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The Breast 17 (2008) 335e340www.elsevier.com/locate/breast

Original article

Australian breast cancer specialists’ involvement inmultidisciplinary treatment planning meetings

James D. Harrison a,*, Ellis T. Choy b, Andrew Spillane b, Phyllis Butow a,c,Jane M. Young a, Alison Evans d

a Surgical Outcomes Research Centre (SOuRCe), Sydney South West Area Health Service, University of Sydney, Sydney, NSW, Australiab Sydney Breast Cancer Institute, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia

c School of Psychology, University of Sydney, Sydney, NSW, Australiad National Breast Cancer Centre, Camperdown, NSW, Australia

Received 12 April 2007; received in revised form 24 September 2007; accepted 29 February 2008

Abstract

Australian breast cancer specialists’ involvement in multidisciplinary team (MDT) treatment planning meetings was ascertained in a crosssectional survey. The format of MDT meetings was also investigated. Medical specialists were regular attendees (�78%) compared to alliedhealth staff and psychologists (�28%). Clinicians based in a major city (AOR 1.90; 95%CI: 1.01e3.58) and who treated �50 new casesa year (AOR 7.34; 95%CI: 3.38e15.96) were more likely to attend. Over 69% reported that the proportion of time devoted to case discussionswas �75%. Topics always discussed were pathology, extent of disease, surgery performed and a treatment plan (�83%). The majority of re-spondents stated that MDT meetings were effective and improved referrals. Suggested improvements included that all key personnel attend,meetings are structured and that the views of all be heard. Work is needed to ensure MDT’s function and co-operate as intended in treatmentplanning meetings.� 2008 Elsevier Ltd. All rights reserved.

Keywords: Breast cancer; Multidisciplinary care; Patient care team; Patient care management; Multidisciplinary team meetings

Introduction

It has been over a decade since multidisciplinary care(MDC) was recommended in Australia as a means of achievingbest practice through different specialists working as teams co-operatively with each other and their patients to diagnose, treatand manage breast cancer.1 Nationally and internationally clin-ical practice guidelines2e4 endorse multidisciplinary care asthe preferred approach to managing breast cancer. A recent re-port5 found that surgery, chemotherapy and hormonal therapyare the most common treatment options for women thus requir-ing input from a variety of breast cancer specialists duringtreatment planning. Care provided by a multidisciplinaryteam (MDT) is thought to offer patients the most appropriate

* Corresponding author. Tel.: þ61 2 9515 3203; fax: þ61 2 9515 3222.

E-mail address: james.harrison@email.cs.nsw.gov.au (J.D. Harrison).

0960-9776/$ - see front matter � 2008 Elsevier Ltd. All rights reserved.

doi:10.1016/j.breast.2008.03.001

evidence-based care as management plans are based on a broadrange of expert knowledge.6,7 Improvements in communicationand decision-making among health professionals in co-ordination of care for their patients are other potential benefits.However, the outcomes of MDT working have not been rigor-ously evaluated and evidence from published empirical studiesand reports on any benefit is limited.6,8

Five principles have been developed by the AustralianNational Breast Cancer Centre (NBCC) for MDC, namelya team approach, good communication, access to the full rangeof treatments available, care in accordance with nationallyagreed standards and the provision to involve patients in thedecision-making process.9,10 Whilst these principles allowMDC to be conceptualised there is currently no standarddefinition of an optimal model to achieve this. This is largelydue to Australia’s special geographical circumstances and itsmix of publiceprivate health care.

336 J.D. Harrison et al. / The Breast 17 (2008) 335e340

A National Multidisciplinary Care Demonstration Project[9] that involved three collaborations each comprising a mixof public and private facilities, from various regions across Aus-tralia, highlighted a range of strategies that could potentiallyimprove MDC. A common strategy employed by all collabora-tions was the formation of regular MDT planning meetings, orcase conferencing, dedicated to treatment planning. Of allendeavours this approach was found to be sustainable.11 MDTplanning meetings are now a regular feature of clinical practicewhereby a core team of medical specialists, with allied and psy-chosocial health staff where possible, discuss each patient’streatment options and decide on a treatment plan.7 To compen-sate for the range of settings and geographical locations withinAustralia video and telephone conference methods are usedwhen face to face meetings are not physically or practicallypossible.

Whilst MDT planning meetings are endorsed in policyguidelines,2e4 at present there is no information about thelevel of involvement of Australian breast cancer specialistsin these meetings. Therefore this national study was conductedto ascertain breast cancer specialists’ involvement, the formatof meetings, topics discussed, views on meeting’s effective-ness and suggested improvements to their running.

