4 A survey conducted in The Netherlands showed that mortality in patients with colon cancer was slightly lower in an MDT group than in a control group (HR Z 0.97, 95% CI Z 0.94e0.99, p < 0.05), but not in patients with rectal cancer (HR Z 0.96, 95% CI Z 0.92e1.01).23 MacDermid et al40 evaluated the effect of MDTs on the survival of patients with colorectal cancer at a single institution and demonstrated that MDT status was an independent predictor of survival (HR Z 0.73, 95% CI Z 0.54e0.98, p Z 0.044). In a subgroup analysis, a significantly improved 3-year survival rate was demonstrated for Dukes’ C patients after MDT establishment (58% vs. 66%, p Z 0.023), but not for Dukes’ B patients (76% vs. 70%, p Z 0.486). The median survival did not differ in patients with metastatic disease who underwent surgery
Colorectal cancer treatment before or after the implementation of an MDT approach (8 months vs. 11.9 months, p Z 0.234).40 Through a multivariate analysis, Ye et al35 revealed that management after the commencement of an MDT approach was a major factor that independently influenced overall survival (p < 0.001). Lordan et al41 conducted a prospective survey on the survival of patients with colorectal cancer who were recommended to undergo hepatic resection with or without an MDT. Patients who were referred by the MDT for hepatic resection had a 3-year overall survival rate of 67.5% and a 3year disease-free survival rate of 31.0%. Patients referred directly without the MDT had a 3-year survival rate of 54.1% and a 3-year disease-free survival rate of 37.6%. The difference in overall survival was significant (p < 0.001), although the difference in disease-free survival was not (p Z 0.205).41 In a survey in Germany, the median overall survival time of patients with metastatic disease who were treated with a multimodal strategy under MDT care was significantly longer than that of patients who were treated only with palliative chemotherapy (49 months vs. 22 months, p < 0.001).42 In addition, the difference in median progression-free survival was considerably significant (18 months vs. 6 months, p < 0.001).42
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5. Conclusion 17.
Establishing MDTs for colorectal cancer care can lead to more complete preoperative evaluation and higher rates of access to multimodal therapies. Moreover, MDTs can improve the quality of pathology reports, provide suitable recommendations for adjuvant chemotherapy, and increase overall survival in patients with colorectal cancer. To enhance the quality of cancer care, government-affiliated hospitals should encourage establishing MDTs.
18.
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20.
References 21. 1. The generic multidisciplinary team (MDT). In: Manual for Cancer Services 2004. London: Department of Health; 2004. 2. Fleissig A, Jenkins V, Catt S, Fallowfield L. Multidisciplinary teams in cancer care: are they effective in the UK? Lancet Oncol. 2006;7:935e943. 3. Haward R, Amir Z, Borrill C, et al. Breast cancer teams: the impact of constitution, new cancer workload, and methods of operation on their effectiveness. Br J Cancer. 2003;89:15e22. 4. Morris E, Haward RA, Gilthorpe MS, Craigs C, Forman D. The impact of the CalmaneHine report on the processes and outcomes of care for Yorkshire’s colorectal cancer patients. Br J Cancer. 2006;95:979e985. 5. Haward RA. Using service guidance to shape the delivery of cancer services: experience in the UK. Br J Cancer. 2003; 89(Suppl. 1):S12e14. 6. Chang JH, Vines E, Bertsch H, et al. The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer. 2001;91:1231e1237. 7. Newman EA, Guest AB, Helvie MA, et al. Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board. Cancer. 2006;107:2346e2351. 8. Tripathy D. Multidisciplinary care for breast cancer: barriers and solutions. Breast J. 2003;9:60e63. 9. Wright FC, Lookhong N, Urbach D, Davis D, McLeod RS, Gagliardi AR. Multidisciplinary cancer conferences: identifying
