Multidisciplinary Clinics for Colorectal Cancer Care Reduces Treatment Time

Multidisciplinary Clinics for Colorectal Cancer Care Reduces Treatment Time

Original Study Multidisciplinary Clinics for Colorectal Cancer Care Reduces Treatment Time Vanessa N. Kozak,1 Alok A. Khorana,2 Sudha Amarnath,2 Kath...

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Original Study

Multidisciplinary Clinics for Colorectal Cancer Care Reduces Treatment Time Vanessa N. Kozak,1 Alok A. Khorana,2 Sudha Amarnath,2 Katherine E. Glass,2 Matthew F. Kalady1,2 Abstract Multidisciplinary clinics aim to facilitate delivery of coordinated care for diseases requiring a multimodal approach. The present retrospective review analyzed the effect of this working model on the time to treatment for patients with colorectal and anal cancer at a single institution. A mean shortening of 7.8 days from the first appointment to treatment was found, with the most benefit realized for patients requiring neoadjuvant chemoradiation. Introduction: Management of locally advanced and metastatic colorectal cancer (CRC) requires the expertise of multiple specialists. Multidisciplinary clinics (MDCs) are a working model designed to facilitate delivery of coordinated care. The present study evaluated the effects of MDC on the time to treatment (TTT). Patients and Methods: Patients with CRC or locally advanced anal cancer who were evaluated at a single-institution MDC from January 2014 to October 2015 were identified from an institutional registry. The clinical characteristics and timelines for various aspects of treatment were retrospectively reviewed and recorded. A control population of patients not evaluated at the MDC was matched 1:2 by disease and the number of treating specialties. The primary endpoints were the TTT from diagnosis and the TTT from the first consultation. Results: A total of 105 patients were included: 35 were evaluated at the MDC and 70 were controls. The MDC patients experienced a 7.8-day shorter TTT from the first consultation (21.5 vs. 29.3 days; P ¼ .01). The difference was greater for patients visiting 3 departments (21.3 vs. 30.6 days; P < .001). Patients requiring neoadjuvant chemoradiation accounted for most of the decreased interval compared with those requiring surgery alone as their first treatment. The proportion of patients initiating treatment within 3 weeks from the first consultation was greater for those seen in the MDC (57.1% vs. 30% for controls; P ¼ .01). Conclusion: Implementation of a multidisciplinary CRC clinic yielded decreased intervals from the first consultation to treatment in our institution. Focusing efforts to increase MDC usage will improve treatment efficiency and improve patient access. Clinical Colorectal Cancer, Vol. -, No. -, --- ª 2017 Elsevier Inc. All rights reserved. Keywords: Colon cancer, Process improvement, Rectal cancer, Time to treatment, Timely care

Introduction The increasing therapeutic options available for the treatment of locally advanced and metastatic colorectal cancer (CRC) requires management by multiple specialists.1,2 Several factors, including cancer stage, patient comorbidities, functional status, and patient wishes, should be considered and balanced when choosing among treatment options and sequencing of therapy.3 The coordination of colorectal surgeons, medical oncologists, radiation oncologists, and 1

Department of Colorectal Surgery, Digestive Disease and Surgery Institute Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH

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Submitted: Sep 16, 2016; Accepted: Mar 16, 2017 Address for correspondence: Matthew F. Kalady, MD, Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, A30, Cleveland, OH 44195 E-mail contact: [email protected]

1533-0028/$ - see frontmatter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.clcc.2017.03.020

hepatobiliary surgeons must be timely and efficient. In such settings, the use of multidisciplinary teams to manage CRC cases has become a common practice in many centers.3,4 The multidisciplinary clinic (MDC) is a working model designed to deliver comprehensive, patient-centered care by centralizing all practitioners at a single physical site.5,6 The MDC model differs from a coordinated care model in which multiple specialties participate in care that can occur at temporally and geographically distinct encounters. MDCs facilitate communication and coordination among specialists and provide patients with cohesive, integrated care conveniently delivered at 1 place.5 Studies of various cancer types have demonstrated the effect of MDCs on patient satisfaction,5,7-9 increased adherence to guidelines,9,10 increased accrual to clinical trials,6,9,10 a shorter time to treatment (TTT),9,11 and, even, better survival.12 Previous studies have also shown that streamlined processes strongly based on coordinated teamwork