Methods

Development of survey

A survey was developed on the basis of a previous pilot andcurrent literature.12 The survey asked respondents to state ifthey attended an MDT planning meeting, and if so, which clin-ical, allied and administrative health staff regularly attended,the frequency of each meeting and the proportion of time de-voted to case discussions of breast cancer patients. The formatof case discussions was then explored in greater detail. Healthprofessionals were then asked to rate the effectiveness of theMDT meeting in optimising treatment recommendations as ei-ther ‘very effective’, ‘effective’ or ‘not very effective’ and toprovide further comments as required. Participants were alsoasked to indicate a response ranging from ‘agree completely’to ‘disagree completely’ to the statement ‘multidisciplinarymeetings have improved the care of breast cancer patients’.An open-ended question was included to allow respondentsto state how they believed the MDT meeting could be im-proved. Personal and professional characteristics were also eli-cited (gender, age, clinical role, year qualified, location ofclinical activity (private, public, cancer centre, universityclinic), geographical location, number of newly diagnosedbreast cancer patients per annum, proportion of patient basethat are breast cancer patients and amount of time devotedto direct patient care in breast cancer management).

Health professional recruitment

The views of all oncology specialities who commonly par-ticipate in MDTs were thought to be relevant. Health profes-sionals were identified through the databases of Australasian

or Australian peak organisations that represent the clinicalspecialists of interest. Breast surgeons were identified throughthe Section of Breast Surgery at the Royal Australasian Collegeof Surgeons, radiation and medical oncologists with a registeredinterest in breast cancer from the Trans-Tasman Radiation On-cology Group and the Medical Oncology Group of Australia.Breast cancer nurses were recruited from the Cancer NursesSociety of Australia. Clinicians were considered ineligible ifthey were not practising medicine, on extended leave ofmore than six weeks or no longer resident in Australasia.

Procedure

Ethical approval for the study was granted by the Universityof Sydney and Sydney South West Area Health Service(RPAH Zone). Permission and written endorsement of the surveywas obtained from each clinical sub-specialities representativebody and the National Breast Cancer Centre. The Breast CancerNetwork Australia (Australia’s National Breast Cancer consumeradvocacy group) was also asked for endorsement. Clinicianswere then mailed a study package containing a letter of invita-tion, an information sheet, a study survey and a reply-paidenvelope. If contact details were not provided to the researchteam these packages were disseminated by the representativebody. Non-responders were contacted 4 and 8 weeks later witha reminder letter and additional copy of the study survey.13

Statistical analysis

Statistical analysis was performed blind to participants’group status (surgeon, medical or radiation oncologist orbreast cancer nurse). Descriptive statistics were used todescribe the sample and their views. t-Tests and chi squareswere used to explore univariate associations between allpersonal and professional variables, and actual attendance atan MDT meeting. Independent predictors for MDT meetingattendance were assessed using logistic regression modelling.Potential predictors included in the model were those exhibit-ing p� 0.25 in univariate analysis14 and these were then suc-cessively removed using a backwards, stepwise approach untilall remaining predictors were significant ( p< 0.05). Analysiswas carried out using SPSS15 and SAS.16

Results

Response rate

Response rates to the mailed survey were 74% (142/192) forbreast surgeons, 85% (56/66) for specialist breast cancer nurses,74% (31/42) for radiation and 56% (65/117) for medical oncol-ogists. Characteristics of the sample are shown in Table 1.

Attendance at the MDT meeting

The majority of breast health professionals’ attended anMDT meeting for the management of breast cancer patients(surgeons 110 (78%), radiation oncologists 27 (87%), medical

Table 1

Clinicians professional characteristics by groupa

Surgeon

(N¼ 142)

Breast

nurses

(N¼ 56)

Radiation

oncologists

(N¼ 31)

Medical

oncologists

(N¼ 65)

SexMale 129 (91) 0 22 (71) 43 (66)

Female 12 (9) 55 (98) 9 (29) 19 (29)

Year qualified<5 0 20 (36) 1 (3) 2 (3)

5e10 21 (15) 17 (30) 2 (7) 19 (29)

10e20 46 (32) 11 (20) 20 (65) 24 (37)

>20 71 (50) 3 (5) 7 (23) 17 (26)

Practice settingb

Public hospital 125 (88) 43 (77) 23 (74) 40 (62)

Private practice 107 (75) 12 (21) 19 (61) 36 (55)

