Analysis of time taken to discuss new patients with head and neck cancer in multidisciplinary team meetings

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  • British Journal of Oral and Maxillofacial Surgery 52 (2014) 128133

    Available online at www.sciencedirect.com

    Analysis of time taken to discuss new pand neck cancer in multidisciplinary tB.J. Mul s a,c,a Oral and M ion Trub University oc Evidence-Ba rsity, Ud Head & Nec ity of LAccepted 7 OAvailable onl

    Abstract

    Multidiscipldisease and evaluate neweach case, thbenign tumorecorded themean of 119discussions patients (p =with early stearly stage dleave more tpatients with 2013 The

    Keywords: M

    Introducti

    Head and ntypes in a serious coeincidence ohead and nNeck Onco

    CorresponL18 1JQ, Uni

    E-mail a

    0266-4356/$ http://dx.doi.oinary team (MDT) meetings have an important role in the management of head and neck cancer. Increasing incidence of thea drive towards centralised meetings on large numbers of patients mean that effective discussions are pertinent. We aimed to

    cases within a single high volume head and neck cancer MDT and to explore the relation between the time taken to discusse number of discussants, and type of case. A total of 105 patients with a new diagnosis of head and neck malignancy or complexur were discussed at 10 head and neck cancer MDT meetings. A single observer timed each discussion using a stopwatch, and

    number of discussants and the diagnosis and characteristics of each patient. Timings ranged from 15 to 480 s (8 min) with a s (2 min), and the duration of discussion correlated closely with the number of discussants (rs = 0.63, p < 0.001). The longest

    concerned patients with advanced T stage (p = 0.006) and advanced N stage (p = 0.009) disease, the elderly (p = 0.02) and male 0.05). Tumour site and histological findings were not significant factors in the duration of discussion. Most discussions on patientsage tumours were short (T1: 58% less than 60 s, mean 90) and fewer people contributed. Many patients, particularly those withisease, require little discussion, and their treatment might reasonably be planned according to an agreed protocol, which wouldime and resources for those that require greater multidisciplinary input. Further studies may highlight extended discussions on

    head and neck cancer, which may prompt a review of protocols and current evidence. British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

    ultidisciplinary team; MDT; Head and neck cancer; Discussion length

    on

    eck cancer covers a wide spectrum of histologicalcomplex anatomical site, and patients often havexisting conditions. Data suggest that the overallf the disease in the UK is rising. The national

    eck cancer audit by DAHNOs (Data for Head andlogists) estimated that between 2010 and 2011 the

    ding author at: 17 Norbury Avenue, Mossley Hill, Liverpoolted Kingdom.ddress: Barrymullan@doctors.org.uk (B.J. Mullan).

    incidence had risen by over 600 cases (from 6747 to 7354,respectively) in England and Wales and included neoplasmsarising from the oral cavity, larynx, oropharynx, hypophar-ynx, nasopharynx, and major salivary glands.1,2 Allied withthis there is a continued trend to manage cancer cases in asmaller number of high volume centres,1,2 which highlightsthe need for efficient and meaningful discussions.

    Diagnosis and treatment of these patients require inputfrom multiple medical professionals and a further spectrumof allied health professionals. Management involves dealingwith the effects of the disease itself as well as the disablingeffects of treatment, and to do this a multidisciplinary team(MDT) approach has become widely adopted.3 It has been

    see front matter 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.rg/10.1016/j.bjoms.2013.10.001lan a,b,, J.S. Brown a, D. Lowe a,c, S.N. Rogeraxillofacial Surgery Department, Aintree University Hospital NHS Foundatf Liverpool, United Kingdomsed Practice Research Centre (EPRC), Faculty of Health, Edge Hill Univek Surgery, Department of Molecular & Clinical Cancer Medicine, Universctober 2013ine 23 November 2013atients with headeam meetings

    R.J. Shaw a,d

    st, Longmoor Lane, Liverpool L9 7AL, United Kingdom

    nited Kingdomiverpool, United Kingdom

  • B.J. Mullan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 128133 129

    recommended that all patients with head and neck cancer areseen by a MDT irrespective of type or stage,13 and thereis evidence that this increases the accuracy of cancer stag-ing and imsurvival ofthose who cantly bettat diagnosithe analysiare improvcoordinatedcomes, andresearch.7