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opportunities to promote implementation. Ann Surg Oncol. 2009;16:2731e2737. Butow P, Harrison JD, Choy ET, Young JM, Spillane A, Evans A. Health professional and consumer views on involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan. Cancer. 2007;110:1937e1944. Zorbas H, Barraclough B, Rainbird K, Luxford K, Redman S. Multidisciplinary care for women with early breast cancer in the Australian context: what does it mean? Med J Aust. 2003; 179:528e531. Association of Breast Surgery @ BASO, Royal College of Surgeons of England. Guidelines for the management of symptomatic breast disease. Eur J Surg Oncol. 2005;31(Suppl. 1): 1e21. Leo F, Venissac N, Poudenx M, Otto J, Mouroux J. Multidisciplinary management of lung cancer: how to test its efficacy? J Thorac Oncol. 2007;2:69e72. Ganesan P, Kumar L, Hariprasad R, Gupta A, Dawar R, Vijayaraghavan M. Improving care in ovarian cancer: the role of a clinico-pathological meeting. Natl Med J India. 2008;21: 225e227. Stephens MR, Lewis WG, Brewster AE, et al. Multidisciplinary team management is associated with improved outcomes after surgery for esophageal cancer. Dis Esophagus. 2006;19:164e171. Davies AR, Deans DA, Penman I, et al. The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer. Dis Esophagus. 2006;19: 496e503. Katz MH, Wang H, Fleming JB, et al. Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol. 2009;16:836e847. Forrest LM, McMillan DC, McArdle CS, Dunlop DJ. An evaluation of the impact of a multidisciplinary team, in a single centre, on treatment and survival in patients with inoperable non-smallcell lung cancer. Br J Cancer. 2005;93:977e978. Junor EJ, Hole DJ, Gillis CR. Management of ovarian cancer: referral to a multidisciplinary team matters. Br J Cancer. 1994; 70:363e370. Lanceley A, Savage J, Menon U, Jacobs I. Influences on multidisciplinary team decision-making. Int J Gynecol Cancer. 2008; 18:215e222. Coory M, Gkolia P, Yang IA, Bowman RV, Fong KM. Systematic review of multidisciplinary teams in the management of lung cancer. Lung Cancer. 2008;60:14e21. Hong NJ, Wright FC, Gagliardi AR, Paszat LF. Examining the potential relationship between multidisciplinary cancer care and patient survival: an international literature review. J Surg Oncol. 2010;102:125e134. Kilsdonk MJ, van Dijk BA, Otter R, Siesling S, van Harten WH. The impact of organisational external peer review on colorectal cancer treatment and survival in the Netherlands. Br J Cancer. 2014;110:850e858. Meagher AP. Colorectal cancer: are multidisciplinary team meetings a waste of time? ANZ J Surg. 2013;83:101e103. Ryan J, Faragher I. Not all patients need to be discussed in a colorectal cancer MDT meeting. Colorectal Dis. 2014;16: 520e526. Shah S, Arora S, Atkin G, et al. Decision-making in Colorectal Cancer Tumor Board meetings: results of a prospective observational assessment. Surg Endosc. 2014;28:2783e2788. Dietz DW. Consortium for Optimizing Surgical Treatment of Rectal Cancer (OSTRiCH). Multidisciplinary management of rectal cancer: the OSTRICH. J Gastrointest Surg. 2013;17: 1863e1868. Wesselmann S, Winter A, Ferencz J, Seufferlein T, Post S. Documented quality of care in certified colorectal cancer centers in Germany: German Cancer Society benchmarking report for 2013. Int J Colorectal Dis. 2014;29:511e518.