Cancer centre 10 (7) 12 (21) 16 (52) 18 (28)

University clinic 8 (6) 2 (4) 6 (19) 5 (8)

Other 2 (1) 14 (25) 2 (7) 0

Location

Major city/metropolitan 76 (54) 30 (54) 29 (94) 55 (85)

Regional 46 (32) 13 (23) 1 (3) 5 (8)

Rural 17 (12) 13 (13) 0 2 (3)

Cases per annum

0 1 (1) 1 (2) 1 (3) 1 (2)

1e5 12 (9) 4 (7) 1 (3) 4 (6)

6e20 39 (28) 10 (18) 3 (10) 10 (15)

21e50 25 (18) 6 (11) 3 (10) 19 (29)

51e150 51 (36) 20 (36) 19 (61) 21 (32)

>150 13 (9) 14 (25) 4 (13) 4 (6)

Patient base breast cancer

<25% 79 (56) 11 (20) 10 (32) 20 (31)

26e50% 32 (23) 8 (14) 13 (42) 28 (43)

51e75% 14 (10) 5 (9) 2 (7) 8 (12)

>75% 16 (11) 30 (54) 6 (20) 5 (8)

Time devoted to breast cancer patients�20 h a week 89 (63) 22 (40) 21 (68) 37 (57)

>20 h a week 52 (37) 33 (59) 10 (32) 24 (37)

a Where data are missing values do not add to 100%.b N¼ 135 for each setting.

Table 2

Independent predictors of attending the multidisciplinary treatment planning

meeting

Univariate association,

n/N (%)

Multivariate analysis

AOR (95%CI)

Practice in a major cityYes 160/188 (85) 1.90 (1.01e3.58)

No 63/96 (66) 1.00

Number of new breast cancer patients treated per year> 50 136/145 (94) 7.34 (3.38e15.96)

< 50 88/139 (63) 1.00

337J.D. Harrison et al. / The Breast 17 (2008) 335e340

oncologists 54 (83%) and nurses 38 (68%)). There was no sig-nificant difference between groups in terms of their attendance(c2¼ 6.46, df¼ 3, p¼ 0.91), although breast care nurses werethe least likely of all groups to attend. There was also no asso-ciation between attending an MDT meeting and working ina public (c2¼ 0.34, df¼ 1, p¼ 0.56) or private (c2¼ 0.16,df¼ 1, p¼ 0.69) hospital setting.

Independent predictors of attending an MDT are shown inTable 2. Clinicians who were based in a major city were sig-nificantly more likely to attend an MDT meeting (AOR 1.90;95%CI: 1.01e3.58). After adjusting for location, clinicianswho treated more than 50 new breast cancer patients a yearwere significantly more likely to attend (AOR 7.34; 95%CI:3.38e15.96).

Composition of MDT meetings

Fig. 1 indicates the types of health professionals who at-tended the MDT meetings as reported by the survey sample.

Of the 229 health professionals who stated they attended, largenumbers indicated that medical specialists such as surgeons(96%), medical (92%) and radiation (90%) oncologists, pathol-ogists (88%), breast care nurses (87%) and radiologists (78%)were regular attendees. Less frequent in attendance were socialworkers (28%), physiotherapists (24%), ward nurses (21%),psychologists (17%) and general practitioners (10%). In addi-tion to the specific personnel listed on the survey cliniciansalso nominated that breast screen staff (5%), a data manager(3%), occupational therapist (2%) and cancer care co-ordinator(1%) also regularly attended. The frequency of meetings isdisplayed in Fig. 2. The majority were held weekly.

The structure of MDT meetings

One hundred and fifty-seven clinicians (69%) who attendMDT meetings, reported that the proportion of time devotedto case discussions about breast cancer patients during the meet-ing was greater than 75%. For 33 clinicians (14%) the timedevoted was only between 50 and 75% of that available. Theremaining 36 clinicians (16%) spent less than 50% of theirtime discussing patients’ treatment plans.

Table 3 indicates the topics of case discussions. The dis-cussion of pathology results, extent of disease, surgery per-formed and appropriate treatment plan were almost alwayspart of a case discussion. In comparison relevant psychosocialissues are always discussed in only 29% of respondents meet-ings. This is significantly lower compared to all other topics(McNemar’s test, all p< 0.001).