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MDCs for CRC Care Reduces Treatment Time result in increased efficiency by eliminating duplicated steps and better addressing eventual overlooked issues.13 Although it seems logical that this model would enhance CRC care, sparse data are available regarding its application for CRC patients.14,15 The multispecialty approach required to deliver best practices provides this framework, with particular needs for patients with locally advanced rectal cancer, anal cancer, and resectable stage IV colon cancer. Nevertheless, because MDC implementation could require significant adaptation by physicians and administrators, the benefits must be evaluated. One objective measure used in previous studies11 and proposed as a surrogate for integrated cancer care16 is the interval that elapses before treatment is initiated (ie, the TTT). This measure represents the timeliness of treatment, which is 1 of the 3 pillars of quality health care delivery proposed by the Institute of Medicine (now the Health and Medicine Division, National Academies of Science, Engineering, and Medicine, Washington, DC).16 In an effort to process improvements and more effective coordination of multidisciplinary care, our CRC program established a physical single-site MDC. In the present study, we have reviewed our early experience and evaluated the effect of CRC MDCs on the TTT. We hypothesized that the implementation of a MDC in the setting of a tertiary referral center would decrease the TTT for CRC patients.

Patients and Methods

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The Cleveland Clinic institutional review board approved the present study. Patients with CRC or squamous cell anal cancer who were evaluated at the MDC from January 2014 to October 2015 were retrospectively identified from the Cleveland Clinic Tumor Registry and a DataMart Registry, using specific MDC department codes for colorectal surgery (CORS), medical oncology (MedOnc), and/or radiation oncology (RadOnc). The patient medical records were reviewed for diagnosis and clinical stage. All rectal adenocarcinoma, anal squamous cell carcinoma (SCC), and stage IV colon adenocarcinoma cases were initially included. The exclusion criteria were as follows: patients evaluated for recurrent cancer, patients who had sought their first therapy elsewhere, patients seen at the MDC only after surgery (emergent surgery or unexpected intraoperative findings), patients with colorectal tumors other than adenocarcinoma; and those seen by 1 specialty only. To define our control group, cases were matched 1:2 with patients who had received a multimodal approach but were seen by each specialist outside the MDC, although during the same study period. The matching criteria were the number of specialties seen (either 2 or 3 among CORS, MedOnc, and RadOnc; always including CORS when 2 specialties only) and the diagnosis (rectal cancer, anal SCC, or colon cancer). Appointments with any department other than CORS, MedOnc, or RadOnc, including hepatobiliary surgery, gynecology, or genetic counseling, were considered as additional specialties and had their appointment dates noted. The need for a combined surgical plan or preoperative procedures was also noted. From the Cleveland Clinic colorectal cancer database and medical record review, the following information was obtained: patient demographic data, tumor- and treatment-related data, including age, gender, date of pathologic diagnosis, place of diagnosis

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(Cleveland Clinic or elsewhere), staging status at first appointment (complete, partially complete, or no staging; as described further below), staging examination dates, all appointment dates, first treatment modality, and its initiation date. First treatment was defined as 1 of the following: surgical resection, initiation of chemotherapy, and delivery of the first radiation dose. Creation of a diverting stoma for symptom control before the most definitive treatment was also considered as initiation of the treatment course, and these data were recorded, along with the data regarding surgery for tumor resection. The TTT was recorded using different points of the management encounter: (1) the interval from the pathologic diagnosis to first treatment (TTT from diagnosis); and (2) the interval from the first office consultation to the first treatment (TTT from first consultation). To define the status of clinical staging at the first appointment, the staging was considered complete for anal SCC if both pelvic magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (CT) had been performed; complete for colon adenocarcinoma if the most definitive chest (either radiography or CT) and abdomen/pelvis (either CT or MRI) imaging studies and serum carcinoembryonic antigen (CEA) measurement had been performed; and complete for rectal adenocarcinoma if the most definitive chest, abdomen, and pelvic (either MRI or endoluminal ultrasound) imaging and serum CEA had been performed. Staging was considered partially complete for patients missing any of the aforementioned imaging studies. Finally, staging was considered not performed for patients presenting without any imaging studies at all or CEA measurement only. Administrative data regarding the date of the patient’s or referring physician’s telephone call to request an appointment and notes regarding the eventual cancellation of earlier appointments were obtained. The primary endpoints were the TTT from diagnosis and TTT from the first consultation for the MDC group and the time from the first appointment to the last appointment for the control group (among the 3 core specialties). Categorical data are described as percentages, and the significance of differences between groups was tested using Fisher’s exact test or the c2 test, as appropriate. Continuous data are described as the mean  standard deviation and median and interquartile range. Differences between groups were tested using Student’s t test and the Wilcoxon rank sum test, as appropriate. P  .05 was considered statistically significant.

