Colorectal cancer: are multidisciplinary team meetings a waste of time?
Post on 08-Dec-2016
Colorectal cancer: are multidisciplinary team meetingsa waste of time?
In this edition of the Journal, Wichmann et al. outlined their expe-rience in treating colorectal cancer in a rural setting.1 This commonsense, practical publication reassuringly demonstrates that excellentresults can be achieved by non-specialists in treating this condition,which affects around 1 in 20 Australians, and often presents as anemergency many miles from metropolitan specialists. An interestingaspect of this publication is that in the last three years of the study,all plans have been discussed and approved by an institutionalmultidisciplinary tumour board. This raises the important questionof the rise of the multidisciplinary team meeting (MDTM), which isworth reviewing.
In 1995, in response to perceived inferior cancer treatment in theNHS, the Calman and Kline report was published.2 It suggested,without any supporting evidence, that the answer was more meetingsand that the treatment of colorectal cancer should be coordinated bya multidisciplinary team (MDT). MDTs became standard of care,and by 2007 in the Guidelines for the Management of ColorectalCancer by the Association of Coloproctology of Great Britain andIreland, it was stated that All patients with colorectal cancer shouldhave the benefit of a suitably informed surgical opinion and theirmanagement should be discussed by the multidisciplinary team GCP.3 While there were 468 references in the total document, therewere none supporting this statement it was proclaimed as GCP,that is, Some recommendations cover topics which are not amena-ble to formal studies (e.g. informed consent) but represent goodclinical practice.
Through a strange mix of politics and medicine, MDTs started tobecome enshrined in government policy, again without reference toevidence or debate. For example, in Western Australia in a Depart-ment of Health publication entitled Colorectal Cancer Model ofCare, it is stated that All patients should have access to a MDT toplan the management of their cancer. It is essential that a cancerspecialist lead the MDT approach and it is available to all patients nomatter where they live.4 It states the MDT should be composed of amedical oncologist, nurse coordinator, pathologist, radiationoncologist, radiologist with expertise in MRI, social worker, surgeon(colorectal for rectal cancer) and stomal therapist, with access to avariety of others including dietitians, as well as video link-ups andassisted travel arrangements.
Regarding colorectal cancer, one of the first publications address-ing MDTs reviewed retrospectively the rate of involved circumfer-ential resection margins (CRMs) in rectal cancer before and one yearafter the introduction of MDTs.5 One hundred seventy-eight patientsunderwent surgery alone, while 81 had neoadjuvant therapy. Theauthors found that 62 of 178 in the surgery alone group did not havemagnetic resonance imaging (MRI)-based MDT discussion, result-
ing in positive CRM in 16 cases (26%), compared to 1 out of 16(1%) in those patients who had MDT discussion of their MRI. Thisfinding has been cited 105 times in the literature, generally tostrongly support the role of MDTs. It is not mentioned in the abstractof the article that in the original audit, only 13% of patients weredeemed palliative as compared to 24% on re-audit, or that in thenon-MDT group, some cases were operated on because of obstruc-tion, or that many of the non-MDT MRI reports were by different,less experienced radiologists who underreported 50% of cases. Theeffect of surgeons knowing that their CRM rate is being measuredmay also have had a major impact. Perhaps most importantly, manywould question the inference that if a patients case is unfortunatelyleft off the list and not discussed at a MDT, then that patientslikelihood of having a positive CRM therefore increases by 2500%.This is not common sense.
A more recent, larger study from Holland found no difference inthe involved CRM rate between those discussed at a MDT meetingand those not discussed.6
In a journal editorial in 2009, it was stated that MDTs have beenimplemented almost universally in many European countries andtoday stand as the gold standard for the selection of surgicaland oncological management of patients with all forms of cancer,and . . . in this issue of the journal, we are presented for the first timeby a study which demonstrates that the MDT-conference results in asignificant improvement in survival.7 In the actual study, 310patients undergoing treatment by one surgeon before and after theintroduction of MDTs are analysed, with the abstract concludingMDT status was shown to be an independent predictor of survivalon hazard regression analysis (P = 0.044).8 The reason for thisincreased survival was the introduction of the appropriate use ofchemotherapy. More patients were given chemotherapy in the MDTgroup (P = 0.00023) and survival for patients with Dukes C cancersimproved from 58% in the pre-MDT group to 66% in the MDTgroup (P = 0.023). Perhaps, MDTs did influence the inappropriatelyinfrequent use of adjuvant chemotherapy, but there are other ways todo this, and these results do not mean that every case of colon cancerhas to be presented at a MDT for evermore.
Particularly in rectal cancer, it must be asked what is the goldstandard adjuvant treatment protocol that is being ensured byMDTs? For example, in one study, the use of radiotherapy in rectalcancer was analysed in four different cancer centres in NorthwestEngland and North Wales.9 Different MDTs, based on their interpre-tation of the literature, gave different advice. For example, in T2 N1tumours of the lower rectum, two of the centres gave short-courseradiotherapy, whereas the other two centres advised long-coursechemoradiotherapy. This is in contrast to another UK MDT group
2013 The AuthorsANZ Journal of Surgery 2013 Royal Australasian College of Surgeons ANZ J Surg 83 (2013) 101108
- where their own data support routine avoidance of any radiotherapyfor rectal cancers stages T1, T2, T3a and T3b (
1. Wichmann MW, Beukes E, Esufali ST, Plaumann L, Maddern G. Five-year results of surgical colorectal cancer treatment in rural Australia.ANZ J. Surg. 2013; 83: 1127.