150 29. 國家癌症防治五年計劃成果別冊. In: 行政院衛生署. 2010. 30. 104年癌症診療品質認證基準及評分說明. In: 國家衛生研究院. 2015. 31. Lamb BW, Brown KF, Nagpal K, Vincent C, Green JS, Sevdalis N. Quality of care management decisions by multidisciplinary cancer teams: a systematic review. Ann Surg Oncol. 2011;18: 2116e2125. 32. Wood JJ, Metcalfe C, Paes A, et al. An evaluation of treatment decisions at a colorectal cancer multi-disciplinary team. Colorectal Dis. 2008;10:769e772. 33. Augestad KM, Lindsetmo RO, Stulberg J, et al. International preoperative rectal cancer management: staging, neoadjuvant treatment, and impact of multidisciplinary teams. World J Surg. 2010;34:2689e2700. 34. Levine RA, Chawla B, Bergeron S, Wasvary H. Multidisciplinary management of colorectal cancer enhances access to multimodal therapy and compliance with National Comprehensive Cancer Network (NCCN) guidelines. Int J Colorectal Dis. 2012; 27:1531e1538. 35. Ye YJ, Shen ZL, Sun XT, et al. Impact of multidisciplinary team working on the management of colorectal cancer. Chin Med J (Engl). 2012;125:172e177. 36. Swellengrebel HA, Peters EG, Cats A, et al. Multidisciplinary discussion and management of rectal cancer: a populationbased study. World J Surg. 2011;35:2125e2133.
Y.-T. Lan et al. 37. Hosein PJ, Rocha-Lima CM. Role of combined-modality therapy in the management of locally advanced rectal cancer. Clin Colorectal Cancer. 2008;7:369e375. 38. Burton S, Brown G, Daniels IR, et al. MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins? Br J Cancer. 2006; 94:351e357. 39. Vaughan-Shaw PG, Wheeler J, Borley NR. The impact of a dedicated multidisciplinary team on the management of early rectal cancer. Colorectal Dis. 2015;20:12922. 40. MacDermid E, Hooton G, MacDonald M, et al. Improving patient survival with the colorectal cancer multi-disciplinary team. Colorectal Dis. 2009;11:291e295. 41. Lordan JT, Karanjia ND, Quiney N, Fawcett WJ, Worthington TR. A 10-year study of outcome following hepatic resection for colorectal liver metastasesdthe effect of evaluation in a multidisciplinary team setting. Eur J Surg Oncol. 2009;35:302e306. 42. Wein A, Emmert M, Merkel S, et al. Palliative treatment of colorectal cancer with secondary metastasis resection in Germanydimpact of the multidisciplinary treatment approach on prognosis and cost: the Northern Bavaria IVOPAK I Project. Oncology. 2014;88:103e121.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.e-fjs.com
MINI-REVIEW
Effects of a multidisciplinary team on colorectal cancer treatment Yuan-Tzu Lan a,b, Jen-Kou Lin a,b, Jeng-Kai Jiang a,b,* a Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan b School of Medicine, National Yang-Ming University, Taipei, Taiwan
Received 2 March 2015; received in revised form 4 May 2015; accepted 3 July 2015
Available online 2 November 2015
KEYWORDS colorectal cancer; multidisciplinary team; quality of cancer care; survival
Abstract Multidisciplinary teams (MDTs) are now widely accepted as a standard of quality control and a model for various approaches to cancer care in many countries. Evidence has shown that MDTs can improve clinical decision-making as well as the outcomes and experiences of patients with various cancers. Adopting MDTs for treating patients with colorectal cancer has considerably influenced current medical practice. Most of the decisions made by MDTs are implemented, and preoperative evaluation can be achieved more completely with more accurate preoperative staging. Patients who receive care under the guidance of MDTs have higher rates of access to multimodal therapies than do patients who do not. In addition, pathology reports are more likely to be of higher quality. In an MDT setting, adjuvant chemotherapies are prescribed in a more suitable manner and overall survival is improved. An MDT can determine whether patients with rectal cancer should first be treated surgically or receive neoadjuvant therapy. MDTs considerably influence decisions regarding the choice of staging modality and neoadjuvant treatment. However, results regarding the reduced rate of positive circumferential resection margins and more favorable overall survival are controversial. In conclusion, most of the influence of MDTs on current treatment for colorectal cancer is positive; therefore, establishing MDTs should be encouraged to enhance the quality of colorectal cancer care. Copyright ª 2015, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
Conflicts of interest: The authors have no conflicts of interest relevant to this article. * Corresponding author. Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Number 201 Section 2, Shih-Pai Road, Beitou District, Taipei 11217, Taiwan. E-mail address: [email protected] (J.-K. Jiang). http://dx.doi.org/10.1016/j.fjs.2015.07.003 1682-606X/Copyright ª 2015, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved.