    Followimendationsspecialist cMDT in a workload.8I evidenceand it is dbetween ceII data, thelines whichargue that dadvanced cstage diseasimilar out

    This stuserves a poreferrals arhigh incidecases/year,(comparedweekly MDor malignawith recurrwith the hiare going tbase and thfor 30 min othat influenof discussa

    Method

    We prospehead and nHospital ovings betwemeetings bpatients wicomplex becussions onor base of excluded.

    A single observer used a stopwatch to time the discussionsin seconds from when a case was announced until the nextwas announced. The duration of any discussion not relevant

    e casessed ose a m

    subseqssionse numwas r

    he cooase, ar with

    atiente meetearm

    betwescussins bession ruskalthe nulso grde a be sing

    attendhose w

    discu

    lts

    mean

    75 (71benignnanci

    y (n =3, 22%e me0180

    of 20le invodiscus0.63,

    fewe 3 (n =80 s w

    gnificaeen thnts (per of he m

    of mere wuratio

    een otproves outcomes.4,5 Friedland et al.6 compared patients who had been treated by an MDT withhad not, and showed that survival was signifi-

    er in those treated by an MDT when stage, ages, and year of diagnosis were controlled for ins. The perceived benefits of treatment by an MDTed communication between health professionals,

    and continuous patient care, better clinical out- better opportunities for education, audit, and

    ng the Improving Outcomes Guidance recom- of 2004 there has been a move towards largerentres. However, big is not always best, and anlarge centre might not cope with the increasedThere is also concern about the lack of level

    to support the benefits of an MDT approach,6ifficult to make valid comparisons of outcomesntres.3 Nevertheless, in the absence of level I orse studies form the basis of the clinical guide-

    inform current best practice.6 Some clinicianselays and expense may justify the referral of onlyases of malignancy to the MDT, and that earlyse that is treated outside an MDT would achievecomes.9

    dy is based on a large MDT in a regional unit thatpulation of over 2.8 million, and around 900 newe discussed each year. The region has a particularlynce of squamous cell carcinoma with 450 new

    which reflects an incidence of 16/100,000/year with the UK mean of 12/100,000/year).10 TheT lasts an hour, during which new complex benign

    nt neoplasms followed by PET scans, and patientsence and ongoing tumours are discussed. It endsstopathological staging of primary tumours thato be resected. Patients with cancers of the skullyroid are discussed separately; each is schedulednce a fortnight. Our aim was to explore the factorsce the duration of the discussion and the numbernts for new cases.

    ctively studied discussions on new cases at 10eck MDT meetings held at Aintree Universityer 2 periods in 2011. Five were consecutive meet-en January and February, and 5 were consecutiveetween August and September. Discussions on allth a new diagnosis of head and neck cancer ornign tumour in these periods were included. Dis-

    PET scans and patients with disease of the thyroidthe skull, recurrence, or ongoing tumours, were

    to thdiscubecauor a

    discuTh

    case

    ing tdatabcance

    the pof th

    Spationof diciatiodiscuor Kwith was a

    proviTh

    who and tin the

    Resu

    The and plex maligcavit(n = 2

    Th90 (6cases

    peopThe (rs = whenwere

    and 1no sibetwcussa

    numb4.3. Tgroup

    Thand dbetw was noted and the time deducted. If a case wasn more than one occasion during the same meetingember of the team had not been present initiallyuent case had similarities, the total sum of the

    was recorded.ber of people who contributed verbally to each

    ecorded (including the chair). During the meet-rdinator filled out the Somerset Cancer Register

    UK web-based clinical data collection register for a designated head and neck section. From this,

    s characteristics, type of disease, and the outcomeing were extracted for the purposes of the study.ans correlation was used to quantify the associ-en numerical or ordinal characteristics (duration

    on, age, and number discussing the case). Asso-tween the patients characteristics and duration ofin seconds were tested using the MannWhitneyWallis test as appropriate, as were associationsmber discussing the case. Duration of discussionouped (up to 60 s, 61120, and more than 120 s) toetter descriptive presentation of results in Table 1.le observer recorded the total number of peopleed the meeting including those who arrived lateho departed before the end. The position of thosession and their roles were not recorded.