The effectiveness of MDT meetings

Clinicians’ views regarding the effectiveness of their MDTmeetings in optimising treatment recommendations are shownin Table 4, with the majority believing they were very effective.Further positive comments include that the MDT meetingallowed for a good contact between disciplines, improvedreferrals and enabled patients to receive the most current treat-ment. The robust discussions within meetings were seen asbeneficial as they facilitated a consensus treatment plan. Re-spondents also indicated factors that inhibited effectiveness;these fell broadly into three themes, namely the sub-optimalattendance of key personnel such as surgeons, radiation andmedical oncologists, the length of the meeting and issuesassociated with a rural locality.

Percen

t

100

80

60

40

20

01010

172021

242528

3840

78

8788909296

Health Professional

Physiotherapist

GPPsychologist

Breast Physician

Ward Nurse

Other Clin. Staff

Genetic Couns.

Social Worker

Clinic Nurse

Research Nurse

Radiologist

Breast Nurse

Pathologist

Rad. Onc.

Med. Onc.

Surgeon

Fig. 1. Proportion of breast health staff who attend MDT planning meetings (n¼ 229).

338 J.D. Harrison et al. / The Breast 17 (2008) 335e340

Several recommendations were made of strategies thatcould be undertaken to improve MDT meetings. The mostcommonly cited was ensuring that key personnel namely radi-ation and medical oncologists, allied and psychosocial healthprofessionals were always present. Allowing the involvementand views of all who attend to be heard, a more structuredmeeting and a better chairperson were also seen as imperativeto the meetings success. Other improvements included involv-ing general practitioners and data managers, having adminis-trative support for the meetings, improved video or telephone

Timing of MDT planning meeting

as requiredothermonthyfortnightlyweekly

Percen

t

60%

40%

20%

0% 1%2%

14%20%

63%

Fig. 2. Frequency of MDT planning meetings (n¼ 229).

conference facilities and a better arrangement of the meetingroom that allowed all to participate.

Discussion

This study has shown that the vast majority (>90%) ofbreast health specialists regard MDT meetings as an effectivemethod for treatment planning and believe that these meetingsresult in substantial improvements in care for women withbreast cancer (�80%).

Large numbers of surgeons, oncologists and breast cancernurses regularly attended MDT meetings. The level of atten-dance for medical oncologists (92%) is particularly notewor-thy given that audits of MDT working internationally have

Table 3

Topics of discussion during the MDT planning meeting (n¼ 229)a

Always Often Sometimes Never

Relevant pathology results 209 (91) 13 (6) 4 (2) 0

Discussion of appropriate

treatment plan

199 (87) 22 (10) 5 (2) 0

Discussion of the extent of disease 194 (85) 22 (10) 9 (4) 0

Description of surgery performed 190 (83) 26 (11) 8 (3) 1 (0)

Presentation of the clinical

assessment for each patient

175 (76) 30 (13) 18 (8) 2 (1)

Findings of initial investigations

or management results

175 (76) 38 (17) 11 (5) 0

Relevant diagnostic radiology 152 (66) 43 (19) 26 (11) 4 (2)

Discussion of relevant

psychosocial issues

66 (29) 71 (31) 83 (36) 3 (1)

a Where data are missing values do not add to 100%.

Table 4

Health professionals’ views on the effectiveness of MDT planning meetings

Very effective Effective Not very effective

Surgeon (n¼ 110) 68 (62) 34 (31) 6 (5)

Radiation oncologist (n¼ 27) 20 (74) 5 (19) 0

Medical oncologist (n¼ 65) 27 (50) 25 (46) 1 (2)

Breast care nurse (n¼ 56) 22 (58) 13 (34) 2 (5)

339J.D. Harrison et al. / The Breast 17 (2008) 335e340

consistently shown that medical oncologists are least likely toattend of all medical specialists.17,18 This though is not sur-prising given that most oncologists in our sample were basedin capital or metropolitan centres where oncology services aremost commonly available.

The core health professional attendance, however, con-tinues to be dominated by medical specialists. The presenceof psychologists was limited despite clinical practice guide-lines19 highlighting the importance of psychosocial care forcancer patients and the well documented elevated levels ofpsychosocial morbidity and unmet emotional and supportivecare needs associated with diagnosis and treatment of breastcancer.20,21 Whilst it may not be feasible for psychologiststo regularly attend MDT meetings, established links shouldbe in place so that patients can be referred if furtherassessment is considered necessary.7 However, this audit foundthat psychosocial issues were not discussed in the majority ofresponses, yet it is not possible to tell from this data whetherlinks to psychosocial services were in place outside of themeeting. The NBCC is currently developing a psychosocialrisk factor checklist that aims to promote appropriate referralby assisting MDTs in the early identification of patients at in-creased risk of psychosocial distress.22