146
1. Introduction The multidisciplinary team (MDT) approach has been adopted in various fields of medicine and patient care. Because treatment options for cancer care have increased rapidly in recent decades, establishing an MDT is crucial to fulfilling the requirement of multimodal treatments in current practice in cancer treatment. Establishing MDTs for treating various cancers is encouraged in some countries and is considered a standard of quality control in cancer care. The influence of MDTs has been evaluated by several researchers, but some controversial results have been obtained. Therefore, clarifying the role of MDTs in cancer treatment is essential. Here, we present a literature review that focuses on the influence of MDTs in colorectal cancer treatment.
2. Definition of MDTs An MDT is defined as “a group of people of different healthcare disciplines, which meets together at a given time (whether physically in one place, or by video or teleconferencing) to discuss a given patient and who are each able to contribute independently to the diagnostic and treatment decisions about the patient”.1 Through regular meetings and discussions within MDTs, healthcare professionals can improve communication, cooperation, and decision-making regarding cancer treatment. In general, the composition of an MDT for cancer care includes specialists from medical oncology, surgical oncology, radiation oncology, pathology, diagnostic and interventional radiology, palliative care, nursing professionals, nutritionists, and social workers.2 The composition of an MDT may vary depending on the cancer type.
3. MDTs in cancer care Since 1996, the Department of Health of the UK has issued a series of population-based publications on the improved outcomes of patients with breast cancer, colorectal cancer, lung cancer, gynecological cancer, and upper gastrointestinal cancer.2 National standards and guidance for cancer care were established in these publications, and the establishment of MDTs has been a consistent recommendation in these reports and other publications since 1996.3e5 MDTs are now widely accepted as a model of various approaches to cancer care in many other countries, such as the USA,6e8 Canada,9 Australia,10,11 and some countries in Europe12,13 and Asia.14 The effect of MDTs on more favorable patient selection and improved patient survival has been demonstrated in patients with esophageal,15,16 gastric,16 pancreatic,17 lung,13,18 breast,7 and gynecological cancers.14,19,20 The cancer-specific outcome is considered more favorable when patients are managed under MDT care. Evidence has shown that MDTs can improve clinical decision-making as well as the outcomes and experiences of patients with various cancers.6,15,21 However, validating the specific effects of MDTs on patient outcomes is challenging because most studies on MDTs are observational or retrospective, and multiple concurrent advances occur
Y.-T. Lan et al. regarding cancer treatment and care.2,22 Therefore, initiating a randomized trial validating the effects of MDTs is impossible.