Results Patient Population Thirty-five MDC patients met the inclusion criteria, with a median age of 56 years (range, 43-84 years), and were equally distributed by gender. These included 25 patients with rectal adenocarcinoma, 6 with anal SCC, and 4 with stage IV colon adenocarcinoma. The clinical stage for rectal cancer was stage cI in 4, stage cII in 6, stage cIII in 11, and stage cIV in 4. For anal SCC, the clinical stage was stage cI in 1, stage cII in 4, and stage cIII in 1. The 35 MDC patients were matched with 70 controls who had received multispecialty care but were seen by each specialty on different days. Of the 35 patients, 6 (17%) received their diagnosis at our institution; the remaining 29 (82.9%) had their consultation at our MDC after receiving the diagnosis at a referring institution.

Vanessa N. Kozak et al In contrast, 41.4% of the control patients received their diagnosis at Cleveland Clinic Foundation. The groups were matched for the number of departments visited and diagnosis. The demographic data and tumor and treatment characteristics for both groups are listed in Table 1.

The mean TTT from the first appointment was 21.5 days for MDC patients, 7.8 days shorter than the 29.3 days for the control group (P ¼ .01; Table 2). When analyzing the data from patients who saw 2 versus 3 specialties separately, this decrease was even more pronounced for patients visiting 3 departments, at 9.3 days (21.3 days for the MDC patients vs. 30.6 days for the controls; P < .001; Table 3). For the control group, the mean interval from the first to last appointment was 14.3 days and did not significantly differ for patients visiting 2 versus 3 departments (11.9 vs. 15 days, respectively; P ¼ .28). The TTT from diagnosis did not differ between the 2 groups (43.3 days for the MDC patients vs. 42.7 days for the controls; P ¼ .90; Table 2). The TTT from diagnosis consisted of the sum of 3 intervals: (1) the interval from the pathologic diagnosis to the patient’s telephone call to schedule the appointment; (2) the interval from the telephone call to the scheduled appointment itself; and (3) the interval from the first appointment to the initiation of treatment. The initial interval from diagnosis to appointment scheduling was beyond the scope of our process, but it was longer for the MDC patients than for the controls (mean, 17 vs. 8.6 days, respectively; P ¼ .01; Table 2). The mean interval from the telephone call to schedule an appointment was not significantly shorter for the MDC patients (4.9 vs. 6.2 days for controls; P ¼ .35; Table 2). Table 1 Demographic Data, Tumor Characteristics, and Treatment Type

Variable

MDC Patients (n [ 35)

Controls (n [ 70)

P Value

Age (y)

59.6  12

59.4  10.6

.93

Female

17 (48.6)

26 (37.1)

Male

18 (51.4)

44 (62.9)

6 (17.1)

12 (17.1)

Gender

.30

Diagnosis

1.00

Colonic adenocarcinoma

4 (11.5)

8 (11.5)

Rectal adenocarcinoma

25 (71.4)

50 (71.4)

I

5 (14.3)

4 (5.7)

II

10 (28.6)

20 (28.6)

III

12 (34.2)

31 (44.3)

IV

8 (22.9)

15 (21.4)

Chemoradiation

20 (57.1)

48 (68.6)

Surgery

13 (37.1)

15 (21.4)

2 (5.8)

7 (10)

Clinical stage

.46

Type of first treatment

Chemotherapy only

Variable

MDC Group (n [ 35)

Control Group (n [ 70) P Value

Time from diagnosis to telephone call

Time to Treatment

Anal SCC

Table 2 Time to Treatment for Different Points in Management

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Data presented as mean  standard deviation or n (%). Abbreviations: MDC ¼ multidisciplinary clinic; SCC ¼ squamous cell carcinoma.