2. Expert Advisory Group on Cancer. A policy framework for commission-ing cancer services the CalmanHine Report. A Report by the ExpertAdvisory Group on Cancer to the Chief Medical Officers of England andWales. London: Department of Health, 1995.
3. Association of Coloproctology of Great Britain and Ireland. Guidelinesfor the Management of Colorectal Cancer. London, UK: Association ofColoproctology of Great Britain and Ireland, 2007; 117 p. [Cited August2012.] Available from URL: http://www.mccn.nhs.uk/userfiles/documents/Nat%20Ass%20of%20Coloproctology%20Guidelines%281%29.pdf
4. Department of Health, Western Australia. Colorectal Model of Care.Perth: WA Cancer & Palliative Care Network, Department of Health,Western Australia; 2008.
5. Burton S, Brown G, Daniels IR, Norman AR, Mason B, Cunningham D.MRI directed multidisciplinary team preoperative treatment strategy: theway to eliminate positive circumferential margins? Br. J. Cancer 2006;94: 3517.
6. Swellengrebel HAM, Peters EG, Cats A et al. Multidisciplinary discus-sion and management of rectal cancer: a population-based study. WorldJ. Surg. 2011; 35: 212533.
7. Wille-Jrgensen P, Blow S. The multidisciplinary team conference inrectal cancer a step forward. Colorectal Dis. 2009; 11: 2312.
8. MacDermid E, Hooton G, MacDonald M et al. Improving patient sur-vival with the colorectal cancer, multi-disciplinary team. Colorectal Dis.2009; 11: 2915.
9. Scott NA, Susnerwala S, Gollins S, Sun Myint A, Levine E. Preoperativeneo-adjuvant therapy for curable rectal cancer reaching a consensus.Colorectal Dis. 2009; 11: 2458.
10. Taylor FGM, Quirke P, Heald RJ et al. for the MERCURY Study Group.Preoperative high-resolution magnetic resonance imaging can identifygood prognosis stage I, II, and III rectal cancer best managed by surgeryalone. A prospective, multicenter, European study. Ann. Surg. 2011; 253:7119.
11. Priego P, Sanjuanbenito A, Morales V et al. Multidisciplinary approachto the treatment of rectal cancer: the benefits of neoadjuvant therapy.Rev. Esp. Enferm. Dig. 2008; 100: 3939.
12. Sharma A, Sharp DM, Walker LG, Monson JRT. Colorectal MDTs: theteams perspective. Colorectal Dis. 2007; 10: 638.
13. Coorya M, Gkolia P, Yangc IA, Bowmanc RV, Fongc KM. Systematicreview of multidisciplinary teams in the management of lung cancer.Lung Cancer 2008; 60: 1421.
14. Augestad KM, Lindsetmo R, Stulberg J et al. International preoperativerectal cancer management: staging, neoadjuvant treatment, and impactof multidisciplinary teams international rectal cancer study group(IRCSG). World J. Surg. 2010; 34: 2689700.
15. Look Hong NJ, Wright FC, Gagliardi AR, MSc MLS, Paszat LF. Exam-ining the potential relationship between multidisciplinary cancer careand patient survival: an international literature review. J. Surg. Oncol.2010; 102: 12534.
Alan P. Meagher, FRACSSt Vincents Hospital, Sydney, New South Wales, Australia
Superdocs of the 21st century: can they really fly?
The shift in modern medicine towards a patient-centric approach hasevolved rapidly in the clinical, ethical and legal spheres. Gone arethe days of the doctor as the bespectacled deity who handed medi-cines without explanation across a desk almost as vast as the powerdifferential in the doctorpatient relationship. The emphasis has nowlanded firmly and squarely (and rightly so) on the patient. The resulthas been a drastic rise in patient demands and expectation. With thisshift in paradigms, it pays to stop and consider the affect this ishaving on our medical students and doctors in specialty training.
Patients are now encouraged to advocate for their own health andto be integral in decision-making processes regarding medical treat-ment. With the freedom and accessibility of information, patientstoday are generally better informed than their counterparts ofdecades past.1 Such ready access to knowledge leads to more ques-tions, more concerns and more expectation, keeping clinicians ontheir toes. Clinicians must stay current with relevant advances in themedical field, an attribute commonly labelled as continuing profes-sional development.
The approach behind compensation disputes is likewise undergo-ing a shift in favour of better patient care. The thinking behindnegligence has shifted from the Bolam test (did the doctor act in away that other practitioners would consider reasonable) to a focus onmaterial risk (what would a reasonable patient expect).2 With this
changing tide, doctors must be aware of medico-legal implicationsin the domains of medicine appropriate to their practice to avoidleaving themselves open to prosecution.
The spotlight is also broadening its vista to include ethics as acentral part of modern medical practice. While ethics has alwaysbeen assumed intrinsic to medical practice from the days ofHippocrates, today ethics has evolved into a discipline in its ownright. There are almost as many buzz words and neologisms crop-ping up as there are emerging ethico-legal complexities.3
In addition, expectation does not rest here. Doctors are expectedto be capable teachers while they themselves are yet studying, topresent and publish while they are yet learning, and to work asintegral members of high-fidelity teams as both as members and asleaders. Todays doctors are challenged to provide optimal healthcare for their individual patients while also advocating for the healthof the community as a whole.
Such changes have been paralleled by diversification of modernmedical curricula. Medicine has shifted from the study of a scienceand the practice of a trade to become much more. Indeed, these arenow merely components of the expected educational achievements.Other common pillars of medical curricula now include such enti-ties as population medicine and personal and professional develop-ment, encompassing health advocacy, ethics and legalities. The
2013 The AuthorsANZ Journal of Surgery 2013 Royal Australasian College of Surgeons