4. MDTs in colorectal cancer treatment The diagnosis and treatment of colorectal cancer have rapidly developed in the past decade, and like other cancers, managing colorectal cancer through a single treatment is difficult. After the 1995 CalmaneHine report was presented in the UK, the implementation of an MDT approach for colorectal cancer has been widely accepted.4,23 Although some limitations regarding MDTs are emphasized in the literature,24e26 such as debates on decisionmaking within MDTs, the costs of MDTs (extra hours and workload for members attending MDT meetings, unnecessary discussion in routine cases), and the limitation of discussion regarding elective cancer patients, MDTs have been incorporated into government policies and guidelines. In the USA, the American College of Surgeons Commission on Cancer has included MDTs as a key program requirement for colorectal cancer care. A project for optimizing rectal cancer treatment has been initiated by the Optimizing Surgical Treatment of Rectal Cancer (OSTRiCh) group, a consortium of 18 healthcare institutions whose purpose is to transform the delivery of rectal cancer care in the USA.27 Establishing MDTs and training MDT members to treat patients with rectal cancer are encouraged by the OSTRiCh group. The German Cancer Society has provided certification for oncological care institutions since 2003 and the numbers of pretreatment and postoperative case presentations at MDT conferences are evaluation indicators for colorectal cancer care.28 According to the 2013 benchmarking report, the rate of pretreatment case presentations on primary-care patients with rectal carcinoma or colon carcinoma at UICC Stage IV increased to 91.8% in 2012, and the rate of postoperative case presentations has remained at an extremely high level of > 95% since 2010.28 In Taiwan, a certification program on the quality of cancer care in hospitals was initiated by the National Health Research Institutes in 2008.29 Establishing MDTs for cancer care is required for certification.30 The results of certification are available on a website for public access and influence national health insurance payments by the government. At Taipei Veterans General Hospital, Taipei, Taiwan an MDT for colorectal cancer was established in October 2007. The core members are surgeons, medical oncologists, radiation oncologists, pathologists, diagnostic and interventional radiologists, nurse specialists, and coordinators. Regular weekly group meetings are held for treatment planning. Initially, the group included colorectal and hepatobiliary surgeons as team members, and because of an increase in treatment demands for pulmonary metastatic lesions, thoracic surgeons have been included since October 2011.
4.1. Decision-making Decisions regarding the choice of treatment may be changed after MDT meetings, but not every decision can be
Colorectal cancer treatment implemented despite an MDT discussion. According to a systematic review, MDTs changed cancer management by individual physicians in 2e52% of cases, whereas decisions could not be implemented in 1e16% of cases.31 Wood et al32 examined the implementation of an MDT approach in the decision-making process and reasons for disagreement in colorectal cancer treatment. The authors demonstrated that most colorectal MDT decisions were implemented and only w10% of the decisions were not implemented in a total of 201 consecutive treatment decisions. Furthermore, they confirmed a colorectal MDT as an effective forum. In cases of disagreement, the final treatment was always more conservative than the initial treatment planned and provided by MDTs. The reasons for changes were mostly associated with patients’ comorbidity, which was not considered during meetings; moreover, treatment with a palliative intent is another major reason for not following MDT recommendations. Ryan and Faragher25 prospectively assessed 197 consecutive cases presented to a colorectal MDT and compared the plans made using routine care pathways and those made at MDT meetings. The authors demonstrated that discussing routine cases of colon cancer rarely changed management (3.4%). Conversely, management changed in 50% of complex cases after MDT discussion. Topics that commonly generated useful discussion were the preoperative management of rectal cancer, management of metastatic or recurrent disease, management of malignant polyps, and patients for whom no written management pathway was present to guide treatment. Only 4% of all cases deviated from the proposed treatment because of complex patient factors, poor prognostic features, patient age, and medical comorbidity.25 These findings highlight the need of information on the general health status of patients and their preference for treatment, which should be available at MDT meetings. Typically, MDT decisions are made by physician members according to biomedical information and patient choice is seldom considered in the decision-making process.31 Nurses should attend MDT meetings because they can offer the views of patients and the psychosocial aspects of care to the meetings. When nurses are actively involved, the performance of an MDT is apparently higher.3
4.2. Preoperative workup Evidence has shown that implementing an MDT approach for managing colorectal cancer can result in more complete preoperative evaluations as well as higher rates of access to multimodal therapies.33,34 When the preoperative tests prescribed by the National Comprehensive Cancer Network guidelines were considered, the proportion of patients with colon cancer who underwent complete preoperative tests was significantly higher under MDT care (91.7% vs. 27.5%, p < 0.001), and this trend was also observed in patients with rectal cancer (84.0% vs. 15.3%, p < 0.001). Differences were observed in the rates of chest computed tomography (CT) scan (95.0% vs. 37.1%, p < 0.001), carcinoembryonic antigen testing (100% vs. 63.8%, p < 0.001), and transrectal ultrasound for rectal cancer (88.0% vs. 37.7%, p < 0.001).34 Another study demonstrated that significantly more