    (SD) age of the 105 patients was 62 (16) years,%) were male. A total of 15 (14%) had com-

    or non-malignant disease, and 90 (86%) had newes. Tumour sites were larynx (n = 32, 30%), oral

    21, 20%), oropharynx (n = 26, 25%), and other). In 3 cases it was not known.

    dian (IQR) time taken to discuss the cases was) s (range 15480), with a total time over all the

    8 min (mean 119 s). The median (IQR) number oflved in the discussion was 4 (35) (range 110).

    sions were longer the more people that joined inp < 0.001, Fig. 1). The median duration was 30 sr than 3 people took part (n = 8), 90 s when there

    39) or 4 (n = 22), 165 s when there were 5 (n = 20),hen there were more than 5 (n = 16). There wasnt difference in the times taken to discuss casese 2 periods (p = 0.48) or in the number of dis-

    = 0.08). In the first group of meetings the meandiscussants was 3.8; in the second group it wasean duration of discussion was 125 s in the firsteetings and 113 s in the second.as no significant correlation between age in yearsn of discussion (rs = 0.07, p = 0.50). Relationsher factors and duration of discussion are shown

  • 130 B.J. Mullan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 128133

    Table 1Clinical factors in relation to the time (s) taken by the multidisciplinary team (MDT) to discuss new cases.

    No. of patients Up to 60 s 61120 s More than 120 s Mean no. of seconds p-Value

    Total ) Sex

    Male ) Female )

    Age group (y

  • B.J. Mullan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 128133 131

    Table 2Clinical factors in relation to the number of people discussing multidisciplinary cases.

    No. of patients Number in discussion Mean p-Value

    5

    Total 20Sex

    Male 16Female 4

    Age group (y

  • 132 B.J. Mullan et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 128133

    Fig. 1. Assocteam (MDT) Spearman cor

    In the involved thwould be bof the persthe same pwhether morospect it wof recruitm(NIHR) po

    All case4 people, aThe chair, the radioloings shouldstaging) bemanagemelimitationsstaging waipated in throle.

    The aimlevel of spinput is avacer networopportunitiimproved. for a multia certain mbest standameeting abonly brieflyconstrainedFriedland eprescriptioease in paticoncentrateous coexist

    predicate multimodal treatment. For those with early stagedisease who are relatively fit and need a single method oftreatment, discussions may be less likely to improve their

    ur resone pe team

    tumo be ss ini, but ing.e ackent of

    centrres thaowledorld

    able, te alsoneficier reseose wiscuse MD

    trials ole of.

    ict of

    e are n

    cs stat

    thical iation between the number of people in the multidisciplinarydiscussion and duration of discussion for 105 new cases.relation rs = 0.63, p < 0.001.

    opinion of the observer the discussions oftene same small group of MDT members. In future iteneficial to record the specialty, grade, and nameon who put the case forward to find out whethereople participate in most of the discussions, andre discussion occurs when they are absent. In ret-

    ould also have been of interest to record discussionent to the National Institute for Health Researchrtfolio trials.s discussed in under 60 s involved no more thannd in 47 of the 105 cases it was no more than 3.the presenting clinician (usually a surgeon), andgist spoke in all cases. As most radiological find-

    have been reported formally (including full TNMfore the meeting, discussion about the patientsnt could be questioned. However, our study had

    because in a large number of cases the full TNMs not recorded. The number of people who partic-e discussion was recorded but not their specific

    of an MDT is to ensure that a uniform and high

    care.