Mean  SD Median (IQR)

17  14.9 11 (7-23)

8.6  11.2

.01

4.5 (1-10.75)

<.001

Time from telephone call to consultation Mean  SD

4.9  7.4

6.2  4.6

.35

Median (IQR)

3 (2-4.5)

6 (3-8)

.02

TTT from first consultation Mean  SD

21.5  11.8

29.3  14.8

.01

Median (IQR)

19 (15-27)

27 (21-35)

<.001

TTT from diagnosis Mean  SD

43.3  23.2

42.7  20.2

.90

Median (IQR)

40 (30.5-48)

40.5 (30-48.75)

.97

Abbreviations: IQR ¼ interquartile range; MDC ¼ multidisciplinary clinic; SD ¼ standard deviation; TTT ¼ time to treatment.

Treatment Time by Type and Number of Specialties In the MDC group, 26 of 35 patients were seen by 3 specialties (CORS, MedOnc, and RadOnc). For the remaining 9 patients, 8 visited CORS and MedOnc and were deemed not to be candidates for radiation therapy (5 with stage IV and 3 with stage I rectal cancer), and their RadOnc appointment was cancelled. One patient was seen by CORS and RadOnc and was recommended to undergo short-course radiotherapy (stage T1N1M0 rectal cancer); thus, his MedOnc appointment was cancelled. No difference was found in the proportion of patients requiring extra preoperative visits, procedures, or combined surgical plans between the 2 groups (17.1% for MDC vs. 7.1% for control patients; P ¼ .17). An analysis comparing the mean TTT from the first consultation according to the type of first treatment found no differences in waiting time for the different modalities within the MDC group (P ¼ .99, 1-way analysis of variance; Figure 1). When comparing the MDC and control patients, the mean TTT for patients requiring neoadjuvant chemoradiation was 8.7 days shorter in the MDCs group (21.5 vs. 30.2 days; P ¼ .02). Some patients experienced treatment delays for various medical or personal reasons beyond the control of the medical system. For example, a patient might have a significant life event scheduled such as a vacation or family wedding, which, for the patient, took precedence over the initiation of treatment. Similarly, outliers will inevitably be present in the TTT data, which skews the mean values. Therefore, the data were analyzed to determine the percentage of patients who had received their first treatment within 3 weeks. Although 20 of 35 MDC patients underwent their first treatment beginning within 3 weeks from the first consultation, only 21 of the 70 controls had treatment initiation within the same period (57.1% vs. 30%, respectively; P ¼ .01).

Time to Complete Clinical Staging Because the complete evaluation for treatment decisions relies on clinical staging, we evaluated the percentage of patients who

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MDCs for CRC Care Reduces Treatment Time Table 3 Time to Treatment According to Number of Specialties Visited 3 Specialties Variable

MDC (n [ 26)

2 Specialties

Control (n [ 52)

P Value

MDC (n [ 9)

Control (n [ 18)

P Value

TTT from diagnosis Mean  SD

44  24

43.6  20.4

.94

41.6  22.1

Median (IQR)

39 (30.5-45.5)

40.5 (30.75-49)

.83

48 (31-48)

40.1  20

.87

38.5 (20-46.75)

.62

Time from diagnosis to telephone call Mean  SD Median (IQR)

16.9  13.6 11 (9-21.5)

8.8  11.9 4.5 (1-11)

.01

17.4  19.1

<.001

8 (5-24)

7.9  9 4.5 (2-10)

.19 .12

Time from telephone call to consultation Mean  SD

5.6  3.9

.91

2.2  1.2

4 (2-7)

5.5 (2-7.25)

.41

2 (1-3)

Mean  SD

21.3  11.3

30.6  15.6

<.001

22  13.8

Median (IQR)

18 (17-26.75)

28 (22-36)

<.001

20 (10-27)

Median (IQR)

5.8  8.4

7.8  6.1 7 (4-8)

<.001 <.001

TTT from first consultation 25.5  11.5 26 (15.25-34.25)