147 patients underwent CT TNM staging when under the care of an MDT (81.3% vs. 41.1%, p < 0.001).35 In a populationbased study in The Netherlands, magnetic resonance imaging (MRI) was used more often (p Z 0.001) and TNM staging was more complete (p < 0.001) under the care of an MDT.36 In addition to the completeness of preoperative workup, staging accuracy also improves after an MDT approach has been established. Radiological TNM staging according to CT scans was compared with the final pathological stage between the periods before and after the establishment of an MDT approach; CT TNM staging was more accurate in the MDT group than in the pre-MDT group (64.0% vs. 45.9%, p Z 0.044).35
4.3. Access to multimodal therapy for rectal cancer The multimodal characteristics of different treatment approaches have rendered the treatment of rectal cancer complex in current daily practice. Therefore, in many respects, MDTs are crucial for treating patients with rectal cancer. According to an international survey, regular MDT meetings significantly influence decisions on the choice of staging modality, neoadjuvant treatment, and several other critical factors in the preoperative planning of rectal cancer treatment.33 The main components of rectal cancer treatment include: (1) total mesorectal excision; (2) assessment of the quality of surgery by pathologists; (3) identification of patients at a high risk of local recurrence through imaging techniques; (4) use of effective neoadjuvant and adjuvant therapies, including radiotherapy and chemotherapy; and (5) an MDT approach that identifies, coordinates, delivers, and monitors the ideal treatment on an individual basis.27 An MDT approach enables distinguishing between patients who should first be treated surgically and those who should be offered neoadjuvant therapy.37 Thus, patients with advanced disease (cT3 or Nþ), those with distal tumors, and those who receive preoperative chemoradiotherapy are more often discussed by MDTs.36 According to an international survey involving 123 colorectal cancer centers in North America, Europe, and Asia, departments with regular MDT meetings were more likely to use MRI to determine local staging and were more likely to encourage patients with threatened circumferential resection margins to undergo neoadjuvant treatment.33 In a survey by Levine et al,34 the proportion of patients who underwent neoadjuvant therapy was significantly higher for patients under MDT care (76% vs. 20%, p < 0.001). This survey also included a subgroup analysis of patients with Stages II and III disease, and the results showed that patients under MDT care were more likely to undergo neoadjuvant therapy (Stage II: 87.5% vs. 31.3%, p Z 0.03; Stage III: 87.5% vs. 23.8%, p Z 0.003). However, controversial results exist regarding MDT care. According to a survey conducted in The Netherlands, the proportion of patients with T2-3/M0 rectal cancer who received preoperative radiotherapy was not different between MDT and control groups [odds ratio (OR) Z 0.98, 95% confidence interval (CI) Z 0.96e1.14].23 Moreover, no difference was observed in using preoperative chemoradiation for patients
148 with T4/M0 rectal cancer (OR Z 1.27, CI Z 0.81e2.01); however, the actual numbers used to calculate the proportion were not mentioned.23 In a survey in the UK, an MDT score was calculated based on each unit’s adherence to the criteria of the ideal colorectal cancer team. An increase of 25% in the MDT score was initially associated with a 58% increased odds of using preoperative radiotherapy for rectal cancer, but after the collinearity of the MDT score and time was considered, the effect of a 25% increase in the MDT score on the use of preoperative radiotherapy was not evident (OR Z 0.99, 95% CI Z 0.75e13.2).4 In addition to neoadjuvant treatment, conducting MDT meetings for treating rectal cancer has resulted in a reduced positive circumferential resection margin rate, a lower rate of local recurrence, more effective evidencebased care, and more favorable overall survival.38 In Burton et al’s38 study, a higher positive rate (26%) of the circumferential resection margin was observed in 62 patients who underwent surgery alone without MRI-based MDT discussion than in those who underwent surgery with MRI-based MDT discussion (1%). Furthermore, the positive circumferential resection margin rate decreased to 7% overall at 1 year of follow-up after compulsory MDT discussion in 96% of patients with rectal cancer.38 However, a population-based study showed that the overall positive rate of the circumferential resection margin did not significantly differ between patients with and without MDT discussion (10% vs. 14%, p Z 0.392).36 For early rectal cancer, determining suitability for local excision is a multifactorial decision that must consider pathological factors, local and regional stages, and patient comorbidities and desires. A retrospective study investigated the influence of introducing an MDT for early rectal cancer and found improvement in preoperative staging, a reduction in margin positivity, and an increase in the use of local excision.39 However, the statistical significance in that study is questionable because the number of patients was excessively low.