The rarity of allied health staff such as social workers, phys-iotherapists and occupational therapists is potentially problem-atic given rehabilitation needs23 of breast cancer patients thatshould be considered during treatment planning. If allied staffdo not regularly attend the standard MDT meeting, alternate ar-rangements may need to be made to establish a non-medicaltreatment plan. Whilst this may be practical it is in conflict tokey recommendations from regulatory and representative bod-ies which state allied and supportive care staff should, wherepossible, be involved.2,7 Indeed, ensuring key personnel suchas surgeons, oncologists and allied health staff are presentwas recommended by respondents in this survey as a meansto improve current MDT meetings.

Not surprisingly clinicians who were based in a major cityand with a high caseload of breast cancer patients were signif-icantly more likely to attend an MDT meeting. This is almostcertainly due to the fact MDT meetings are more possible ina high caseload centre compared to regional and rural areaswhere there is not the full repertoire of staff or services. It isalso likely that high caseload specialists have only one ortwo MDT meetings to attend, whereas breast specialists withlower caseloads will have competing meetings at widespreadsites to attend. Geographic and demographic barriers to thedelivery of multidisciplinary care have been echoed else-where.22,24 Our study of individual clinicians’ views suggests

further resources are required to facilitate MDC and treatmentplanning or that new models need to be developed to ensurethe disparity in access to MDC services between city, regionaland rural patients are reduced.

An analysis of the topics discussed and structure of breastMDT meetings indicates that in a third of instances the timedevoted to case discussion about breast cancer patients isless than 75% indicating that treatment planning meeting areused for other functions. Indeed, it has been suggested thatMDT meetings are the ideal place for health professional ed-ucation.7 All breast cancer patients were always discussed in76% of MDT meetings, a figure comparable with audits ofMDT meetings in the UK which suggest that this can rangefrom 60 to 94%.17,18 It is interesting to note that in 13% ofcases, a discussion of the appropriate treatment plan for thepatient does not always happen.

Several recommendations were made by clinicians abouthow to improve MDT meetings, such as allowing the involve-ment and views of all who attend. This problem is not uncom-mon. One observational study25 exploring MDT members’interaction found that nurses and allied health professionalswere less likely to voice opinions and ask questions comparedto medical specialists. This implies that compared withpatients medical needs, other aspects of care such as func-tional and social need may not have been addressed asadequately. Alternatively, it may mean that key medicaldecisions, including the review of radiology, pathology andmanagement recommendations are prioritised given the shorttime available in the MDT meeting. Other aspects of care areperhaps more appropriately dealt directly with the patients.Given that it is only feasible to allocate 5e10 min for eachcase discussion it is impossible to cover all of the complexissues facing each patient. Nevertheless, this current studyhighlights that there is further work needed to ensure thatMDT’s function and co-operate as intended during treatmentplanning meetings.

The limitations of this study are the over representation ofclinicians working in major centres. A recent mapping exer-cise,24 however, highlighted a lack of oncology services andspecialist breast surgeons out of major centres which suggeststhat our sampling strategy for this study was adequate. Incorpo-rating the opinions of general surgeons who treat breast cancer,allied and psychosocial health staff may provide further insightsinto MDT planning meetings across Australia. We acknowledgethat the self-reported responses of attendance to MDT meetingsmay differ from actual attendance registers, however, given thenational focus of this study, resources were unavailable to checkthe reliability of clinicians’ responses.

This national study is the first to ascertain breast cancerspecialist’s involvement in MDT treatment planning meetings.It has also provided an insight into MDT meeting structure andformat. The majority of health professionals regard MDT meet-ings as an effective method for treatment planning and believethey have resulted in substantial improvements in care forwomen with breast cancer. Further work though is needed toensure that MDT’s function and co-operate as intended andthat all breast cancer patients have access to an MDT.

340 J.D. Harrison et al. / The Breast 17 (2008) 335e340

Acknowledgements

We would like to thank all health professionals who tookpart in this study. We also wish to acknowledge the supportgiven to us by executive committees of the clinical interestgroups involved, namely the Section of Breast Surgery at theRoyal Australasian College of Surgeons, Trans-Tasman Radi-ation Oncology Group, Medical Oncology Group of Australiaand the Cancer Nurses Society of Australia. Dr Ellis Choy wassupported by scholarships from the National Breast CancerFoundation and the Royal Australasian College of SurgeonsFoundation.

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