.52 .43

Abbreviations: IQR ¼ interquartile range; MDC ¼ multidisciplinary clinic; SD ¼ standard deviation; TTT ¼ time to treatment.

presented to the clinic with complete clinical staging already performed. A low proportion of patients in both groups presented to their first appointment with complete clinical staging data available, and it did not significantly differ between the 2 groups (22.9% MDC vs. 12.9% control patients; P ¼ .26). For patients with no clinical staging procedures performed, the mean interval to complete staging was 11 and 11.4 days for the MDC patients and controls, respectively (P ¼ .90). For patients with partial staging completed, the mean interval to complete staging was 6 and 9.1 days for the MDC and control groups, respectively (P ¼ .30). Five MDC patients who had had no staging (n ¼ 1) or partially complete staging (n ¼ 4) were able to complete the needed imaging studies on the same day of their appointments. Using 15 days as an arbitrary point to define a delay in completing staging, we evaluated the

differences between the MDC and control patients. Although only 11.1% of the MDC patients required  15 days to complete clinical staging, 28.3% of the controls required > 15 days.

Prolonged TTT and Underlying Reasons The patients with prolonged intervals to starting treatment, arbitrarily defined as > 30 days from the first consultation, were reviewed. Patients seen at the MDC were less likely to have prolonged intervals compared with the controls (n ¼ 8 [22.9%] vs. n ¼ 30 [42.9%], respectively; P ¼ .05). The medical records of the patients with intervals > 30 days were scrutinized. In 7 of the 8 delayed cases from the MDC group, reasons had been noted in the medical records providing an explanation. Two patients experienced a delay of 18 and 28 days because they were waiting to undergo liver

Figure 1 Time to Treatment According to First Treatment Modality. Error Bars Represent Minimum and Maximum (Max) Values

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Abbreviation: MDC ¼ multidisciplinary clinic.

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Vanessa N. Kozak et al and rectal MRI, respectively. Two patients experienced a delay of 20 and 21 days because they were waiting for a consultation with cardiology and thoracic surgery, respectively. Three patients had prolonged intervals because of patient choice. Of the 30 controls with a prolonged TTT interval, 12 waited 15 to 41 days to obtain appropriate clinical imaging studies for staging; 9 experienced an interval  2 weeks (range, 14-30 days) from the first appointment to the last specialty appointment needed (among the 3 core specialties only); 2 experienced a treatment delay because of financial- or insurance-related issues; 1 had to wait 17 days to undergo a procedure by pulmonology; and 1 because of appointment cancellation per patient choice. Explanations or extenuating circumstances were not identified for the remaining 5 controls with a treatment delay.

Discussion The present study has demonstrated that within our health care system, CRC patients evaluated in a specialized multidisciplinary cancer clinic receive streamlined care resulting in a shorter TTT, with a reduction of > 7 days. This efficiency seemed to be related mainly to the ability to schedule the needed specialty appointment in 1 day, rather than as separate noncoordinated appointments. This benefit was seen primarily for patients requiring neoadjuvant chemoradiation before surgery. As might be expected, the MDC structure resulted in a more drastic reduction in the TTT for patients requiring treatment by 3 specialties compared with those requiring only 2 specialties. Furthermore, the administrative support of MDC scheduling provided a more efficient process for coordinating additional tests to complete the clinical staging evaluation. In an era of cost containment and emphasis on value of care, it is increasingly important to address systematic methods of improving the patient care processes and the patient experience. Using the analogy of an efficient assembly line, the workflow in health care should ideally move from 1 step to the next, ensuring good communication and seamless interaction between the moving parts.17 One of the challenges to coordinated patient flow is the need for complex cases to be managed by multiple specialties, often at different geographic locations or even separate practice groups or institutions. The creation of needs-centered or patientcentered services represented by MDCs is 1 strategy to improve patient care. MDCs are commonly used for patients with liver,7,12 pancreatic,10 prostate,5 gynecologic,9 lung,9 and rectal14,15 cancer. Implementation of an MDC approach has been shown to increase patient satisfaction,5,7-9 improve adherence to guidelines,9,10 increase clinical trial accrual,6,9,10 and decrease the TTT for patients with lung,9 gynecologic,9 and pancreatic11 cancer. Regarding the TTT for CRC patients, the data are sparse. One retrospective cohort study reported that although more patients received neoadjuvant chemoradiation, no difference was found in the interval from diagnosis to the initiation of treatment for rectal cancer patients.14 This is consistent with our data; however, our data also provide both a broader and more detailed analysis, including colon, rectal, and anal cancer and the interval from the initial consultation to the first treatment. This is an important distinction, because patients are often referred for treatment after