4.4. Quality of pathology reports MDTs significantly affected the quality of pathology reports (relative risk Z 4.85, 95% CI Z 1.34e17.46, p Z 0.01) in one study,33 where good quality required measuring the circumferential resection margin in millimeters. In addition, the number of lymph nodes examined in an MDT group was significantly higher than that in a pre-MDT group (8.5 vs. 13.7, p < 0.001).35 Microsatellite instability analysis was more likely to be performed if patients were under the care of an MDT (29.6% vs. 10.6%, p < 0.001).34 These results suggest that MDT meetings and discussions encourage pathologists to improve their reports to fulfill guidelines and provide more information for diagnosis and decision-making regarding treatment planning.
4.5. Adjuvant chemotherapy MDTs can provide suitable recommendations for adjuvant chemotherapy for patients with colorectal cancer. MacDermid et al40 demonstrated that significantly more patients were prescribed adjuvant chemotherapy after the
Y.-T. Lan et al. implementation of an MDT approach, even after substaging analysis (31.3% vs. 13.0%, p < 0.001; Dukes’ B, p Z 0.002; Dukes’ C, p Z 0.004). A survey conducted in The Netherlands showed a similar result. Patients with Stage III colon cancer, who were diagnosed in hospitals with MDT meetings and discussions, received adjuvant chemotherapy more frequently than control group patients did (OR Z 1.33, 95% CI Z 1.15e1.55, p < 0.05).23 Ye et al35 revealed that significantly fewer patients with Stages I and IIA disease were prescribed adjuvant chemotherapy after the implementation of an MDT approach (64% vs. 0%, p < 0.001; 82% vs. 12%, p < 0.001). No significant differences were observed in the prescription of adjuvant chemotherapy to patients with Stages IIB and III colon cancer between pre-MDT and MDT groups (Stage IIB: p Z 0.183; Stage IIIA: p Z 0.577; Stage IIIB: p Z 0.728; and Stage IIIC: p Z 0.616).35
4.6. Chemotherapy for metastatic disease For patients with metastatic disease, MDTs significantly influenced the use of new chemotherapy regimens if liver metastases were present (relative risk Z 6.41, CI Z 1.34e30.64, p Z 0.02).33 However, no difference was observed in the number of patients who were prescribed palliative chemotherapy before and after the implementation of an MDT approach (p Z 0.750 and p Z 0.431, respectively).35,40
4.7. Patient survival Most studies have confirmed a positive effect of MDTs on patient survival. However, because these studies on MDTs were observational or retrospective, the effects of multiple concurrent changes in cancer treatment and care should always be considered when the study results are interpreted, particularly regarding the influence of MDTs on patient outcome. A population-based retrospective survey by Morris et al4 showed that a 25% increase in the MDT score was associated with a 3% reduction in the risk of death for all patients with colorectal cancer [hazard ratio (HR) Z 0.97, 95% CI Z 0.94e0.99, p Z 0.01]. This reduction was significant in patients with colon cancer (HR Z 0.96, 95% CI Z 0.93e0.99, p < 0.01), but not in patients with rectal cancer (HR Z 0.99, 95% CI Z 0.95e1.04, p Z 0.81).4 A survey conducted in The Netherlands showed that mortality in patients with colon cancer was slightly lower in an MDT group than in a control group (HR Z 0.97, 95% CI Z 0.94e0.99, p < 0.05), but not in patients with rectal cancer (HR Z 0.96, 95% CI Z 0.92e1.01).23 MacDermid et al40 evaluated the effect of MDTs on the survival of patients with colorectal cancer at a single institution and demonstrated that MDT status was an independent predictor of survival (HR Z 0.73, 95% CI Z 0.54e0.98, p Z 0.044). In a subgroup analysis, a significantly improved 3-year survival rate was demonstrated for Dukes’ C patients after MDT establishment (58% vs. 66%, p Z 0.023), but not for Dukes’ B patients (76% vs. 70%, p Z 0.486). The median survival did not differ in patients with metastatic disease who underwent surgery