    Oonly by thmarycouldstudyMDTmeet

    Wagemthat aensu

    acknthe wavail(sombe befurthas thout dof thneckthe rMDT

    Con

    Ther

    Ethi

    No eecialist care with appropriate multidisciplinaryilable to all patients. With the introduction of can-ks in the UK following the Calman Hine report,3es for audit and clinical trials have also beenThe complexity of cancer treatment and the needdisciplinary approach require that clinicians haveinimum caseload and competence to ensure therds of care.11 However, these data show that in aout a large number of patients, many are discussed, and with an increasing incidence of disease and

    finances, some rationalisation may be needed.t al.6 showed improved survival and increased

    n of multimodal treatment for higher stage dis-ents discussed by a MDT. It might seem logical to

    resources on patients with complex needs, seri-ing conditions, or locally advanced disease, which

    Reference

    1. National Hand WaleDAHNO shttp://www

    2. National Hand WaleDAHNO shttp://www

    3. Calman Kframeworkmedical of1995. AvResources

    4. Birchall MHead and Npatients wJ Cancer 2ults show that in the cases of 2 female patients,erson spoke, and no treatment was recommended

    . Both had presented with neck lumps but pri-urs had been identified elsewhere. Although theyeen as outliers they highlight cases that fit thistial criterion and criteria of the head and neckrealistically may not need to be presented at a

    nowledge that the MDT has a role in the man- head and neck cancer and we support the viewalised meeting of the team allows discussion andt decision-making is fully rationalised. We also

    ge that teams in other centres in the UK and acrossdiffer in their organisation and in the resourceshe number of meetings, and in those who attend

    include the patients and their family).2,3,8 It mayal to look into these aspects and also to continuearch into the meetings to identify subgroups suchith early disease, that could be managed with-sion. There is also a need to explore the roleT in NIHR portfolio recruitment for head andand cohort studies, and for further research into

    allied health professionals in the head and neck

    interest

    o conflicts of interest.

    ement/conrmation of patient permission

    approval needed.

    s

    ead and Neck Cancer Audit. Key findings for Englands for the audit period October 2009 to November 2010.ixth annual report. NHS Information Centre. Available from.ic.nhs.uk/cancerauditsead and Neck Cancer Audit. Key findings for England

    s for the audit period October 2010 to November 2011.eventh annual report. NHS Information Centre. Available from.ic.nhs.uk/canceraudits, Hine D, Expert Advisory Group on Cancer. A policy

    for commissioning cancer services: a report to the chiefcers of England and Wales. London: Department of Health;ailable from http://www.dhcarenetworks.org.uk/ library/

    /ICN/Policy documents/Calman Hine.pdf, Bailey D, King P, South West Cancer Intelligence Serviceeck Tumour Panel. Effect of process standards on survival of

    ith head and neck cancer in the south and west of England. Br004;91:147781.

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    5. Stephens MR, Lewis WG, Brewster AE, et al. Multidisciplinary teammanagement is associated with improved outcomes after surgery foresophageal cancer. Dis Esophagus 2006;19:16471.

    6. Friedland PL, Bozic B, Dewar J, et al. Impact of multidisciplinaryteam management in head and neck cancer patients. Br J Cancer2011;104:12468.

    7. Westin T, Stalfors J. Tumour boards/multidisciplinary head and neckcancer meetings: are they of value to patients, treating staff or a politicaladditional drain on healthcare resources? Curr Opin Otolaryngol HeadNeck Surg 2008;16:1037.

    8. Bradley PJ, Zutshi B, Nutting CM. An audit of clinical resources availablefor the care of head and neck cancer patients in England. Clin Oncol (RColl Radiol) 2005;17:6049.

    9. Taylor C, Ramirez AJ, Cancer Research UK Promoting Early Pre-sentation Group. Multidisciplinary team members views about MDTworking: results from a survey commissioned by the National CancerAction Team. London: National Health Service; 2009. Available fromhttp://www.ncin.org.uk/view?rid=137

    10. Murdoch D. Standard, and novel cytotoxic and molecular-targeted,therapies for HNSCC: an evidence-based review. Curr Opin Oncol2007;19:21621.

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    Analysis of time taken to discuss new patients with head and neck cancer in multidisciplinary team meetingsIntroductionMethodResultsDiscussionConflict of interestEthics statement/confirmation of patient permissionReferences

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