diagnosis at another institution. Thus, multiple factors outside the system and beyond our control can influence the time from the pathologic diagnosis to the initial consultation. The TTT from the initial consultation accurately measures the factors under institutional control. The association between therapeutic delay and oncologic outcomes for CRC patients remains debated.18,19 Therapeutic delay was reported to be a negative prognostic factor for long-term survival in rectal cancer patients when treatment was initiated > 60 days after the diagnosis.19 A prolonged delay could contribute to perforation or result in worse outcomes.20 A systematic review of colorectal cancer did not identify an association between the TTT and prognosis; however, that review did not consider colon and rectal cancers as separate entities.18 The association of delayed treatment and worse outcomes has been demonstrated for other symptomatic tumors.21 Admittedly, decreasing the TTT by 7 days is not likely to affect the overall oncologic outcomes in colorectal or anal cancer. However, it is rational that decreasing the time to starting treatment will improve patient satisfaction.16,22 For most people, receiving a cancer diagnosis is emotionally and psychologically devastating. Fear of the unknown is a common theme, and patients often “just want the cancer out as soon as possible.” Each day of waiting results in more anxiety and fear, which can lead to dysfunctional decisionmaking16 and jeopardize the physicianepatient relationship. Even if moving forward 1 week does not affect the clinical outcome, the reduction in waiting time could generate value from a patient perspective, simply by reducing distress.16 Furthermore, from a process and value standpoint, decreasing the TTT will also increase patient access, allowing more patients to be treated, and improved efficiencies can lower overall costs.13 We acknowledge the limitations in our study. First, the study cohort was relatively small; however, this was done to narrowly define and match patients who would benefit from an MDC approach. In an effort to give more patients an opportunity for MDC care, we are fairly broad in our criteria for scheduling. However, this results in patients at the MDC who do not necessarily need the care of multiple specialties. Thus, many MDC patients were excluded from the present narrowly defined study, which required  2 specialties. Despite the small numbers, we still found clear differences between the MDC and control populations, and we suspect these findings will be consistently reproduced as we continue to refer our CRC patients to the MDC. Next, the present study did not provide long-term follow-up data; thus, we could not comment on the outcome of the decreased interval. However, as discussed, this was not the point of the present study and multiple other benefits result from expediting care. Future, larger studies could address this issue. Finally, although we have not performed formal patient satisfaction surveys, the anecdotal feedback regarding the patient experience at the MDC has been overwhelmingly positive.

Conclusion Adoption of a single-location MDC decreased the interval from the initial consultation to the initiation of treatment at our institution. We have continued to study patient flow and process issues to improve our own efficiency and enhance patient-centered care.

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MDCs for CRC Care Reduces Treatment Time Clinical Practice Points  Increasing evidence has shown that the multidisciplinary







   

approach results in more appropriate management of several complex diseases. Among the possible working models to deliver multimodal care, MDCs have shown some extra benefits compared with multidisciplinary meetings alone. Increased patient satisfaction, greater accuracy of care, more accrual to clinical trials, and decreased TTT are some of the described benefits; however, data on colorectal cancer remain scarce. The present study has demonstrated the positive effect of the implementation of a multidisciplinary single-site cancer center on the TTT for patients with colorectal and anal cancer. Patients seen in the MDC initiated treatment a mean of 7.8 days more quickly than did the control non-MDC patients. Evaluation of the TTT according to the number of specialties involved in management and the type of first treatment is new. The present study identified a subset of patients who will benefit most from the MDC structure. Optimizing systematic processes is important both for the patient, who will receive the best of care in a timely fashion, and for the health system, because more efficient patient flow will yield increased access.

Acknowledgments The authors acknowledge Emily Monteleone for helping with the collection of administrative data.

Disclosure The authors have stated that they have no conflicts of interest.

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