Colorectal cancer treatment before or after the implementation of an MDT approach (8 months vs. 11.9 months, p Z 0.234).40 Through a multivariate analysis, Ye et al35 revealed that management after the commencement of an MDT approach was a major factor that independently influenced overall survival (p < 0.001). Lordan et al41 conducted a prospective survey on the survival of patients with colorectal cancer who were recommended to undergo hepatic resection with or without an MDT. Patients who were referred by the MDT for hepatic resection had a 3-year overall survival rate of 67.5% and a 3year disease-free survival rate of 31.0%. Patients referred directly without the MDT had a 3-year survival rate of 54.1% and a 3-year disease-free survival rate of 37.6%. The difference in overall survival was significant (p < 0.001), although the difference in disease-free survival was not (p Z 0.205).41 In a survey in Germany, the median overall survival time of patients with metastatic disease who were treated with a multimodal strategy under MDT care was significantly longer than that of patients who were treated only with palliative chemotherapy (49 months vs. 22 months, p < 0.001).42 In addition, the difference in median progression-free survival was considerably significant (18 months vs. 6 months, p < 0.001).42
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5. Conclusion 17.
Establishing MDTs for colorectal cancer care can lead to more complete preoperative evaluation and higher rates of access to multimodal therapies. Moreover, MDTs can improve the quality of pathology reports, provide suitable recommendations for adjuvant chemotherapy, and increase overall survival in patients with colorectal cancer. To enhance the quality of cancer care, government-affiliated hospitals should encourage establishing MDTs.
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Y.-T. Lan et al. 37. Hosein PJ, Rocha-Lima CM. Role of combined-modality therapy in the management of locally advanced rectal cancer. Clin Colorectal Cancer. 2008;7:369e375. 38. Burton S, Brown G, Daniels IR, et al. MRI directed multidisciplinary team preoperative treatment strategy: the way to eliminate positive circumferential margins? Br J Cancer. 2006; 94:351e357. 39. Vaughan-Shaw PG, Wheeler J, Borley NR. The impact of a dedicated multidisciplinary team on the management of early rectal cancer. Colorectal Dis. 2015;20:12922. 40. MacDermid E, Hooton G, MacDonald M, et al. Improving patient survival with the colorectal cancer multi-disciplinary team. Colorectal Dis. 2009;11:291e295. 41. Lordan JT, Karanjia ND, Quiney N, Fawcett WJ, Worthington TR. A 10-year study of outcome following hepatic resection for colorectal liver metastasesdthe effect of evaluation in a multidisciplinary team setting. Eur J Surg Oncol. 2009;35:302e306. 42. Wein A, Emmert M, Merkel S, et al. Palliative treatment of colorectal cancer with secondary metastasis resection in Germanydimpact of the multidisciplinary treatment approach on prognosis and cost: the Northern Bavaria IVOPAK I Project. Oncology. 2014;88:103e121.